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10575366-DS-4 | 10,575,366 | 25,153,307 | DS | 4 | 2175-01-30 00:00:00 | 2175-01-30 15:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Erythromycin Base / simvastatin / lovastatin /
fenofibrate / doxycycline / latex
Attending: ___.
Chief Complaint:
Abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with HTN,
anxiety/depression, GERD, IBS, GERD, COPD, chronic low back
pain,
COPD, and episode of colitis in ___ (?ischemic) who p/w acute
onset abdominal pain, diarrhea, and vomiting.
In terms of her history of colitis, she had an episode of bloody
diarrhea in ___ with severe abdominal pain with CT scan showing
aortic narrowing (but normal SMA, ___ takeoff and celiac) and
colitis in the splenic flexure to descending colon, raising
concern for ischemic colitis. She was treated with cipro/flagyl
and discharged home. Her bowel function returned to normal. She
had a colonoscopy in ___ incomplete to the sigmoid; virtual
colon was negative at that time.
She had been feeling well until yesterday. She ate fried shrimp
and ice cream at a restaurant as a late lunch yesterday. No one
else in her party ate the shrimp. Afterwards she had a headache,
unusual for her, and took naproxen. She was then awoken from
sleep at midnight with severe abdominal pain. The pain was
crampy, non-radiating, and extended across her lower abdomen.
There was associated nausea/vomiting (4 episodes NBNB) and
diarrhea > 10 times that was watery and brown, possibly with
some
dark brown blood in it. She denies fevers/chills, urinary
symptoms, joint pain, chest pain, recent travel, or recent
antibiotics.
ED Course:
Vitals: T 97.9, HR 100s, BP 136/86, SpO2 99% on RA
Data: WBC 19.0, Hct 44.9, CT A/P w/ transverse/sigmoid colitis
Interventions: NS 2L, cipro, flagyl, dilaudid IV
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Colitis ___
IBS-C
GERD
COPD
Chronic low back pain
HTN
Depression
Social History:
___
Family History:
No family history of IBD or other gastrointestinal disease
Physical Exam:
Admission:
GENERAL: Uncomfortable appearing, holding abdomen
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Tachycardic, Heart regular, no murmur, no S3/S4. JVP 6cm
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, +TTP over lower quadrants
without rebound/guarding. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge:
GENERAL: NAD, comfortable
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3/S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, slightly distended, +TTP over lower quadrants
without rebound/guarding. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission:
___ 08:40AM URINE HOURS-RANDOM
___ 08:40AM URINE UHOLD-HOLD
___ 08:40AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 06:10AM GLUCOSE-180* UREA N-20 CREAT-0.9 SODIUM-143
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-21*
___ 06:10AM estGFR-Using this
___ 06:10AM ALT(SGPT)-17 AST(SGOT)-35 ALK PHOS-95 TOT
BILI-0.5
___ 06:10AM LIPASE-19
___ 06:10AM ALBUMIN-4.5 CALCIUM-9.9 PHOSPHATE-2.9
MAGNESIUM-2.1
___ 06:10AM WBC-19.0* RBC-4.75 HGB-14.9 HCT-44.9 MCV-95
MCH-31.4 MCHC-33.2 RDW-12.7 RDWSD-43.9
___ 06:10AM NEUTS-87.7* LYMPHS-4.4* MONOS-7.1 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-16.62* AbsLymp-0.84* AbsMono-1.34*
AbsEos-0.00* AbsBaso-0.06
___ 06:10AM PLT COUNT-227
Discharge:
___ 06:30AM BLOOD WBC-6.5 RBC-3.31* Hgb-10.2* Hct-31.7*
MCV-96 MCH-30.8 MCHC-32.2 RDW-12.3 RDWSD-43.5 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-27.2 ___
___ 06:30AM BLOOD Glucose-90 UreaN-10 Creat-1.0 Na-141
K-3.7 Cl-98 HCO3-29 AnGap-14
___ 06:30AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0
___ 06:30AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0
___ 10:54AM BLOOD Lactate-2.4*
CT A/P:
- Normal small bowel
- Transverse to sigmoid colon wall edema, mucosal
hyperenhancement, and pericolonic fat stranding
- Similar distribution to ___
- Mesenteric vasculature is patent.
- Moderate atherosclerotic disease
- No fluid collection, free air, or pneumatosis.
Microbiology:
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Brief Hospital Course:
___ w/ HTN, anxiety/depression, GERD, IBS, GERD, COPD, chronic
low back pain, COPD, and episode of colitis in ___ (?ischemic)
who p/w acute onset abdominal pain, diarrhea, and vomiting and
found to have colitis on CT scan, concern for infectious vs.
ischemic colitis.
ACUTE/ACTIVE PROBLEMS:
#Colitis: Differential includes infectious colitis (most likely)
vs. ischemic colitis (less likely given lactate only 2.4), and
IBD (given CRP>300). She presented with multiple episodes of
diarrhea with blood mixed in, which tapered off significantly
throughout the hospital course. GI was consulted and recommended
outpatient colonoscopy. She will receive a 7 day course of cipro
and flagyl. She will have close GI follow up 2 days after
discharge with Dr. ___ gastroenterologist and with her
PCP. She continued to require a few doses of her home oxycodone
dose for abdominal pain which she will continue to use only as
absolutely necessary. Despite small amount of blood loss, her
hgb stabilized at 10.2 prior to discharge.
#HTN: We continued HCTZ but we are holding losartan given BP has
been normal and we are concerned about over-treating blood
pressure since there was concern for possible ischemic colitis.
#HLD: atorvastatin
#Depression: bupropion, lamictal
#Anxiety: clonazepam QHS PRN
#COPD: advair, albuterol inhaler, holding Umeclidinium given
formulary
#GERD: ranitidine/omeprazole
Transitional Issues:
============================
[] At next visits, ensure no BM w/ blood. Consider checking CBC
[] Check BP and re-initiate losartan as appropriate.
[] Consider colonoscopy and further ischemic colitis workup
[] Patient would like to discuss therapy specifically aimed at
PTSD. Our social work team gave her a form with local psych
resources
[]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. umeclidinium 62.5 mcg/actuation inhalation DAILY
4. ClonazePAM 1 mg PO QHS:PRN insomnia
5. Ranitidine 150 mg PO QHS
6. Atorvastatin 10 mg PO QPM
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Omeprazole 40 mg PO DAILY
9. BuPROPion XL (Once Daily) 150 mg PO DAILY
10. LamoTRIgine 12.5 mg PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO QHS:PRN Pain -
Severe
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H Duration: 3 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times daily
Disp #*7 Tablet Refills:*0
3. Atorvastatin 10 mg PO QPM
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. ClonazePAM 1 mg PO QHS:PRN insomnia
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. LamoTRIgine 12.5 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO QHS:PRN Pain -
Severe
11. Ranitidine 150 mg PO QHS
12. umeclidinium 62.5 mcg/actuation inhalation DAILY
13. HELD- Losartan Potassium 100 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until your doctor
tells you to restart it
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Infectious vs. Ischemic colitis
Secondary: Hypertension, hyperlipidemia, depression, anxiety,
COPD, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you had colitis, which we
felt was caused by ischemia (lack of blood flow) or an
infection. It improved significantly with antibiotics and you
were able to eat so we felt it was safe for you to go home. You
should go to all your appointments and take the medications you
see below as prescribed.
Followup Instructions:
___
|
10575413-DS-27 | 10,575,413 | 22,658,105 | DS | 27 | 2155-10-31 00:00:00 | 2155-10-31 20:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Reglan
Attending: ___
Chief Complaint:
nausea,vomiting, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o diabetic nephropathy s/p
living-related kidney transplant in ___ with initial
post-transplant course complicated by humoral rejection and DSA
positivity who presents with 2 days of nausea/vomiting and
diarrhea with associated difficulty taking in POs. Creatinine
checked by outpatient provider, was elevated to ___ yesterday
(was 1.6-1.7 in ___ and was referred to ___ ED. Additionally
she reports pain over her transplanted kidney and recent
hematuria. Otherwise no fevers, chills, chest pain, shortness of
breath, cough, dysuria or rashes.
In the ED, initial vitals were 96.9 78 150/46 18 96%.
Labs notable for Hgb/Hct 9.8/32.3, WBC 10.5, plt 239, K 6.0,
BUN/Cr 48/2.7, INR 0.9. Patient was given 1L NS, 10U insulin,
1amp d50, 1g calcium gluconate, and 60 mg IV lasix for
hyperkalemia. Renal ultrasound was normal. Patient was seen by
nephrology fellow who recommended admission to kidney service,
IVF resuscitation, and treatment for hyperkalemia as above.
ROS: per HPI
Past Medical History:
-- Coronary Artery Disease s/p BMS x 3 in ___
-- Diabetes Mellitus Type 1, diagnosed ___ years ago
-- Diabetic nephropathy s/p living donor renal transplant
___ c/b by rejection requiring plasmapharesis, IVIG,
rituximab, and steroids
-- Hypertension
-- Sleep apnea on CPAP
-- s/p appendectomy
-- s/p Cholecystectomy
-- s/p C-section x2
Social History:
___
Family History:
Per OMR, Mother and father had hypertension. Her father is still
alive at the age of ___. Mother is deceased at the age of ___ with
diabetes type 2 and myocardial infarction.
Physical Exam:
Admission
General: no acute distress, lying in bed
HEENT: NCAT
CV: normal s1/s2, rrr, no murmurs/rubs
Lungs: clear anteriorly
Abdomen: +BS, soft, nontender
GU: no foley
Ext: no ___ edema
Neuro: alert, oriented
Skin: no rashes noted
Discharge
General: no acute distress, lying in bed
HEENT: NCAT
CV: normal s1/s2, rrr, no murmurs/rubs
Lungs: clear anteriorly
Abdomen: +BS, soft, nontender
GU: no foley
Ext: no ___ edema
Neuro: alert, oriented
Skin: no rashes noted
Pertinent Results:
Admission
___ 03:30PM BLOOD WBC-10.5# RBC-3.62* Hgb-9.8* Hct-32.3*
MCV-89 MCH-27.2 MCHC-30.5* RDW-16.3* Plt ___
___ 03:30PM BLOOD Neuts-80.4* Lymphs-11.2* Monos-6.4
Eos-1.7 Baso-0.2
___ 06:18PM BLOOD ___ PTT-33.4 ___
___ 05:45AM BLOOD ALT-12 AST-15 LD(LDH)-152 AlkPhos-120*
TotBili-0.2
___ 05:45AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.3
___ 04:39PM BLOOD tacroFK-11.0
___ 04:48AM BLOOD WBC-7.0 RBC-3.23* Hgb-8.8* Hct-28.9*
MCV-90 MCH-27.2 MCHC-30.3* RDW-16.1* Plt ___
___ 05:45AM BLOOD Neuts-76.7* Lymphs-13.7* Monos-6.5
Eos-2.7 Baso-0.5
___ 04:48AM BLOOD ___ PTT-33.9 ___
___ 04:48AM BLOOD Glucose-182* UreaN-38* Creat-1.8* Na-138
K-5.6* Cl-109* HCO3-20* AnGap-15
___ 04:48AM BLOOD ALT-12 AST-13 LD(LDH)-181 AlkPhos-109*
TotBili-0.2
___ 04:48AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.6 Mg-2.4
___ 09:14AM URINE Color-Straw Appear-Clear Sp ___
___ 09:14AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 09:14AM URINE RBC-1 WBC-24* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
MICRO
UCX : NEG
BCX X 2 : NEGATIVE
CMV VL : NOT DETECTED
EBV IgM/IgG: NEG
STUDIES
___
Transplant U/S
IMPRESSION:
No hydronephrosis. Relatively unchanged, mildly elevated
resistive indices.
CT ABD&PELVIS w/o contrast
___
IMPRESSION:
1. Unremarkable noncontrast CT appearance of a left lower
quadrant transplant
kidney without evidence of stones, hydronephrosis, or
perinephric fluid
collection.
2. Extensive atherosclerotic calcification seen within the aorta
and its major
branches.
3. Small axial hiatal hernia, trace simple free fluid along the
right
pericolic retroperitoneum, and moderate rectal prolapse.
Brief Hospital Course:
___ yo F with ESRD due to type 1 diabetes s/p LRRT in ___ on
prednisone, tacrolimus, and azathioprine who presented with
nausea, vomiting, and diarrhea and was found to have acute on
chronic kidney injury.
# L-sided pain/N/V/Diarrhea: Pt on sun developed sudden L sided
flank pain, with nausea, vomiting, and diarrhea. On mon, noticed
hematuria. N, v, diarrhea resolved. Sudden L sided pain,
initially associated with sudden n, v, diarrhea, that have now
resolved and hematuria suggestive of passed renal stone. No
stones on renal US. Given immunosuppresion, there is also
concern for infection(BK, CMV, EBV). viral gastroenteritis also
a possibility, but L sided pain persisting not consistent with
viral gastro. also found to have a UTI. CT abd/pelvis normal.
CMV/BK studies pending on discharge.
# ___ on CKD:
Patient with baseline creatinine 1.6-1.7 per ___ labs. Acute
elevation in setting of n/v/diarrhea and poor PO intake
suggestive of pre-renal azotemia. Renal u/s reassuring. Given
h/o past transplant rejection and DSA positivity raises spectre
of rejection. Also possibly in the setting of UTI as below. Some
concern for passed kidney stone as above. Cr improved back to
baseline.
- lisinopril held on discharge , lasix restarted at 40mg daily
# UTI: UA notable for 24 WBC, mod leucks. given above symptoms,
started CTX. Discharge with 2 weeks of cipro.
# Hyperkalemia:
Patient with K at 6.0 on admission. Likely related to ___. Given
60 IV lasix, 1L IVF, calcium, insulin and D50 in ED. Improved to
5.6.
# Hypertension:
- continued home amlodipine, metoprolol, doxazosin
- held lisinopril on discharge
TRANSITIONAL ISSUES
- Recheck labs tomorrow. Patient given prescription.
- Ciprofloxacin 500 mg Q12H for 2 weeks
- Lasix 40 mg daily. Titrate up to 80 mg daily as tolerated.
- DSA pending on discharge
- Patient to check daily weights and blood pressures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 1.5 mg PO Q12H
2. PredniSONE 2.5 mg PO DAILY
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Azathioprine 50 mg PO BID
8. Metoprolol Succinate XL 200 mg PO BID
9. Alendronate Sodium 70 mg PO QMON
10. Furosemide 80 mg PO BID
11. Amlodipine 10 mg PO DAILY
12. Simvastatin 10 mg PO QPM
13. Doxazosin 2 mg PO HS
14. Zolpidem Tartrate 10 mg PO QHS insomnia
15. melatonin 3 mg oral QHS:PRN insomnia
16. Aspirin 81 mg PO DAILY
17. Glargine 18 Units Breakfast
Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Doxazosin 2 mg PO HS
3. FoLIC Acid 1 mg PO DAILY
4. Glargine 18 Units Breakfast
Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Succinate XL 200 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. PredniSONE 2.5 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO QHS insomnia
9. Alendronate Sodium 70 mg PO QMON
10. Aspirin 81 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Tacrolimus 1 mg PO Q12H
13. Azathioprine 100 mg PO DAILY
14. melatonin 3 mg oral QHS:PRN insomnia
15. Simvastatin 10 mg PO QPM
16. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*28 Tablet Refills:*0
17. Outpatient Lab Work
Please check CBC, electrolytes including calcium, magnesium, and
phosphate, and renal function. Please fax to Transplant Clinic
at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Gastroenteritis
- Hypovolemia
- Acute on chronic kidney disease
Secondary diagnoses:
- ESRD s/p renal transplant
- Type 1 diabetes
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 while you were a patient at
___. You came to us with
nausea, vomiting, and diarrhea. This was most likely due to
gastroenteritis. Your renal function was worse than baseline,
most likely because you were dehydrated. We treated you with IV
fluids and on discharge you were at your baseline renal
function.
You need labs drawn tomorrow. You can do this at ___. We are
giving you a prescription for these labs. You will need to take
ciprofloxacin for the next 2 weeks. Please weigh yourself every
day. If your weight goes up by more than 2 lb. in 1 day or 5 lb.
in 1 week call the renal transplant clinic. Check your blood
pressure every day. If the top number is over 160 consistently,
call the renal transplant clinic at ___.
Followup Instructions:
___
|
10575886-DS-10 | 10,575,886 | 21,924,344 | DS | 10 | 2150-09-18 00:00:00 | 2150-09-18 10:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Right ankle pain.
Major Surgical or Invasive Procedure:
___ - Open reduction internal fixation of right bimalleolar
ankle fracture
History of Present Illness:
___ who fell while walking down steep stairs at home in the dark
to turn on furnace, missed step, fell and twisted her ankle few
hours prior to presenting to ED. Pain and swelling over right
medial and lateral mal. She had immediate pain & inability to
bear weight. No head strike or LOC. No other injuries.
Past Medical History:
Hypothyroidism
Hypertension
Right distal radius fracture managed non-operatively
Social History:
___
Family History:
Non-contributory.
Physical Exam:
EXAM ON DISCHARGE:
Vital signs - Afebrile with stable vital signs
General - No acute distress
Abdomen - Soft, non-tender, non-distended
Right lower extremity Fires extensor hallucis longus, flexor
halluces longus. Sensation intact to light touch in sural,
saphenous, superficial peroneal, deep peroneal, and tibial
distributions. Distal extremity warm and well perfused with
capillary refill less than 2 seconds. Compartments soft with no
pain on passive range of motion of toes. Splint
clean/dry/intact.
Pertinent Results:
___ 02:50AM BLOOD WBC-9.3 RBC-4.90 Hgb-13.7 Hct-42.2 MCV-86
MCH-27.9 MCHC-32.4 RDW-13.0 Plt ___
___ 02:50AM BLOOD Neuts-62.8 ___ Monos-5.9 Eos-3.0
Baso-0.5
___ 02:50AM BLOOD Glucose-100 UreaN-25* Creat-1.0 Na-141
K-4.2 Cl-107 HCO3-24 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 right bi-malleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
of her right ankle bi-malleolar fracture, which the patient
tolerated 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 home 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, splint was clean/dry/intact,
and the patient was voiding/moving bowels spontaneously. The
patient is non weight bearing in your right lower extremity and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ 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:
Atenolol
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC UNDEFINED
RX *enoxaparin 40 mg/0.4 mL 40 mg injection Daily Disp #*14
Syringe Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 hours Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right ankle bimalleolar 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:
- Please keep you splint on, clean, and dry at all times until
it is removed in follow up.
- 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.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing in your right lower extremity.
Followup Instructions:
___
|
10576009-DS-20 | 10,576,009 | 24,137,225 | DS | 20 | 2119-05-13 00:00:00 | 2119-05-14 10:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Back pain, delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of HTN and chronic LBP ___ scoliosis who p/w acute on
chronic worsening of LBP.
For her LBP, she takes tramadol prn ___ pills of 50 mg qhs) as
well rhizotomy (radiofrequency therapy) which she has had 2
treatments.
In the ED, initial vitals were: Afebrile, HR 85, BP 180s/80s, RR
16, RA
Exam notable for writhing in pain, tachycardic, no midline back
pain.
Labs notable for cr 0.8, wbc 10.4
Imaging notable for CXR without widening and CTA without signs
of dissection.
Patient was given given IV morphine 2 mg x2, Ativan 1 mg IV, and
500 mL NS. She became acutely agitated and combative after
administration of those medications.
She was admitted for delirium.
On the floor, speaking to her and her daughter, she endorses
acute on chronic worsening LBP. No history of CVA/MI/clots. No
history of dementia, but has mild cognitive impairment.
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:
HTN
Scoliosis
Breast cancer s/p lumpectomy ___ years ago with radiation
Social History:
___
Family History:
Father died of a stroke and mother died when she was ___. No
history of MI, clots, or cancer in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.7, BP 149/75, HR 75, RR 20, 98% 1 lpm NC
Gen: Sleepy, but alert and answers questions when asked
HEENT: Pupils pinpoint, but reactive to light. Dry mucus
membranes
CV: ___ SEM RUSB nonradiating. Regular rhythm.
Pulm: CTAB, no w,r,r
Abd: NTTP, normal bowel sounds, nondistended
GU: No foley
Ext: No lower extremity edema, warm distal extremities
Skin: Echymoses bilateral upper and lower extremities
Neuro: A+Ox2 (knows name, year, hospital, but not month or day
of week). CN II-XII intact. ___ strength bilateral wrist
extensors/flexors, lumbricals, biceps/triceps, deltoids, hips,
ankle extensors/flexors
Psych: Pleasant and cooperative
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.7, BP 154/81, HR 78, RR 20, 96% room air
Gen: Mildly anxious, sitting on bed and shaking right leg
HEENT: PERRL, MMM
CV: ___ SEM RUSB nonradiating. Regular rhythm.
Pulm: CTAB, no w,r,r
Abd: NTTP, normal bowel sounds, nondistended
GU: No foley
Ext: No lower extremity edema, warm distal extremities
Back: Prominent scoliotic back, nontender to palpation, no
vertebral step off or concerning skin changes
Skin: Echymoses bilateral upper and lower extremities
Neuro: A+Ox3 and able to say days of week backwards. CN II-XII
intact. ___ strength bilateral wrist extensors/flexors,
lumbricals, biceps/triceps, deltoids, hips, ankle
extensors/flexors. Walking around without gait abnormalities.
Psych: Pleasant and cooperative, but mildly anxious
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:20AM BLOOD WBC-10.4* RBC-3.75* Hgb-12.4 Hct-39.0
MCV-104* MCH-33.1* MCHC-31.8* RDW-12.7 RDWSD-48.1* Plt ___
___ 04:20AM BLOOD Neuts-55.3 ___ Monos-10.2 Eos-1.2
Baso-0.4 Im ___ AbsNeut-5.77 AbsLymp-3.36 AbsMono-1.06*
AbsEos-0.12 AbsBaso-0.04
___ 04:20AM BLOOD ___ PTT-28.9 ___
___ 04:20AM BLOOD Glucose-110* UreaN-25* Creat-0.8 Na-138
K-3.7 Cl-100 HCO3-22 AnGap-20
___ 04:20AM BLOOD ALT-28 AST-27 AlkPhos-78 TotBili-0.2
___ 03:50AM URINE Color-Straw Appear-Clear Sp ___
___ 03:50AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 03:50AM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:54AM URINE CastHy-1*
MICRO LABS:
===========
Urine culture x2 (___): Negative
IMPORTANT IMAGES/STUDIES:
=========================
CXR (___): No mediastinal widening or focal consolidation.
CTA chest (___): 1. No evidence of aortic dissection. 2.
Extensive atherosclerotic disease as detailed above. 3.
Intermediate density rounded lesion measuring 1.4 cm in the
lower pole of the left kidney. Non urgent renal ultrasound is
recommended for further characterization. 4. Thoracic aortic
aneurysm measuring up to 3.8 cm across maximal diameter. 5. Two
4 mm solid pulmonary nodules in the right middle lobe.
Correlation with prior imaging to document stability is
recommended. If not available, chest CT in 12 months is
recommended if patient has elevated risk factors for lung
cancer.
RECOMMENDATION(S):
1. Non urgent returned ultrasound is recommended for further
characterization.
2. 2 4 mm solid pulmonary nodules in the right middle lobe
should be
correlated with any prior imaging, if available to document
stability. If not available, chest CT in 12 months is
recommended if patient has elevated risk factors for lung
cancer.
LABS ON DISCHARGE:
==================
___ 07:25AM BLOOD WBC-5.6 RBC-3.55* Hgb-11.8 Hct-37.0
MCV-104* MCH-33.2* MCHC-31.9* RDW-12.7 RDWSD-49.1* Plt ___
___ 07:25AM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-142
K-3.5 Cl-104 HCO3-24 AnGap-18
___ 07:25AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
Brief Hospital Course:
This is an ___ year old female with past medical history of
hypertension, chronic lower back pain attributed to scoliosis
who presented to ___ ED with worsening of lower back pain, and
was subsequently admitted for altered mental status thought to
be secondary to medication effect, resolved and able to be
discharged home
# Acute toxic encephalopathy - Patient presented to the ED with
acute on chronic worsening of her back pain without new
neurologic deficits. In the ED, she underwent a CTA torso which
did not show any acute abnormalities. ED course was
notable for receipt of morphine 2 mg IV x2 and Ativan 1 mg IV.
She subsequently became acutely agitated and delirious and was
admitted to the medicine service. Infectious and metabolic
workups were without positive findings. Her mental status
improved back to baseline over the subsequent 12 hours, verified
by her husband who was at the bedside. They believed that
recently initiated outpatient cyclobenzaprine also contributed.
# Lower back pain - no focal neurologic deficits. Pain control
complicated as above. Once mental status improved to baseline,
patient reported her symptoms were at baseline. She was
discharged with recommendations to use lidocaine patch and
Tylenol, and avoid sedating medications. At patient's request
cyclobenzaprine was recommended to be held pending PCP ___
and discussion.
#Hypertension: She was continued on her home valsartan 80 mg qd.
#Hyperlipidemia: She was continued on her home atorvastatin 10
mg qd.
#Primary prevention: She was continued on her home aspirin 81 mg
qd.
#Nutrition: She was continued on her home vitamin B complex and
vitamin D
TRANSITIONAL ISSUES:
====================
- Discharged home with husband
- CTA showed intermediate density rounded lesion measuring 1.4
cm in the lower pole of the left kidney. Non urgent renal
ultrasound is recommended for further characterization.
- CTA also showed two 4 mm solid pulmonary nodules in the right
middle lobe. Recommended chest CT in 12 months is recommended
if patient has elevated risk factors for lung cancer.
- CTA also showed "Thoracic aortic aneurysm measuring up to 3.8
cm across maximal diameter"
-Code status: DNR/DNI
-Emergency contact: ___ (husband) ___, ___
(daughter) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Vitamin B Complex 1 CAP PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Cyclobenzaprine 10 mg PO BID:PRN back pain
6. Tolterodine 2 mg PO DAILY
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
8. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*2
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % apply to back once a day Disp #*30 Patch
Refills:*1
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Tolterodine 2 mg PO DAILY
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
7. Valsartan 80 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- Cyclobenzaprine 10 mg PO BID:PRN back pain This
medication was held. Do not restart Cyclobenzaprine until your
doctor says it is alright
Discharge Disposition:
Home
Discharge Diagnosis:
Acute toxic encephalopathy
Lower Back Pain
Hypertension
Abnormal findings on CT lung and kidney
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
You originally came to the hospital for back pain. You received
medications in the emergency room (morphine and Ativan) that
made you loopy, agitated, and delirious. You were admitted for
this and your mental status improved while you were here. You
were started on lidocaine patches for your back pain. Please
___ with your primary care physician regarding your
hospital stay. Also, please continue taking your medications as
directed by your primary physician. We will give you a
prescription for Tylenol and lidocaine patches that you can
apply to your back.
It was a pleasure caring for you,
-Your ___ care team
Followup Instructions:
___
|
10576063-DS-16 | 10,576,063 | 20,754,943 | DS | 16 | 2169-08-13 00:00:00 | 2169-08-17 07:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Bactrim
Attending: ___.
Chief Complaint:
Confusion, Unsteady Gait
Major Surgical or Invasive Procedure:
PICC placement.
History of Present Illness:
___ male with NPH presenting with confusion, unsteady
gait, and urinary incontinence. He was just hospitalized for
elective right VP shunt placement which he underwent on ___
with no intraoperative or immediat post-operative complcations.
He was discharged to rehab neurolgically intact and has been
home since the beginning of ___. His family notes that his
gait and orientation had improved after rehab, but over the last
couple of days, he has been having trouble with his orientation
and has been having decreased mobility with instability and
lethargy. He had an indwelling catheter prior to the VP shunt
placement, and this was removed at rehab, but the pt remains
incontinent. He just finished a course of nitrofurantoin a few
days ago, that he was prescribed by his urologist for a UTI. He
was recently seen in the outpatient neurosurgery office on
___ and the VP shunt was dialed from 2.0 to 1.5.
In the ED, initial vitals: 98 73 113/63 18 99%. Labs notable
for slight leukocytosis (11.8) with left shift. INR 3.4, Cr 1.3,
and lactate 2.1. Neurosurgery saw the pt and commented that the
CTH and shunt series within normal limits. They felt his
confusion and worsening gait is likely explained by UTI. Vitals
prior to transfer: 98.3 72 101/56 16 94% RA.
Currently, the pt's only complaint is an itch on his back. He
notes that he has had urgency and frequency lately, but no
dysuria or hematuria. He denies any other complaint. Pt was
prescribed macrobid ___ when UA was positive, Ucx: Beta
Streptococci, Group B
>100,000 cfu/mL. He saw his PCP ___ with similar complaints who
felt he may have a UTI v. urinary frequency ___ irritable
bladder and referred the pt to Dr. ___.
___: No fevers, chills. No cough, no shortness of breath. No
chest pain. No nausea or vomiting. No dysuria or hematuria. No
hematochezia, no melena.
Past Medical History:
CAD with Hx Quadruple bypass
Afib
CHF
DM
Hyperlipidemia
TIA post cardiac surgery
Diverticulosis
Chronic venous insufficiency in ___
BPH
Depression
Social History:
___
Family History:
Daughters - HTN
both parents deceased
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.5 106/51 61 18 98 RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MM dry, oropharynx clear
Lungs- CTAB no wheezes, rales, rhonchi
CV- irregularly irregular, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused. BLE wrapped in ACE bandages
DISCHARGE PHYSICAL EXAM:
Vitals- 97.5 - 110/47 -56 - 18 - 92RA ___ 169
i/o 240/600 since midnight. yest ___ foley
General- Alert, oriented to ___, no acute distress,
chronically unwell looking gentleman, appears stated age,
pleasant, interactive
HEENT- Head w healed scars and prominence at area of VP shunt at
right forehead. Sclera anicteric, MM moist, oropharynx clear.
Lungs- CTAB no wheezes, rales, rhonchi
CV- irregularly irregular, not tachy, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- foley in palce draining turbid urine
Ext- warm, well perfused. BLE wrapped in ACE bandages
Neuro: able to lift both legs against opposition, but weak.
wiggles toes. arms flex/ext ___. face symmetric, speech fluent.
gait not tested.
SKIN: confluent erythemata over back only, w/ thick leathery
skin in areas of erythema - no papules, no macules
Pertinent Results:
ADMISSION LABS
===============
___ 11:05AM BLOOD WBC-11.8* RBC-4.33* Hgb-11.8* Hct-36.7*
MCV-85 MCH-27.2 MCHC-32.0 RDW-15.1 Plt ___
___ 11:05AM BLOOD Neuts-88.6* Lymphs-6.1* Monos-4.0 Eos-1.1
Baso-0.2
___ 11:05AM BLOOD ___ PTT-34.0 ___
___ 11:05AM BLOOD Glucose-369* UreaN-27* Creat-1.3* Na-139
K-4.4 Cl-105 HCO3-28 AnGap-10
___ 07:20AM BLOOD Calcium-9.0 Phos-1.9* Mg-1.9
___ 11:19AM BLOOD Lactate-2.1*
OTHER
=====
___ 07:44AM BLOOD Lactate-1.4
DISCHARGE LABS
===============
___ 07:00AM BLOOD WBC-11.3* RBC-4.75 Hgb-13.0* Hct-41.0
MCV-86 MCH-27.3 MCHC-31.6 RDW-15.0 Plt ___
___ 07:00AM BLOOD ___
___ 07:00AM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-28 AnGap-13
___ 12:20PM URINE Color-Straw Appear-Hazy Sp ___
___ 12:20PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 12:20PM URINE RBC-4* WBC->182* Bacteri-NONE Yeast-NONE
Epi-0
MICROBIOLOGY
=============
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL {BETA
STREPTOCOCCUS GROUP B}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{BETA STREPTOCOCCUS GROUP B}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {BETA
STREPTOCOCCUS GROUP B}
OTHER STUDIES
==============
ECG Study Date of ___ 11:06:56 AM
Sinus rhythm. Occasional premature atrial contractions.
Extensive myocardial infarction, age indeterminate. Low voltage
in the precordial leads. Compared to the previous tracing of
___ no diagnostic change.
Rate PR QRS QT/QTc P QRS T
81 128 96 366/402 47 26 59
CT HEAD W/O CONTRAST ___
FINDINGS: There has been no significant interval change. Again
a right frontal approach shunt catheter terminates in the
frontal horn of the left lateral ventricle.
Mild to moderate prominence of the ventricles without
significant dilatation of the temporal horns is stable. Mild to
moderate atrophy is also stable.
There is no evidence of hemorrhage, edema, mass effect or acute
large vascular territory infarction. Periventricular white
matter hypodensities are consistent with sequelae of chronic
small vessel ischemic disease. The basal cisterns appear patent
and there is preservation of gray-white differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air
cells and middle ear cavities are clear. Atherosclerotic mural
calcification of the internal carotid arteries is noted. The
globes are unremarkable.
RENAL ULTRASOUND ___
IMPRESSION: Unchanged appearance compared to the prior study,
with stable ventricular size and unchanged positioning of a
right transfrontal ventricular shunt catheter reaching the
frontal horn of the left lateral ventricle.
FINDINGS: The right kidney measures 11.7 cm. The left kidney
measures 14.8 cm. A 1.6 cm simple cyst is identified at the
upper pole of the right kidney laterally. Mild fullness of the
right collecting system is noted. Moderate left hydronephrosis
and proximal hydroureter is noted. Dependent debris is
identified within the dilated left renal pelvis and calices. No
obstructing stone or masses are seen bilaterally. The 6.4 cm
simple cyst identified at the upper pole of the left kidney
laterally. The 5.0 cm simple cyst identified at the lower pole
of the left kidney laterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The urinary bladder is markedly trabeculated, with slightly
echogenic
dependent debris identified. The dilated left ureter is
identified at the left UVJ, demonstrating a ureteric jet. No
definite right urinary jet was
identified. The prostate was difficult to identify owing to
significant
shadowing.
IMPRESSION:
1. Moderate left hydronephrosis and hydroureter. Dependent
debris within the dilated left renal pelvis and calices, may
suggest pyonephrosis. Dilated left ureter identified to the
level of left UVJ. Mild fullness of right collecting system.
2. Markedly trabeculated urinary bladder, with slightly
echogenic dependent debris identified. Findings are in keeping
with chronic bladder outlet obstruction and may be the cause of
the hydronephrosis.
3. Bilateral renal simple cysts.
TRANS THORACIC ECHO ___
___ ___ MRN: ___ TTE (Complete)
Done ___ at 3:54:03 ___ FINAL
Referring Physician ___
___.
___, PBS-2
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 68
BP (mm Hg): 100/50 Wgt (lb): 195
HR (bpm): 65 BSA (m2): 2.02 m2
Indication: Endocarditis.
ICD-9 Codes: ___
___ Information
Date/Time: ___ at 15:54 ___ MD: ___,
MD
___ Type: TTE (Complete) Sonographer: ___, ___
Doppler: Full Doppler and color Doppler ___ Location: ___
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: ___-0:23 Machine: Vivid ___
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 116 ml/beat
Left Ventricle - Cardiac Output: 7.56 L/min
Left Ventricle - Cardiac Index: 3.74 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 28
Aortic Valve - LVOT diam: 2.3 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.70
Mitral Valve - E Wave deceleration time: *282 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Overall normal LVEF (>55%). Estimated cardiac index is
high (>4.0L/min/m2). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. No masses or vegetations
on aortic valve, but cannot be fully excluded due to suboptimal
image quality. No AS. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No masses
or vegetations on mitral valve, but cannot be fully excluded due
to suboptimal image quality. Trivial MR.
___ VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PS. No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - ___ unable to
cooperate. The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is high (>4.0L/min/m2). Right
ventricular chamber size and free wall motion 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. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No echocardiographic
evidence of endocarditis. If clinically indicated, a
transesophageal echocardiogram may better assess for valvular
vegetations. Normal global biventricular systolic function.
Technically suboptimal to exclude focal wall motion abnormality.
Mild aortic regurgitation.
RENAL U/S ___ PRELIMINARY
FINDINGS: The right kidney measures 10.3 cm. The left
kidney measures 13.6 cm. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
Since the prior study, there has been interval
improvement in moderate left hydronephrosis and proximal
hydroureter, with only mild left pelvicaliectasis
remaining. The left ureter is no longer visualized.
There is no evidence of obstructing stone or mass
bilaterally. Previously demonstrated fullness of the
right renal collecting system has resolved.
A 1.25 x 0.9 x 0.5 cm simple cyst in the upper pole
of the right kidney was not visualized previously, and a
1.6 x 1.5 x 1.4 cm upper pole renal cyst is re-
demonstrated. In the left kidney, an interpolar 2.6 x
2.5 x 2.4 cm cyst as well as a 6.2 x 5.0 x 6.2 cm
upper pole cyst and a 5.5 x 4.7 x 4.0 cm lower pole
cyst are again seen.
The bladder is decompressed by a Coude catheter, and is
not well visualized.
IMPRESSION: 1. Interval improvement of left pyonephrosis
and hydroureteronephrosis following placement of urinary
Coude catheter, with only mild pelvicaliectasis remaining.
2. Resolution of previously seen pelvicaliectasis on the
right.
3. Bilateral simple renal cysts.
CXR ___ PRELIMINARY
FINDINGS: The right PICC ends in the upper right atrium
and could be withdrawn by 2 cm to be in the low SVC.
A shunt catheter is partially visualized passing into
the right upper quadrant. A hiatal hernia is
unchanged. Stable heart size
and mediastinal contours. No focal consolidation,
pleural effusion or pneumothorax.
IMPRESSION: Right PICC ends in the upper right atrium
and could be withdrawn by 2 cm in the low SVC.
Brief Hospital Course:
BRIEF HOSPITAL COURSE.
======================
___ gentleman with NPH presenting with confusion,
unsteady gait, and urinary incontinence. His encephalopathy was
likely toxic in the setting of GBS bacteremia and renal
infection. He had pyonephrosis and urinary obstruction likely
secondary to BPH and resulting obstructing debris in the renal
calyces. Coude catheter was placed with moderate post
obstructive diuresis. His electrolytes were stable despite
significant output. He should follow up with urology ___
(discharged with catheter in place).
ACTIVE ISSUES
==============
# Encephalopathy- Likely toxic/metabolic secondary to
UTI/bacteremia, and improved with antibiotic therapy. He denied
chest pain, shortness of breath, symptoms/signs of pneumonia (no
hypoxia and no cough). VP shunt was evaluated by imaging and
Neurosurgery and was intact with unchanged position. We
attempted to minimize sedating meds, including diphenhydramine.
# Group B strep bacteremia: His admission blood cultures grew
high grade (in several bottles) group B streptococcus. Source is
likely urine, though usually not pathogenic, he could have had
decerased immune response in setting of chronic prednisone. ID
was consulted and were not concerned for VP shunt involvement.
Transthoracic echo showed no valvular vegetations. Cultures were
pan-sensitive and plan is for ___ to complete a 14 total day
course of penicillin IV via PICC.
- Will need CBC/diff, LFTs, and BUN/cre sent to PCP ___
___ on ___ if discharged from facility. If still
residing at facility, these labs should be followed by presiding
MD.
# Pyelonephrosis/Pyelonephritis- Likely explanation for pt's
recent encephalopathy. Did complete a course of nitrofurantoin
for a UTI, prescribed by his urologist, but likely partially
treated his pyelonephrosis. Debris in calyces is likely from
acute obstruction ___ BPH, and hydroureter was resolving after
coude catheter was placed.
- Antibiotics (penicillin as above) x14 days total.
- Follow up with outpatient urology ___. Consider repeat
renal ultrasound as an outpatient.
# Acute on chronic kidney injury- Resolved. Initially Cr 1.3,
above baseline of 0.9-1.1. In the setting of acute illness,
likely pre-renal (increased lactate on admission). Also likely
some contribution from post obstructive. Treatment for urinary
obstruction as below.
# Acute urinary retention/obstruction likely secondary to BPH
and debris in renal calyces: Continued finasteride, and a coude
catheter was placed by urology. He was started on tamsulosin 0.4
mg PO HS. Did had significant post obstructive diuresis (~2L)
with stable electrolytes, so torsemide was held in this setting.
He did not appear volume depleted.
- Please check next electrolytes on ___. Restart torsemide
___ if lytes stable and ___ does not appear dehydrated.
- Will need coude catheter at least one week, will need to
remove coude catheter early morning of ___. This will serve
as a voiding trial. Any retention can then be addressed at
clinic appointment that afternoon.
# Normal pressure hydrocephalus- He is s/p VP shunt placement
___ with no intraoperative or immediate post-operative
complications. Per imaging studies, shunt is in good position.
Neurosurgery saw and was satisfied with its placement.
# Contact Dermatitis- Per notes, felt to be caused by bactrim.
However is localized to back. Previously on prednisone for this.
Encouraged ___ to be more mobile. We tapered off his
prednisone. Started calcium/vit D. Local treatment for back:
sarna, triamcinolone 0.1% (class 4/mid strength) ointment TID
x10 days. Can also try EMLA once daily as needed.
# Atrial fibrillation - Irregularly irregular CV exam, seemingly
sinus with PAC on EKG. CHADS score 5 (age, CHF, DM, TIA),
anticoagulated with warfarin, however was subtherapeutic. Rate
control with metoprolol XL. Restarted warfarin at increased
dose, please check next INR ___.
# DM - Last HbA1C 8.6 on ___. Hyperglycemic here, potentially
in setting of infection. As such, we increased glargine to 22
from 20 units daily. Discharged on humalog sliding scale and
glargine.
# CAD s/p bypass - No cardiac symptoms at this time. EKG was
unchanged. He was continued on aspirin and simvastatin.
# Diastolic CHF - EF 55% per ECHO ___. Held torsemide while
post obstructive urine output was >2L. Plan to restart on ___
___.
# Depression - Continued sertraline
# Hyperlipidemia: Continued simvastatin.
TRANSITIONAL ISSUES
====================
- Code status: Full (confirmed with ___.
# Emergency contact: Ex-wife ___ (___) ___. cell
___.
- Studies pending on discharge: Final read of CXR and renal
ultrasound. Blood cultures from ___ x2, ___ x2.
- Please check next electrolytes on ___. Restart torsemide
___ if lytes stable and ___ does not appear dehydrated.
- Regarding in-dwelling coude, ___ has follow up appointment
with Dr. ___ Urology, ___ 2:15pm. PLEASE
REMOVE COUDE CATHETER IN THE EARLY MORNING OF ___ MORNING
FOR VOIDING TRIAL. Any retention can then be addressed at clinic
appointment that afternoon.
- Will need CBC/diff, LFTs, and BUN/cre sent to PCP ___
___ on ___ if discharged from facility. If still
residing at facility, these labs should be followed by presiding
MD.
- Last day of IV penicillin will be ___. Please remove PICC
on ___.
- Please continue to manage warfarin/INR. Subtherapeutic on
discharge. Increased warfarin from 3.75 3x/wk and 5 4x/wk to 5
mg daily on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Glargine 20 Units Breakfast
4. Metoprolol Succinate XL 25 mg PO DAILY
5. PredniSONE 15 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Sertraline 100 mg PO DAILY
8. Simvastatin 80 mg PO QPM
9. Torsemide 10 mg PO EVERY OTHER DAY
10. Warfarin 5 mg PO 4X/WEEK (___)
11. Warfarin 3.75 mg PO 3X/WEEK (___)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Glargine 22 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Sertraline 100 mg PO DAILY
7. Simvastatin 80 mg PO QPM
8. Warfarin 5 mg PO DAILY16
9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
10. Docusate Sodium 100 mg PO BID
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. Heparin 5000 UNIT SC TID
14. Lidocaine-Prilocaine 1 Appl TP DAILY:PRN skin discomfort on
back
15. Miconazole Powder 2% 1 Appl TP TID:PRN rash
16. Sarna Lotion 1 Appl TP QID:PRN itch
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
18. Tamsulosin 0.4 mg PO HS
19. Vitamin D 800 UNIT PO DAILY
20. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID
Duration: 10 Days
21. Torsemide 10 mg PO EVERY OTHER DAY
RESTART ___.
22. Penicillin G Potassium 4 Million Units IV Q4H
23. Calcium Carbonate 500 mg PO TID
24. Acetaminophen ___ mg PO Q6H:PRN pain, fever
25. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Encephalopathy
Group B strep bacteremia
Pyelonephrosis/Pyelonephritis
Acute on chronic kidney injury
Acute urinary retention/obstruction likely secondary to BPH and
debris in renal calyces
Contact Dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___! You were
admitted because of increased confusion. You were found to have
a urinary tract infection, kidney infection, and blood
infection. We treated you with antibiotics. You were seen by
Urology and a catheter was placed to help the flow of urine past
your prostate. You were seen by Infectious disease, who
recommended continuing penicillin. You had a heart echo which
showed no infection of your heart.
You are being discharged to a rehab facility for IV antibiotics
and continued physical therapy. You will need to follow up with
Urology and Infectious disease. You will need a follow up
cytoscopy (a study to image your bladder).
Followup Instructions:
___
|
10576063-DS-17 | 10,576,063 | 27,922,879 | DS | 17 | 2169-11-17 00:00:00 | 2169-11-18 10:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Bactrim
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old gentleman w/PMH of normal pressure
hydrocephalus s/p VP shunt, venous insufficiency who presents
with confusion and altered mental status. The patient was
recently admitted in ___ with confusion, unsteady gait, and
urinary incontinence. He was found to have group b strep
bacteremia likely from a urinary source and
pyelonephrosis/pyelonephritis, both treated with Penicillin IV.
At baseline, Mr. ___ is normally AOx3, but recently per ED
notes he has been more somnolent, confused, and weak. He can
normally stand and use his walker on his own, but has been more
unsteady. He recently was started on PO PCN for a positive UA,
which was switched to Macrobid based on culture data per
patient.
In the ED, initial vital signs were T 102.6 RR 28 BP 122/43
O2Sat 97% RA. Exam was notable for Left CVA tenderness, and
guaiac negative stools. Significant labs include wbc 14.1, H/H
12.6/39.5, lactate of 1.7, UA with lrg leuks, 15 wbc, and few
bacteria. CT head showed no acute process, with ventriculostomy
catheter in position and no change in ventricular size. Shunt
series imaging showed no evidence of shunt discontinuity or
kinking, though the tip could not be visualized.
In the ED he received Tylenol and Ceftrixaone and was admitted
to the floor.
On arrival to the floor the patient has no acute complaints. He
endorses some nausea and an episode of emesis this AM. He denies
any new pain or dysuria, endorses chronic back pain, and states
that he may have been treated with the wrong antibiotic for his
UTI. He would like to know if the ___ sox won, and states that
he has not been recently confused at all, and specifically
denies any new weakness. The patient lives alone with his cat,
but does have people come to his home to help with ADLs. He also
endorses that his ___ swelling from chronic venous insufficiency
is improved from prior.
Review of Systems:
(+) per HPI with rhinorrhea, intermittent HA and chronic back
pain
(-) dysuria, pain, chills, night sweats
Past Medical History:
CAD with Hx Quadruple bypass
Afib
CHF
DM
Hyperlipidemia
TIA post cardiac surgery
Diverticulosis
Chronic venous insufficiency in ___
BPH
Depression
Social History:
___
Family History:
Daughters - HTN
both parents deceased
Physical Exam:
Admission
===========
Vitals - T: 97.6 BP: 104/51 HR: 80 RR: 20 02 sat: 95% RA
GENERAL: NAD, alert to place, president, year
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM,
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs appreciated
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles, decreased breath sounds at the
bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, b/l warmth and
erythema with (+) edema
SKIN: warm and well perfused, b/l warmth and erythema with (+)
edema up to the patella b/l with skin thinning
=============
DISHCARGE
=============
VS - 99.0 110/53 65 20 95% RA
General: pleasant elderly man in NAD
HEENT: atraumatic, normocephalic, mucus membranes moist
Neck: supple
CV: regular rate, irregular rhythm, no murmurs
Lungs: CTAB, breathing comfortably on room air
Abdomen: soft nontender nondistended +BS
Ext: chronic venous stasis changes with hyperpigmentation
present bilaterally as well as scabbed over lesions bilaterally.
1+ edema bilaterally to ___ up leg. 2+ ___ pulses. Ext warm
and well perfused.
Back: No CVAT
Neuro: A&OX3, able to name president, conversant, CNII-XII
intact
Pertinent Results:
ADMISSION
==============
___ 05:00PM BLOOD WBC-14.1* RBC-4.62 Hgb-12.6* Hct-39.5*
MCV-86 MCH-27.3 MCHC-32.0 RDW-16.5* Plt ___
___ 05:00PM BLOOD Neuts-92.7* Lymphs-2.4* Monos-4.2 Eos-0.7
Baso-0.1
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-133* UreaN-19 Creat-1.1 Na-139
K-3.9 Cl-102 HCO3-28 AnGap-13
___ 04:42AM BLOOD Calcium-9.1 Phos-1.5* Mg-1.8
___ 05:10PM BLOOD Lactate-1.7 K-4.1
==========
IMAGING
==========
CT Head: No acute intracranial process. Ventriculostomy
catheter remains in position with unchanged ventricular size.
Shunt series: Shunt visualized throughout the majority of its
course and appears patent though the tip is not seen within the
imaged field.
Renal US: 1. Residual mild fullness of the left collecting
system with marked
improvement since ___ and mild improvement since ___.
2. Unchanged trabeculated irregular urinary bladder, likely
reflecting chronic
bladder outlet obstruction.
3. Multiple stable simple left renal cysts.
==========
DISCHARGE
==========
___ 05:55AM BLOOD WBC-10.1 RBC-4.01* Hgb-10.7* Hct-33.7*
MCV-84 MCH-26.8* MCHC-31.8 RDW-16.6* Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-123* UreaN-26* Creat-1.2 Na-138
K-3.4 Cl-103 HCO3-25 AnGap-13
___ 05:55AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.8
Urine Culture URINE CULTURE (Final ___: NO GROWTH
Brief Hospital Course:
Mr. ___ is an ___ year old gentleman w/PMH of normal pressure
hydrocephalus s/p shunt, venous insufficiency, recent admission
for GBS bacteremia and pyelonephritis/pyelonephrosis who
presents with report of confusion, weakness, and AMS, found to
have UTI.
====================
ACUTE ISSUES:
====================
#UTI: This patient was found to have a UTI at an OSH on ___ and
was started on penicillin. His cultures grew staph sensitive to
tetracycline, vanc, and nitrofurantoin, so his PCN was DC'ed and
he was started on nitrofurantoin on ___. His UA during this
hospitalization at ___ showed lrg leuks, pyuria, and
bacteriuria, and he also had leukocytosis and initial fever. His
urine culture came back negative. He had a renal ultrasound
which showed no evidence of hydronephrosis. However, he was
continued on a 7 day course of nitrofurantoin for his original
urina culture. On discharge, he was afebrile for >48 hours and
asymptomatic.
# Confusion/AMS: Patient presented with reports of
confusion/AMS/weakness from ex-wife and home health aid per ED
nursing notes. Patient is alert to person, place, and date
today, and can name days of week forwards and backwards. THe
patient's confusion seemed to inprove with treatment of his UTI.
===================
CHRONIC ISSUES:
===================
# Venous Stasis: Patient has a long history of venous stasis,
recently seen in the vascular surgery clinic. No signs of active
infection now, though b/l ___ are warm to touch with erythema. On
Fluocinonide at home.
-Clobetasol BID as Fluocinonide is non-formulary
-wound care consult
-encourage leg elevation
# Normal pressure hydrocephalus: Pt is s/p VP shunt. per imaging
studies, shunt is in good position though tip was not
visualized. CT head showed unchanged ventricular size from
prior.
# ___: Cr bumped to 1.4, now back down to 1.2; could be ___
infection or poor PO intake
- 1 L IVF
- monitor Cr
# Atrial fibrillation: CHADS score 5 (age, CHF, DM, TIA), on
warfarin at home. Currently rate controlled. At goal with INR
2.4 today.
-cont. warfarin
-monitor INR
-continue home metoprolol
# Diastolic CHF - EF >55% per ECHO ___. No signs of
decompensation at this time.
-cont. Metoprolol
-cont torsemide 10mg QOD
# DM
-cont. home Glargine
-ISS
# CAD s/p bypass
-cont. aspirin
-cont. simvastatin
# Depression
- Continue sertraline
# BPH
-cont tamsulosin
-cont. finasteride
====================
TRANSITIONAL ISSUES
====================
[]patient should continue nitrofurantoin ___
[]patient should have repeat CMP to monitor renal functioning
[]patient should follow up with urology to consider TURP so he
doesnt get repeat UTIs from straight cath
{} Patient should have blood culture final results from ___
reviewed on outpatient f/u; were no growth on discharge
{}Patient also with mild anemia and thrombocytopenia seen during
this hospitalization. LIkely dilutional, and should have
recheck at outpatient f/u
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral TID
2. Warfarin 5 mg PO 2X/WEEK (MO,FR)
3. Warfarin 6.25 mg PO 5X/WEEK (___)
4. Glargine 20 Units Breakfast
5. Tylenol Extra Strength (acetaminophen) 500 mg oral Q8HR PRN
PAIN
6. Vitamin D 800 UNIT PO DAILY
7. Aspirin 81 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO DAILY
10. Sertraline 100 mg PO DAILY
11. Simvastatin 80 mg PO HS
12. Tamsulosin 0.4 mg PO HS
13. fluocinonide 0.1 % topical DAILY
14. Torsemide 10 mg PO EVERY OTHER DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Glargine 20 Units Breakfast
4. Metoprolol Tartrate 25 mg PO DAILY
5. Sertraline 100 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Torsemide 10 mg PO EVERY OTHER DAY
8. Vitamin D 800 UNIT PO DAILY
9. Warfarin 5 mg PO 2X/WEEK (MO,FR)
10. Warfarin 6.25 mg PO 5X/WEEK (___)
11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth two times daily Disp #*9 Capsule Refills:*0
12. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral TID
13. fluocinonide 0.1 % topical DAILY
14. Tylenol Extra Strength (acetaminophen) 500 mg oral Q8HR PRN
PAIN
15. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: UTI
SECONDARY DIAGNOSIS: Normal pressure hydrocephalus, venous
insufficiency, CHF, AFib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
As you know, you were admitted to ___
___ because of a UTI. You were treated with nitrofurantoin
(Macrobid) which you should continue taking at home for another
5 days.
We changed your dose of simvastatin from 80mg to 40mg. The
higher dose has more risk of toxicity and is not any better than
the lower dose.
Please note the specific medication changes:
CHANGE Simvastatin 80 mg daily to Simvastatin 40 mg daily
CONTINUE Nitrofurantoin(MacroBID) 100 mg twice daily from
___
You should call your doctor if you experience fevers >101,
confusion, worsening burning with urination, or any other
concerning symptoms.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10576063-DS-20 | 10,576,063 | 29,775,725 | DS | 20 | 2170-08-26 00:00:00 | 2170-08-27 08:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / oxycodone
Attending: ___.
Chief Complaint:
HMED Admission Note
___
cc: AMS
Major ___ or Invasive Procedure:
PICC line
History of Present Illness:
___ yo M with CAD s/p CABG, afib on warfarin, DM, chronic venuous
stasis, NPH s/p VP shunt, and BPH requiring intermittent
straight caths complicated by recurrent UTI's who presents with
concern for AMS by ___ in the setting of treatment for UTI. Pt
with urinary frequency for the past week, two days prior to
admit pt had urine culture at ___ and started on Keflex. This
morning, pt seen by his ___ who noted him to be irritable so ___
was sent to the ED for evaluation.
In the ED, pt febrile to 101.2, hemodynamically stable. WBC
12.9, urinalysis showed pyuria. Pt recultured, given CTX and
admitted for further care.
On admission, pt denies dysuria. Appears alert and oriented.
Thinks his ___ over-reacted.
ROS: negative except as stated above
Past Medical History:
CAD s/p CABG
ATRIAL FIBRILLATION
CHF
DM
HYPERLIPIDEMIA
HX OF TIA
DIVERTICULOSIS
VENOUS STASIS DISEASE
BPH
DEPRESSION
NPH s/p VP Shunt
Social History:
___
Family History:
___ also has a daughter with hypertension.
Mother with ___
Father w/ MI at ___
Sister died from ovarian cancer at ___
Physical Exam:
Vitals: 98.2 92/52 66 16 98%RA
Gen: NAD
HEENT: NCAT
CV: rrr, no r/m/g
Pulm: clear bl
Abd: soft, nontender, no CVA or suprapubic tenderness
Ext: bilateral venous stasis changes
Neuro: alert and oriented x 3
Pertinent Results:
___ 04:15PM WBC-12.9* RBC-4.69 HGB-11.3* HCT-35.8*
MCV-76* MCH-24.2* MCHC-31.7 RDW-15.2
___ 04:15PM PLT COUNT-180
___ 04:15PM GLUCOSE-176* UREA N-27* CREAT-1.3* SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
___ 04:21PM LACTATE-0.8
___ 04:15PM ___ PTT-34.9 ___
___ 04:30PM URINE RBC-1 WBC-50* BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
UCX ___ (___) - Enterococcus Facealis (resistant to
tetracycline, otherwise sensitive)
CXR:
No evidence of acute cardiopulmonary disease.
___ 4:15 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin (MIC) 2.0 MCG/ML Sensitivity testing
performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ @ 10:04AM ON
___.
Brief Hospital Course:
___ y.o male with h.o CAD s/p CABG, afib on warfarin, DM, chronic
venous status, NPH s/p VP shunt and BPH requiring straight cath
complicated by recurrent UTI who presents with confusion in the
setting of UTI.
#Bacteremia- blood culture on ___ with ampicillin sensitive
Enterococcus. ___ was initially treated with IV cipro and vanco
given culture data from his wound swabs at ___. ID was
consulted to consolidate antibiotics and they recommended not
treating his skin cultures and only treating with IV ampicillin
for 14 days - to be completed ___.
#urinary tract infection, complicated. Hx of resistant
pseudomonas and VRE but most recent ucx sensitive enterococcus
at ___. PO cipro for now as last culture sensitive at ___.
#Severe Sepsis. ___ had a fever in the ED, leukocytosis and
hypotension on admit with a urinary source. ___ required
intermittent small boluses for BP support.
#encephalopathy, metabolic-likely due to above, improved prior
to discharge.
#afib on warfarin-continued home dose of warfarin. On discharge
his INR was 3.8, please hold his warfarin until INR <3, and
resume at 3.5mg daily (the lower dose of his alternating doses).
Metoprolol was intermittently held due to hypotension, and
bradycardia.
#DM2-decreased dose of lantus given hypoglycemia on admission.
The patient had been targeting 40-50 as a fasting blood sugar.
It was discussed with him that ___ should be targeting 100.
#chronic venous stasis- Held torsemide given hypotension and
wound care was consulted:
Recommendations: Pressure relief per pressure ulcer guidelines
Support surface:Atmos Air
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times
Waffle Boots (x ) Multipodis Splints ( )
If OOB, limit sit time to one hour at a time and
Elevate ___ while sitting.
Moisturize B/L ___ and feet, periwound tissue BID Sooth and
___
___ Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue
with each dressing change.
Apply Xeroform gauze over open areas (to decrease moisture
and
decrease local bacterial bioburden)
Cover with large Sofsorb sponges, Kerlix wrap
No tape on skin
Change dressing daily.
Apply Spiral Ace Wraps to B/L ___ from just above toes to
just below knees, before patient gets OOB or after elevating
___
for ___ minutes prior to application.
Remove ace wraps at bedtime.
___ should f/u at the ___ clinic upon
discharge.
Support nutrition and hydration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. melatonin 1 mg oral QHS
2. Donepezil 10 mg PO QHS
3. Torsemide 10 mg PO DAILY
4. Warfarin 5 mg PO 6X/WEEK (___)
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Calcium Carbonate 500 mg PO TID
8. Simvastatin 40 mg PO QPM
9. Sertraline 100 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Vitamin D 800 UNIT PO DAILY
12. Aspirin 81 mg PO DAILY
13. Glargine 20 Units Bedtime
14. Warfarin 3.5 mg PO 1X/WEEK (MO)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bacteremia
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 evaluated for concern of confusion in the setting of
having a urinary tract infection. Your confusion improved but
you were found to have bacteria growing in your blood. You were
started on antibiotics initially with vancomycin and cipro,
which was narrowed to ampicillin alone. You will need to
continue IV antibiotics until ___.
Followup Instructions:
___
|
10576313-DS-17 | 10,576,313 | 21,243,043 | DS | 17 | 2146-10-11 00:00:00 | 2146-10-11 20:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
morphine / mold / dogs and cats
Attending: ___.
Chief Complaint:
Productive cough and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a patient known to us with TMB s/p TBP ___
and multiple readmissions. She presents to the emergency
department today with a productive cough and fever. She reports
she has had a worsening cough since ___. Last night she
became febrile to 101*F and had chills. This morning her cough
became productive and she produced dark green sputum. She has
been afebrile all morning. She denies any other problems or
concerns. She denies any dysuria, changes in bowel or bladder
habits, or pain along her surgical site.
Past Medical History:
PMH:
Asthma
GERD
RLS
TBM
Vertigo
BPPV
Concussion
PSH:
Right shoulder repair ___
Right inguinal repair ___
Right Femoral nerve decompression ___
Kidney stone removal ___
Social History:
___
Family History:
Family History:
Mother: ___ cancer, glaucoma
Father: Pulmonary fibrosis, asthma, RA
Physical Exam:
Gen: AAOx3, NAD
Chest: Unlabored breathing, incision C/D/I
Abdomen: Soft nontender
Extremities: warm, well perfused, no tenderness or swelling in
the upper or lower extremities bilaterally
Pertinent Results:
___ 11:15AM WBC-14.8* RBC-3.56* HGB-10.5* HCT-33.3*
MCV-94 MCH-29.5 MCHC-31.5* RDW-14.6 RDWSD-50.7*
___ 12:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
Brief Hospital Course:
Ms. ___ was seen in the emergency department. Given her
recent surgery, she was admitted to Thoracic Surgery for
observation. Her chest x-ray revealed no focal infiltrate,
inflammatory changes, or pneumonia. Her laboratory testing
revealed an elevated white blood cell count. A diagnosis of
tracheobronchitis was made and the patient was started on
antibiotics. She was continued on a regular diet and her home
medications.
The following morning, additional studies revealed her
leukocytosis to have resolved. She remained afebrile for 24
hours, and the decision was made to discharge the patient. At
time of discharge, Ms. ___ was walking independently,
tolerating a regular diet, and taking her home medications. She
was advised to return to the hospital if her fever or symptoms
returned. She will follow up in clinic with Dr. ___
her TBP protocol and call if she develops any other concerns.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN wheezing, SOB
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate 110mcg 3 PUFF IH BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN shortness of
breath
7. Senna 8.6 mg PO BID:PRN Constipation - Second Line
8. dexlansoprazole 60 mg oral QAM
9. GuaiFENesin ER 1200 mg PO Q12H
10. ipratropium bromide 2 sprays EACH NOSTRIL BID
11. Mirapex ER (pramipexole) 0.75 mg oral BID
12. Polyethylene Glycol 17 g PO DAILY
13. Ranitidine 300 mg PO QHS
14. Gabapentin 300 mg PO QHS
15. Loratadine 10 mg PO DAILY
16. Montelukast 10 mg PO DAILY
17. Anoro Ellipta (umeclidinium-vilanterol) 1 INHALATION
inhalation DAILY
18. azelastine 2 Sprays EACH NOSTRIL DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
2. Sodium Chloride 3% Inhalation Soln 15 mL NEB TID:PRN
Wheezing, SOB, congestion
RX *sodium chloride [NebuSal] 3 % 15 mL NEB every 4 hours Disp
#*30 Vial Refills:*2
3. Anoro Ellipta (umeclidinium-vilanterol) 1 INHALATION
inhalation DAILY
4. azelastine 2 Sprays EACH NOSTRIL DAILY
5. dexlansoprazole 60 mg oral QAM
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 3 PUFF IH BID
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Gabapentin 300 mg PO BID
10. GuaiFENesin ER 1200 mg PO Q12H
11. ipratropium bromide 2 sprays EACH NOSTRIL BID
12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN shortness of
breath
13. Loratadine 10 mg PO DAILY
14. Mirapex ER (pramipexole) 0.75 mg oral BID
15. Montelukast 10 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Ranitidine 300 mg PO QHS
18. Senna 8.6 mg PO BID:PRN Constipation - Second Line
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
** You were admitted for tracheobronchitis. You were started on
a 5 day course of azithromycin for this infection**
**Please resume all your home medications and nebulizers**
** Call the office or return to the emergency department if you
develop a fever >101 **
Followup Instructions:
___
|
10576601-DS-14 | 10,576,601 | 23,825,389 | DS | 14 | 2173-08-10 00:00:00 | 2173-08-11 18:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fast Heart Rate
Major Surgical or Invasive Procedure:
Transesophageal Echocardiography
Direct cardioversion
History of Present Illness:
___ yo male with HTN and Hx ETOH abuse who was found to have new
onset afib at a routine PCP ___. At the PCP, BP 153/98 and
144/88 when re-checked. Pulse was irregularly irregular with
rate of 140. Pt denied symptoms at that time. Specifically he
denied dizziness, CP, SOB, n/v, pedal edema. He did report
increased drinking ("two large martinis") in the recent months
because of stress/frustration of his job as a ___. He
denies ever experiencing withdrawal symptoms or being in
treatment for alcohol use.
Of note, pt reports chronically elevated HR in the ___ at his
PCP and heat intolerance. He also has lost 9lbs since ___.
To his knowledge, never worked up for thyroid abnormalities.
In the ED, initial vitals were 100.6F, HR 150-190s, 153/76, 16,
98% RA. EKG: with afib at 170, no STE. Troponin negative.
Positive D-dimers (780), getting CTA to r/o PE. Dilt 20mg push
x3 with Diltiazem 30mg po with Hr only down to 130s. Started on
Dilt gtt. Pt received NS 3L IVF. Given his recent alcohol
history and signs of tremors, he was treated with Ativan 2mg IV
and valium 5mg IV with good response. Received thiamine and
folic acid. Other lab work: negative urine for benzo, barbs,
opiates, cocaine, amphet, mthdne. UA negative. lactate 1.6.
Urine cx and blood cx pending.
Vitals on transfer were 98.1F, 102, 115/61, 16, 97% RA.
On arrival to the floor, patient was alert, oriented x3 with
vitals T: 98.2 HR 119, BP 142/94, 18, 96% RA.
REVIEW OF SYSTEMS: As above, positive also for occasional ankle
swelling.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he 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,
palpitations, syncope or presyncope.
Past Medical History:
-Alcohol abuse
-Depression/seasonal affective disorder
-HTN
-BPH
-Hernia s/p repair
Social History:
___
Family History:
Mother: stroke at age ___
Father: MI at age ___
Physical Exam:
ADMISSION EXAM:
VS: T: 98.2 HR 119, BP 142/94, 18, 96% RA.
GENERAL: WDWN male in NAD, wearing glasses. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: LOW JVD, no thyromegaly appreciated.
CARDIAC: Tachycardic, irreg irreg No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: Thin, shiny skin of lower legs. No stasis dermatitis,
ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
DISCHARGE EXAM:
VS: T: 98.2 HR 110, BP 124/82, 16, 96% RA.
GENERAL: WDWN male in NAD, wearing glasses. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: LOW JVD, no thyromegaly appreciated.
CARDIAC: Tachycardic, irreg irreg No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
SKIN: Thin, shiny skin of lower legs. No stasis dermatitis,
ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
ADMISSION LABS:
___ 10:10AM BLOOD WBC-5.6 RBC-4.65 Hgb-15.9 Hct-47.0
MCV-101*# MCH-34.2* MCHC-33.9 RDW-12.6 Plt ___
___ 10:10AM BLOOD ___ PTT-31.0 ___
___ 10:10AM BLOOD Neuts-66.4 ___ Monos-5.9 Eos-0.7
Baso-0.5
___ 10:10AM BLOOD Glucose-112* UreaN-16 Creat-0.7 Na-135
K-3.7 Cl-96 HCO3-26 AnGap-17
___ 10:10AM BLOOD ALT-41* AST-44* AlkPhos-54 TotBili-1.8*
DirBili-0.4* IndBili-1.4
___ 10:10AM BLOOD Lipase-23
___ 10:10AM BLOOD cTropnT-<0.01
___ 04:55PM BLOOD CK-MB-4 cTropnT-<0.01
___ 10:10AM BLOOD Albumin-5.0 Calcium-9.5 Phos-2.8 Mg-1.8
___ 10:10AM BLOOD Free T4-1.4
___ 10:10AM BLOOD TSH-0.67
___ 10:10AM BLOOD D-Dimer-780*
___ 10:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 08:35AM BLOOD WBC-7.1 RBC-4.52* Hgb-15.5 Hct-45.3
MCV-100* MCH-34.2* MCHC-34.1 RDW-12.5 Plt ___
___ 08:35AM BLOOD ___ PTT-41.7* ___
___ 08:35AM BLOOD Glucose-114* UreaN-14 Creat-0.6 Na-136
K-4.1 Cl-101 HCO3-26 AnGap-13
___ 04:55PM BLOOD ALT-34 AST-35 CK(CPK)-181 AlkPhos-45
TotBili-1.8*
___ 08:35AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.1
EKG ___:
Atrial fibrillation with rapid ventricular response. Prominent
precordial
voltage for left ventricular hypertrophy. Compared to the
previous tracing of ___ atrial fibrillation with rapid
ventricular response has appeared.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
162 0 84 268/446 0 30 -86
CXR ___:
PA and lateral views of the chest: There is a marked S-shaped
scoliosis which causes a tortuous aorta. The lungs appear
clear. Cardiomediastinal silhouette and hilar contours are
grossly unremarkable. Bones appear intact.
IMPRESSION: No acute process identified.
CTA ___:
CT OF THE CHEST: Noncontrast imaging demonstrates no aortic
intramural
hematoma. Following the administration of IV contrast, the
pulmonary arterial tree opacifies normally without filling
defect to suggest the presence of a PE. Aorta is of normal
caliber and course through its thoracic course.
Tracheobronchial tree is patent to the subsegmental level.
There is mild emphysema. There is no pericardial or pleural
effusion. No mediastinal, hilar, or axillary lymphadenopathy.
The lungs are clear with the exception of minimal dependent
atelectasis. There is no worrisome nodule. mass, or
consolidation.
A small hiatal hernia is present. The liver is fat replaced.
Otherwise the imaged portion of the upper abdomen is
unremarkable.
BONES: There is dextroscoliosis of the T-spine. No worrisome
lytic or blastic osseous lesions seen.
IMPRESSION:
1) No pulmonary embolism.
2) Small hiatal hernia.
3) Fatty liver.
TRANSESOPHAGEAL ECHO ___:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A patent foramen ovale may be
present. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the aortic arch. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are structurally normal.
Mild to moderate (___) mitral regurgitation is seen.
IMPRESSION: No intracardiac thrombus. Possible PFO. Mild to
moderate mitral regurgitation.
Cardioversion Note:
Mr. ___ is a ___ yo M with PMH of HTN, alc overuse who is
admitted for newly diagnosed AFib with RVR currently @118
referred for TEE followed by cardioversion.
The patient was brought to the cardioversion room after informed
consent was obtained. The patient was sedated by a member of the
anesthesia staff with 70 mg IV propofol and when appropriate was
shocked with 200J external biphasic energy with prompt return to
sinus rhythm. The patient tolerated the procedure well and left
the cardioversion room awake and in stable condition.
Successful electrical cardioversion of atrial fibrillation to
sinus rhythm.
Recommendations:
- Continue pradaxa
- Please discontinue diltiazem infusion and also diltiazem PO
which was started yesterday
- Return to ward for further care
Brief Hospital Course:
___ yo male with HTN and ETOH abuse presenting asymptomatically
in new afib with RVR, patient was successfully cardioverted and
discharged on pradaxa without additional rate control.
.
# Atrial fibrillation with RVR: Patient presented to PCP for
routine ___ and found to have new asymptomatic afib with RVR.
He was sent to the emergency department where rate was
responsive to diltizem drip after failed IV boluses. He was
started on pradaxa and successfully cardioverted after ___
failed to demonstrate ventricular or atrial clot. Patient did
not require addtional rate or rhythm control medications per
EP's assessment. He was found to be euthyroid to sub-clinically
hyperthyroid and CTA from the emergency department was negative
for pulmonary embolism. Given patient's history of heavy
alcohol use this was felt to be the leading cause of his atrial
tachycardia. patient discharged with planned 1 month of
anticoagulation following cardioversion and future cardiology
follow up.
.
#ETOH Abuse: patient prsented with no signs of withdrawl,
though did recieve several doses of ativan for "tremors" in the
emergency department. He was given folate and multivitamin
supplmentation in house. Patient was not forth coming with his
degree of alcohol use, but did endorse having several large
martini's everynight. He identified the year anniversary of his
mother's passing and his current job hunt as stressors causing
him to drink more in the past few weeks. Social work provided
the patient with counsiling and refferals to sobriaty programs.
he was deemed to be in the contimplative state of change.
.
# HTN: stable, continued lisinopril and HCTZ.
# BPH: stable, continued on tamsulosin
--------------------
Transitional Issues:
-patient needs Fasting Lipid Panel and consideration of statin
and aspirin pending results
-patient is full code
-patient reffered to alcoholics ___ need follow up
of his alcohol use.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 10 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
RX *Pradaxa 150 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*3
2. Lisinopril 10 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with fast ventricular response
alcohol abuse
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 while you were in the
hospital. You were admitted for evaluation of your fast heart
beat and found to be in an abnormal heart rhythm called atrial
fibrillation. You were given medications to slow your heart
rate and underwent a procedure called electrocardioversion to
shock your heart back into a normal rhythm. You tolerated this
procedure well and had a return of a normal heart rhythm called
sinus rhythm. You will need to take a blood thinner called
dabigatran or pradaxa for the next month to prevent a stroke
from occuring. You were also noted to have been drinking an
excess of alcohol which was felt to have caused your fast heart
rate. You were seen by our social workers who have provided
names and number of support groups to help you abstain from
alcohol moving forward.
Followup Instructions:
___
|
10576646-DS-10 | 10,576,646 | 26,800,358 | DS | 10 | 2175-10-03 00:00:00 | 2175-10-03 14:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
hypotension, abdominal pain, emesis
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, right medial
visceral rotation and ___ maneuver, ABThera placement.
___: 1. Exploratory laparotomy with abdominal washout.
2. Application of negative pressure ABThera V.A.C. dressing
___: 1. Reopening of recent laparotomy with abdominal wash
out.
2. Application of negative pressure ABThera VAC dressing.
___: Reopening of recent laparotomy, abdominal washout, and
placement of VAC as temporary abdominal closure.
___: Abdominal washout, partial closure and application of
___ patch.
___: Reopen recent laparotomy, washout, closure, and
placement of a Dobhoff tube.
History of Present Illness:
Mrs. ___ is a ___ ___ with h/o afib on
Coumadin, CVA x2, T2DM who p/w worsening abdominal pain and
coffee ground emesis who presented on ___. Briefly, pt had
small volume coffee ground emesis per nursing report at her
living facility and subsequently developed abdominal pain. She
reportedly had one episode of melenic stool and given all her
symptoms she was transferred to ___ for further evaluation. On
arrival, pt was tachycardic to 120s though her systolic BPs
remained in the 110-120s range. She was found to have: WBC 20.4,
lactate 9.5, K 7.2 (not hemolyzed), Cr 1.7 (baseline ~0.9), and
INR 4.2. On further review, pt denies fevers/chills, diarrhea,
severe epigastric abdominal pain, CP/SOB. ACS was consulted
given finding on CT A/P demonstrating extra-luminal air in the
region of the pylorus.
ROS:
(+) per HPI
(-) Denies fevers, chills, night sweats, unexplained weight
loss,
fatigue/malaise/lethargy, trouble with sleep, pruritis,
jaundice,
rashes, easy bruising, headache, dizziness, vertigo, syncope,
weakness, paresthesias, hematemesis, bloating, cramping, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
1. AF on Coumadin since ___ difficult to control INR
with multiple hospitalizations for supratherapeutic INR's.
2. CVA with L sided residual weakness- ___, again in ___
3. HTN
4. GERD
5. vascular dementia
6. Depression
7. Hypothyroidism
8. L sided muscle spasms treated with baclofen in past. Now no
spasm pain.
Hx of aspiration pneumonia per NH records
*******
New Diagnoses With Discharge
1. HFrEF (40%)
2. Insulin Dependent DM2
3. NSTEMI w/medical management w/o PCTA or stenting
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam at Admission:
Vitals: 97.6 116 94/53 27 100% RA
Gen: A&Ox3, uncomfortable-appearing female, in NAD
HEENT: No scleral icterus, no palpable LAD
Pulm: mildly tachypneic, no w/r/r
CV: tachycardic, irregular rhythm
Abd: soft, distended, diffusely TTP, most notably in
epigastrium,
with voluntary guarding and rebound; no palpable masses
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Physical Exam at Discharge:
Vitals ___: Tmax 98.5/98.0, BP 94/64, HR71, RR16, O2 sat 96% RA
General: Laying calmly in bed, answering questions
appropriately, comfortable, cooperative
Pulm: unlabored breathing
Cardio: irregular rhythm
Abd: nontender, distention stable from previous exam
Pertinent Results:
___ 05:23AM BLOOD WBC-13.8* RBC-3.07* Hgb-9.0* Hct-29.2*
MCV-95 MCH-29.3 MCHC-30.8* RDW-18.4* RDWSD-60.3* Plt ___
___ 05:23AM BLOOD Glucose-134* UreaN-12 Creat-0.9 Na-139
K-4.7 Cl-102 HCO3-22 AnGap-15
___ 05:40AM BLOOD ALT-10 AST-19 CK(CPK)-105 AlkPhos-68
TotBili-0.2
___ 05:11AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
___ 02:04PM BLOOD calTIBC-170* VitB___* Folate-5
Ferritn-110 TRF-131*
___ 10:04AM BLOOD Lactate-1.9
___ Omental Biopsy:
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS: Omental node, biopsy:
- Organizing nodular fat necrosis possibly consistent with
infarcted epiploic appendage.
___ CT abd/pelvis:
1. Foci of extraluminal air with inflammatory changes adjacent
to the pylorus of the stomach with a small amount fluid tracking
along the right anterior pararenal fascia. Findings are highly
suggestive of a perforated gastric ulcer, likely within the
pyloric channel. No organized fluid collections indentified.
2. Markedly distended stomach, for which decompression with
enteric tube is recommended.
3. Cholelithiasis without cholecystitis.
4. No evidence of diverticulitis.
Brief Hospital Course:
In the ED at ___ on ___, the patient persistently became
tachycardic, lactate 9, and therefore was given a transfusion of
1 unit of packed red blood cells. CT scan showed there is a
perforated gastric ulcer and therefore surgery was consulted. GI
was consulted, and recommended administering a PPI. The patient
lost her IV access and therefore a central line was placed. The
patient was admitted to the surgical ICU. On ___, Dr.
___ performed ___ laparotomy, right medial
visceral rotation and ___ maneuver, ABThera placement. (3RBC,
___ FFP, ___ crystalloid, UOP 750). Please see operative report
for details. The patient
was then left intubated and transferred back to the ICU in
stable condition.
GI was then consulted on ___. EGD showed deep, penetrating
ulcer which was 1 cm in diameter without any visible vessel or
adherent clot or active bleeding. They recommended continuing IV
nexium BID, checking h PYLORI stool (negative), monitoring CBC.
On ___, she went for an ex lap with abdominal washout and
application of negative pressure ABTHERA VAC dressing with Dr.
___. On ___, the patient went for reopening of recent
laparotomy with abdominal washout and application of negative
pressure Abthera dressing with Dr. ___ (findings:
perforated viscus).
GI team continued following and on ___, noted slowly
downtrending H and H, no evidence of active GI bleed, likely
downtrending due to slow losses through wound vac. Given her
findings on EGD, GI team concerned for underlying malignancy.
Recommend continuing BID PPI, and patient should undergo repeat
EGD between ___ weeks for further evaluation of ulcer with
biopsies.
The Heme/Onc team was consulted on ___ regarding her
progressive thrombocytopenia and anemia. Give her significant
intraoperative bleed that caused a 4-point intraoperative
hemoglobin drop and required 4 units of PRBCs and multiple
transfusions of FFP, the team felt that the anemia and
thrombocytopenia were likely explained by significant bleeding
and platelet consumption by wound, and recommended to
discontinue meropenem and considered alternative antibiotics.
On ___, patient returned to OR with Dr. ___ reopening
of recent laparotomy, abdominal washout, placement of VAC as
temporary abdominal closure. No evidence of bleeding inside the
abdomen.
Patient had Right brachial DL power PICC placed on ___. Also
on ___, cardiology was consulted regarding atrial
fibrillation. Based on patient's history of atrial fibrillation
and prior CVAs (as well as risk factors of hypertension, age,
female sex, and diabetes), cardiology recommended long term
anticoagulation for stroke prevention. Based on CHADS2 score =
4, annual stroke risk is approximately 10% without
anticoagulation. Therefore, risk of stroke on day to day basis
small, but elevated compared to the general population without
AF.
On ___, patient returned to OR with Dr. ___ for
abdominal washout, partial closure and application ___
patch, ___ drain. Please see operative note.
On ___, returned to OR with Dr. ___ reopen recent
laparotomy, washout, closure, placement of Dobhoff tube. Please
see operative note.
___ diabetes service began following patient on ___.
On ___, patient transferred to floor on telemetry.
On ___, restarted tube feeds at 20, goal 50 per nutrition.
Tube feeds were then held secondary to abdominal distension in
the evening, and a KUB was ordered, showing nonspecific bowel
gas pattern with relative paucity of bowel gas; if clinically
concerned for obstruction, radiology advised obtaining
cross-sectional imaging.
On ___, patient was triggered for hypotension and labored
breathing. She had CT abd/pelvis that showed no evidence of
small-bowel obstruction or ileus, no collection, resolution of
pleural effusions, cholelithiasis.
From the bedside swallow evaluation on ___, recommended puree
and nectar thick liquids, medications crushed in puree,
aspiration precautions (1:1 supervision with meals, frequent
oral care TID, HOB greater than 30 degrees at all times).
On ___, foley was removed, positive urinalysis. Placed on
Bactrim for UTI on ___.
On ___, acute care surgery team determined that patient was
stable for discharge to LTAC (with heparin drip and dobhoff).
Medications on Admission:
___:
-loratidine 5'
-levothyroxine 50'
-metoprolol 25'
-duloxetine 30''
-simethicone 80'''' prn
-acetaminophen 325 q6h prn
-artificial tears
-Lasix 20'
-bisacodyl 10' prn
-baclofen 10''
-trazodone 25'
-Coumadin
Discharge Medications:
acetaminophen 650 po q6hr
Albuterol 0.083% Neb Soln, 1 NEB IH Q6H:PRN wheezing
Atorvastatin
40 mg PO/NG DAILY
Baclofen
10 mg PO/NG BID
Chlorhexidine Gluconate 0.12% Oral Rinse
15 mL ORAL BID
Furosemide
20 mg PO/NG DAILY
Hold for BP <100
Heparin
IV Infusion per Non Weight-Based Dosing Guidelines
Last Documented Infusion Rate: 700 units/hr (Recorded ___ @
1208)
Hold infusion for 60 minutes
Continue infusion at rate: 700 units/hr
Insulin SC Fixed Dose
Glargine 16 units @ Bedtime
Insulin SC Fixed Dose
Regular 6 units Q6H
Insulin SC Sliding Scale
Regular @ Q6H
Fingerstick Blood Glucose: 6hr
Lansoprazole Oral Disintegrating Tab
30 mg PO/NG BID
Prevacid SoluTab should not be crushed or chewed.
Levothyroxine Sodium
50 mcg PO/NG DAILY
Metoclopramide
10 mg PO/NG Q6H
Take 30 minutes before meals.
Metoprolol Tartrate
12.5 mg PO/NG BID
hold for HR<60 SBP<100
Ondansetron
4 mg IV Q8H Nausea
Doses less than 8 mg may be given undiluted. Doses of 2 to 32 mg
may be diluted in 50 ml D5W or NS and infused on 15 minutes.
Sucralfate
1 gm PO/NG TID
Sulfameth/Trimethoprim DS
1 TAB PO/NG BID
Duration: 5 Days
Ordered by ___ on ___ @ 17:24
Start: ___,
Warfarin (see dosing sheet)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gastric ulcer, perforated viscus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
abdominal pain, nausea, and vomiting, and a gastric ulcer, and
underwent Exploratory laparotomy, right medial
visceral rotation and ___ maneuver, ABThera placement. 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.
Followup Instructions:
___
|
10576646-DS-9 | 10,576,646 | 22,924,618 | DS | 9 | 2173-11-15 00:00:00 | 2173-11-15 11:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
___ central line
History of Present Illness:
___ F h/o CVA in ___ and ___, vascular dementia, A fib, HTN,
who was found to be unresponsive this AM in her rehab, and she
is being admitted to the MICU for HHS. Pt was in her USOH until
this morning. Per family, pt was found to be lethargic this
morning, with O2 saturation of 81%. Oxygen saturation improved
to 100% w/2LNC. FSBG was greater than assay, and patient was
given 10U regular insulin. Pt's MS reportedly improved after
that, and she was admitted to ___ MICU for further evaluation.
Of note, the patient's family reports that she has been overall
stable since being transferred to ___ in ___.
Yesterday, her husband visited her at rehab and noticed that she
was more tired and lethargic than usual but otherwise acting
normally. At baseline she is active and uses exercise bike daily
at rehab. Per the family, she remained quite altered mentally
from her baseline until about noon, and overall improved with
some waxing and waning throughout the day.
In the ED, initial vitals: T 101.4 Tmax 103.8 ___ BP125/50
RR20 100% Nasal Cannula.
Labs were notable for: pro-BNP 3800, Trop-T 0.32, lactate
3.6->3.2->4.5. UA: large glucose, hyaline cast. ABG:
7.34/40/50/23.
Chem: creat 1.7, HCO3 16, anion gap 25.
Hgb 15.6, Hct 47.5, WBC 10.7, Plt 285, INR 1.5, , LFT's wnl,
She was started on an insulin drip, given Vanc and Zosyn, and 3L
IV fluids.
Studies were significant for: CT abd/pelvis: no abnormalities.
CT head w/o contrast: prior R MCA infarct with chronic sequelae.
On transfer, vitals were: 99.8 76 125/89 18 100% RA
On arrival to the MICU, the patient reported feeling comfortable
and denied pain. Otherwise ROS was limited. Per the family, she
has not had any other complaints recently except mild abdominal
pain over the last few days. Per the family, the patient has
never had a diagnosis of diabetes; however, at ___ the
physicians have added insulin sliding scale to her regimen
recently due to elevated blood sugars.
Past Medical History:
1. AF on Coumadin since ___ difficult to control INR
with multiple hospitalizations for supratherapeutic INR's.
2. CVA with L sided residual weakness- ___, again in ___
3. HTN
4. GERD
5. vascular dementia
6. Depression
7. Hypothyroidism
8. L sided muscle spasms treated with baclofen in past. Now no
spasm pain.
Hx of aspiration pneumonia per NH records
*******
New Diagnoses With Discharge
1. HFrEF (40%)
2. Insulin Dependent DM2
3. ___ w/medical management w/o PCTA or stenting
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.5; 88; 120/60; 20; 99%RA LOS Fluid Balance: +6.9L
General- Alert, oriented to name, year. States "I live in a
nursing home" when asked current location
HEENT- Sclera anicteric, MMM, oropharynx clear; bilateral eyes
with drainage and Crusting
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, harsh ___ systolic
murmur heard throughout precordium, most pronounced at LSB
Abdomen- obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, could not appreciate pulses, trace
edema
Neuro- Unable to move LUE and LLE. Pupils equal bilaterally.
Able to move RLE, strength ___ ___ISCHARGE PHYSICAL EXAM:
Vitals: T: 97.4 BP: 99/57 (100s-110s/60s) HR: 79 (70s ___ RR:
16 SaO2: 98% RA
General: AOx2+ (place: ___)
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Lungs clear to auscultation at apicies and posterior
upper lobes. Some minimal rales in lower ___V - Regular rate and rhythm, normal S1 + S2, harsh ___
systolic murmur heard throughout precordium, most pronounced at
LSB
Abdomen- obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, dp +1 could not palpate ___. radial
2+, No appreciable edema
Neuro- Unable to move LUE and LLE. Pupils equal bilaterally.
Able to move RLE, strength ___ in RUE.
Pertinent Results:
ADMISSION LABORATORY VALUES:
___ 10:36PM GLUCOSE-395* UREA N-24* CREAT-1.1 SODIUM-150*
POTASSIUM-3.7 CHLORIDE-118* TOTAL CO2-17* ANION GAP-19
___ 10:36PM CK-MB-13* cTropnT-0.25*
___ 10:36PM CALCIUM-7.8* PHOSPHATE-1.6* MAGNESIUM-2.0
___ 08:53PM ___ TEMP-36.7 O2 FLOW-2 PO2-38* PCO2-44
PH-7.34* TOTAL CO2-25 BASE XS--2 INTUBATED-NOT INTUBA
___ 08:53PM LACTATE-1.8
___ 08:31PM %HbA1c-13.4* eAG-338*
___ 08:26PM AMYLASE-75
___ 08:26PM LIPASE-38
___ 08:26PM WBC-11.0* RBC-4.85 HGB-15.0 HCT-44.7 MCV-92
MCH-30.9 MCHC-33.6 RDW-13.1 RDWSD-42.6
___ 08:26PM PLT COUNT-189
___ 08:26PM ___ PTT-150* ___
___ 05:10PM cTropnT-0.41*
___ 05:10PM CK-MB-14* MB INDX-4.5
___ 05:10PM CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-2.2
___ 05:10PM ASA-6.5 ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:58PM PO2-232* PCO2-24* PH-7.47* TOTAL CO2-18* BASE
XS--3
___ 04:58PM GLUCOSE-356* LACTATE-4.5*
___ 11:12AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:12AM URINE RBC-3* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:49AM LACTATE-3.6*
___ 10:43AM ALT(SGPT)-25 AST(SGOT)-23 ALK PHOS-83 TOT
BILI-0.5
___ 10:43AM LIPASE-28
___ 10:43AM cTropnT-0.32* proBNP-3800*
___ 10:43AM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-3.4
MAGNESIUM-2.4
___ 10:43AM TSH-0.54
___ 10:43AM ___ PTT-25.1 ___
PERTINENT IMAGING:
___ CXR:
IMPRESSION:
As compared to the previous radiograph from ___,
12:36 the
extent and severity of the pre-existing pulmonary edema has
decreased. The
edema is now mild. Moderate cardiomegaly persists. Small
atelectasis at the
left lung basis. Unchanged position of the right PICC line.
___ CXR:
IMPRESSION:
Worsening bibasilar opacities may reflect atelectasis, infection
cannot be
excluded. The appearances of the left lung base in particular
are concerning.
___ TTE (ECHOCARDIOGRAM):
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears mildly-to-moderately
depressed (LVEF = 40%) secondary to inferior posterior akinesis.
The right ventricular free wall thickness is normal. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
(___) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
___ CXR:
IMPRESSION:
No acute intrathoracic process.
___ CT AB/PELVIS W AND W/O:
IMPRESSION:
1. No acute intra-abdominal or intrapelvic findings to explain
the patient's
symptoms.
___ CT HEAD W AND W/O:
IMPRESSION:
No acute intracranial abnormality. Prior right MCA infarct with
chronic
sequelae. If there is further concern for acute process, MRI
can be
considered for further evaluation.
DISCHARGE LABORATORY VALUES:
___ 06:00AM BLOOD WBC-7.5 RBC-4.13 Hgb-12.5 Hct-38.1 MCV-92
MCH-30.3 MCHC-32.8 RDW-12.6 RDWSD-42.4 Plt ___
___ 04:04AM BLOOD Neuts-51.0 ___ Monos-8.6 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-3.69 AbsLymp-2.82 AbsMono-0.62
AbsEos-0.05 AbsBaso-0.02
___ 06:10AM BLOOD ___
___ 06:10AM BLOOD Glucose-285* UreaN-8 Creat-0.8 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-15
___ 06:10AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ F h/o right MCA CVA in ___ and ___ with
residual L sided deficits, vascular dementia - A&Ox2-3 at
baseline, A fib, HTN, who was found to be unresponsive on the
morning of ___ at her rehab who was determined to be in a
hyperglycemic hyperosmolar nonketotic state and hypoxic who's
clinical course was complicated by an ___ presumably
secondary to hypovolemic state.
#Hyperglycemic Hyperosmolar Non-Ketotic Syndrome/New Diagnosis
of Type 2 Diabetes Mellitus
-Patient on admission was found to be altered, hypoxic and in
florid HHNKS with blood sugar into 800s. Following admission to
the ICU for hydration and insulin drip Ms. ___ blood sugars
were brought within acceptable ranges. An A1C of 13.4 was
discovered revealing what was long standing undiagnosed
diabetes. Ms. ___ was transferred to the general floors
following a complicated ICU course (see below). Following
adequate control of blood sugars she was placed on standing
basal glargine to be given in the morning, per geriatrics,
versus in the evening as geriatric patients tend to have better
AM glucoses with poorer control in the post prandial state. She
was also started on Metformin XL 500mg daily. Close follow up
as an outpatient is required as a goal A1C of ___ is ideal in
populations with multiple comorbidities.
#Non-ST-Elevation Myocardial Infarction; Type II
-Patient troponin on admission to ED was found to be elevated
with repeat testing showing increasing CKMB and troponins. Peak
at 0.4. It is presumed to be due to poor perfusion secondary to
hypovolemia. Cardiology was consulted and it was determined that
at this time, because of the type of MI, there were no
procedural interventions needed and Ms. ___ was
medically managed with statin, beta blocker, aspirin and an ACE
inhibitor at low doses to be uptitrated as an outpatient.
#Heart Failure with Reduced Ejection Fraction (40%)
-Sequelae of ___, as evidence on echocardiogram, there were
areas of the LV that were both hypokinetic and akinetic. This
causes some pulmonary edema and fluid overload which contributed
to Ms. ___ presenting hypoxemia. After gentle diuresis her
oxygen requirement was no longer necessary and became euvolemic.
*****TRANSITION ISSUES*****
-Diabetes: New Diagnosis. Basal insulin with metformin started
as inpatient. Follow up fasting glucose (in evenings before
dinner typically as in elderly it is best to give basal in
morning). Consider monitoring EF and LFTs and renal function as
just starting Metformin.
-Follow up with cardiology as outpatient for new diagnosis of
heart failure with reduced EF (40%) and significant valvular
regurgitation.
-Reassess diuresis needs.
-Will require assistance to take daily weights at same time of
day to assess for volume overload.
-Anemia: Mild Anemia w/phenotype of underproduction. Low
reticulocyte correction. Would benefit from outpatient work up.
However it may have been secondary to significant hemodilution
during volume resuscitative process.
-On lovenox. Will require daily INR until therapeutic for ___
hours within target range of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES BID
3. Baclofen 10 mg PO BID
4. Duloxetine 30 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Loratadine 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Warfarin 1.5 mg PO 2X/WEEK (___)
11. Warfarin 2 mg PO 2X/WEEK (WE,TH)
12. Warfarin 1 mg PO 3X/WEEK (___)
13. TraZODone 25 mg PO QHS
14. Acetaminophen 650 mg PO Q6H
15. Bisacodyl 10 mg PO DAILY
16. Simethicone 80 mg PO TID
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 70 mg SC daily Disp #*20 Syringe
Refills:*0
2. Acetaminophen 650 mg PO Q6H
3. Artificial Tears ___ DROP BOTH EYES BID
4. Aspirin 81 mg PO DAILY
5. Baclofen 10 mg PO BID
6. Duloxetine 30 mg PO BID
7. Furosemide 20 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. Warfarin 2 mg PO 2X/WEEK (WE,TH)
11. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
12. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Test] test blood sugar
with each meal and morning before breakfast Disp #*1 Package
Refills:*0
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 15 SC
15 Units before BKFT; Disp #*1 Syringe Refills:*0
RX *blood-glucose meter [FreeStyle Freedom] check blood sugar
each morning and before and after each meal daily Disp #*1 Kit
Refills:*0
RX *lancets [FreeStyle Lancets] 28 gauge use with glucometer and
test strips as directed Disp #*1 Package Refills:*0
13. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
RX *metformin 500 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
15. Bisacodyl 10 mg PO DAILY
16. Loratadine 5 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY
18. Simethicone 80 mg PO TID
19. TraZODone 25 mg PO QHS
20. Warfarin 1.5 mg PO 2X/WEEK (___)
21. Warfarin 1 mg PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: 1. Hyperglycemic Hyperosmolar Non Ketotic
Syndrome 2. Non-S T-Segment Elevation Myocardial Infarction 3.
Heart Failure with Reduced Ejection Fraction 4. Insulin
Dependent Type 2 Diabetes Mellitus.
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:
Ms. ___,
You were admitted to the ___
directly from your extended care facility, ___, after
the staff found you laying on the ground and difficult to
arouse. It was found that you had dangerously high levels of
sugar in your blood. A condition known as "hyperglycemia."
Additionally, it was noted that you were having a difficult time
getting oxygen into your blood. A chest xray could not rule out
that you had an infection of the lungs called, pneumonia. Due to
this constellation of symptoms it was decided to transfer you to
one of our intensive care units (ICU). You were given
antibiotics. With repeat testing it appeared that your low
oxygen level was due to fluid in your lungs and not an
infection. You no longer required antibiotics and you were given
medication to help relieve your lungs of this fluid burden.
During your care in the ICU subsequent testing showed that you
had suffered a minor heart attack, "myocardial ischemia." You
were subsequently evaluated by our heart specialists,
"cardiologists," who determined that it would be in your best
interest to treat your heart attack with medicines only. That is
to say, not to take you to the operating room. Subsequent
imaging showed that there was some reduced "squeezing function"
of your heart which is called "heart failure." This was a
relatively minor finding, but one that we needed to treat. This
is also the most probable cause of why you initially had fluid
in your lungs.
Following a stable course in the ICU where your high blood
sugar, need for oxygen, and heart attack w/a minor degree of
heart failure were stabilized you were transferred to the
general medicine floor.
While on the medicine floor your high blood sugars were
managed with insulin, a medication that acts in the same way as
the insulin your body naturally produces to help take the sugar
from food you eat and utilize it as energy in your various
organs. To manage your heart attack we started you on a
cholesterol medication "atorvastatin," a drug which controls
your heart rate, Metoprolol, aspirin and a medication which
helps both your heart, blood pressure and your kidneys,
lisinopril. For your heart failure, to prevent fluid from
accumulating in your lungs, legs, abdomen, we continued your
home water pill, furosemide (Lasix).
New medications upon your discharge:
#For Diabetes Mellitus Type 2
1. Insulin glargine (Lantus): you should take 15 units in the
form of an injection in your skin of your abdomen at a different
spot every day every morning before breakfast.
2. Metformin XR 500mg by mouth daily for treatment of your
newly diagnoses Type 2 Diabetes.
3. Your Metoprolol XL was decreased from 25mg to 12.5mg once
daily
4. You were started on atorvastatin 80mg once daily
5. You were started on lisinopril 5mg once daily
6. You were given the pneumonia vaccine (pneumovax (23
valent))
It was a pleasure taking care of your during your
hospitalization at ___.
Best,
Your ___ Internal Medicine and Geriatrics Teams
Followup Instructions:
___
|
10577202-DS-10 | 10,577,202 | 29,184,404 | DS | 10 | 2130-04-14 00:00:00 | 2130-04-15 16:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Leg Swelling and Redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HIV (last CD4 count 746 and CD4% 49, VL 20 copies
(detection range lower limit is 20) on ___ Presents with 1
week of leg swelling and erythema concerning for cellulitis. The
patient said that he has noticed over the last week, he has had
increasing edema of the left leg. It was not bothering him much
so he paid nto attention to it, but over the last 2 days he has
noticed erythema that started on the foot and progressed up to
his knee. He said it is tender, but not painful if not touched.
He denies fevers, chills, joint pain. No recent truama to the
area. Denies IVDU recently and not injecting into the foot. Not
sure how it happened. Said he has not had this before. He has
not been more immobile recently and no history of blood clots.
He had is sister look at it because she works at a hospital and
felt that he should come in for abx because it was thought to be
infected.
Initial VS in the ED: 98.6 73 128/60 16 93% Exam notable for
significant erythema and warmth of left lower leg up to knee,
several small lesions base of foot likely nidus for infection.
Labs notable for WBC 7.1 (N:63.6 L:24.1 M:7.7 E:3.7 Bas:0.8),
BUN/Cr: ___ (baseline Cr 1.0), H/H: 11.8/33.3 (baseline
11.9-13.8/35.5-38.7). Lactate 1.4. Left lower extremity duplex
ordered that showed no evidence of DVT. Patient was given Unasyn
and bactrim DS 2 tabs in the ED. VS prior to transfer: 98.3 63
133/70 18 85%.
.
.
On the floor, Patient was sleeping, but when I awoke him, he
felt well and without symptoms.
Past Medical History:
AC JOINT SEPARATION
ASTHMA
ATRIAL FIBRILLATION
CHRONIC BRONCHITIS
CORONARY ARTERY DISEASE
DILATED DUCTS/DORSAL DUCT DOMINANT
ENLARGED PROSTATE
HCV INFECTION
HEMMORHOIDS
HIV INFECTION
HYPERCHOLESTEROLEMIA
HYPERTENSION
LOW BACK PAIN
LOW TESTOSTERONE
LOW VIT B12
POS H PYLORI
SLEEP APNEA
VENTRAL HERNIA
Social History:
___
Family History:
mother and sister both with breast CA.
Physical Exam:
Admission exam:
Vitals: T: 97.6 BP: 116/102 P: 84 R: 18 O2: 98%RA
General: Dischevelled man, with dentures falling out while
sleeping, pleasant and wanting to go home tomorrow
HEENT: Sclera anicteric, EOMI, OP moist, dentures in place
Neck: No LAD
CV: RRR, no m/r/g
Lungs: CTAB bialterally
Abdomen: Soft, distended and firm, nontender, difficult to
appreciate liver border
Ext: 2+ radial pulses, bilateral upper extremities sunburned,
well healing scab on left dorsal aspect of his hand, LEft lower
extremity is edematous to the knee, with 1+ pitting edema.
Erythema over dorsal aspect of his foot extending up shin and
calf to tibial tuberosity, warm and tender to touch with some
areas of induration.
Neuro: CNII-XII
Skin: As above in extremity exam.
.
.
Discharge exam:
Vitals: T: 97.6-97.8 BP: 116-117/84-102 P: ___ R: 18 O2:
92-98%RA
General: pleasant man, slightly dishevelled in NAD, standing at
bedside, AxOx3, speech clear and fluent, affect appropriate
HEENT: Sclera anicteric, EOMI, OP clear without lesions, MMM,
dentures in place
Neck: No LAD
CV: RRR, no m/r/g
Lungs: CTAB bialterally
Abdomen: Soft, mildy distended, nontender, difficult to
appreciate liver border
Ext: 2+ radial pulses, bilateral upper extremities sunburned,
well healing scab on left dorsal aspect of his hand, bilateral
hands with well-healed track marks from remote IVDU.
Left lower extremity is edematous to 3cm below the knee
(improved from admission exam), with 1+ pitting edema. Erythema
over dorsal aspect of his foot extending up shin and calf to
tibial tuberosity, warm and tender to touch with some areas of
induration. ___ is significantly more swollen than the R.
RLE also with evidence of hyperpigmentation due to venous stasis
L foot base callus, dry, nonerythematous, nontender on my exam
but he reports point tenderness
significant onychomycosis on all toes bilaterally with dry
flaking skin throughout.
___ sign negative bilaterally
Neuro: CNII-XII, motor ___ throughout
Skin: As above in extremity exam.
Pertinent Results:
Admission labs:
___ 07:15PM BLOOD WBC-7.0 RBC-4.06* Hgb-11.8* Hct-33.3*
MCV-82 MCH-29.0 MCHC-35.3* RDW-14.0 Plt ___
___ 07:15PM BLOOD Neuts-63.6 ___ Monos-7.7 Eos-3.7
Baso-0.8
___ 07:15PM BLOOD Glucose-81 UreaN-12 Creat-1.3* Na-137
K-4.7 Cl-100 HCO3-25 AnGap-17
___ 07:22PM BLOOD ___ Comment-GREEN TOP
___ 07:22PM BLOOD Lactate-1.4
.
.
Discharge labs:
___ 02:28PM BLOOD UreaN-13 Creat-1.1
.
Microbiology:
___ 7:15 pm BLOOD CULTURE pending
.
Imaging:
___ ___: 1. No deep venous thrombosis in the left lower
extremity.
2. Subcutaneous edema in the left calf with minimally enlarged
reactive left inguinal lymph nodes.
Brief Hospital Course:
___ with HIV (last CD4 count 746 and CD4% 49, VL 20 copies
(detection range lower limit is 20) on ___ Presents with 1
week of leg swelling and erythema concerning for cellulitis and
lymphangitic spread.
.
ACUTE ISSUES:
# Cellulitis: Patient with left lower extremity cellulitis and
lymphangitic spread up to tibial tuberosity without systemic
signs, no fevers or chills, no leukocytosis. ___ negative for
DVT. He received one dose vancomycin and unasyn and given
significant improvement he was switched to Bactrim DS 1 tab
twice a day for 10 days and Augmentin 875mg twice a day for 10
days at discharge.
- follow up with PCP for resolution of infection
.
# Acute Kidney Injury: Creatinine slightly elevated from
baseline likely from hypovolemia in the setting of infection. He
received IVF and was encouraged in increase PO fluid intake.
Repeat creatinine was pending at time of discharge. Patient was
anxious to leave the hospital and understood that worsening of
creatinine would require change of antibiotics and could result
in further injury without medical attention. He agreed to close
follow up and verbalized understanding of risks involved.
- patient will be contacted by inpatient team when creatinine
returns
- repeat creatinine with PCP/post-discharge follow up to ensure
further resolution
.
.
# Anemia: Normocytic and near baseline. Likely anemia of chronic
inflammation with acute inflammation in the setting of
infection. He had no signs or symptoms of bleeding.
.
.
CHRONIC ISSUES:
# ASTHMA: Continued home medications:
- Continued Albuterol inhaler ___ puffs(s) by mouth every four
(4) to six (6) hours as needed for cough/wheezing
- Continued Spiriva 1 puff Daily
.
# CHRONIC BRONCHITIS: Continued home medications:
- Continued Albuterol inhaler ___ puffs(s) by mouth every four
(4) to six (6) hours as needed for cough/wheezing
- Continued Spiriva 1 puff Daily
.
# CORONARY ARTERY DISEASE: Continued home medications:
- Continued atenolol 25 mg tablet ___ Tablet(s) by mouth once a
day
- Continued pravastatin 40 mg tablet one Tablet(s) by mouth once
a day with dinner
- Continued Aspirin 81mg PO Daily
.
# HIV INFECTION: Last CD4 count 746 and CD4% 49, VL 20 copies
(detection range lower limit is 20) on ___. Continued home
medications:
- Continued Prezista 600 mg tablet 1 Tablet(s) by mouth twice
daily
- Continued Truvada 200 mg-300 mg tablet 1 Tablet(s) by mouth
once a day
- Continued Norvir 100 mg capsule 1 Capsule(s) by mouth twice
daily
.
# HYPERCHOLESTEROLEMIA: Continued Pravastatin as above
.
# HYPERTENSION: Normotensive throughout hospitalization.
Continued home atenolol as above
.
# H/O of substance abuse: Continued methadose 10 mg tablet
tablet(s) by mouth 85mg daily from ___ in
___
.
# LOW TESTOSTERONE: Continued home AndroGel 1 % (50 mg/5 gram)
Transdermal Packet apply 1 packet as directed daily rub on
shoulders and abdomen
.
.
TRANSITIONAL ISSUES:
- Code: Full
- Communication: Patient (has HCP forms, but has not submitted
them)
- Discharged on Bactrim and Augmentin for 10 day course
- Follow up with PCP for resolution of symptoms and repeat Cr
- Pending studies at time of discharge
### blood culture (___) - no growth to date, final pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheezing
2. Atenolol 12.5 mg PO DAILY
Hold for HR<60, SBP<100
3. Darunavir 600 mg PO BID
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. HydrOXYzine 25 mg PO DAILY:PRN anxiety
6. Methadone 85 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. RISperidone 0.5 mg PO BID
One in the am and one at bedtime.
10. RiTONAvir 100 mg PO BID
11. AndroGel *NF* (testosterone) 1 %(50 mg/5 gram) Transdermal
Daily
Rub on shoulders and abdomen
12. Tiotropium Bromide 1 CAP IH DAILY
13. Aspirin 81 mg PO DAILY
14. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral Daily
15. Nicotine Patch 14 mg TD DAILY
16. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
chew and park in mouth.
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheezing
2. AndroGel *NF* (testosterone) 1 %(50 mg/5 gram) Transdermal
Daily
3. Aspirin 81 mg PO DAILY
4. Atenolol 12.5 mg PO DAILY
5. Darunavir 600 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. HydrOXYzine 25 mg PO DAILY:PRN anxiety
8. Methadone 85 mg PO DAILY
9. Nicotine Patch 14 mg TD DAILY
10. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
11. Pravastatin 40 mg PO DAILY
12. RISperidone 0.5 mg PO BID
13. RiTONAvir 100 mg PO BID
14. Tiotropium Bromide 1 CAP IH DAILY
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*20 Tablet Refills:*0
16. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
17. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral Daily
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: acute kidney injury, cellulitis
Secondary diagnosis: HIV, CAD, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for treatment of cellulitis. You were also found to
have acute kidney injury, probably from the infection in your
leg. You were given IV antibiotics and your infection started to
improve, and you were switched to oral antibiotics.
You received fluids to help your kidney function resolve. You
had labs drawn prior to leaving the hospital and you will be
contacted with the results. In the meantime, you should continue
to drink lots of water and fluids to continue to help your
kidneys.
Please see the attached sheet for your updated medications.
START Bactrim DS 1 tab twice a day for 10 days
START Augmentin 875mg twice a day for 10 days
Please continue to take these antibiotics until they are
finished even if all of your symptoms resolve.
Followup Instructions:
___
|
10577202-DS-11 | 10,577,202 | 28,246,165 | DS | 11 | 2132-05-09 00:00:00 | 2132-05-13 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hand pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/HIV, HCV cirrhosis, recent C.Diff presents with abdominal
pain and hand errosions. Pt reports he went to routine PCP
follow up yesterday to meet new resident and was sent to BI ED
for evaluation of hand infection. He reports that hand pain and
swelling over dorsum of both hands has been present for 8
months. Right worse than left. No fever, no other lesions.
States he saw a hand specialist for this previously, does not
recall diagnosis but was told to keep hands wrapped and use A&D
ointment. States hands are improving.
Also with chronic RLQ abd pain, dull, constant, for several
months, nonradiating, associated w/nausea and intermittent loose
nonbloody, stools once a day.
Also with depression, again chronic for ___ months, worsening
apathy, fatigue, decreased appetite, 60lb weight loss over 4
months, denies SI/HI. Self discontinued all anti-depressants and
has not follow up with psych.
In ED hand surgery consulted. Pt given cefepime, vanco,
morphine.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
# HTN/hyperchol
# afib
# CAD ___
# asthma
# chronic bronchitis
# OSA noncompliant BiPAP
# HIV
- last CD4 680 (___), Viral Load <20 (___)
# HCV s/p ribavirin/interferron ___ HCV viral loads (___)
undetected
- cirrhosis, liver bx (___): Stage III-IV and grade ___
- EGD ___ - no varices
# Dilated CBD s/p ERCP sphx ___
# + H pylori ___ rx
# ventral hernia
# depression: last seen psychoatrist ___
# PTSD
Social History:
___
Family History:
mother and sister both with breast CA.
Physical Exam:
Vitals: T:97.7 BP:146/93 P:58 R:16 O2:93%ra
PAIN: 0
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender RLQ, no rebound or
guarding
Ext: no e/c/c
Skin: b/l hands w/deep ulceration, weeping on dorsum, non
pitting edema of hands and fingers, nontender, no crepitus
Neuro: alert, follows commands
Pertinent Results:
___ 08:00PM GLUCOSE-79 UREA N-7 CREAT-0.7 SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
___ 08:07PM LACTATE-1.5
___ 08:00PM ALT(SGPT)-16 AST(SGOT)-23 ALK PHOS-99 TOT
BILI-0.5
___ 08:00PM ALBUMIN-3.8
___ 08:00PM CRP-12.0*
___ 08:00PM WBC-7.9 RBC-4.45* HGB-13.1* HCT-36.7* MCV-82
MCH-29.4 MCHC-35.7* RDW-14.4
___ 08:00PM NEUTS-65.7 ___ MONOS-7.9 EOS-2.2
BASOS-0.3
___ 08:00PM ___ TO PTT-UNABLE TO ___
TO
___ 08:00PM PLT COUNT-235
___ 09:00PM ___ PTT-28.8 ___
# CXR (___): PA and lateral views of the chest provided.
Lungs appear clear. There is no focal consolidation, effusion,
or pneumothorax. Stable blunting of the left CP angle likely
reflect mild pleural thickening as this is stable since ___.
The cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION: No acute intrathoracic process.
# Hand x-ray (___): Soft tissue prominence most notable along
the dorsum of both hands. No underlying bony abnormalities.
Please correlate clinically.
# Abd CT (___): No evidence of colitis or diverticulitis.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ w/HIV last CD4 600, HCV cirrhosis,
recent C.Diff presents with chronic abdominal pain and hand
errosions
# Hand Erosions: Mr. ___ has chronic dorsal hand ulcers.
Here there was no clear evidence of systemic symptoms: no fever,
chills, or leukocytosis. Hand surgery evaluated the patient and
felt the ulcers did not require any debridement and there were
no abscess. There was mild erythema and drainage - mild
elevation in CRP and as a result the decision was to treat for a
short course of Keflex (7 days).
Local wound care was given (per recommendations of hand
surgery): Xeroform daily dressing changes wrapped in kerlex.
Daily wound washing with gentle scrubbing. To prevent future
worsening, Mr. ___ knows that he should avoid picking at
them. The dressings will help with providing a barrier in the
middle of the night. Establishing a new psychiatrist will be
helpful to help manage his OCD.
# Abdominal Pain: Mr. ___ was admitted with chronic abdominal
pain a/w mild nausea and intermittent loose stool, wt loss.
Exam here was unremarkable and he had no evidence of diarrhea
(in fact had no BM's) during this admission. To further
evaluate, an Abd/pelvic CT scan was done and it was normal. CD4
was checked to ensure that the abdominal pain/wt loss was not
attributed to AIDS-related symptoms. The CD4 count was 550.
Ritonavir can be a/w abd pain but he has been on this med for
many years.
Stool c.diff was ordered, but because of an absence of BMs,
it was not sent. The decision was to treat with flagyl anyhow,
since he was to receive Keflex for the hand cellulitis. Mr
___ was concerned of IBS and requested a trial of bentyl as
outpt.
# Depression: denies SI/HI
- wil likely need outpt psych input for OCD behavior
# HIV: cont Truvada, darunavir, rionavir. CD4 count here 550.
No indication for prophylaxis
# Asthma: cont albuterol PRN, tiotropium
# CV: HTN, Afib, CAD. Mod hypertensive here with SBP 170s.
Asymptomatic
- cont home atenolol, pravachol and ASA. Room for increase of
atenolol
# h/o IVDU (heroin addiction): on methadone. Confirmed dose of
110 mg Daily
# OTHER ISSUES AS OUTLINED.
# FEN: gen diet
# PPX: heparin
# ACCESS: piv
# FULL CODE
# CONTACT: Girlfriend ___ ___. ___
___ Substance Abuse ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheeze
2. Atenolol 12.5 mg PO DAILY
3. Darunavir 600 mg PO BID
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Methadone 105 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. RiTONAvir 100 mg PO BID
8. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Aspirin 81 mg PO DAILY
11. Nicotine Patch 14 mg TD DAILY
12. calcium carbonate-vitamin D3 (Ca-D3-mag
___ 600 mg(1,500mg) -400 unit oral DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheeze
2. Aspirin 81 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Darunavir 600 mg PO BID
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Methadone 105 mg PO DAILY
7. Nicotine Patch 14 mg TD DAILY
8. Pravastatin 40 mg PO QPM
9. RiTONAvir 100 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. Cephalexin 250 mg PO Q6H Duration: 7 Days
RX *cephalexin 250 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
12. DiCYCLOmine 20 mg PO QID:PRN abd pain, discomfort
please take only as needed.
RX *dicyclomine [Bentyl] 20 mg 1 tablet(s) by mouth four times a
day Disp #*60 Tablet Refills:*0
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
14. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
15. calcium carbonate-vitamin D3 (Ca-D3-mag
___ 600 mg(1,500mg) -400 unit oral DAILY
16. Xeroform Petrolatum Dressing (bismuth tribrom-petrolatum,wh)
4 X 4 topical DAILY
apply to wound daily
RX *bismuth tribrom-petrolatum,wh [Xeroform Petrolatum Dressing]
2" X 2" apply to hand ulcers Daily Disp #*2 Package Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Hand ulcers, mild cellulitis
Chronic abd pain, no clear etiology
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure looking after you, Mr. ___. As you know,
you were admitted for hand ulcers and chronic abdominal pain.
Your hands were evaluated by the hand surgeons and there did not
seem to be evidence of significant infection. There was some
redness around the hand, and as a result, you will be given a
7-day course of antibiotics (Keflex) to see if the redness
improves. Please apply Xeroform daily dressing changes
wrapped in kerlex. Covering the wounds would help prevent you
picking at it as well. Wash the wound gently daily. Due to your
history of C.diff, you will also be given another antibiotic to
prevent the development of C.diff.
Your abdominal pain was evaluated with an abdominal CT scan -
and there were no evident abnormalities. You also did not have
any diarreha during this stay. CD4 count here was 550, making
AIDS-related symptoms unlikely. Due to your concern for IBS,
you were given a prescription for Bentyl, but do not take it
until after the antibiotic regimen is tried first.
There are otherwise no other changes to your medication.
Followup Instructions:
___
|
10577418-DS-12 | 10,577,418 | 21,683,583 | DS | 12 | 2178-02-01 00:00:00 | 2178-02-02 19:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lumbar back pain, peripheral neuropathy
Major Surgical or Invasive Procedure:
___ laminectomy
___ EGD
History of Present Illness:
Mrs. ___ is a ___ who presents three weeks after fall at
home. She presented to the ___ at that time for facial
trauma from the fall and was discharged. Shortly thereafter, she
developed low back pain. She presented to her PCP who referred
her to a pain management specialist. She received some sort of
injections to the spine last week. Three days later, she
developed worsening low back pain and numbness and paresthesias
starting distally in toes and ascending towards the torso. She
does report saddle paresthesias. No repeat trauma. She also
repeats lower extremity weakness with right greater than left.
Past Medical History:
Afib, HTN, Hypercholesterolemia, pericarditis/galucoma/macular
degeneration/pyoderma, history of kidney stones ___ with
s
sepsis,gangrenosum/depression/gastritis/nephrolithiasis/meralgia
paresthetica/spinal stenosis/osteoporosis/basal cell CA/
Social History:
___
Family History:
non contributory
Physical Exam:
PHYSICAL EXAMINATION:
General: alert and oriented
Vitals: stable
Spine exam:
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 2 4 3 4 3 4
R 5 ___ ___ 2 4 3 4 3 4
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
___ Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R dm, L dm
L4 (Knee) R dm, L dm
L5 (Grt Toe): R dm, L dm
S1 (Sm toe): R dm, L dm
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: diminsihed
Rectal tone: diminished
DISCHARGE PHYSICAL EXAM
VS: 98.3 140/87 64 18 96% ___
GENERAL: NAD, AAOx3
HEENT: multiple ecchymoses over face, EOMI, PERRL, anicteric
sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: mild bibasilar crackles, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no clubbing or edema, moving all 4 extremities with
purpose, ulnar deviation of fingers at MCP joints
PULSES: 2+ DP pulses bilaterally
NEURO: no gross motor/coordination abnormalities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission:
___ 08:50PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 08:50PM ___
___ 08:50PM ___
___
___ 08:50PM PLT ___
___ 10:50AM URINE ___
___ 10:50AM URINE ___
___ 10:50AM URINE ___ SP ___
___ 10:50AM URINE ___
___
___
___ 08:30AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 08:30AM ___ this
___ 08:30AM CK(CPK)-77
___ 08:30AM ___ cTropnT-<0.01
___ 08:30AM ___
___
___ 08:30AM ___
___ IM ___
___
___ 08:30AM PLT ___
___ 08:30AM ___ ___
Discharge Labs
___ 07:03AM BLOOD ___
___ Plt ___
___ 07:03AM BLOOD Plt ___
___ 07:03AM BLOOD ___
___
___ 07:03AM BLOOD ___
Imaging:
Thoracic and Lumbar spine Xray: No evidence for fracture or
subluxation. Mild to moderate, multilevel
degenerative changes of the lumbar spine, more fully
characterized on recent
MRI..
B/l Lower Extremity Dopplers
Limited exam due to ___ inability to tolerate the exam.
The right
posterior tibial and peroneal veins were not seen. Within these
limits, no evidence of deep venous thrombosis in the right or
left lower extremity veins centrally.
CXR ___
Left PICC tip is in themid SVC. Cardiac size is mildly
increased. The aorta is
tortuous. There is a large hiatal hernia. ___
opacities in the lower
lobes right greater than left could correspond to aspiration
EGD ___
Procedure: The procedure, indications, preparation and potential
complications were explained to the ___, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The ___ was administered MAC
anesthesia. Supplemental oxygen was used. The ___ was placed
in the left lateral decubitus position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the third part of the duodenum was reached.
Careful visualization of the upper GI tract was performed. The
procedure was not difficult. The ___ tolerated the procedure
well. There were no complications.
Findings:
Esophagus:
Lumen: A large size hiatal hernia was seen.
Stomach:
Excavated Lesions Multiple patchy erosions were noted in the
antrum. Cold forceps biopsies were performed for histology at
the antrum. A single cratered clean baed ___ 5 mm ulcer
was found in the fundus. Cold forceps biopsies were performed
for histology at the stomach ulcer.
Duodenum: Normal duodenum.
Impression: Large hiatal hernia
Ulcer in the fundus (biopsy)
Erosions in the antrum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: GI consult service to discuss with inpatient
primary team.
Continue max dose twice daily PPI
___ biopsy results and treat for H. pylori if positive
Repeat EGD in ___ weeks
Brief Hospital Course:
___ h/o rheumatoid arthritis, HTN, HLD, OA, pAF not
anticoagulated, and spinal stenosis s/p lumbar laminectomy and
nerve root decompression ___, transferred from the Ortho
spine service to the MICU for hematemesis and hypotension with
SBP to the ___, found to have fundal ulcer and antral erosions.
# Acute GI blood loss anemia: Pt had ~200ml of reported maroon
hematemesis and hypotension with SBP to the ___ ___ on ___
(POD 4), initially presumed to be ___ upper GI bleeding. She
received a total of 4U total pRBCs (last ___. EGD on ___
revealed a 5 mm fundal ulcer as well as antral erosions.
Biopsies were H. pylori negative, and consistent with gastritis.
She was was maintained on a PPI. Hemoglobin nadir was 6.4, and
on discharge was 8.6 and stable. Anticipate repeat EGD in ___
weeks.
# Spinal stenosis s/p lumbar laminectomy: s/p fall 3 weeks prior
to admission. Presented to
ortho spine service with rapidly progressing back pain with
lower extremity, numbness, paresthesias in the lower extremities
in the setting of severe lumbar spinal stenosis. s/p laminectomy
___ on ___. Pain was controlled with tramadol.
# ?PNA: CXR with concern for RUL opacity. Leukocytosis peaked at
20.6. She received a seven day course of antibiotics,
cefepime->ceftriaxone->cefpodoxime on discharge.
# Chest pain, calf pain: Trops neg. Most likely related to
migratory pain from ___ limited but negative for DVT. No
hypoxia to suggest PE.
# Chronic back pain: Continued gabapentin, lidocaine patch
# Hypertension: Held home lisinopril due to recent hypotension,
GIB. Restarted prior to discharge.
# Afib: Home metoprolol held in setting of hypotension and GIB,
resumed prior to discharge. Not anticoagulated, deferred
discussion/initiation to outpatient setting given recent GIB.
# Rheumatoid arthritis: On prednisone, leukovorin, and
methotrexate at home. Home prednisone was briefly held in the
setting of upper GIB, resumed prior to discharge.
# Depression: Continued citalopram
# Hyperlipidemia: Continued atorvastatin
# Glaucoma: Continued brimonidine and latanoprost eye drops.
Transitional issues:
====================
- Discharge Hg: 8.6
- Started on BID PPI
- Pt is not anticoagulated for Afib, would have this discussion
with ___ discharged on Cefpodoxime to complete 7 days of abx
___, to end ___
- Needs repeat EGD ___ weeks after discharge
HCP: ___
Son: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. trospium 20 mg oral DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Atorvastatin 40 mg PO QPM
5. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
6. Methotrexate 25 mg PO 1X/WEEK (___)
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
8. Leucovorin Calcium 10 mg PO 1X/WEEK (___) 8 hours after
methrotrexate dose
9. FoLIC Acid 1 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. LORazepam 0.5 mg PO QHS:PRN insomnia
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Lisinopril 5 mg PO DAILY
14. Citalopram 20 mg PO DAILY
15. Floranex (Lactobacillus ___ 1 million cell
oral DAILY
16. Gabapentin 100 mg PO TID
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H
2. Pantoprazole 40 mg PO Q12H
3. Atorvastatin 40 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Citalopram 20 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Floranex (Lactobacillus ___ 1 million cell
oral DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 100 mg PO TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Leucovorin Calcium 10 mg PO 1X/WEEK (___) 8 hours after
methrotrexate dose
12. Lisinopril 5 mg PO DAILY
13. LORazepam 0.5 mg PO QHS:PRN insomnia
14. Methotrexate 25 mg PO 1X/WEEK (___)
15. Metoprolol Succinate XL 50 mg PO DAILY
16. PredniSONE 10 mg PO DAILY
17. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
18. trospium 20 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
acute blood loss anemia
hematemesis
spinal stenosis s/p lumbar laminectomy
pneumonia
Secondary:
rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___. You were admitted
because you had increasing low back pain and leg weakness. The
ortho spine team performed a laminectomy to treat your spinal
stenosis. During your hospitalization, you had low blood
pressure and vomited some blood. You underwent an endoscopy,
which showed a stomach ulcer. You will need a repeat endoscopy
in ___ weeks.
Please follow up with your PCP as scheduled.
Your ___ team
Followup Instructions:
___
|
10577547-DS-5 | 10,577,547 | 27,606,187 | DS | 5 | 2145-10-06 00:00:00 | 2145-10-10 04:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Atrial flutter with variable heart block
Major Surgical or Invasive Procedure:
Temporary pacemaker placement (___)
Transesophageal echocardiogram (___)
History of Present Illness:
FROM ADMISSION NOTE:
Mr. ___ is a ___ year old male with a history of OSA on home
CPAP who presented to ___ with three weeks of
lightheadedness, dizziness and SOB.
Patient reports that he was in his usual state of health until
three weeks ago after he took a shower and felt very dizzy. His
wife noted a large circular splotchy red rash on his back (not
bulls eye pattern). That day, he also had fever, weakness, and
myalgias. Due to suspicion for Lyme disease, he had titers drawn
one week later which were negative.
Over the course of these three weeks, he has felt increasingly
dizzy and weak. He reports that he is normally an active person
but that he is unable to engage in normal activity without
feeling short of breath. He has had increasing myalgias and
arthralgias. He notes exposure to ticks over the summer (has
gone on many bike rides in ___.
The patient felt increasingly dizzy on the day of admission, at
which point he presented to ___.
At ___, the patient was given 2 grams of IV ceftriaxone
empirically around 1PM for coverage of tick born illnesses.
Lyme, Anaplasma, and Babesia DNR PCRs were sent. Paper pads were
placed but he required no pacing at any point and remained
hemodynamically stable.
A CXR was also done which showed mild cardiomegaly. Mild
cephalization the pulmonary vasculature. No focal infiltrates or
pleural effusions. Mediastinal contour stable.
Labs at ___ were significant for elevated ___ at 13.9. WBC 12.
He was transferred to ___ for higher care. Here, he was found
to have atrial flutter with complete heart block and a
ventricular escape rhythm in the ___.
In the ED, initial vitals were found to be T 97.7, HR 39, BP
133/49, RR 14 O2 100% RA.
Initial labs in the ED were as follows:
142 | 103 |13
-------------<96
4.2 | 23 |0.9
Ca: 8.3 Mg: 2.1 P: 3.6
CBC: 11.4>12.7/38.1<221
Trop-T: <0.01
ALT: 22 AP: 71 Tbili: 0.7 Alb: 3.5 AST: 15
On arrival to CCU, he continues to be hemodynamically stable. He
denies any chest pain or shortness of breath. He still continues
to feel weak and slightly dizzy. Reports good appetite and is
thirsty.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, or
syncope.
On further review of systems, he has had intermittent fevers,
arthralgias, and myalgias. Denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
All of the other review of systems were negative.
Past Medical History:
FROM ADMISSION NOTE:
Obstructive sleep apnea
Social History:
___
Family History:
FROM ADMISSION NOTE:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 38.3 HR 47 BP 132/60 RR 22 O2 SAT 9%
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. 0.5cm cystic lesion on R face near
temple, not tender to palpation. Male pattern baldness.
NECK: Supple. no JVD appreciated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Bradycardic. Irregular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Mildly tachypneic. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
=======================
VS: T 98.8, BP 113/56, HR 55, RR 18, 94% on RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. 0.5cm cystic lesion on R face near
temple,
not tender to palpation. Male pattern baldness.
NECK: Supple. no JVD appreciated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular paced. No m/r/g.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bibasilar crackles L>R.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace
___
edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:35PM cTropnT-<0.01
___ 04:35PM WBC-11.4* RBC-4.09* HGB-12.7* HCT-38.1*
MCV-93 MCH-31.1 MCHC-33.3 RDW-13.1 RDWSD-44.5
___ 04:35PM NEUTS-79.0* LYMPHS-12.2* MONOS-6.1 EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-9.01* AbsLymp-1.39 AbsMono-0.69
AbsEos-0.10 AbsBaso-0.04
___ 04:35PM PLT COUNT-221
___ 04:35PM GLUCOSE-96 UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
___ 04:35PM ALT(SGPT)-22 AST(SGOT)-15 ALK PHOS-71 TOT
BILI-0.7
___ 04:35PM ALBUMIN-3.5 CALCIUM-8.3* PHOSPHATE-3.6
MAGNESIUM-2.1
PERTINENT LABS:
==============
___ 12:40AM BLOOD WBC-15.9* RBC-3.97* Hgb-12.4* Hct-37.2*
MCV-94 MCH-31.2 MCHC-33.3 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:53AM BLOOD WBC-12.2* RBC-3.94* Hgb-12.7* Hct-37.1*
MCV-94 MCH-32.2* MCHC-34.2 RDW-13.3 RDWSD-45.6 Plt ___
___ 05:53AM BLOOD ALT-24 AST-17 LD(LDH)-222 CK(CPK)-24*
AlkPhos-65 TotBili-0.5
DISCHARGE LABS:
==============
___ 07:00AM BLOOD WBC-8.2 RBC-4.27* Hgb-13.2* Hct-39.4*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.4 RDWSD-44.7 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-98 UreaN-18 Creat-0.8 Na-140
K-4.6 Cl-103 HCO3-23 AnGap-14
___ 07:00AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
MICROBIOLOGY:
============
Lyme IgM, IgG positive by EIA
Lyme IgM, IgG positive by Immunoblot
Babesia microti IgM, IgG pending
Anaplasma phagocytophilim IgM, IgG pending
Blood cultures: no growth
PERTINENT IMAGING/STUDIES:
==========================
CXR (___):
IMPRESSION
No prior chest radiographs available for review.
Right transjugular right ventricular pacer lead follows the
expected course. Mild mediastinal widening has no tracheal
displacement to suggest hematoma, probably a combination
mediastinal fat deposition and venous engorgement. Pulmonary
vessels are also plethoric and the cardiac silhouette is mildly
enlarged, but there is no pulmonary edema. Pleural effusions
small if any. No pneumothorax.
TTE (___):
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve is bicuspid. No masses
or vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No masses or
vegetations are seen on the mitral 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. Bicuspid aortic valve with
focally thickened leaflets and mild aortic regurgitation in the
setting of focal leaflet thickening. No discrete valvular
vegetations or abscesses appreciated. Mildly dilated aortic root
and ascending aorta. Moderately dilated left ventricle. Moderate
pulmonary artery systolic hypertension.
Given the suboptimal image quality, a valvular vegetation cannot
be excluded. If clinical suspicion is high and patient
management would change a transesophageal echocardiogram may be
considered.
TEE (___):
Good image quality. No spontaneous echo contrast or thrombus in
the left atrium/left atrial appendage/right atrium/right atrial
appendage. Bicuspid aortic valve with mild-moderate aortic
regurgitation. Mild mitral regurgitation.
CXR (___):
IMPRESSION
A right chest wall single lead pacemaker is present with the tip
of the lead projecting over the right ventricle. There is
minimal bibasilar atelectasis. No focal consolidation, pleural
effusion or pneumothorax identified. The size of the cardiac
silhouette is enlarged but unchanged. Pulmonary vascular
congestion is present without overt pulmonary edema.
Brief Hospital Course:
___ male with history of obstructive sleep apnea who
presented with 2-week duration of lightheadedness/dizziness in
the setting of recent fevers, myalgias, and rash, found to have
atrial flutter with variable AV block and ventricular escape at
rate of 40.
#) Atrial flutter with variable heart block: suspicious for lyme
carditis in the context of positive IgM/IgG serology by EIA and
confirmatory Immunoblot. Anaplasma phagocytophilum titer pending
at discharge. No AV nodal blocking agents at baseline. Given
high risk for R-on-T phenomenon in the setting of slow
ventricular escape rhythm, temporary pacing was recommended;
however, patient declined (i.e., transcutaneous pacing pads were
applied). Patient then had a witnessed syncopal episode in the
context of 10-second asystole, prompting temporary screw-in
pacemaker placement on ___. TEE was obtained and DCCV performed
thereafter with termination of atrial flutter. Of note,
rivaroxaban initiated for uncertain chronicity. He was
discharged with temporary pacing wire and ___ of Hearts event
monitor with close EP follow-up.
#) Lyme carditis: IgM/IgG positive by EIA and confirmatory
Immunoblot. Received CTX -> doxycycline; to complete 21-day
course (day 1 = ___. Conduction delay likely reversible. PR
interval <300 ms by day of discharge.
#) Babesiosis: B. microti PCR positive at OSH. Parasite smear x2
negative on arrival. Received azithromycin/atovaquone; to
complete 7-day course (day 1 = ___.
#) Insomnia, anxiety: increased stress and trauma at home.
Trazodone held due to concern for QTC prolongation.
#) Cystic lesion, right face: outpatient dermatology follow-up
was suggested.
#) OSA: diagnosed on sleep study (___). Home CPAP continued.
TRANSITIONAL ISSUES
[]Please ensure follow-up with electrophysiology and ID
[]To complete 7-day course azithromycin, atovaquone for
babesiosis (last day = ___
[]To complete 21-day course doxycycline (last day = ___
[]Follow-up B. microti, A. phagocytophilum serologies
[]Patient started on rivaroxaban
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS:PRN insomnia
2. Citalopram 20 mg PO DAILY
3. tadalafil 20 mg oral PRN
Discharge Medications:
1. Atovaquone Suspension 750 mg PO BID
RX *atovaquone 750 mg/5 mL 750 MG by mouth twice a day
Refills:*0
2. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*32 Tablet Refills:*0
4. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
5. Citalopram 20 mg PO DAILY
6. tadalafil 20 mg oral PRN
7. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY:
-Atrial flutter with variable heart block
-Lyme carditis
SECONDARY:
-Babesiosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized with abnormal heart conduction probably
due to Lyme disease of your heart. You required a temporary
pacing wire to stabilize your heart rate. You received
antibiotics too.
Please continue your antibiotics, as directed, and follow-up
with cardiology and infectious diseases, as indicated below.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
10577647-DS-14 | 10,577,647 | 29,805,803 | DS | 14 | 2145-04-16 00:00:00 | 2145-04-18 19:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with past medical history
significant for type II DM complicated by gastroparesis, insulin
dependence, HTN, GERD, Depression and recurrent UTIs who has had
multiple admissions this month for acute on chronic abdominal
pain in setting of her gastroparesis who is now presenting with
acute abdominal pain since this morning and inability to
tolerate PO.
In the ED, initial vitals: Pain ___ T 98 P ___ BP 154/123 RR
20 O2 98% ra. She reported her symptoms were very consistent
with past episodes of her past flares of abdominal pain and
nausea from her gastroparesis. She was given Zofran ODT 4mg,
Ativan 1mg for nausea. She additionally received Reglan 20mg,
Benadryl 25mg and Dilaudid 4mg. She was givne Insulin SC 10u
for blood sugar in the 400s. Her labs showed a
leukocytosis/thrombocytosis consistent with her baseline
leukocytosis and thrombocytosis of unclear etiology. She was
noted to have some ___ with creatinine of 1.3 from baseline of
1.0 and a mild hyponatremia to 132, thought to be volume down
and was started on 1L IVF. She had a femoral central line placed
in the ED because of difficult IV access.
- Vitals prior to transfer: 98.1 101 129/76 16 100% RA
On arrival to the floor, pt is somnolent and intermittently
falls asleep in the middle of conversation. She endorses
diffuse abdominal pain that she has had since this morning. She
reports three episodes of emesis which is "white colored". She
has not eaten today but did try to take her important
medications (blood pressure medications). She does endorse
taking a small amount of Humalog this morning and took her
Glargine last night. She says this abdominal pain happens "too
often" and that no one has ever told her why she has it. She
has not seen a gastroenterologist.
Per most recent discharge summary from ___ admission
(admission for abdominal pain):
Her care at ___ begins 3 months ago. Initially she was seen in
the ED x 2 for abdominal pain (___) and discharged home
from the ED after being treated with tramadol. Since then, she
has been admitted for abdominal pain with most ED presentations.
This is her ___ admission in the past 2 months, summarized in
reverse chronological order as follows:
___: gastroparesis flare; treated symptomatically with
minmal opiates; also treated for uncomplicated cystitis although
UCx ultimately demonstrated only contamination
___: gastroparesis flare; treated symptomatically with
minimal opiates
___: severe abdominal pain and inability to take PO;
admitted to MICU with hypertensive emergency (demonstrated by
AMS), treated with bolus labetalol
___: RUQ and flank pain, presumed ___ pyelonephritis.
UCx demonstrated fecal contamination. Treated w/ 2 week course
of ciprofloxacin.
ROS: (limited by patient lethargy/cooperation)
No fevers, chills. No headache. No cough, no shortness of
breath. No chest pain or palpitations. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena.
Past Medical History:
#DM: type 2
-- dx age ___ initially on POs, now on insulin
#Gastroparesis
-- dx around ___
#GERD
#HTN
#Depression
-- denies prior SA/SI or prior psych hospitalizations
#Obesity: BMI 46
-- previously evaluated for gastric bypass surgery at ___; per
patient's report, surgery was deferred due to concerns for her
ability to maintain post-surgical diet
#Recurrent UTIs ___ urethral diverticulum
#Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION EXAM:
Vitals- 98.1 133/72 98 18 O2 100%RA
blood sugar 362
General- Alert, oriented to person, place, month but not exact
date, lethargic but arousable.
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- distant breath sounds, CTAB no wheezes, rales, rhonchi
CV- tachy to low 100s, normal S1, physiologically split S2, No
MRG
Abdomen- + BS, soft, nondistended. Voluntary guarding present.
Abdomen is diffusely tender to even light palpation but exam is
nonfocal. No masses appreciated.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Vitals- 98.5 153/86 95 18 100%RA
blood sugar ___
yesterday blood sugar ___
8hr I/O O/700
General- Alert, oriented to person, place, month but not exact
date, lethargic but arousable.
HEENT- Sclerae anicteric, mucus membranes sl dry, oropharynx
clear
Neck- supple, JVP not elevated
Lungs- distant breath sounds, CTAB no wheezes, rales, rhonchi
CV- RRR, normal S1, physiologically split S2, No MRG
Abdomen- + BS, soft, nondistended. Voluntary guarding present.
Abdomen is diffusely tender to even light palpation but exam is
nonfocal. She has heat pack on her abdomen. No masses
appreciated. Right CVL in place with dressing.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISISON LABS:
___ 12:00PM WBC-17.7* RBC-4.08* HGB-9.6* HCT-31.0*
MCV-76* MCH-23.6* MCHC-31.1 RDW-16.8*
___ 12:00PM NEUTS-78.2* LYMPHS-17.2* MONOS-3.2 EOS-0.9
BASOS-0.5
___ 12:00PM PLT COUNT-624*
___ 12:00PM ___ PTT-31.9 ___
___ 12:00PM ALBUMIN-3.4*
___ 12:00PM LIPASE-24
___ 12:00PM ALT(SGPT)-17 AST(SGOT)-9 ALK PHOS-131* TOT
BILI-0.2
___ 12:00PM GLUCOSE-409* UREA N-27* CREAT-1.3*
SODIUM-132* POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14
___ 12:11PM LACTATE-1.7
___ 12:40PM URINE UCG-NEGATIVE
___ 12:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:40PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
___ 12:40PM URINE HYALINE-3*
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-11.4* RBC-3.85* Hgb-9.1* Hct-29.2*
MCV-76* MCH-23.6* MCHC-31.1 RDW-17.1* Plt ___
___ 08:00AM BLOOD Glucose-229* UreaN-20 Creat-1.1 Na-133
K-4.3 Cl-97 HCO3-28 AnGap-12
___ 08:00AM BLOOD Calcium-8.8 Phos-5.0* Mg-1.9
MICRIOBIOLOGY:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
KUB ___
IMPRESSION:
No evidence of obstruction or perforation.
Brief Hospital Course:
Ms. ___ is a ___ year old female with past medical history
significant for type II DM complicated by gastroparesis, insulin
dependence, HTN, GERD, Depression and recurrent UTIs now
presenting with acute on chronic abdominal pain.
ACTIVE ISSUES:
# Acute on Chronic Abdominal Pain: Abdominal exam overall benign
on presentation. Pain is diffuse and nonlocalizable and patient
reports it as similar to prior flares of her gastroparesis and
chronic abdominal pain. She was made NPO and given medications
for pain and nausea. Overnight she ultimately got a KUB to rule
out any evidence of obstruction or perforation given persistent
pain overnight which was negative. Her diet was slowly advanced
and she continued home meds including Metoclopramide, Tylenol
and Tramadol. At discharge she was tolerating a regular diet of
fried chicken and fries without recurrence of symptoms. Overall
felt consistent with gastroparesis flare.
# Acute Renal Failure: Creatinine on presentation of 1.3 with
baseline closer to 1.0. In the setting of mild
hyponatremia/hypochloremia, thought to be most like pre-renal
etiology. ___ resolved with fluid resuscitation.
CHRONIC ISSUES:
# Type II DM: Chronic insulin dependent, poorly contolled,
complicated. No ketones in urine on presentation though UA
significant for both glucose/protein. Blood sugar noted to be
409 without anion gap and normal bicarb. Ms. ___ does endorse
a history of DKA in the past. She continued home insulin
regimen and her blood sugars improved.
# Leukocytosis
# Thrombocytosis:
Unclear etiology though appear to be at baseline for patient.
Has no fever or other infectious symptoms. Likely reactive
process, unclear how long this has been going on given
fragmented medical care.
# HTN:
Complicated by hypertensive emergency at prior admission.
Normotensive on presentation, she does report having taken blood
pressure medications preferentially morning of presentation even
though she was nauseated. She continued Lisinopril 40mg daily
and Nifedipine CR 60mg daily
# GERD: continued home Pantoprazole.
# Depression: Unclear if contributing factor to recurrent
admissions. She continued home Sertraline.
# Iron deficiency anemia: at baseline, asymptomatic during
admission though noted to be still microcytic. Her oral iron
supplement was resumed at discharge.
# Chronic back pain: Not actively a complaint on admission.
She continued home doses of Gabapentin, Tylenol and Tramadol as
above.
TRANSITIONAL ISSUES:
# CODE STATUS: Full
# Emergency Contact: ___ (Daughter) ___
- patient transitioning primary care to ___ from ___
- patient needs referral to Ob/GYN to work up abnormal uterine
bleeding (as she notes she is post menopausal, now having
bleeding/cramping)
- patient may benefit from referral to GI for ongoing work up
given recurrent admissions for gastroparesis, ongoing iron
deficiency anemia of unclear etiology
- consider tapering off multiple QTc prolonging agents as
possible (on Zofran, Reglan)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO TID
5. Gabapentin 600 mg PO TID
6. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
7. Sertraline 150 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Pantoprazole 40 mg PO Q12H
10. NIFEdipine CR 60 mg PO DAILY
11. Metoclopramide 10 mg PO QIDACHS
12. Lisinopril 40 mg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
14. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 40 mg PO DAILY
7. Metoclopramide 10 mg PO QIDACHS
8. NIFEdipine CR 60 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
10. Pantoprazole 40 mg PO Q12H
11. Senna 8.6 mg PO BID:PRN constipation
12. Sertraline 150 mg PO DAILY
13. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
14. Ferrous Sulfate 325 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Gastroparesis
Type 2 Diabetes Mellitus
SECONDARY
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted because of
abdominal pain, nausea, and vomiting caused by your
gastroparesis. We gave you medications to treat your nausea and
pain, and you were able to tolerate a regular meal prior to
leaving the hospital.
The best treatment for your gastroparesis is good control of
your diabetes, and frequent small meals.
Please follow up with the appointment listed below.
We wish you the best,
Your ___ Medicine Team
Followup Instructions:
___
|
10577647-DS-15 | 10,577,647 | 20,405,881 | DS | 15 | 2145-04-24 00:00:00 | 2145-04-24 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / aspirin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of DM gastroparesis presents with abdominal pain,
n/v x 8hrs. Patient reports the pain began this AM and is
similar to prior gastroparesis pain. Patient reports continued
MJ use. Denies f/c/cp/sob/bowel or bladder changes. She took
tramadol at home without relief. She has had several prior
visits to the ED for the same thing, each visit requiring a
central line due to poor vascular access and admission for
intractable pain/nausea. In the ED vitals were 97.9 ___
25 100% RA. FSG was 413. She had two episodes of diarrhea in the
ED. She was intiatially admitted to the medicine floor. She
received 125cc/hr NS for an elevated lactate and mild ___ as
well as Macrobid for a possible UTI. She continued to have
elevated BPs and was given 200mg PO labetalol x1. Given
significantly elevated BPs (systolics as high as 260s, she was
transferred to the MICU.
Prior to transfer, vitals were reportedly stable with HR in the
___ and systolic pressures in the 130s following 1mg IV
Dilauded. However, upon arrival to the MICU, patient tacycardic
to 137 and SBP 260s. She was writhing in pain and moaning and
unable to state more that to identify her stomach as the source
of her pain. She was given 1mg IV dialuded with good effect. BPs
decreased but remained elevated at 220s-230s systolic after
dilauded.
Past Medical History:
#DM: type 2
-- dx age ___ initially on POs, now on insulin
#Gastroparesis
-- dx around ___
#GERD
#HTN
#Depression
-- denies prior SA/SI or prior psych hospitalizations
#Obesity: BMI 46
-- previously evaluated for gastric bypass surgery at ___; per
patient's report, surgery was deferred due to concerns for her
ability to maintain post-surgical diet
#Recurrent UTIs ___ urethral diverticulum
#Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION:
Vitals- T: 97.5, 259/142, HR 137, RR 22, SaO2 100% RA
GENERAL: Alert, oriented, mild distress, moaning and writhing in
bed
HEENT: Sclera anicteric, MMM, oropharynx clear but poor
dentition
NECK: supple, no LAD, unable to appreciate JVP ___ obesity
LUNGS: Clear to auscultation bilaterally in posterolateral
fields, no wheezes, rales, rhonchi appreciated. Exam limited as
patient would not sit up ___ pain
CV:tachy, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: BS+. Patient guarding and refusing general abdominal exam.
Diffuse tenderness to gentle paplpation of mid-epigastric area.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Diphoretic. No obvious lesions/rashes.
NEURO: A&Ox3.
DISCHARGE:
Gen: obese female
HEENT: NCAT, MMM, anicteric sclerae
Neck: Supple
Pulm: Generally CTA b/l on anterior exam
Cor: RRR, (+)S1/S2, no audible murmurs
Abd: Soft, hypoactive bowel sounds, minimal tenderness , no
rebound/guarding
Extrem: No edema
Pertinent Results:
ADMISSION:
___ 06:00PM URINE HOURS-RANDOM
___ 06:00PM URINE UHOLD-HOLD
___ 06:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 06:00PM URINE RBC-2 WBC-19* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:31PM ___ PO2-39* PCO2-50* PH-7.34* TOTAL
CO2-28 BASE XS-0
___ 04:31PM ___ PO2-39* PCO2-50* PH-7.34* TOTAL
CO2-28 BASE XS-0
___ 04:31PM O2 SAT-65
___ 04:25PM GLUCOSE-492* UREA N-21* CREAT-1.3*
SODIUM-132* POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-23 ANION GAP-23
___ 04:25PM estGFR-Using this
___ 04:25PM ALT(SGPT)-17 AST(SGOT)-16 ALK PHOS-183* TOT
BILI-0.2
___ 04:25PM LIPASE-24
___ 04:25PM ALBUMIN-4.2
___ 04:25PM WBC-20.7*# RBC-4.60 HGB-11.1* HCT-34.6*
MCV-75* MCH-24.2* MCHC-32.2 RDW-16.6*
___ 04:25PM NEUTS-92.9* LYMPHS-4.7* MONOS-1.6* EOS-0.4
BASOS-0.3
DISCHARGE:
___ 05:45AM BLOOD WBC-13.5* RBC-3.76* Hgb-8.9* Hct-28.4*
MCV-76* MCH-23.7* MCHC-31.4 RDW-16.4* Plt ___
___ 05:45AM BLOOD Glucose-190* UreaN-19 Creat-1.1 Na-133
K-4.2 Cl-97 HCO3-26 AnGap-14
IMAGING:
___ CT AP
1. Limited examination due to lack of IV contrast, however no
acute
intra-abdominal findings identified.
2. Stable cystic structure adjacent to the urethra, likely a
urethral
diverticulum, as seen on prior examination.
Brief Hospital Course:
Ms. ___ is a ___ with history of hypertension, GERD,
depression and diabetes mellitus complicated by gastroparesis
presenting with significant abominal pain, elevated lactate,
leukocytosis as well as hypertensive urgency.
#Abdominal Pain
Patient presenting with abdominal pain typical of her usual
gastroparesis flares. Also considered was bowel ischemia, small
bowel obstruction, and marijuana hyperemesis syndrome. A CT
abdomen was performed which was without finding suggesting a
flare. After discussion with patient, her prior gastric emptying
study performed years ago at ___ was not actually suggestive of
gastroparesis, thus her symptoms may be related to functional
abdominal pain rather than gastroparesis. A work-up at ___ has
not occurred, though patient insisted on discharge prior to
inpatient work-up this stay. The patient's pain was initially
treated with narcotics, though were quickly transitioned to
standing acetaminophen and as-needed tramadol with nausea
control and bowel regimen. Several recommendations were made to
the patient about ways of preventing further pain episodes.
#Hypertensive Ugency
Patient found to be hypertensive on admission to 200s systolic
which improved with pain/nausea control but then worsened again
on floor with peak SBPs in the 260s. She was transferred to the
MICU for further BP management. Patient had recent ICU admission
in ___ for hypertensive urgency which was treated with
nicardapine gtt. It was thought that her hypertension was
secondary to pain give the improvement in her blood pressure
with pain control. She was given labetalol initially in the
MICU, and pressures remained stable afterwards on her home
medications.
#Acute kidney injury
Patient presenting with elevated creatinine from baseline which
corrected with IVF. Likely secondary to volume depletion in
setting of decreased po's.
#Hyponatremia
Patient initially presenting with hyponatremia which was thought
to be hypovolemic hyponatremia vs SIADH secondary to pain. This
improved with IVF.
#Leukocytosis
Patient with baseline leukocytosis of unclear etiology, slightly
elevated beyond baseline to 20k on admission. She had no fevers
during her stay. A urinalysis was concerning for infection,
though culture was with mixed bacterial species. Reviewing her
prior cultures, there were no specimens with isolated organisms,
thus treatment was held.
#Thrombocytosis
Patient presenting with thrombocytosis on admission which is at
her recent baseline. There was no clear infection.
#Diabetes mellitus
Continued home Glargine 35U qHS and SS insulin
Transitional:
-Patient desires to establish with a PCP at ___.
-Patient likely needs follow-up with Gastroenterology ___,
___ for consideration of additional
gastroparesis evaluation. This work-up should include:
*repeat gastric emptying study
*EGD
*Small bowel follow through
-Patient needs evaluation of chronic leukocytosis and
thrombocytosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS
7. NIFEdipine CR 60 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
9. Pantoprazole 40 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
13. Ferrous Sulfate 325 mg PO TID
14. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO TID
5. Gabapentin 600 mg PO TID
6. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
7. Lisinopril 40 mg PO DAILY
8. Metoclopramide 10 mg PO QIDACHS
9. NIFEdipine CR 60 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Senna 8.6 mg PO BID:PRN constipation
12. Sertraline 150 mg PO DAILY
13. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
14. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Hypertensive urgency/accelerated hypertension
Leukocytosis
Thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with abdominal pain and found to have a very
high blood pressure. A CT scan of your abdomen was performed
because of your pain and was negative. Your pain was attributed
to a gastroparesis flare.
Please continue to take acetaminophen (Tylenol) and tramadol
(Ultram) for your abdominal pain. Continue to use your insulin
and aim for a well-controlled blood sugar (no blood sugars
higher than 300). Avoid foods that are high in fat and fiber
which are more difficult for your stomach to empty. You should
also avoid narcotic medications like oxycodone/oxycontin,
Percocet, morphine, and Dilauded. Avoid the use of tobacco or
marijuana as these can cause slowing of your stomach and
nausea/vomiting. Use a stool softener like Colace every day and
avoid constipation as this will worsen your gastroparesis.
It is very important that you follow-up so that a plan of action
can be made for your symptoms.
Followup Instructions:
___
|
10577647-DS-16 | 10,577,647 | 20,883,219 | DS | 16 | 2145-05-03 00:00:00 | 2145-05-04 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / aspirin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of insulin-dependent diabetes
mellitus complicated by gastroparesis with frequent flares and
recurrent urinary tract infections due to urethral diverticulum
who presented with abdominal pain. She was in her usual state of
health until the morning of admission, when she developed
diffuse abdominal pain in association with nausea and vomiting
entirely consistent with past gastroparesis flares. She endorsed
chills and sweats, but denied fevers, URI symptoms, chest pain,
shortness of breath, cough, hematochezia/melena, loose stools,
or myalgias. She noted urinary frequency without frank dysuria.
Of note, she was admitted most recently from ___ for
abdominal pain consistent with prior gastroparesis flares, with
CT abdomen/pelvis at that time reassuring against alternative
acute pathology. She was treated initially with opioids, with
rapid transition to acetaminophen and tramadol, and counseled on
behavioral modifications to reduce gastroparesis. Her admission
was complicated by hypertensive urgency to 260s, requiring brief
MICU transfer and attributed to pain, managed successfully with
labetalol. She also experienced acute kidney injury attributed
to prerenal azotemia and improved with volume repletion.
Urinalysis on that admission grew out Enterobacter, for which
she did not receive dedicated treatment. She represented to the
ED soon after on ___ for abdominal pain and was found to
have a positive urinalysis, for which she was prescribed a 5-day
course of nitrofurantoin, though urine culture ultimately grew
out a contaminant.
In the ED, initial vital signs were as follows: 97.4, ___, 24, 98% RA. Admission labs were notable for Wbc of
20.9, Hct of 31.3, platelets of 575, normal LFTs with the
exception of AlkP of 149, normal lipase, Cr of 1.3, lactate of
2.2, and positive urinalysis. EKG was interpreted as
demonstrating known RBBB. CXR was unremarkable. Left IJ CVL was
placed due to difficult IV access, with follow-up CXR
demonstrating appropriate position. She received ondansetron 4mg
ODT x2, morphine sulfate 4mg x2 (SC, followed by IM),
hydromorphone 1mg IV x2, lorazepam 1mg IV, and ceftriaxone 2g
IV. Vital signs at transfer were as follows: 95, 161/66, 18, 95%
RA. Of note, blood pressure peaked at 230s systolic, improved
with treatment of pain and anxiety.
Past Medical History:
IDDM (type 2) complicated by gastroparesis diagnosed in ___
GERD
Hypertension
Depression
Elevated BMI
Recurrent urinary tract infections due to urethral diverticulum
Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION:
General- Alert, oriented to person, place, month but not exact
date, lethargic but arousable.
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- distant breath sounds, CTAB no wheezes, rales, rhonchi
CV- tachy to low 100s, normal S1, physiologically split S2, No
MRG
Abdomen- + BS, soft, nondistended. Voluntary guarding present.
Abdomen is diffusely tender to even light palpation but exam is
nonfocal. No masses appreciated.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
LABS: reviewed, see below
MICRO: blood and urine cultures pending
EKG: from ___ with QTc 458ms
IMAGING: None new
DISCHARGE:
GEN: lying flat in bed
HEENT: NCAT, MMM, anicteric sclerae
NECK: Supple with lymphadenopathy
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR, (+)S1/S2 no m/r/g
ABD: Soft, voluntary guarding, some diffuse discomfort, + BS,
nondistended,
EXTREM: warm, well perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION:
___ 11:00AM BLOOD WBC-20.9* RBC-4.00* Hgb-10.0* Hct-31.3*
MCV-78* MCH-24.9* MCHC-31.8 RDW-16.7* Plt ___
___ 11:00AM BLOOD Neuts-87.7* Lymphs-8.3* Monos-3.2 Eos-0.5
Baso-0.3
___ 11:00AM BLOOD Glucose-368* UreaN-26* Creat-1.3* Na-135
K-4.5 Cl-95* HCO3-26 AnGap-19
___ 11:00AM BLOOD ALT-22 AST-18 AlkPhos-149* TotBili-0.3
___ 11:00AM BLOOD Albumin-4.0
DISCHARGE:
___ 04:45PM BLOOD Hct-29.8*
___ 07:28AM BLOOD Glucose-110* UreaN-22* Creat-1.3* Na-134
K-6.3* Cl-96 HCO3-20* AnGap-24*
IMAGING:
___ CXR
Cardiac, mediastinal and hilar contours are normal. Pulmonary
vasculature is normal. The lungs are clear. No focal
consolidation, pleural effusion or pneumothorax is identified.
The right subclavian central venous catheter has been removed.
Brief Hospital Course:
Ms. ___ is a ___ with history of insulin-dependent diabetes
mellitus complicated by gastroparesis with frequent flares and
recurrent urinary tract infections due to urethral diverticulum
who presented with acute-on-chronic abdominal pain.
# Acute-on-chronic abdominal pain
Patient presented with abdominal pain consistent with her prior
episodes of pain which have been attributed to gastroparesis
flares. Patient has had multiple episodes for this without clear
etiology of her symptoms. Patient reported that she previously
had a gastric emptying study which confirmed this finding,
though the primary documentation was not available. The
patient's PCP at ___ was contacted who noted multiple admissions
there for similar episodes. The patient's diet was initially
held, but later advanced as tolerated. Her blood glucoses were
controlled and pain was controlled with her home acetaminophen
and tramadol with continuation of her metoclopramide.
# Positive urinalysis
Patient presented with pyuria and few bacteria on urinalysis.
Patient has complained of symptoms on many of her past
admissions with only one culture returning positive. A culture
obtained during the patient's prior admission had actually
returned positive after discharge, but an interim culture
between the last, but before this admission was negative. The
patient initially received antibiotics, but this was later
discontinued as the patient denied symptoms. She has been seen
by Urology before at ___ for similar symptoms per conversation
with PCP.
# Acute kidney injury
Patient's creatinine on admission was 1.3, up from 1 at
baseline. The patient received IV fluids with improvement of her
creatinine.
# Insulin-dependent diabetes mellitus
The patient was hyperglycemic on admission without a gap
acidosis. She was continued on her home glargine with sliding
scale insulin as needed.
# Leukocytosis/thrombocytosis
Patient has a known chronic leukocytosis and thrombocytosis of
unclear etiology. This has been present on all of her ___
admissions, and after discussing with her PCP, has been present
since at least ___ when she was seen by ___ Hematology. Per
PCP, ___ was not able to find a specific abnormality
causing her leukocytosis and thrombocytosis.
# Hypertension
Blood pressures peaked in the 230s systolic in the ED, though
improved to the 150-160s in the setting of pain control. She was
continued on her home lisinopril and nifedipine.
# GERD
The patient was continued on her home pantoprazole.
# Depression
The patient was continue on her home sertraline.
# Chronic back pain
The patient was continued on her home gabapentin with
acetaminophen and tramadol as needed.
TRANSITIONAL ISSUES:
-Patient desires to establish with a PCP at ___.
-Patient likely needs follow-up with Gastroenterology ___,
___ for consideration of additional
gastroparesis evaluation. This work-up should include:
*repeat gastric emptying study
*EGD
*Small bowel follow through
-Patient needs further evaluation of chronic leukocytosis and
thrombocytosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO TID
5. Gabapentin 600 mg PO TID
6. Lisinopril 40 mg PO DAILY
7. Metoclopramide 10 mg PO QIDACHS
8. NIFEdipine CR 60 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
13. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
14. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Metoclopramide 10 mg PO QIDACHS
8. NIFEdipine CR 60 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
13. Ferrous Sulfate 325 mg PO TID
14. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Hypertensive urgency/accelerated hypertension
Leukocytosis
Thrombocytosis
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with an episode of abdominal pain which was
consistent with your prior episodes of gastroparesis. Your blood
pressure was also found to be high on admission. You were given
medications for the pain and for your blood pressure with
improvement in both. You were given antibiotics for a UTI which
you had during your last admission.
Please continue to take acetaminophen (Tylenol) and tramadol
(Ultram) for your abdominal pain. Continue to use your insulin
and aim for a well-controlled blood sugar (no blood sugars
higher than 300). Avoid foods that are high in fat and fiber
which are more difficult for your stomach to empty. You should
also avoid narcotic medications like oxycodone/oxycontin,
Percocet, morphine, and Dilauded. Avoid the use of tobacco or
marijuana as these can cause slowing of your stomach and
nausea/vomiting. Use a stool softener like Colace every day and
avoid constipation as this will worsen your gastroparesis.
It is very important that you follow-up so that a plan of action
can be made for your symptoms.
Followup Instructions:
___
|
10577647-DS-17 | 10,577,647 | 25,931,423 | DS | 17 | 2145-05-24 00:00:00 | 2145-05-26 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / aspirin
Attending: ___.
Chief Complaint:
Diabetic Ketoacidosis/Diabetic Gastroparesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of insulin-dependent diabetes
mellitus complicated by gastroparesis with frequent flares and
recurrent urinary tract infections due to urethral diverticulum
who is presenting with abdominal pain. She was recently
hospitalized this past month with similar symptoms, which was
managed with home medications. She was found to have no acute
intraabdominal pathology, but rather her symptoms were
attributed to a pain flair secondary to gastroparesis. Her pain
was controlled with her home acetaminophen and tramadol with
continuation of her metoclopramide.
On ___, she develoepd acute on chronic abodminal pain that is
non-focal and associated with nasuea and inability to take her
medications. She felt shaky, her BP was high, and her BS was
elevated to the 300s-400s. She was seen at ___ on ___ where she
reports labs wer normal, CT scan was not done, and she was
discharged home. On ___, she had one episode of NBNB vomiting.
She called EMS who took her to the ED.
In the ED, her vitals were stable. Her exam was notable for mild
suprapubic tenderness, and her UA was notable for trace ketones,
lg leukocytes, and moderate bacteria. Given her hyperkalemia
(___) w/anion gap (17), there was concern for DKA. She was
started on an insulin drip briefly and given 10U insulin with
___ amp of D25, and her values corrected (K 4.8). Her insulin
drip was stopped after normalization of her bicarb.
Additionally, she was started on Cipro for her UTI. She was
given tylenol, GI cocktail, morphine drip, and zofran for her
abdominal pain, which responded.
She was transferred tot he floor, where her abdominal pain
improved. This morning she endorses more abdominal pain and
appears distressed. The pain is still widely distributed.
However, she is distractable and her pain is not constant or
increasing. She does endorse some headache.
Past Medical History:
IDDM (type 2) complicated by gastroparesis diagnosed in ___
GERD
Hypertension
Depression
Elevated BMI
Recurrent urinary tract infections due to urethral diverticulum
Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
Admission:
Vitals: 98.5 98.5 ___ 18 99RA ___ 168
General: alert, oriented, appears distressed, obese
HEENT: sclera anicteric, oropharynx clear
Neck: supple, no LAD, Left IJ in place
Lungs: clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: regular rate and rhythm, no mrg
Abdomen: soft, non-tender, minimally-distended, bowel sounds
present but far spaced, no rebound tenderness or guarding,
GU: no foley
Ext: warm, well perfused,
Neuro: motor function grossly normal
Discharge:
Vitals: 98.8 98.8 100-148/67-68 ___ 18 RA ___ 134-270s
General: alert, oriented, no acute distress
Neck: L IJ in place, c/d/i
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, no mrg
Abdomen: soft, non-tender, non-distended, bowel sounds present.
Ext: WWP, no edema
Neuro: motor function grossly normal, ambulatory
Pertinent Results:
Admission:
___ 02:25PM BLOOD Glucose-279* UreaN-34* Creat-1.6* Na-132*
K-5.3* Cl-96 HCO3-19* AnGap-22*
___ 11:20PM BLOOD Glucose-203* UreaN-28* Creat-1.3* Na-133
K-4.8 Cl-96 HCO3-29 AnGap-13
___ 02:25PM BLOOD Albumin-4.1
___ 11:20PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1
___ 03:55PM BLOOD WBC-21.9* RBC-4.28 Hgb-10.2* Hct-33.5*
MCV-78* MCH-23.9* MCHC-30.5* RDW-15.8* Plt ___
___ 03:55PM BLOOD Neuts-83.0* Lymphs-13.0* Monos-3.0
Eos-0.4 Baso-0.6
___ 03:55PM BLOOD Plt ___
___ 03:55PM BLOOD Plt ___
___ 02:25PM BLOOD ALT-19 AST-21 AlkPhos-180* TotBili-0.2
___ 11:37PM BLOOD ___ Temp-37.2 pO2-39* pCO2-47*
pH-7.43 calTCO2-32* Base XS-5 Intubat-NOT INTUBA
___ 02:32PM BLOOD Glucose-271* Na-132* K-5.9* Cl-97
___ 02:32PM BLOOD Hgb-11.4* calcHCT-34
Microbiology:
___ 2:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Cx x2 NGTD
CXR
IMPRESSION:
Left internal jugular central venous line ends in the low SVC.
No evidence of pneumothorax.
Discharge:
___ 06:00AM BLOOD Glucose-144* UreaN-30* Creat-1.2* Na-137
K-4.7 Cl-98 HCO3-29 AnGap-15
___ 06:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.2
Brief Hospital Course:
This is a ___ year old female with PMhx DM type 2 poorly
controlled complicated by gastroparesis, recurrent UTIs, recent
admission ___ for gastroparesis, admitted ___ with
abdominal pain, hyperglycemia, hyperkalemia and ___, treated for
dehydration and gastroparesis, now improving and able to
tolerate a normal diet.
# Abdominal Pain / Gastroparesis - patient with a history of
nausea / vomitting presumed to be from gastroparesis; trigger
for symptoms was thought to be recent uncontrolled blood sugars.
Patient treated symptomatically, with NPO, IV fluids, prn
symptom control, then advanced diet to regular and discharged
home. Given that she was previously followed at ___ for primary
care and has been in the process of transitioning care to ___
(but had not established with PCP or gastroenterology) we set up
PCP and GI appointments post-discharge.
# hyperosmolar hyperglycemic nonketotic syndrome - treated with
IV fluids, insulin, with normalization of ___ from 300-400 to
less than 200. Uptitrated lantus from 35 units qHS to 40 units
and continued sliding scale
# Hyponatremia - from dehydration, corrected with IV fluids
INACTIVE ISSUES
#Hypertension: continued home nifedipine and lisinopril
Transitional Issues:
- Patient high risk for readmission, discharged home with close
PCP and GI ___
- Counseled on importance of glucose control
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS
7. NIFEdipine CR 60 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 150 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
12. Ferrous Sulfate 325 mg PO TID
13. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
14. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO TID
4. Gabapentin 600 mg PO TID
5. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 40 mg PO DAILY
7. Metoclopramide 10 mg PO QIDACHS
8. NIFEdipine CR 60 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Sertraline 150 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
13. Senna 8.6 mg PO BID:PRN constipation
14. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis, Diabetic Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
We had the pleasure of taking care of you during this admission.
You were admitted because you had severe abdominal pain and
nausea, and you were found to have very elevated blood sugars.
We treated your blood sugars with insulin therapy. Your
abdominal pain was thought to be due to an acute worsening of
your existing diabetic gastroparesis. After your sugars were
better under control, your pain subsided and you were able to
tolerate your diet without nausea or vomiting. We have set you
up with outpatient follow up appointments with a primary care
physician and gastroenterologist at ___. It is very important
that you follow through with these appointments, as they will
help you manage your blood sugars and abdominal pain over the
long term. If you continue to miss these appointments, you will
no longer be allowed to schedule appointments at ___.
Thank you,
___ MDs
Followup Instructions:
___
|
10577647-DS-19 | 10,577,647 | 24,646,166 | DS | 19 | 2145-06-05 00:00:00 | 2145-06-07 13:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / aspirin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Central line placement (___)
History of Present Illness:
___ yoF with PMH significant for longstanding DM, complicated by
gastroparesis, neuropathy, and proteinuria, hypertension, and
recurrent UTI ___ urethral diverticulum who presents with
acute-on-chronic ___ abdominal pain. Of note, patient is a
poor historian and is uncooperative with interview. Patient
reports her symptoms are similar to prior gastroparesis pain,
which resulted in the inability to tolerate PO. She also
complains of nausea and vomiting. She had 3 episodes of
nonbloody, nonbilious emesis on the day of admission. Last bowel
movement was 1 week ago.
The patient was recently admitted to ___ from ___ and
___ with similar symptoms. The patient was given home
medications, which included reglan, tramadol, gabapentin, and
anti-emetics. Reglan was later discontinued due to lack of
efficacy.
Per chart review, the patient was previously followed at ___ and
only recently transferred care to ___. She has been
hospitalized at ___ multiple times a month "for the past ___
years" for both gastroparesis and HHS/DKA. No acute GI pathology
had ever been
diagnosed on imaging. She had an EGD performed in ___, which
revealed ___ esophagitis, treated with fluconazole. The
patient
reports no medical intervention has ever truly helped her
symptoms. In regard to her transfer of care, she states "I just
got tired of them sending me home sick. They kept giving me pain
and nausea medications but I was still sick." She denies having
previously been on maintenance opiates for pain control, citing
the fact that ___ physicians were reluctant to give pain
medication due to the potential for worsening gastric motility.
In the ED, initial vitals were: 98.0 130 SBP253 18 100%. Finger
stick blood sugar was 170. Initial exam notable for patient in
severe pain. Labs were notable for WBC 18.5 (baseline), Cr 1.2,
lactate 3.9. UA showed Lg leuks, neg nit, 100 protein, 1000
gluc, >182 WBC, and few bacteria. A central line was placed d/t
poor IV access. She was given metopclopromide 5mg,
diphenhydramine 25mg, morphine sulfate 5mg, hydromorphone 0.5mg
x3, diazepam 5mg, and 3L of NS. She was given one dose of
cefepime. Vitals prior to transfer were: 98.3 91 173/87 22 100%
RA.
Upon arrival to the floor, she continues to have severe
abdominal pain. She reports that after her recent discharge she
was well for only one day but then had recurrence of her chronic
symptoms. Last BM was 1 week ago. She reports poor appetite. No
dysuria.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
- IDDM (type 2): HbA1c 8.3#, complicated by gastroparesis
diagnosed in ___
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ON ADMISSION:
VS: 98.5 173/76 93 100%RA
GENERAL: Alert, oriented. middle-aged F lying in bed. NAD
HEENT: PERRL, MMM, poor dentition, +hirsutism
NECK: Supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi. bre
CV: RRR, Nl S1, S2, No MRG
ABD: obese, soft, tender throughout, most markedly at the
epigastrium, hypoactive bowel sounds. no flank tenderness
BACK: No CVA tenderness.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. xerosis; no lesions
NEURO: CNs2-12 intact, motor function grossly normal. diminished
plantar sensation
SKIN: No excoriations or rash.
ON DISCHARGE:
98.1 140/80 79 100%RA
GENERAL: Alert, oriented. middle-aged F lying in bed. NAD
HEENT: PERRL, MMM, poor dentition, +hirsutism
NECK: Supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi. bre
CV: RRR, Nl S1, S2, No MRG
ABD: obese, soft, NT, +BS. no flank tenderness
BACK: No CVA tenderness.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. xerosis; no lesions
NEURO: CNs2-12 intact, motor function grossly normal. diminished
plantar sensation
SKIN: No excoriations or rash.
Pertinent Results:
ON ADMISSION:
___ 03:05PM GLUCOSE-299* UREA N-19 CREAT-1.2* SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
___ 03:05PM ALT(SGPT)-18 AST(SGOT)-16 ALK PHOS-131* TOT
BILI-0.2
___ 03:05PM ___ PTT-31.4 ___
___ 03:02PM TYPE-CENTRAL VE COMMENTS-GREEN TOP
___ 03:02PM LACTATE-2.1*
___ 01:48PM TYPE-CENTRAL VE PO2-38* PCO2-49* PH-7.37
TOTAL CO2-29 BASE XS-1
___ 01:48PM O2 SAT-64
___ 01:06PM TYPE-CENTRAL VE COMMENTS-GREEN TOP
___ 01:06PM LACTATE-3.9*
___ 12:15PM GLUCOSE-350* UREA N-21* CREAT-1.4* SODIUM-137
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-23 ANION GAP-22*
___ 12:15PM estGFR-Using this
___ 12:15PM WBC-18.5*# RBC-4.34 HGB-10.4* HCT-33.9*
MCV-78* MCH-24.0* MCHC-30.7* RDW-17.2*
___ 12:15PM NEUTS-86.2* LYMPHS-11.4* MONOS-1.7* EOS-0.3
BASOS-0.4
___ 12:15PM PLT COUNT-546*
___ 10:00AM URINE UCG-NEG
___ 10:00AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 10:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 10:00AM URINE RBC-1 WBC->182* BACTERIA-FEW YEAST-NONE
EPI-1
ON DISCHARGE:
___ 05:16AM BLOOD WBC-10.3 RBC-3.49* Hgb-8.4* Hct-27.3*
MCV-78* MCH-24.1* MCHC-30.8* RDW-16.6* Plt ___
___ 05:16AM BLOOD Glucose-185* UreaN-11 Creat-1.0 Na-136
K-4.0 Cl-100 HCO3-29 AnGap-11
___ 05:16AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
MICROBIOLOGY:
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON
___ - ___.
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 2:56 pm BLOOD CULTURE: pending
___ 9:00 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:38 pm BLOOD CULTURE Source: Line-R IJ.
Blood Culture, Routine (Pending):
IMAGING:
CXR (___)
Status post left internal jugular central venous line. No
pneumothorax.
OTHER STUDIES:
EKG ___: Sinus, RBBB (chronic), QTc 447
___ EGD:
Patient was intubated due to 600 cc of emesis prior to procedure
with retching. Mild bleeding in oropharynx prior to procedure.
Impression: Normal mucosa in the esophagus
No food contents found in stomach. Mildly pale appearance to
stomach with erythema in antrum. (biopsy)
Normal mucosa in the duodenum
Patient was intubated due to 600 cc of emesis prior to procedure
with retching.
Mild bleeding in oropharynx prior to procedure.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ with history of IDDM (c/b gastroparesis and neuropathy),
HTN, recurrent UTI ___ urethral diverticulum), and obesity
presented with acute-on-chronic abdominal pain, clinically
consistent with a gastroparesis flare.
ACTIVE ISSUES:
# Abdominal Pain: Her history and exam were consistent with
gastroparesis flare. She had longstanding IDDM c/b dysautonomia
and neuropathy. Infrequent bowel movement and hypoactive bowel
sounds on exam further supported gastroparesis. She was given
fluids and anti-emetics, and her pain was managed with standing
tylenol, tramadol, and dilaudid (PO+IV) for breakthrough pain.
Given hx of prolonged QTc and lack of prior response to
metoclopramide, this was not used. Her diet was advanced as
tolerated. GI was consulted, who agreed with the presumed
diagnosis. She also underwent an EGD on ___, which was negative
for ulcer or gastritis. It is recommended that she have an
gastric emptying study done, for which she needs to be off any
opiates, as they can interfere with the study.
# HYPERTENSION: Poorly controlled. SBP 253 on arrival. Increased
nifedipine to 90mg qd with good response. Continued lisinipril
40mg.
# Bacteremia: Patient grew GPC in pairs/clusters on 1 set of
blood cultures, all subsequent were negative. She received a
single dose of daptomycin (due to vancomycin allergy), however
given lack of fevers, clinical signs of infection, or any
subsequent positive cultures, this was felt to be contaminant.
She did not receive further antibiotics, was monitored, and
remained without sign of infection. Her leukocytosis was
chronic and at baseline, however it even improved by the time of
discharge.
# Pyuria: She had a positive urinanalysis but remained
asymptomatic without dysuria, fever, or CVA tenderness.
Leukocytosis was chronic and at baseline. No antibiotics were
given outside of the above. Urine culture remained negative.
Would recommend repeating u/a as an outpatient for work-up of
pyuria.
# Leukocytosis: Chronic neutrophilia and at baseline according
to our OMR results. Etiology not entirely clear. No clinical
suspicion for infection as discussed above. Hematologic
malignancy was thought to be less likely given that she denied
constitutional symptoms and the WBC was only mildly elevated.
Differential was otherwise normal. Given her prior elevated
platelet count, one could consider an underlying
myeloproliferative disorder. Given its normalization to 10 by
day of discharge, however, it was felt that this could be a
stress-response in association with her gastroparesis flares,
however further work-up and possible Hematology evaluation
should be considered.
CHRONIC ISSUES:
# DM2: Poorly-controlled. HbA1c 8.3%. She was continued on her
home glargine 40 units with sliding-scale coverage.
# GERD: Continued home pantoprazole 40mg
# DEPRESSION: Continued home sertraline 150mg.
TRANSITIONAL ISSUES:
-------------------
- Difficult Access: Contact ___ for consideration of
port placement given frequent admissions and need for multiple
central lines
- Gastric emptying study to confirm gastroparesis. Needs to be
off opiates, since opiates can interfere with the study
- f/u with GI - consideration of domperidone or other less
common agents may be considered for her recurrent, severe
gastroparesis
- Blood pressures elevated during hospitalization. Pain may have
contributed. Nifedipine increased to 90mg daily with improved
control
- Because she has a history of recurrent hospitalization with
hyperglycemia, tighter control of her blood sugar is
recommended. consider referral to ___ if indicated
- could consider IV iron infusion to spare the GI side effects
of her ferrous sulfate
- Encourage compliance with medications, particularly insulin.
- Chronic leukocytosis work-up
- close f/u made with PCP and GI
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Ferrous Sulfate 325 mg PO TID
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. NIFEdipine CR 60 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Senna 8.6 mg PO BID:PRN constipation
9. Sertraline 150 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
11. Promethazine 25 mg PO Q8H:PRN nausea
12. Prochlorperazine 25 mg PR Q12H:PRN nausea
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
14. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Gabapentin 600 mg PO TID
4. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 40 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
RX *nifedipine 90 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
8. Prochlorperazine 25 mg PR Q12H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 150 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
12. Ferrous Sulfate 325 mg PO TID
13. Promethazine 25 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Gastroparesis
Acute kidney injury
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 caring for you at ___
___. You were admitted for abdominal pain, which is
due to a recurrent gastroparesis flare. We treated you with IV
fluids, and pain and anti-nausea medications. We also increased
your blood pressure medication nifedipine since your pressure
was very high.
You underwent an upper endoscopy scope (EGD) by our GI doctors
which did not show ulcers or other causes of abdominal pain. We
advanced your diet when you felt ready. It is important your
diabetes remains under control, as this can cause worsening of
your gastroparesis.
We are glad you are feeling better and we wish you the best.
Your ___ team
Followup Instructions:
___
|
10577647-DS-20 | 10,577,647 | 27,650,358 | DS | 20 | 2145-06-13 00:00:00 | 2145-06-22 14:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ - Femoral temporary CVL placement
___ - Port placement (double-lumen)
History of Present Illness:
___ with history of IDDM (c/b gastroparesis and neuropathy),
HTN, recurrent UTI ___ urethral diverticulum), gastroparesis,
obesity, and almost weekly admissions for intractable
nausea/vomiting and abdominal pain who presents for a similar
episode. She was just discharged from ___ on ___. She
experienced the onset of abdominal pain, nausea, vomiting and
inability to tolerate PO meds. History taking difficult at
present due to patient's pain. She does report taking her blood
pressure medications this AM.
Patient recently transfered care from ___ to ___ and has had
frequent admissions for intractable nausea/vomiting and
abdominal pain which have been treated with pain medications.
She has been unable to follow-up with GI outpatient due to her
frequent hospitalizations.
During her last admission, she was treated with IV fluids and
standing acetaminophen, PRN tramadol, and PRN dilaudid PO/IV.
She also had an EGD, which was normal. Repeat gastric emptying
study was recommended, but not performed because she has to be
off opioids.
In the ED, initial VS were 98.6 ___ 25 100%
Exam significant for diffuse abdominal pain.
Labs significant for WBC 16.2 (85.6%N), H/H 9.2/28.9, PLT 488,
ALK PHOS 130, GLU 288
Received 1L NS, ondansetron, and 2 mg IV dilaudid and right
femoral line was placed due to difficulty obtaining venous
access.
Transfer VS were 98.6 98 153/95 17 RA
On arrival to the floor, patient is writhing in pain and unable
to answer my questions. She does say yes to having taken her BP
medications this AM, as well as having a bowel movement this AM.
Past Medical History:
- IDDM (type 2): HbA1c 8.3#, complicated by gastroparesis
diagnosed in ___
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION EXAM:
VS 98.6 98 SBP 180
GENERAL: In distress, writhing in bed
HEENT: Sclera anicteric. EOMI
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 tenderness, no
rebound/guarding, no hepatosplenomegaly. Right femoral line in
place, bandage bloody
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, unable to evaluate CN2-12 due to pain
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: 98.2 139/71 73 17 97%RA
GENERAL: middle-aged, obese woman lying comfortably in bed
HEENT: Sclera anicteric
CHEST WALL: left-sided double-lumen port in place, no
bleeding/oozing. minimal tenderness at site, no redness/swelling
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, no tenderness, no rebound/ guarding,
no hepatosplenomegaly. Right femoral line removed, groin site
clean, dry, intact
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: fully oriented and conversive. walking around room.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 12:17PM BLOOD WBC-16.2*# RBC-3.74* Hgb-9.2* Hct-28.9*
MCV-77* MCH-24.6* MCHC-31.8 RDW-17.0* Plt ___
___ 12:17PM BLOOD Neuts-85.6* Lymphs-11.7* Monos-1.9*
Eos-0.3 Baso-0.3
___ 12:17PM BLOOD Glucose-288* UreaN-21* Creat-1.0 Na-137
K-4.3 Cl-98 HCO3-24 AnGap-19
___ 12:17PM BLOOD ALT-27 AST-19 AlkPhos-130* TotBili-0.2
___ 12:30PM BLOOD Lactate-1.1
DISCHARGE:
___ 05:13AM BLOOD WBC-12.4* RBC-3.24* Hgb-7.8* Hct-25.4*
MCV-78* MCH-24.2* MCHC-30.8* RDW-16.8* Plt ___
___ 05:13AM BLOOD Glucose-251* UreaN-29* Creat-1.1 Na-134
K-4.6 Cl-100 HCO3-26 AnGap-13
___ 05:13AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
___ MRCP:
Lower Thorax: The lung bases are grossly clear. There is no
pleural or
pericardial effusion.
Ascites: There is no ascites.
Liver: The liver is normal in signal intensity without evidence
of focal mass.
Gallbladder and Biliary System: The gallbladder is absent. There
is no
intrahepatic bile duct dilation. The common bile duct is 6 mm,
within the
range seen after cholecystectomy, with normal tapering at the
ampulla.
Pancreas: The pancreas is normal in signal intensity and
enhancement. There is
no evidence of focal mass. There is classic pancreatic ductal
anatomy without
dilatation.
Spleen: The spleen is not enlarged.There is no focal splenic
lesion.
Kidneys and Adrenals: The adrenal glands are normal
bilaterally. The kidneys
enhance symmetrically without hydronephrosis. No focal renal
lesion is
identified.
Bowel: The visualized bowel loops and mesentery are within
normal limits. The
stomach and duodenum are not dilated.
Lymph Nodes: There is no mesenteric or retroperitoneal
lymphadenopathy in the
upper abdomen.
Vessels: The imaged abdominal aorta is normal in caliber. The
celiac axis and
SMA are patent at their origins. Apparent narrowing at the
origin of the
celiac artery is likely due to the normal effect of the median
arcuate
ligament in expiration. There are no collateral vessels to
suggest chronic
stenosis of the celiac artery and it is widely patent on the
axial images.
The SMA-aortic angle is wide and the underlying renal vein is
patent. The main
portal vein, splenic vein, and SMV are patent.
Bones: The osseous structures are unremarkable and there is no
suspicious bone
lesion.
IMPRESSION:
Normal MRI of the abdomen. Specifically, normal examination of
the pancreas.
No evidence of SMA syndrome.
___ 07:10AM BLOOD CRP-8.9*
___ 05:17AM BLOOD IgA-273
___ 05:17AM BLOOD tTG-IgA-7
___ ___
Metanephrines (Plasma)
Test Name Flag Results Units
Reference Value
--------- ---- ------- -----
---------------
Metanephrines, Fract., Free
Normetanephrine, Free <0.20 nmol/L <
0.90
Metanephrine, Free <0.20 nmol/L <
0.50
___ 14:45
HISTAMINE, PLASMA
Test Result Reference
Range/Units
HISTAMINE, PLASMA <1.5 0.1-1.8
___ 10:47
HEAVY METAL SCREEN
Test Result Reference
Range/Units
ARSENIC, BLOOD <3 <23 mcg/L
Whole Blood Arsenic level >100 mcg/L is indicative of
acute/chronic exposure. Urine is usually the best
specimen for the analysis of arsenic in body fluids.
Blood levels tend to be low even when urine
concentrations are high
Test Result Reference
Range/Units
MERCURY, BLOOD <4 <=10 mcg/L
LEAD, BLOOD <2 <10 mcg/dL
LEAD(B) COLLECTION SAMPLE Venous
___ 10:47
C1 ESTERASE INHIBITOR, FUNCTIONAL ASSAY
Test Result Reference
Range/Units
C1 INHIBITOR, FUNCTIONAL >100 >=68 %
Reference Range (%):
>= 68 Normal
41-67 Equivocal
<= 40 Abnormal
___ 10:47
TRYPTASE
Test Result Reference
Range/Units
TRYPTASE 6 ___ ng/mL
___ 09:30
LEAD (BLOOD)
Test Result Reference
Range/Units
LEAD, BLOOD <3 <10 mcg/dL
LEAD(B) COLLECTION SAMPLE VENOUS
Brief Hospital Course:
___ with history of IDDM (c/b gastroparesis and neuropathy),
HTN, recurrent UTI ___ urethral diverticulum), and obesity
presented with acute-on-chronic abdominal pain, clinically
consistent with a gastroparesis flare.
ACTIVE ISSUES:
# Abdominal pain, nausea, emesis: Improved on standing po
metoclopramide and bethanechol. Given her recurrent symptoms,
poorly-controlled IDDM, and relatively normal EGD last week, the
clinical impression remains most consistent with gastroparesis.
There are some atypical features as pointed out by Dr. ___
___ week including onset ___iagnosis, report of
prior borderline gastric emptying study, and lack of retained
food in the stomach on EGD (though significant retained fluid).
She has had no infections symptoms to raise suspicion for this
as a precipitating factor. Dietary indiscretion with poor
glycemic control is presumed to be contributing to her recurrent
flares. Given severity of flares and some atypical features as
above, expanded work-up to ensure not missing less common
etiologies, see lab work-up below.
Other agents like domperidone, tegaserod, cisapride are both
difficult to obtain and may have more dangerous side effect
profile. While she previously had report of QTc prolongation and
lack of response to metoclopramide, she was re-challenged with
10mg standing metoclopramide q6h initially IV with EKG and
telemetry monitoring - she tolerated it well, seemed to respond
clinically, and had a stable QTc around 430-450. She was also
started on standing bethanechol per GI recs 25mg qachs and
seemed to respond to this combination well.
Expanded lab work-up was performed including MRCP which was
negative for pancreatic disease or mesenteric vasculature
disease, along with negative screening for heavy metals, lead,
histamine, tryptase, C1 esterase inhibitor, and urine
porphobilinogen.
# Venous access: Given history of recurrent nearly weekly
hospitalizations requiring similar frequent invasive CVL
placement along including femoral lines, decision was made in
conjunction with pt to place a port for more durable access and
less invasive overall compared to the above, s/p placement ___.
Arranged with her PCP to ensure appropriate f/u for flushes in
the pheresis unit monthly if she is not admitted in the interim.
Femoral line was placed in our emergency department, removed
___ after port placed.
# Hypertensive Urgency: Improved. She had SBP to 250s overnight
___, asymptomatic. Had more significant than anticipated
response to 100mg po labetalol x1 with SBP decrease to 120 or
so, though no new neurological symptoms/deficits amidst this
decrease. She is prone to hypertensive urgency in setting of
pain from her flares. We continued her home nifedipine and
lisinopril, and her BP remained stable subsequently throughout
her course. As an outpatient, it may be worth discontinuing
nifedipine for a non calcium channel blocker given potential to
slow smooth muscle contraction of gut
# Leukocytosis: Frequently present amidst her gastroparesis
flares along with similar rise in inflammatory makers. This has
resolved as her flares resolve. She had no clinical or
localizing signs of infection.
# Anemia: She had a slight downtrend over the last few days of
her course. No clinical evidence of bleeding currently. ___ be
slight dilutional effect from drawing off port in background of
probable iron deficiency anemia. Most recent ferritin was 26 in
___. Holding iron po supplementation given GI effects,
though could potentially benefit from IV iron infusion as
outpatient. Additionally, further work-up should be done as
outpatient including possible colonoscopy.
# ___: Improved after IVF. Consistent with mild pre-renal in
setting of NPO for procedure.
# Diabetes: Poorly controlled. HbA1c 8.3%. Control is critical
in helping to improve gastroparesis flares as above.
- Continued home glargine and humalog SSI
CHRONIC ISSUES:
# GERD: Continue home pantoprazole 40mg BID
# DEPRESSION: Continue home sertraline 150mg.
# CODE: Full
# CONTACT: ___ (___) ___
TRANSITIONAL ISSUES:
- Needs flushing of BOTH lumen of her double-lumen Port every 4
weeks (q4-6 weeks OK). Therefore if she is not hospitalized she
will need this arranged as an outpatient via the Pheresis unit.
Contact is ___ in the pheresis unit
- Continue standing metoclopramide and bethanechol in effort to
control gastroparesis. Bethanechol may be up-titrated to 50mg
dose if continues to tolerate.
- Should undergo gastric emptying study as outpatient when more
consistently off of narcotics amidst flares
- Continue to counsel on importance of compliance with low-fat
diet and avoidance of anything that can precipitate
gastroparesis flares (marijuana; poor glycemic control)
- f/u iron-deficiency anemia as outpatient - consider IV iron
infusion given GI effects of ferrous sulfate
- Hypertension: If able, could consider discontinuation of
nifedipine given possible GI-slowing effects of calcium channel
blockade
- f/u final results of expanded laboratory work-up to rule out
other potential though rare causes of GI symptoms: (heavy
metals, lead, histamine, tryptase, C1 esterase inhibitor)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Gabapentin 600 mg PO TID
4. Lisinopril 40 mg PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Prochlorperazine 25 mg PR Q12H:PRN nausea
8. Senna 8.6 mg PO BID:PRN constipation
9. Sertraline 150 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
11. Ferrous Sulfate 325 mg PO TID
12. Promethazine 25 mg PO Q8H:PRN nausea
13. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Gabapentin 600 mg PO TID
4. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 40 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Senna 8.6 mg PO BID:PRN constipation
9. Sertraline 150 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
11. Bethanechol 25 mg PO QID
RX *bethanechol chloride 25 mg 1 tablet(s) by mouth four times a
day Disp #*56 Tablet Refills:*0
12. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN moderate pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*5 Tablet Refills:*0
13. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times a day
Disp #*56 Tablet Refills:*0
14. Prochlorperazine 25 mg PR Q12H:PRN nausea
Contact your doctor if you need multiple doses of this medicine
since it can interact with others.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Severe gastroparesis
Secondary Diagnosis
- Hypertensive urgency
- Mild Acute kidney injury
- Leukocytosis, stress-induced
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted to ___ on ___ after having another severe
flare of abdominal pain, nausea, and vomiting. You underwent an
extensive work-up including physical exams, blood tests, and
imaging tests. Based on these results, we do feel that the most
likely cause of your symptoms continues to be severe
gastroparesis (slow-moving stomach and intestines) related to
diabetes.
We did perform several additional lab tests to ensure there are
no other causes - these results are pending and can be discussed
as an outpatient.
Since you require very frequent placement of large IV lines in
your neck and groin, you underwent a procedure to place a Port
which will give hospitals easier and quicker access to give you
IV fluids and medications if needed.
** You need to always carry your Portacath card on you so that
it can be safely accessed if needed **
** You need to have your Port flushed in the ___ clinic
every 4 weeks. We are notifying your PCP ___ to
help facilitate this **
You were started on 2 medications to help with your
gastroparesis. These are called metoclopramide (Reglan) and
bethanechol. Please be sure to take these as prescribed.
Lastly, it is really important to avoid common triggers of
gastroparesis - this includes any fatty foods, making sure your
sugars are in good control, and not using any drugs that could
slow the gut down (including marijuana). Please be sure to
follow-up at your scheduled appointments below.
We wish you the best of luck!
Your ___ Care Team
Followup Instructions:
___
|
10577647-DS-27 | 10,577,647 | 23,684,639 | DS | 27 | 2145-08-12 00:00:00 | 2145-08-12 23:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
right flank pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx morbid obesity, DM2 c/b gastroparesis, recurrent UTI d/t
urethral diverticulum, frequent hospitalizations, chronic
leukocytosis (unexplained) presents for R Flank Pain, N/V/D.
She was recently hospitalized ___ for abdominal pain. She
had been diagnosed with C. diff on her stay immediately prior
(discharged ___, treated with 10d PO Flagyl, due to finish
___ that was attributed to gastroparesis flare. She had sx of
syncope thought vasovagal and orthostatic, AoCKI that resolved
with IVF.
She returned to the ED with R flank pain. Sharp, intermittent
pain that started at 0500 and woke her from sleep. No relief
from tramadol. Denies fever, dysuria. Endorses hematuria, nausea
and vomiting. States pain is different from her abdominal pain.
Took insulin last night.
In the ED, initial vitals were: 98.8 80 149/86 20 100%.
- Labs were significant for: WBC 15.7, H/H 9.8/31.8, AP 124, nl
Chem7, Lactate 1.6, UA with MOD Leuks, MOD Bld, 76 WBC, Few
Bacteria, 300 Protein, no Glucose or Ketones. UCG negative.
- Imaging revealed thickened bladder wall with internal
echogenic debris.
- The patient was given: morphine 5mg IV x1, Dilaudid 1mg IV x2,
1L NS, CTX 1g, Zofran 4mg IV x1.
Vitals prior to transfer were: 98.1 78 155/89 16 100% RA.
Upon arrival to the floor, patient is found moaning while lying
in bed. She is minimally cooperative with interview and physical
exam. She does confirm the story above, specifies that her
current pain is in the R flank, not in the abdomen like her
gastroparesis pain. She has not had pain like this previously.
Also of note, after pt arrival to the floor, Hospital Dr. ___
___ a call from Radiology, results conveyed to me, that a
hypodensity was seen at the catheter tip, if the catheter is
working fine then this is no issue, if not she should have an
angiogram to evaluate for clot.
Past Medical History:
- IDDM (type 2): HbA1c 8.7% (___), complicated by
gastroparesis diagnosed in ___
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
Vitals: 98.1 ___ 100%RA
General: Moaning but alert, attentive, appears to be in distress
which patient reports is from her pain
HEENT: NCAT, pupils symmetric, anicteric sclera, clear OP, dry
MM
NECK: supple
Heart: RRR, no r/g/m
Lungs: CTAB anterolaterally
Abdomen: Obese, R-sided tenderness worse when approaching the
flank, +BS
Genitourinary: Tenderness at the R flank with minimal touch (no
percussion)
Extremities: WWP, no edema
Neurological: Face symmetric, moving all four limbs while supine
DISCHARGE PHYSICAL EXAM:
================================
Vitals: 98.4 (98.7) 154/80 (SBP 125-161) 78 (75-84) 20 100%
RA (95-100% RA)
I/O: PO=720, IV=50, URINE=650, BM=1
General: Sleeping, awakes to voice. Appears comfortable; notes
mild pain, falling asleep frequently during interview.
HEENT: NCAT, pupils symmetric, anicteric sclera, clear OP, moist
oral mucosa
NECK: supple
Heart: RRR, no r/g/m
Lungs: CTAB, unlabored breathing on room air
Abdomen: Obese, ttp to LUQ/RUQ/epigastrium; no r/g
Genitourinary: Tenderness at R flank improved; overall severity
of pain has decreased to mild today, significantly improved
since admission
Extremities: WWP, no edema
Neurological: Face symmetric, moving all four limbs while supine
Neuro: AOX3, CN2-12 intact. Strength ___ in BUE/BLE. Sensation
intact to light touch in distal extremities. No
tremor/dysmetria. Gait not assessed.
Pertinent Results:
ADMISSION LABS:
===============================
___ 01:05PM BLOOD WBC-15.7* RBC-4.08* Hgb-9.8* Hct-31.8*
MCV-78* MCH-24.1* MCHC-30.8* RDW-21.6* Plt ___
___ 01:05PM BLOOD Neuts-82.5* Lymphs-13.6* Monos-3.3
Eos-0.3 Baso-0.4
___ 01:05PM BLOOD Glucose-204* UreaN-17 Creat-0.9 Na-136
K-4.4 Cl-99 HCO3-27 AnGap-14
___ 01:05PM BLOOD ALT-20 AST-13 AlkPhos-124* TotBili-0.2
___ 01:05PM BLOOD Lipase-18
___ 01:05PM BLOOD Albumin-3.5
___ 05:37AM BLOOD Calcium-8.8 Phos-4.7*# Mg-1.8
___ 01:05PM BLOOD HCG-<5
___ 01:10PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:50PM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:10PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 04:50PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 01:10PM URINE RBC-3* WBC-82* Bacteri-FEW Yeast-NONE
Epi-10
___ 04:50PM URINE RBC-1 WBC-76* Bacteri-FEW Yeast-NONE
Epi-6
PERTINENT LABS:
================================
___ 04:52PM BLOOD WBC-12.5* RBC-3.83* Hgb-9.5* Hct-29.6*
MCV-77* MCH-24.8* MCHC-32.1 RDW-21.3* Plt ___
___ 04:52PM BLOOD Glucose-208* UreaN-17 Creat-0.9 Na-132*
K-4.4 Cl-97 HCO3-26 AnGap-13
___ 05:27AM BLOOD CK(CPK)-37
DISCHARGE LABS:
==================================
___ 05:51AM BLOOD WBC-10.3 RBC-3.80* Hgb-9.4* Hct-30.3*
MCV-80* MCH-24.6* MCHC-30.9* RDW-20.2* Plt ___
___ 05:51AM BLOOD Plt ___
___ 05:51AM BLOOD Glucose-141* UreaN-22* Creat-1.1 Na-135
K-4.2 Cl-102 HCO3-26 AnGap-11
___ 05:51AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.9
MICROBIOLOGY:
================================
___ 1:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:18 pm URINE Source: ___.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
___ 1:58 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
IMAGING:
===================================
#TRANSVAGINAL PELVIC ULTRASOUND ___:
The uterus is anteverted and measures 3.8 x 7.9 x 4.6 cm. The
endometrium ishomogenous and measures 4 mm. A urethral
diverticulum is again visualized. The ovaries are
morphologically normal, however, flow could not be
obtained,likely technical. Within the right pelvis, there is a
region of complex fluidin an area corresponding to the patient's
point of tenderness, potentiallywithin bowel. This measures
approximately 5 x 2 cm. The bladder appears thick walled with
internal echogenic debris. Trace amountof pelvic free fluid is
also noted. IMPRESSION: 1. Morphologically normal ovaries.
Vascular flow could not be obtained,likely technical.2.
Thickened bladder wall with internal echogenic debris.
Correlation withurinalysis is recommended to exclude
infection.3. Complex fluid collection within the right pelvis,
potentially within abowel loop, in the region of pain. CT can
be obtained for further assessment.
#CT ABD/PELVIS ___:
LOWER CHEST:The included lung bases show no pleural effusion or
pneumothorax. A leftcentral catheter is partially imaged with
the tip terminating in the rightatrium. A 17 mm low density
rounded structure to the tip is may reflectmixing artifact from
injected normal saline after contrast administration,however,
thrombus is difficult to exclude. Coronary calcifications
arepresent. ABDOMEN: HEPATOBILIARY: The liver demonstrates
homogenous attenuation throughout. There is no evidence of focal
lesions. There is no evidence of intrahepaticor extrahepatic
biliary dilatation. The gallbladder is surgically
absent..PANCREAS: The pancreas has normal attenuation
throughout, without evidence offocal lesions or pancreatic
ductal dilatation. There is no peripancreaticstranding.SPLEEN:
The spleen shows normal size and attenuation throughout,
withoutevidence of focal lesions.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 stones, focal renal lesions or hydronephrosis.
Thereis no perinephric abnormality.GASTROINTESTINAL: Small
bowel loops demonstrate normal caliber, wallthickness and
enhancement throughout. The cecum is located in the
pelvis(2:73). The appendix is not visualized, however, there are
no secondary signsfor appendicitis. There is no free air or free
fluid.RETROPERITONEUM: There is no evidence of retroperitoneal
and mesentericlymphadenopathy.VASCULAR: There is no abdominal
aortic aneurysm. There is minimal calciumburden in the
abdominal aorta and great abdominal arteries. PELVIS:The bladder
is mildly thickened despite under distention. A 2.6 cmurethral
diverticulum is again noted. The uterus and adnexa are
unremarkable.The right ovary is visualized superior to uterus
(2:63). There is no evidenceof pelvic or inguinal
lymphadenopathy. There is no free fluid in the pelvis. BONES
AND SOFT TISSUES: There are no lytic or blastic osseous lesions
ofconcern. A fat containing periumbilical hernia is present..
IMPRESSION: 1. Thickening of the bladder wall should be
correlated with urinalysis toexclude infection.2. Unchanged
urethral diverticulum.3. Hypodensity at the tip at the central
catheter may relate to artifact,however, thrombus is difficult
to exclude. Further evaluation can be performednon emergently
with echocardiogram.
ECGStudy Date of ___ 11:52:52 AM
Sinus rhythm. Limb leads are misattched. Right bundle-branch
block. No major
change from the previous tracing.
IntervalsAxes
___
___
#TRANSTHORACIC ECHOCARDIOGRAM ___:
The left atrium is elongated. 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%). 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. No masses or vegetations are seen on the
aortic valve. The increased aortic velocity is likely related to
increased stroke volume. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) 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
preserved regional and global biventricular systolic function.
Mild aortic regurgitation. Mild mitral regurgitation. No
discrete vegetations identified.
Brief Hospital Course:
___ year old woman with obesity, recurrent urinary tract
infection in setting of urethral diverticulum, insulin dependent
type 2 diabetes mellitus complicated by gastroparesis, multiple
hospital admissions with port-a-cath for poor venous access,
presenting with acute right flank pain, nausea, and vomiting.
Urine culture with ampicillin resistant enterococcus; patient
treated with daptomycin given rash/desquamation with vancomycin.
Pain treated with dilaudid, improved on day of discharge.
# R Flank Pain with N/V/D: likely due to pyelonephritis, as
exam demonstrated severe pain with even light palpation over a
large area including the right flank and lower back into right
buttock and hip. Urinalysis with moderate blood and pyuria,
consistent with either infection or inflammation. She was
started on treatment with ceftriaxone. No evidence of toxic
megacolon in setting of recently treated C diff infection. No
evidence of other intra-abdominal pathology on imaging. Pain
improved with dilaudid, and she had no further episodes of
nausea or vomiting. On ___, urine culture turned positive for
enterococcus. She was switched from ceftriaxone to daptomycin
given vancomycin allergy. Antibiotic sensitivity testing of
enterococcus demonstrated resistance to ampicillin, and so she
was continued on daptomycin. Patient to continue daptomycin for
a total of 14 days (___). By day of discharge, patient's
pain had markedly improved so dilaudid was stopped.
# Upper abdominal pain: ttp in LUQ/epigastrium/RUQ; patient
states this has been going on since arrival to hospital. Likely
due to gastroparesis. Patient continued on home
metoclopramide, home bowel regimen, ondansetron PRN nausea, and
PPI.
# Question of thrombus on central catheter: CT scan done on
admission with question of thrombus on tip of port-a-cath
central venous catheter. Although this was acknowledged to be
possible CT artifact, this was followed-up with transthoracic
echocardiogram, which was unable to rule out thrombus on the
catheter tip. On admission, blood could not be drawn from one
of the two ports. TPA was instilled overnight, after which
blood was able to be drawn from the previously occluded port
lumen. In discussion with interventional radiology and IV access
team, it was felt that either the area concerning for thrombus
was CT artifact, or was removed with instillation by TPA and
subsequently not visible on TTE. She had no symptoms of stroke
or pulmonary embolism.
#Diarrhea: reported increasing frequency of diarrhea (4 episodes
on ___. With recent C diff and current antibiotic exposure,
team was worried about mild-moderate first recurrence. C Diff
negative, though patient was treated empirically with oral
metronidazole, which she will continue prophylactically
throughout her daptomycin course (until ___.
# Diabetes mellitus: due to nausea, vomiting, and poor PO intake
on admission, she was initially treated with 70% of her home
Lantus dose, along with sliding scale humalog. Lantus dose was
gradually increased during her hospital course as she was
tolerating regular diet without further vomiting. By day of
discharge, patient was sent out on home lantus.
# HTN: Continued on home atenolol, nifedipine, lisinopril
# Asthma: continued on home Flovent, albuterol prn
# Urinary Incontinence: home bethanechol held while in-house,
but restarted upon discharge.
# Depression: continued on home sertraline
# Anemia: No evidence of bleed.
TRANSITIONAL ISSUES:
========================
# CODE STATUS: full confirmed
# CONTACT: ___ (daughter, ___
- Patient to continue daptomycin for a total of 14 days
(___). Patient setup with home infusion services.
- Patient to continue prophylactic Flagyl (to prevent C diff)
while on daptomycin, until ___. C diff pending on discharge.
- CT scan on admission showed ?thrombus on tip of port-a-cath
central venous catheter. TTE subsequently obtained was unable to
view tip of catheter. After alteplase infusion, catheter now
working appropriately. Discussed between IV access team and ___
-> since port working appropriately, TEE not thought to be
necessary at this time.
- Patient to see GI for management of her gastroparesis
- Consider referral to H/O for evaluation of chronic
leukocytosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Atenolol 12.5 mg PO DAILY
4. Bethanechol 25 mg PO QID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Gabapentin 600 mg PO TID
7. Metoclopramide 10 mg PO QIDACHS
8. NIFEdipine CR 90 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Prochlorperazine 25 mg PR Q12H:PRN nausea
11. Sertraline 150 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
13. Lisinopril 40 mg PO DAILY
14. Docusate Sodium 100 mg PO DAILY:PRN constipation
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 8.6 mg PO BID:PRN constipation
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
18. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Daptomycin 300 mg IV Q24H
This is to be taken until ___ to complete a 14-day course.
RX *daptomycin [Cubicin] 500 mg 300 mg IV daily Disp #*12 Vial
Refills:*0
2. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen ___ mg PO Q8H:PRN pain
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
5. Atenolol 12.5 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Lisinopril 40 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
9. Sertraline 150 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Pantoprazole 40 mg PO Q12H
13. NIFEdipine CR 90 mg PO DAILY
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
This is to be taken until ___.
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*36 Tablet Refills:*0
15. Metoclopramide 10 mg PO QIDACHS
16. Gabapentin 600 mg PO TID
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. Prochlorperazine 25 mg PR Q12H:PRN nausea
19. Bethanechol 25 mg PO QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
========================
-Enterococcal urinary tract infection
SECONDARY DIAGNOSIS:
========================
-Insulin dependent type 2 diabetes mellitus
-Gastroparesis
-GERD
-Hypertension
-Depression
-Chronic low 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 meeting you and taking care of you during your
hospitalization at ___.
Unfortunately you were admitted to the hospital after developing
sudden right flank and lower back pain, as well as nausea and
vomiting. A CT scan of the abdomen did not reveal the cause of
your pain. A urine test indicated an infection in the urinary
tract. The bacteria identified in the urine was resistant to
typical antibiotics, and so you were treated with an antibiotic
called daptomycin, which you will continue to take at home.
Your pain was treated with dilaudid, and improved by the day of
discharge, and you were no longer having nausea or vomiting.
Followup Instructions:
___
|
10577647-DS-28 | 10,577,647 | 29,684,927 | DS | 28 | 2145-08-18 00:00:00 | 2145-08-19 06:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx morbid obesity, DM2 c/b gastroparesis, recurrent UTI d/t
urethral diverticulum, frequent hospitalizations, chronic
leukocytosis (unexplained) presents with 1 day history of
abdominal pain. Was recently admitted for enterococcus UTI,
discharged on daptomycin for a total of 14 days (___).
Also, diagnosed with C diff and discharged with PO flagyl until
___. She reports that day prior to presentation, developed acute
onset nausea and feeling that "having symptoms from my
gastroparesis." Given these symptoms, she did not eat the day of
admission. Denies episodes of hematemsis. Did have normal bowel
movement this AM. Denies fevers, chills, night sweats, nausea,
vomiting. Passing gas and having bowel movements.
Of note, patient was admitted from ___ with c/f
pyelonephritis. Patient's urine grew enterococcus resistant to
ampicillin. She was started on daptomycin given vanc allergy.
Patient was to complete 14d course (___). Additionally
patient was noted to have increasing diarrhea, given prior h/o
c.diff was treated empirically with oral metronidazole. C.diff
testing was negative, however decision was made to treat
prophylactically with PO flagyl through completion of her
datpomycin course (until ___.
In the ED, initial vitals were: 98.2 92 130/80 18 100% RA.
Initial labs notable for WBC 17.8, Hgb/Hct 9.9/31.5, Plt 496,
Na/K 136/4.1, BUN/Cr ___, Glucose 219, U/A with mod leuks/neg
nitrities, no bacteria.
ED exam notable for: Minimal diffuse abdominal TTP, Guaiac
negative
-EKG for QT monitoring - sinus rhythm, rate 81, left axis,
prolonged QRS, QTc 456, RBBB
In the ED: patient given a total of 2.5 mg hydromorphone, zofran
4 mg x 2, daptomycin 300 mg IV, Metaclorpamide 10 mg PO x 1,
metronidazole 500 mg PO x 1, pantoprazole 40 mg PO x 1,
sertraline 150 mg PO.
On the floor, patient noted having abdominal discomfort. Denied
chest pain or chest pressure. Denied any further episodes of
vomiting in Emergency Department. Passing gas and having normal
bowel movements. No diarrhea currently.
Review of systems:
Please see HPI.
Past Medical History:
- IDDM (type 2): HbA1c 8.7% (___), complicated by
gastroparesis diagnosed in ___
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
EXAM ON ADMISSION:
========================
Vital Signs: 98.7, 156/53, 82, 20, 100% on RA.
General: Alert and oriented, crying during physical examination
although easily distractable. Continues to have sputum.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, thick
neck, JVP not elevated.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese abdomen, tender to superficial palpation in the
epigastric region. Non-tender in all other areas of abdomen. 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, 2+ reflexes bilaterally, gait
deferred.
EXAM ON DISCHARGE:
========================
Vital Signs: 98.3 (98.7) 161/85 (SBP 121-161) 81 (64-81) 18
(___) 100% RA (96-100% RA)
I/O: PO=1180, IV=100, URINE=2920, BM=1
BG=125, 134, 173, 221, 262, 322
General: Alert and oriented, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, thick neck
CV: RRR, normal s1/s2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: obese abdomen, slight cramping discomfort when
epigastrium palpated, otherwise no r/g
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: grossly intact
Pertinent Results:
LABS ON ADMISSION:
=======================
___ 01:40AM BLOOD WBC-17.8*# RBC-4.01* Hgb-9.9* Hct-31.5*
MCV-79* MCH-24.8* MCHC-31.5 RDW-21.1* Plt ___
___ 01:40AM BLOOD Neuts-83.2* Lymphs-13.4* Monos-2.9
Eos-0.3 Baso-0.3
___ 01:40AM BLOOD Glucose-219* UreaN-24* Creat-1.1 Na-136
K-4.1 Cl-99 HCO3-23 AnGap-18
___ 12:06PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:06PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 12:06PM URINE RBC-3* WBC-12* Bacteri-NONE Yeast-NONE
Epi-20 TransE-<1
LABS ON DISCHARGE:
=======================
___ 05:16AM BLOOD WBC-10.3 RBC-3.79* Hgb-9.4* Hct-29.3*
MCV-77* MCH-24.9* MCHC-32.1 RDW-20.8* Plt ___
___ 05:16AM BLOOD Glucose-282* UreaN-18 Creat-1.1 Na-135
K-4.9 Cl-102 HCO3-25 AnGap-13
___ 05:16AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
MICROBIOLOGY:
=======================
___ 12:06 pm URINE UCU ADDED TO ___.
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/Tazobactam sensitivity testing confirmed
by ___
___. Cefepime sensitivity testing confirmed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STUDIES:
=======================
ECG Study Date of ___ 1:43:36 AM
Sinus rhythm. Right bundle-branch block. Compared to the
previous tracing of ___ the limb leads are correctly
attached. Otherwise, there are no
major changes.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 ___ 45 -1 21
ABDOMEN (SUPINE & ERECT) Study Date of ___ 3:20 ___
FINDINGS:
There is a nonobstructive bowel gas pattern. No evidence of
bowel obstruction, free intraperitoneal air, or pneumatosis is
present. There are no differential air-fluid levels on the left
lateral decubitus view. Surgical clips from prior
cholecystectomy are seen in the right upper quadrant of the
abdomen. There are no acute osseous abnormalities.
IMPRESSION:
No evidence of bowel obstruction or free intraperitoneal air.
Brief Hospital Course:
___ year old female with morbid obesity, DM2 c/b gastroparesis,
recurrent UTI d/t urethral diverticulum, frequent
hospitalizations, chronic leukocytosis (unexplained) presents
with 1 day history of nausea, vomiting, and abdominal pain - c/w
flare of gastroparesis. Initially made NPO and treated with IV
dilaudid until nausea, vomiting, abdominal pain resolved. Diet
progressively advanced without difficulty, until patient was
successfully tolerating solids on day of discharge.
# Diabetic Gastroparesis: epigastric discomfort, nausea, and
vomiting very similar to past attacks. Obstruction less likely
given patient is passing gas/stool and ___ KUB showed no
evidence of bowel obstruction or free intraperitoneal air.
Patient has history of c.diff colitis, and while she is
currently on daptomycin, she has also been on prophylactic
flagyl, making c.diff colitis less likely. For gastroparesis,
patient was continued on home reglan, protonix, bethanechol.
Erythromycin wasn't an option due to pt's allergy. GI was
consulted, and felt the mainstay in her mgmt at this time was
pain control; no room to optimize gastroparesis regimen any
further. Home tramadol was continued, and she was given IV
dilaudid for severe pain. PRN zofran for nausea. As of ___ AM,
abdominal pain much better well-controlled. Tolerated clear
liquids and full liquids on ___, and solids on ___ without
difficulty. She will need close PCP and outpatient GI follow-up
regarding gastroparesis; may be considered for for gastro-pacer.
# Enterobacter Urine Cx (>100k organisms): as per ___ prelim
urine cx; this may be colonization as she has grown this
organism in the past; currently patient is without any symptoms.
Of note, patient found to have Enterococcus pyelonephritis on
___, for which she was treated with a 14-day course of
daptomycin (___), which she is still being treated for.
Upon discharge, she was setup with IV infusion services to
continue IV daptomycin until ___. She will also continue PO
flagyl prophylactically (given recent +c.diff on ___ while on
antibiotics (until ___.
# Type 2 Diabetes mellitus Uncontrolled with Complications:
given ongoing nausea/vomiting on presentation, lantus dose
reduced to 80% with HISS. After resuming regular diet, sugars
starting to creep into 200s-300s, so patient was resumed on home
lantus + home ISS upon discharge.
# Benign Hypertension: continued on home atenolol and
lisinopril. Because BPs persistently in 160s-170s, nifedipine
increased from 90 to 120 mg qd,
# Chronic Stable Asthma: continued on home Flovent, albuterol
prn
# Urinary Incontinence: continued on home Bethanechol 25 mg PO
QID
# Depression: continued on home sertraline
TRANSITIONAL ISSUES:
========================
# CODE STATUS: full confirmed
# CONTACT: ___ (daughter, ___
- Close follow-up with PCP ___: management of diabetes and
gastroparesis
- Close follow-up with gastroenterologist for optimal management
of gastroparesis
- Will continue IV daptomycin for Enterococcus pyelonephritis to
complete 14-day course (last day ___
- Will continue PO flagyl prophylactically (to prevent C Diff)
while on IV daptomycin (last day ___
- Increased home nifedipine from 90 mg qd to 120 mg qd given
uncontrolled blood pressures
- Consider referral to H/O for evaluation of chronic
leukocytosis
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Daptomycin 300 mg IV Q24H
2. Acetaminophen ___ mg PO Q8H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
4. Atenolol 12.5 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY:PRN constipation
6. Lisinopril 40 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
8. Sertraline 150 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Pantoprazole 40 mg PO Q12H
12. NIFEdipine CR 90 mg PO DAILY
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
14. Metoclopramide 10 mg PO QIDACHS
15. Gabapentin 600 mg PO TID
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. Prochlorperazine 25 mg PR Q12H:PRN nausea
18. Bethanechol 25 mg PO QID
19. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
last dose ___. Atenolol 12.5 mg PO DAILY
4. Bethanechol 25 mg PO QID
5. Daptomycin 350 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 350 mg IV every 24 hours Disp
#*5 Vial Refills:*0
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Gabapentin 600 mg PO TID
9. Lisinopril 40 mg PO DAILY
10. Metoclopramide 10 mg PO QIDACHS
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*18 Tablet Refills:*0
12. NIFEdipine CR 120 mg PO DAILY
RX *nifedipine 60 mg 2 tablet(s) by mouth once daily Disp #*60
Tablet Refills:*0
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
16. Senna 8.6 mg PO BID:PRN constipation
17. Sertraline 150 mg PO DAILY
18. Prochlorperazine 25 mg PR Q12H:PRN nausea
19. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Gastroparesis
Secondary:
- Diabetes
- UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ because you were having abdominal pain,
consistent with gastroparesis you have had in the past. Here, we
managed your discomfort with pain medications, and subsequently
advanced your diet once your nausea/vomiting had resolved. On
day of discharge, you felt comfortable and were able to tolerate
a regualar diet without difficulty.
Please follow-up with your PCP and gastroenterologist, as below.
It was our pleasure taking care of you, and we wish you all the
best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10577647-DS-32 | 10,577,647 | 26,372,908 | DS | 32 | 2145-09-10 00:00:00 | 2145-09-12 20:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / Narcotics
Attending: ___.
Chief Complaint:
+ Blood cx
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of longstanding DM (c/b gastroparesis, neuropathy,
proteinuria without significantly impaired GFR), HTN,
depression, recurrent UTIs (urethral diverticulum), and obesity,
who was recently admitted for gastroparesis c/b Enterococcus UTI
on ___, later re-admitted for gastroparesis flares from
___, and ___, and then was brought back in
ED on ___ for GNR bacteremia, left AMA on ___, and now returns
with nausea/vomiting on ___.
After being discharged from ___ on ___, patient was found to
have GNR bacteremia in ___ blood cultures from ___. She was
brought back in on ___, at which time she stated she felt fine
fine with no fevers. She was started on IV cefepime. On ___,
she left AMA because she wanted to attend her daughter's baby
shower. She was arranged to have IV infusion services come to
her home. The next morning (this morning), the patient woke up
with epigastric abdominal pain and nausea/vomiting, and returned
to the ER. In the
In the ED, initial vitals were: 96.8 81 144/74 16 100% RA
- WBC 17.4 (83% N), LFTs WNL aside from AP 136, lactate 1.2
- UA 29 WBC, few bacteria, mod leuk, neg nitrite
- Given 500 mg iv meropenem before being admitted to Medicine
Patient notes that she has increased frequency and foul odor in
urine, both of which are new. Still denies dysuria. Of note,
patient has leukocytosis at baseline and has had previous urine
cultures with ENTEROBACTER AEROGENES resistant to all PO
options.
On the floor, initial vitals were: 98.6 180/88 87 18 99% RA
Past Medical History:
- IDDM (type 2): HbA1c 8.7% (___), complicated by
gastroparesis diagnosed in ___
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
- Enterococcus UTI
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
EXAM ON ADMISSION:
================
VS: 98.6 142/89 88 18 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
LUNGS: CTAB, no w/r/r
CV: RRR, normal s1/s2, slight systolic murmur heard in RUSB
ABD: soft, bs+, no ttp, no r/g
BACK: no CVA tenderness
EXT: Warm, well perfused, 1+ pitting edema bilaterally
SKIN: no obvious excoriations throughout body
NEURO: PERRLA
EXAM ON DISCHARGE:
================
PHYSICAL EXAM:
VS: T 98.4 BP 152/82 (100-160s/40-80) HR 74 RR 20 O2 99%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
LUNGS: CTAB, no w/r/r
CV: RRR, normal s1/s2, no m/r/g
ABD: soft, bs+, no ttp, no r/g
BACK: slight ttp in L back
EXT: Warm, well perfused, 1+ pitting edema bilaterally
NEURO: PERRLA
Pertinent Results:
LABS ON ADMISSION:
================
___:03AM BLOOD WBC-13.3* RBC-4.03* Hgb-10.2* Hct-32.2*
MCV-80* MCH-25.3* MCHC-31.6 RDW-18.1* Plt ___
___ 06:03AM BLOOD Glucose-214* UreaN-14 Creat-0.9 Na-134
K-4.4 Cl-99 HCO3-27 AnGap-12
___ 06:03AM BLOOD Mg-1.7
___ 10:20AM BLOOD Neuts-82.5* Lymphs-13.5* Monos-2.9
Eos-0.5 Baso-0.5
___ 10:20AM BLOOD ALT-22 AST-15 AlkPhos-136* TotBili-0.2
___ 10:20AM BLOOD Albumin-3.4*
___ 10:31AM BLOOD Lactate-1.2
___ 02:30PM URINE Color-Straw Appear-Clear Sp ___
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 02:30PM URINE RBC-2 WBC-29* Bacteri-FEW Yeast-NONE
Epi-5
LABS ON DISCHARGE:
================
___ 06:34AM BLOOD WBC-10.5 RBC-3.90* Hgb-9.9* Hct-30.2*
MCV-77* MCH-25.3* MCHC-32.7 RDW-18.7* Plt ___
___ 06:34AM BLOOD Glucose-92 UreaN-17 Creat-0.9 Na-137
K-4.6 Cl-103 HCO3-27 AnGap-12
___ 06:34AM BLOOD ALT-20 AST-18 CK(CPK)-38 AlkPhos-114*
TotBili-0.2
___ 06:34AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9
MICROBIOLOGY:
================
___ 6:03 am BLOOD CULTURE Source: Line-port.
Blood Culture, Routine (Pending):
___ 9:35 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 10:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 2:30 pm URINE
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
___ 11:49 pm BLOOD CULTURE Source: Line-port .
Blood Culture, Routine (Pending):
___ 5:31 am BLOOD CULTURE Source: Line-port.
Blood Culture, Routine (Pending):
___ 8:37 am STOOL CONSISTENCY: SOFT Source: Stool.
C. difficile DNA amplification assay (Pending): Positive
STUDIES:
================
PORTABLE ABDOMENStudy Date of ___ 9:55 AM
IMPRESSION:
Nonobstructive bowel gas pattern.
RENAL U.S.Study Date of ___ 7:23 ___
FINDINGS:
The right kidney measures 10 cm. The left kidney measures 10.6
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. The bladder is moderately
well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound.
Brief Hospital Course:
This is a ___ year old female with past medical history of DM
type 2, uncontrolled, complicated by gastroparesis, neuropathy,
proteinuria, recurrent UTIs, multiple readmissions (22
admissions since ___, recent admissions ___ for
gastroparesis flare, with blood culture returning postive for
GNRs after discharge, prompting call-back from admission
___, from which patient left AMA, readmitted ___ with
nausea/vomitting, course notable for additional diagnoses of
Cdiff Colitis and UTI, necessitating discharge home with home
antibiotics infusions
# GNR bacteremia: ___ bottles from ___ grew non-fermenter
non-Pseudomonas bacteria (which include acinetobacter,
bordetella, burkholderia, legionella, moraxella, and
stenotrophomonas). No fevers, no leukocytosis worse than
baseline. Per ID's discussion with micro lab, pathogen did not
readily grow and thus unable to identify further or provide
sensitivities. Atypical for a true GNR bacteremia to not grow on
other blood cx from ___ and ___ (all before antibiotics).
Regarding other sources, consider urinary source vs. port.
Repeat blood cultures all negative. ID consulted on ___, and
recommended Cefepime 2g IV Q12H x14 day total course, as
previously planned ___ until ___. Because short course
outpatient IV abx, patient was not enrolled in OPAT program.
# C diff: patient had nausea, vomiting and diarrhea on arrival
with recent Cdiff infection. Cdiff returned positive on ___.
She was started on flagyl with plan to continue for 1 week after
other antibiotics finish (___).
# Hematuria: Patient with reported hematuria during her
admission in setting of flank pain; Recent CT did not show
nephrolithiasis; repeat ultrasound on this admission negative as
well. UA was concerning for UTI, and urine culture was positive
(see below). This was attributed to UTI, but should it recur,
it will likely require additional urologic workup.
# Enterococcus UTI/Pyelonephritis: Patient has long hx of
asymptomatic bacteriuria, but on this admission, had urinary
frequency, foul odor of urine, CVA tenderness, pyuria and
positive urine culture. Renal U/S on ___ revealed normal
kidneys bilaterally with no evidence of hydronephrosis. Urine cx
from ___ revealed 10k-100k Enterococcus with sensitivities
to vancomycin. Culture was repeated with same result.
Ultimately, given her persistant symptoms patient was treated
with daptomycin for ___s per ID's recommendations.
# Diabetic gastroparesis flare (improved-resolved): Pt initially
presented to hospital with her usual pattern of abdominal pain
when having a gastroparesis flare. Unconcerning for an acute
abdomen. However, as of ___ night onward, patient tolerating
solids well and complaining of pain, more concerning for kidney
infection. Needs an outpatient gastric emptying study
# Type 2 Diabetes mellitus: HgbA1c 6.8 as of ___. Continued
home Lantus and SSI. Continued Gabapentin for neuropathic pain.
# Hypertension: continued home atenolol, lisinopril, nifedipine
# Chronic Stable Asthma: continued home albuterol PRN
# Urinary Incontinence: continued home Bethanechol 25 mg PO QID
# Depression: continued home sertraline
# CODE STATUS: Full code
# CONTACT: ___ (daughter, ___
TRANSITIONAL ISSUES:
================================
- Patient should continue cefepime until ___ for GNR
bacteremia, Daptomycin for UTI until ___, and flagyl for C diff
until ___ (1 week post cefepime DC)
- Please repeat UA to ensure resolution of hematuria
- Please check following safety labs at ___ follow-up: CBC
with differential, BUN, Cr, AST, ALT, TB, ALK PHOS, CK
- Consider outpatient urology referral given recurrent UTIs
-Please note that Sertraline and Metoclopromide put patient at
risk for serotonin syndrome. Since she was stable on such
medications, they were not adjusted, but would be adviseable to
discontinue one as an outpatient.
-Prochlorperazine was stopped as also has significant possible
drug-drug interactions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CefePIME 2 g IV Q12H
2. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
4. Atenolol 12.5 mg PO DAILY
5. Bethanechol 25 mg PO QID
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Gabapentin 600 mg PO TID
8. Lisinopril 40 mg PO DAILY
9. Metoclopramide 10 mg PO QIDACHS
10. NIFEdipine CR 120 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Prochlorperazine 25 mg PR Q12H:PRN nausea
14. Senna 8.6 mg PO BID:PRN constipation
15. Sertraline 150 mg PO DAILY
16. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. CefePIME 2 g IV Q12H
RX *cefepime [Maxipime] 2 gram 2 G IV twice a day Disp #*17 Vial
Refills:*0
2. Daptomycin 350 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 350 mg IV daily Disp #*6 Vial
Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth Q 8 hours Disp
#*46 Tablet Refills:*0
4. Sertraline 150 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Pantoprazole 40 mg PO Q24H
8. NIFEdipine CR 120 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
11. Atenolol 12.5 mg PO DAILY
12. Bethanechol 25 mg PO QID
13. Docusate Sodium 100 mg PO DAILY:PRN constipation
14. Gabapentin 600 mg PO TID
15. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. Lisinopril 40 mg PO DAILY
17. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
RX *heparin lock flush (porcine) 10 unit/mL 5 ml IV daily and
prn flush port Disp #*14 Syringe Refills:*0
18. Metoclopramide 10 mg PO QIDACHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Clostridium difficle infection
Secondary: Urinary tract infection, GNR bacteremia, hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with nausea and vomiting. While in
the hospital you were treated for your known blood infection
with the antibiotic cefepime. You will need to continue this
until ___. You were found to have a C diff infection which
causes diarrhea and may have been the cause of your nausea,
vomiting and diarrhea. You will take metronidazole (flagyl)
until ___ to treat this infection. You were also found to
have another urinary tract infection and will need to take
daptomycin for 7 days. You had blood in your urine which may
have been from your UTI but you should have a repeat urine test
with your primary care physician to make sure that this
resolves.
Please take your medications as prescribed and follow up with
your providers as scheduled. It is very important that you see a
primary care physician regularly to manage your medical
conditions.
We wish you the best!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10577647-DS-33 | 10,577,647 | 28,496,992 | DS | 33 | 2145-09-17 00:00:00 | 2145-09-28 11:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / Narcotics
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of longstanding DM (c/b neuropathy, proteinuria
without significantly impaired GFR), HTN, depression, recurrent
UTIs (urethral diverticulum), and obesity, who was recently
admitted for suspected gastroparesis c/b Enterococcus UTI on
___, later re-admitted for gastroparesis flares from
___, and ___, and then was brought back in
ED on ___ for GNR bacteremia, left AMA on ___, returned with
nausea/vomiting on ___, found to recurrent enterococcus UTI and
c.diff, discharged on ___, and now presenting to the ED with
abdominal pain.
After being discharged from ___ on ___, patient was found to
have GNR bacteremia in ___ blood cultures from ___. She was
brought back in on ___, at which time she stated she felt fine
fine with no fevers. She was started on IV cefepime. On ___,
she left AMA because she wanted to attend her daughter's baby
shower. She was arranged to have IV infusion services come to
her home. The next morning ___, the patient woke up with
epigastric abdominal pain and nausea/vomiting, and returned to
the ER. Patient found to have C. Diff and another Enterococcus
UTI. She was continued on cefepime for her known GNR bacteremia
while inpatient. The patient's diarrhea resolved on the day of
admission and her nausea and vomiting resolved during her stay.
The patient was discharged home on ___ on IV antibiotics for
treatment of her blood infection, c.diff and for a resistant UTI
(Cefepime/Dapto/Flagyl).
On ___ the patient woke around 630AM in severe abdominal
pain. The patient reports a sharp ___ abdominal pain that is
worse than her usual gastroparesis pain. The patient says that
her pain is diffuse across her abdomen. She reports that she had
an episode of diarrhea in the morning after she awoke. The
patient says that she has not had anything to eat today and her
last meal the night before admission was reported to be cereal,
which she usually tolerates.
In the ED her initial vitals were 10 96.5 ___ 20 100%
RA. She received 5mg IV morphine, zofran, and 3mg of IV
dialaudid (3x 1mg). The patient was noted to have an increased
WBC up to 20 from 15 at discharge. She had a CT w/ contrast
showing no acute intra-abdominal process.
On arrival to the floor the patient's vitals were 98.0 184/78
112 20 99RA. Patient was pacing around her room in emotional
distress from her uncontrollable abdominal pain. The patient was
unable to provide more information other than above for her
presentation. She reported that the pain medicine provided in
the ED did not help her pain. Approximately 1.5 hrs after
arriving onto the patient was able to lie down and fall asleep
with a single of dose of IV tylenol.
ROS:
(+) Per HPI
Past Medical History:
- IDDM (type 2): HbA1c 8.7% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 184/78 112 20 99% RA
GENERAL: Alert, oriented, diaphoretic, severe distress, pacing
around room
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
LUNGS: CTAB, no w/r/r
CV: RR, tachycardic, normal s1/s2, ___ systolic murmur heard
best at RUSB
ABD: soft, bs+, severe TTP diffusely
BACK: no CVA tenderness
EXT: Warm, well perfused, 1+ pitting edema bilaterally
SKIN: no obvious excoriations throughout body
NEURO: PERRLA
DISCHARGE PHYSICAL EXAM:
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 08:13AM BLOOD WBC-20.0*# RBC-4.66 Hgb-11.7* Hct-37.6
MCV-81* MCH-25.2* MCHC-31.3 RDW-18.1* Plt ___
___ 08:13AM BLOOD Neuts-79.6* Lymphs-15.7* Monos-3.5
Eos-0.8 Baso-0.4
___ 08:13AM BLOOD Glucose-230* UreaN-21* Creat-0.9 Na-136
K-4.2 Cl-101 HCO3-23 AnGap-16
___ 08:19AM BLOOD Lactate-1.8
PERTINENT LABS:
___ 05:16AM BLOOD CK(CPK)-64
___ 05:16AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:00PM URINE UCG-NEG
___ 06:57PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICRO:
___ 12:00PM URINE Color-Straw Appear-Clear Sp ___
___ 12:00PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:00PM URINE RBC-3* WBC-8* Bacteri-FEW Yeast-NONE
Epi-2
___ 6:57 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood culture: negative
IMAGING:
___ CT A/P with contrast:
IMPRESSION:
1. No acute intra-abdominal process.
2. Stable appearing cystic lesion previously described as a left
urethral diverticulum.
3. Stable appearing right-sided Bartholin's gland cyst.
___ CXR:
Left-sided Port-A-Cath is stable in position, terminating in the
proximal
right atrium. There are relatively low lung volumes. No focal
consolidation
is seen. There maybe minimal central vascular congestion. No
pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are
unremarkable.
IMPRESSION:
No focal consolidation to suggest pneumonia.
___ KUB:
There is paucity of the bowel gas pattern, no evidence of bowel
obstruction.
Osseous structures are unremarkable. Surgical clips project in
the right
upper quadrant
IMPRESSION:
Limited study due to patient body habitus. No evidence of bowel
obstruction.
Brief Hospital Course:
This is a ___ year old female with past medical history of DM
type 2, uncontrolled, complicated by gastroparesis, neuropathy,
proteinuria, recurrent UTIs, multiple readmissions (23
admissions since ___, recent admissions ___ for
gastroparesis flare, with blood culture returning postive for
GNRs after discharge, prompting call-back from admission
___, from which patient left AMA, readmitted ___ with
nausea/vomitting, course notable for diagnosis of VRE UTI and
Cdiff Colitis, discharged home, readmitted ___ with nausea
and vomiting of unclear etiology, prompting us to revisit
diagnosis and management, now resolving, on trial of new
pharmacologic approach, discharged home with PCP and GI
appointments immediately following discharge.
# Abdominal pain: patient presented with abdominal pain of
unclear etiology; in the past it has been attributed to
gastroparesis, but this has never been proven on gastric
emptying study; pain did not improve with IV narcotics in the ED
so these were discontinued and patient received tylenol,
simethicone for pain. CT abd/pelvis did not show any acute
findings. The patient's pain often occurred early in the morning
prior to taking her medications. It was epigastric pain which
caused nausea and dry heaving. Pain often subsided after morning
medications. Esophageal spasm was thought to be a potential
cause and so the patient was continued on her am nifedipine and
started on QHS imdur. Given that reglan was not helping her
symptoms and she was thought to be lactating as a side effect of
this medication it was discontinued. Can consider Bethanechol
side effect and discontinue in the future if no improvement in
her symptoms. Given that she often misses follow up
appointments, patient was discharged directly to PCP and GI
outpatient appointments. Now that she is off all narcotics and
reglan, she should be considered for outpatient gastric emptying
study.
# Hypertension/Tachycardia: Likely in the setting of severe pain
and distress. The patient reports that she took her blood
pressure medications in the AM on day of admission. Received
labetalol 200mg PO x 1. Continued home meds
# Leukocytosis: The patient presented with elevated WBC to 20.
She frequently presents with leukocytosis on admission to
hospital which spontaneously resolved during admission. She has
had persistent elevated counts on last admission. The patient
was being treated for GNR bacteremia, UTI, and C.Diff. She has
visiting nurses administering IV antibiotics at home. It is
possible that the elevation is in the setting of stress and less
likely that she developed a new infection being untreated with
current course. No source of any infection or inflammation
identified during admission.
# GNR bacteremia - blood culture from prior admission, ___,
non-fermenter, not pseudomonas aeruginosa; unclear source; see
prior discharge summary for more information on this; continued
on IV cefepime and arranged for home infusion (last day =
___
# Enterococcus UTI: Diagnosed during last admission based on
frequency, foul odor, CVA tenderness, UA with 27 WBCs. Patient
has long hx of asx bacteriuria, but seemed to be symptomatic
during last admission so was treated. Renal U/S on ___ revealed
normal kidneys bilaterally with no evidence of hydronephrosis.
Continued daptomycin IV Q24hr for 7 days. Repeat UA/culture
negative.
# C diff Colitis: positive during last admission on ___ in the
setting of recent C diff infection and diarrhea prior to
admission. Now pt with mainly formed stool but treated in the
setting of broad antibiotics. Continued flagyl for planned
duration 1 weeks post cefepime completion.
# Type 2 Diabetes mellitus, uncontrolled with complications:
HgbA1c 6.8 as of ___. Continued home Lantus and SSI with
good control. Continued Gabapentin for neuropathic pain.
# Hypertension: continued home lisinopril, nifedipine.
Discontinued atenolol given that nifedipine was started
# Chronic Stable Asthma: continued home Flovent, albuterol PRN
# Depression/anxeity: continued home sertraline. Patient had
significant anxiety while inpatient and was already on maximum
dose SSRI.
# CODE STATUS: Full code
# CONTACT: ___ (daughter, ___
TRANSITIONAL ISSUES:
- Please schedule outpatient gastric emptying study as patient
is now off all opioids and reglan
- Please consider discontinuing bethanchol as unclear benefit at
this point, and could potentially be another cause for abdominal
discomfort
- Consider social work referral for anixety, coping skills
- Patient should continue cefepime until ___ for GNR bacteremia
and and flagyl for C diff until ___ (1 week post cefepime DC)
- Consider outpatient urology referral given recurrent UTIs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CefePIME 2 g IV Q12H
2. Daptomycin 350 mg IV Q24H
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
4. Sertraline 150 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Pantoprazole 40 mg PO Q24H
8. NIFEdipine CR 120 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
11. Atenolol 12.5 mg PO DAILY
12. Bethanechol 25 mg PO QID
13. Docusate Sodium 100 mg PO DAILY:PRN constipation
14. Gabapentin 600 mg PO TID
15. Lisinopril 40 mg PO DAILY
16. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
17. Metoclopramide 10 mg PO QIDACHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Bethanechol 25 mg PO QID
4. CefePIME 2 g IV Q12H
RX *cefepime [Maxipime] 2 gram 2 G IV Q12 hours Disp #*3 Vial
Refills:*0
5. Docusate Sodium 100 mg PO DAILY:PRN constipation
6. Gabapentin 600 mg PO TID
7. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush
8. Lisinopril 40 mg PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
10. NIFEdipine CR 120 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
14. Sertraline 150 mg PO DAILY
15. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. Isosorbide Mononitrate 10 mg PO QHS
RX *isosorbide mononitrate 10 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: abdominal pain
Secondary: hypertension, leukocytosis, UTI, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with
recurrent abdominal pain. You had another CT scan of your
abdomen and pelvis which did not show any cause of your
abdominal pain. You were still having normal bowel movements and
your pain was not related to food intake so it was felt that
this was not gastroparesis. Your pain could be from an
esophageal spasm so you were started on a new medication called
isosorbide mononitrite to be taken at night to help relax the
muscles of your esophagus as well as to help lower your blood
pressure. We stopped your atenolol as it is no longer needed. We
also stopped your reglan as you were having side effects with
lactation and it does not seem to be helping you. Since your
pain did not improve with opioids in the emergency room and
could potentially worsen with these medications please stop
taking them. While you are off opioids and reglan, you should
see your gastroenterologist for a gastric emptying study.
It is very important that you take your medications as
prescribed at home. It is also very important that you establish
a relationship with your primary care physician and outpatient
gastroenterologist to follow your abdominal pain.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10577647-DS-34 | 10,577,647 | 27,011,815 | DS | 34 | 2145-09-24 00:00:00 | 2145-09-28 10:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / Narcotics / ___
Attending: ___.
Chief Complaint:
Nausea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with past medical history of
DM type 2(uncontrolled, complicated by gastroparesis,
neuropathy, proteinuria), recurrent UTIs, multiple readmissions
(24 admissions since ___, recent admissions ___ for
gastroparesis flare complicated by GRN bacteremia currently on
cefepime last day ___, and hx. of cdiff colitis (recurrence
x1, on PO flagyl until ___ who presents with recurrent
nausea, vomiting, and inability to tolerate POs.
Pt. was admitted on ___ for nausea/vomiting course
complicated by VRE UTI (completed course of dapto on ___ and
CDiff colitis. She has had several admissions since then, most
recently from ___ to ___ for nausea/vomiting. On most
recent admission, it was thought that pt's presentation was not
related to gastroparesis as it did not respond to usual
treatment. Additionally, pt. has a long history of
non-compliance and poor coping. She began lactating from reglan
and as such this was stopped. There was concern for esophageal
spasm and pt. was continued on nifedipine and started on imdur.
She was tolerating meals at time of discharge.
Since discharge, pt. has developed worsening nausea and
vomiting. Pt. saw PCP and GI doctor today. She had no pain at
that time. When she returned home at ___, pt. developed acute
onset abdominal pain. Pain is located in the lower abdomen and
is sharp. Daughter has not seen her mother in pain like this
before. She denies chest pain, SOB, cough.
In the ED, initial vitals were: 97.9 ___ 18 100% ra
- Labs were notable for WBC 21.7, H/H ___, lactate 1.2, AP
114, lipase 25
- The patient was given lorazepam 1mg IV x2
Vitals prior to transfer were: 98.6 109 184/87 22 97% RA
Upon arrival to the floor, pt. in significant pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
- IDDM (type 2): HbA1c 8.7% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6, 210/80, 123, 28, 100 on RA
General: Alert, oriented, writhing in pain, slightly diaphoretic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals: T 98 BP 131/62 (110-208) HR 84 RR 20 O2 100%RA
General: Alert, oriented, sitting in bed, comfortable eating
breakfast
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese, Soft, tender in epigastric area, non-distended,
bowel sounds present, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
==========================
LABS ON ADMISSION:
==========================
___ 12:45AM BLOOD WBC-21.7*# RBC-4.33 Hgb-11.1* Hct-34.2*
MCV-79* MCH-25.6* MCHC-32.3 RDW-18.7* Plt ___
___ 12:45AM BLOOD Neuts-90.0* Lymphs-6.8* Monos-2.5 Eos-0.4
Baso-0.3
___ 12:45AM BLOOD ___ PTT-29.9 ___
___ 12:45AM BLOOD Glucose-301* UreaN-19 Creat-1.1 Na-135
K-4.6 Cl-98 HCO3-21* AnGap-21*
___ 12:45AM BLOOD ALT-23 AST-21 AlkPhos-114* TotBili-0.3
___ 12:45AM BLOOD Lipase-25
___ 12:45AM BLOOD Albumin-4.1 Calcium-9.8 Phos-3.4 Mg-2.0
___ 12:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:50AM BLOOD Lactate-1.2
==========================
PERTINENT LABS:
==========================
___ 06:19AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL
___ 06:19AM BLOOD Hb A-97.7 Hb S-0 Hb C-0 Hb A2-2.3 Hb F-0
___ 06:19AM BLOOD calTIBC-243* Ferritn-65 TRF-187*
___ 06:19AM BLOOD TSH-1.0
___ 01:15AM URINE UCG-NEGATIVE
___ 12:54PM URINE Porphob-NEGATIVE
___ 03:48PM URINE Porphob-NEGATIVE
___ 04:57PM URINE Porphob-NEGATIVE
___ 01:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 06:18AM URINE CATECHOLAMINES-Test
___ 06:18AM URINE METANEPHRINES, FRACTIONATED, 24HR
URINE-Test
METANEPHRINES, FRACTIONATED, 24HR URINE
Test Result Reference
Range/Units
24 HR URINE VOLUME ___ mL
METANEPHRINE 66 58-203 mcg/24
h
NORMETANEPHRINE 300 88-649 mcg/24
h
METANEPHRINES, TOTAL ___ mcg/24
h
A four fold elevation of urinary normetanephrines
is extremely likely to be due to a tumor, while a
four fold elevation of urinary metanephrines is
highly suggestive, but not diagnostic of the tumor.
Measurement of plasma Metanephrines and Chromogranin
A is recommended for confirmation.
CATECHOLAMINES
Test Result Reference
Range/Units
24 HR URINE VOLUME ___ mL
EPINEPHRINE, 24 HR URINE see note
Results are below the reportable range for this
analyte, which is 2.0 mcg/L.
Test Result Reference
Range/Units
NOREPINEPHRINE, 24 ___ 33 ___ mcg/24
h
CALCULATED TOTAL (E+NE) 33 ___ mcg/24
h
DOPAMINE, 24 HR URINE 206 52-480 mcg/24
h
CREATININE, 24 HOUR URINE 1.58 0.63-2.50 g/24
h
MICRO:
___ 5:20 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
___ 05:20PM URINE Color-Straw Appear-Clear Sp ___
___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 05:20PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-2
___ 03:48PM URINE Hours-RANDOM Creat-65 TotProt-219
Prot/Cr-3.4*
==========================
IMAGING:
==========================
___ KUB:
FINDINGS:
Overall there is a paucity of abdominal air. No distended large
bowel loops
are identified. No free air. Cholecystectomy clips are seen
the right upper
quadrant. Bony structures are unremarkable.
IMPRESSION:
No colonic distention.
___ MRI head with and without contrast:
1. Allowing for motion degradation, no ___ evidence for focal
lesion within
the pituitary gland.
2. Bilateral subcortical and periventricular T2/FLAIR
nonspecific white matter
hyperintensities. In a patient of this age, the differential is
broad but
given the history of hypertension, this may represent chronic
microangiopathy.
Differential considerations include infectious/inflammatory
etiology, prior
trauma, sequela of chronic headache or demyelinating process.
3. Moderate dilation of the lateral and the third ventricles,
out of
proportion to the sulcal size, can relate to preferential
central parenchymal
volume loss with or without communicating hydrocephalus, as
mentioned on the
prior CT studies. Correlate clinically for etiology of the
ventricular
dilation and white matter changes.
___ Gastric Emptying Study:
TECHNIQUE: ISOTOPE DATA: (___) 542.0 uCi Tc-99m Egg Whites
Labelled with
Sulfur Colloid;
Patient Consumed:100% percent 4 oz eggs, 100% 4 oz water, 100% 2
pieces of white
bread with jelly.
Within 10 minutes of beginning the meal, the patient was placed
supine in the
gamma camera. Continuous anterior and posterior images of tracer
activity in the
stomach and bowel were recorded for 45 minutes. Delayed anterior
and posterior
images were obtained at the time points below.
FINDINGS: Residual tracer activity in the stomach is as
follows:
At 45 mins 75% of the ingested activity remains in the stomach
At 2 hours 38% of the ingested activity remains in the stomach
At 3 hours 18% of the ingested activity remains in the stomach
At 4 hours 12% of the ingested activity remains in the stomach
IMPRESSION: Normal gastric emptying study.
Brief Hospital Course:
Ms. ___ is a ___ year old female with past medical history of
DM type 2(complicated by neuropathy, proteinuria), recurrent
UTIs, multiple readmissions (24 admissions since ___,
recent admissions ___ for abdominal pain complicated by
GNR bacteremia currently on cefepime (last day ___, and hx.
of cdiff colitis (recurrence x1, was on PO flagyl but switched
to PO vanc, until ___ who presents with recurrent nausea,
vomiting, and inability to tolerate POs.
# Abdominal Pain / Nausea: Unlikely to be gastroparesis given
that it started without any PO intake and patient continues to
have formed, regular BMs. Patient is now off reglan and
bethanacol and they were not helping and to eliminate any
contribution to ___ pain. Flagyl was switched to vanc
yesterday in GI clinic to rule out this as a contributing
factor. Pt having normal stools, therefore, exacerbation of
cdiff is unlikely. Serum tox/urine tox negative, does not appear
pt. taking narcotics at home at this time. She did receive 1mg
IV dilaudid in ED without effect. No narcotics since getting to
the floor. KUB unremarkable. Has been screened for porphyria in
past (___). Repeated screen on this admission given that
testing may be false negative in between attacks. However,
porphyrin spot test negative again. 24 hour pending on
discharge. Gastric emptying study negative. 24hr urine sent to
rule out pheo and was negative. Unclear etiology of the
patient's abdominal pain as she has had an extensive work up
without etiology idenitified. Patient often presents with
nausea, abdominal pain, elevated blood glucose levels,
hypertensive urgency, and leukocytosis. This usually resolves on
the morning after admission.
# Headache: pt with chronic headaches which she states are worse
recently. Describes this as a dull pain and occasionally sharp
over the front of her head which could be a tension headache
given the location. As discussed previously, obtained MRI to r/o
pituitary adenoma causing the patient's lactation as below.
Patient has intermittent episodes of profound hypertension,
tachycardia, diaphoresis and leukocytosis so also obtained 24hr
urine metanephrines and catecholamines to rule out pheo.
Headache improved on ___. Final read of MRI brain showed no
___ abnormalities; non-specific findings suspicious of small
vessel disease; and Moderate dilation of the lateral and the
third ventricles, out of proportion to the sulcal size, can
relate to preferential central parenchymal volume loss with or
without communicating hydrocephalus, as mentioned on the prior
CT studies. Neuro exam benign.
# Right flank pain: patient developed right sided flank pain
during admission radiating to lower back. She states that this
is a new type of pain distinct from her usual low back pain.
However, it is similar to last admission when she had left sided
flank pain which resolved without intervention. She has had pain
films of her lumbar spine in the past which show mild
degenerative changes. She has had numerous CT scans and MRIs of
abdomen/pelvis. One of which notes "Mild degenerative changes
affect lump lower lumbar facet joints. Sclerotic focus in the L3
vertebral body is consistent with a bone island. There vertebral
body heights and interspaces appear preserved." patient does not
have any red flag symptoms and strength is perserved in lower
extremities. She did not have any symptoms of dysuria or
hematuria. Received tylenol, ibuprofen prn pain and tramadol prn
severe pain. She should have outpatient ___
# Leukocytosis: Acute on Chronic. Patient with acute on chronic
leukocytosis on first day of all recent admissions (12 -> 21
from ___ to ___ which resolves without any changes to plan
during hospital course. Left shift. Possibly stress induced
leukocytosis. CBC always appears concentrated on arrival with
elevated WBC, H/H compared to prior, and plt count. Pt. afebrile
with no localizing symptoms of infection. Ruled out pheo.
# Anion Gap Acidosis: On admission Likely ___ mild DKA as
ketones in the urine with increased blood glucose. Lactate
normal. Resolved overnight after IVF
# Hypertensive Urgency: BPs notably elevated (SBP 200s) on
arrival. Received PO and IV labetalol overnight with resolution
of hypertensive urgency. BP better controlled during rest of
hospitalization. Continued home nifedipine, lisinopril
# Cdiff Colitis: recurrence x 1 during last hospitalization;
positive stool ___ has been on flagyl and GI changed to PO
vanc on ___ (last day ___, 1 week following cessation of
cefepime). Continued PO vanc 125 Q6H until ___
# Social stress: patient does have significant stress at home.
She states that she has difficulty keeping up with her rent and
bills. She initially stated that she was unable to afford
batteries for her glucometer. However, daughter states that the
glucometer malfunctions at times but that they always administer
insulin four times per day. She was given a new glucometer
during this hospitalization. She was set up with a home ___ for
assistance with medications in addition to her daughter and son
who help patient significantly. She was ordered for home ___ as
patient is essentially homebound. We had a meeting with patient,
case management, social work, and medical team. We discussed
resources available to patient. Patient emphasized that she does
not want to be in the hospital so often but comes in when pain
flares. We discussed that she will follow closely with
outpatient PCP and GI to continue work up and management of her
pain. We also discussed that significant social stress can
worsen pain which patient acknowledged. She was set up with an
appointment with complementary and alternative medicine as
patient expressed desire to try acupuncture and alternative
methods of controlling pain. She was set up with the ___
___ for assistance getting to outpatient appointments.
CHRONIC ISSUES
===================
# Hx. of recurrent UTIs: Recent VRE s/p course of dapto
completed on ___. Consider outpt. urology referral given
recurrent.
# GNR bacteremia: patient completed ___ of
cefepime for GNR in ___ bottles from ___
# Type 2 DM, complicated by neuropathy, proteinuria: HgbA1c 6.8
as of ___. Continued home Lantus and SSI. Continued
Gabapentin for neuropathic pain. She was provided with a new
glucometer. She had a normal gastric emptying study and does not
have gastroparesis. She was seen by a nutritionist with
education re: diabetic diet and would benefit from outpatient
nutrition follow up which patient was agreeable to.
# Depression: continued home sertraline
# CODE STATUS: Full code
# CONTACT: ___ (daughter, ___
TRANSITIONAL ISSUES
# Patient had a normal gastric emptying study as does not have
gastroparesis
# Of note, patient started on a nitrate last admission to treat
possible esophageal spasm. Please discontinue this medication in
the outpatient setting if more likely diagnosis is confirmed.
# Please follow up 24hr urine metanephrines and porphyria
studies.
# Please arrange for nutrition clinic follow-up. Patient is
agreeable to meeting with nutrition once a month to educate on
diabetic diet. Patient may need assistance to go to these
appointments and/or coordination with other appointment times.
# Patient is amenable to alternative/complementary medicine. She
has a follow-up appointment on ___ for which she will be
assisted with transportation.
# Please be aware that patient needs assistance with rides to
clinic appointments.
# MRI noted: "Moderate dilation of the lateral and the third
ventricles, out of proportion to the sulcal size, can relate to
preferential central parenchymal volume loss with or without
communicating hydrocephalus, as mentioned on the prior CT
studies. Correlate clinically for etiology of the ventricular
dilation and white matter changes" patient did not have any
signs of infection and had a unremarkable neuro exam
# Bethanechol discontinued as not helping and may contribute to
abdominal cramping
# Needs monthly port flushes when not admitted
# Pt has chronic back pain which flared during admission and for
which she should have home ___ and pursue complementary and
alternative methods of pain control
# Patient has significant stressors at home and would benefit
from therapy
# Continues to have leukocytosis on admission without infectious
or inflammatory source identified which spontaneously resolves
prior to discharge without intervention. ___ benefit from
hematology referral
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Bethanechol 25 mg PO QID
4. CefePIME 2 g IV Q12H
5. Docusate Sodium 100 mg PO DAILY:PRN constipation
6. Gabapentin 600 mg PO TID
7. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush
8. Lisinopril 40 mg PO DAILY
9. NIFEdipine CR 120 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO BID:PRN constipation
13. Sertraline 150 mg PO DAILY
14. Isosorbide Mononitrate 10 mg PO QHS
15. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Gabapentin 600 mg PO TID
5. Lisinopril 40 mg PO DAILY
6. NIFEdipine CR 120 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 150 mg PO DAILY
11. Vancomycin Oral Liquid ___ mg PO Q6H
LAST DOSE ___
12. Isosorbide Mononitrate 10 mg PO QHS
13. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Contour Meter (blood-glucose meter) fingerstick TID
Duration: 12 Months
RX *blood-glucose meter Please check sugars three times daily
Disp #*1 Kit Refills:*0
15. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: abdominal pain
Secondary: hypertensive urgency, leukocytosis, UTI, diabetes,
headache, clostridium difficile infection
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 here at ___. You were
admitted with recurrent abdominal pain, nausea, and
hypertension. You underwent a gastric emptying studying that
was normal and did not show gastroparesis. We also obtained
urine studies for several rare conditions and we are still
waiting on the results. You also had an MRI while inpatient that
did not show any masses or abnormalities except for changes that
are seen with chronic high blood pressure. You finished your
course of cefepime while in the hospital and you only have 1 day
of antibiotics left for the C diff infection. We have arranged
for you to have follow-up with your primary care doctor, your
gastroenterologist, and an alternative medicine physician. You
were seen by nutrition to help you follow a diabetic diet and
make healthy choices. Your primary care doctor ___ help with
arranging for a nutrition follow-up appointment. Please take
your medications as prescribed and let us know if you have
difficulty making any appointments so we can provide you with
assistance. We wish you the best of luck.
Sincerely,
Your ___ team.
Followup Instructions:
___
|
10577647-DS-38 | 10,577,647 | 29,524,698 | DS | 38 | 2145-11-19 00:00:00 | 2145-11-19 21:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o woman with a PMH notable for IDDM, recurrent UTIs, and
numerous admissions for abdominal pain, recurrent c difficile,
who presents with abdominal pain. Reports this am ~0400 awoken
from sleep with abdominal pain that is not typical for her, has
vomited x 3 clear liquids. Reports pain is significantly worse
than her baseline/chronic pain. Last stool today, denies dark or
bloody stool. Also endorses "a little pain in my chest", no SOB,
feels very nauseated.
In the ED, initial vitals were: 98.2 97 159/78 16 99% RA
- Labs were significant for wbc 19.3, H/H 9.5/29.7, plt 516, INR
1. LFTs wnl except Alk Phos 150, Na 135, K 4.7, BUN 24, Cr 1.
Glucose 272. Trop <0.01 x2.
- CXR with no acute intrathoracic process
- The patient was given dilaudid PO 4mg once, 2mg x2. Zofran 4mg
x2, 2L NS.
Patient initially responded to PO trial, but then failed POs and
was admitted. Vitals prior to transfer were: 99.2 100 158/69 16
100% RA
Upon arrival to the floor, 98.8, 191/87, 20, 100RA. Patient
crying, difficult to obtain more information. Patient states
that pain started yesterday. Had few episodes of nasuea and
vomiting. Had bowel movements in the ED. Pain is severe ___.
No medication changes since last admission. Says that she is
taking her vancomycin as directed.
Of note, patient missed isosorbine mononitrate evening dose
while in the ED.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Difficult to assess full ROS as patient is crying and
uncooperative with exam
Past Medical History:
- IDDM (type 2): HbA1c 6.8% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections due to urethral
diverticulum
- Chronic back pain
- IUD placement
Social History:
___
Family History:
Mother - DM
Father - died of Alzheimer's
Siblings - sister with DM
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals: 98.8, 191/87, 20, 100RA
General: Alert, oriented, crying in bed, moaning in pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, hypoactive bowel sounds, diffusely tender to
palpation, no guarding, minimal rebound
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: patient did not cooperate with exam, moving all
extremities without signs of focal neurologic deficit.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T: 98.6 BP 148/70 mmHg RR 18 O2 100% RA
General: Obese woman, comfortable appearing.
HEENT: Sclera anicteric; MMM; OP clear.
Neck: Supple, JVP difficult to assess, no LAD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Obese, soft, non-tender, non-distended. Refused rectal
examination.
Extremities: Warm, well-perfused. 2+ pulses, no edema.
Skin: Dry; no lesions.
Neuro: A&Ox3; ___ strength to dorsiflexion/plantar flexion b/l;
___ grip strength. Distal sensation to light touch intact
bilaterally. Narrow-based, steady gait.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:35PM BLOOD WBC-19.3* RBC-3.69* Hgb-9.5* Hct-29.7*
MCV-81* MCH-25.7* MCHC-32.0 RDW-15.4 RDWSD-44.9 Plt ___
___ 05:35PM BLOOD Neuts-74.7* ___ Monos-4.3*
Eos-0.2* Baso-0.5 Im ___ AbsNeut-14.43* AbsLymp-3.79*
AbsMono-0.83* AbsEos-0.03* AbsBaso-0.09*
___ 05:35PM BLOOD Glucose-272* UreaN-24* Creat-1.0 Na-135
K-4.7 Cl-99 HCO3-25 AnGap-16
___ 05:35PM BLOOD ALT-17 AST-10 AlkPhos-150* TotBili-0.2
___ 11:45PM BLOOD cTropnT-<0.01
___ 05:35PM BLOOD cTropnT-<0.01
___ 05:35PM BLOOD HCG-<5
============
INTERIM LABS
============
___ 08:22PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:35PM BLOOD HCG-<5
==============
DISCHARGE LABS
==============
___ 04:10AM BLOOD WBC-19.0* RBC-3.57* Hgb-8.9* Hct-29.0*
MCV-81* MCH-24.9* MCHC-30.7* RDW-15.6* RDWSD-45.9 Plt ___
___ 04:10AM BLOOD Glucose-86 UreaN-16 Creat-1.1 Na-136
K-4.1 Cl-97 HCO3-26 AnGap-17
___ 04:10AM BLOOD ALT-17 AST-12 AlkPhos-133* TotBili-0.3
___ 04:10AM BLOOD GGT-41*
============
MICROBIOLOGY
============
___ 9:30 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 5:37 pm
URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
__________________________________________________________
___ 10:39 pm STOOL CONSISTENCY: WATERY
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ AT 10:16 AM
ON ___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
__________________________________________________________
___ 7:54 pm BLOOD CULTURE Source: Line-port.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
=======
IMAGING
=======
CHEST (PA & LAT) (___)
FINDINGS:
PA and lateral views of the chest provided. Port-A-Cath is
unchanged with tip residing in the low SVC region.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right hemidiaphragm
is seen.
IMPRESSION:
No acute intrathoracic process.
ABDOMEN (SUPINE & ERECT) (___)
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air. Osseous structures are
unremarkable.
IUD is in unchanged, standard position.
IMPRESSION:
No evidence of toxic megacolon.
Brief Hospital Course:
Mrs. ___ is a ___ year old woman with a history of of chronic
abdominal pain with numerous hospitalizations, recurrent UTIs,
and recurrent C. difficile, who presented with abdominal pain
and vomiting.
============
ACUTE ISSUES
============
# Abdominal pain/nausea/vomiting: As above, the patient has a
history of recurrent abdominal pain. Upon admission, she had
significant pain, with highly elevated blood pressure (SBPs in
the 190s). Chest radiograph was negative for intrathoracic
process. ACS was ruled out via negative troponins and EKG with
no changes. Abdominal radiographs did not show evidence of toxic
megacolon. She initially required IV hydromorphone and lorazepam
for management of her pain, anxiety, and nausea, but these were
transitioned to PO medications within 24 hours of her admission.
She subsequently required no pain medications. Pain improved
with ambulation, and she felt better after walking in hall. She
reported several episodes of loose stools and among them stated
that she was incontinent of stool once; she reported that this
was a long-standing issues for her, and she was continued on her
treatment of C. difficile. She tolerated po without further N/V.
Possible etiologies include abdominal migraine, esp given sudden
onset assoc with N/V in patient with personal and family hx
migraines, and no other organic pathology on last CT scan
___, also GES normal ___. Other Ddx includes acute
intermittent prophyria and mastocytosis; results for these
studies were pending on discharge. GI follow-up was previously
scheduled.
# Recurrent Clostridium difficile: The patient had been
discharged on vancomycin 125 mg PO q6h previously for a
recurrent C. difficile infection, with an end date of ___.
She was continued on this treatment and discharged on it.
# Hypertension. Her blood pressure was highly elevated on
admission (SBPs 190s), which was historically difficult to
control. This was thought to be largely secondary to pain, as it
did respond to pain control and administration of her home
anti-hypertensive regimen (which was continued without change).
==============
CHRONIC ISSUES
==============
# GERD. Home PPI was held in the setting of recurrent
Clostridium difficile.
# Asthma. Stable; her home regimen was continued.
# Depression: Home sertraline was continued.
# IDDM: She was continued on her home insulin sliding scale.
===================
TRANSITIONAL ISSUES
===================
.
# Recurrent Clostridium difficile: Patient will continue 14 day
course of PO vancomycin 125 mg q6h, to be completed ___.
.
# Pending Labs: Please follow up on pending studies (urine
prophyrins, serum tryptase), to rule out other causes of her
symptoms, including acute intermittent porphyria or
mastocytosis.
.
# PPI. As above, her PPI was held on her previous admission in
the setting of recurrent C. diff infection and was not restarted
on this admission. Please consider restarting at your
discretion.
.
# Stable Right bundle branch block: Please continue to monitor
with yearly EKG, and f/u with further workup as needed.
.
# CODE: FULL
# CONTACT: Daughter ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Vancomycin Oral Liquid ___ mg PO Q6H
2. Acetaminophen 1000 mg PO Q8H pain/discomfort
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Gabapentin 600 mg PO TID
6. Isosorbide Mononitrate 10 mg PO QHS
7. Lisinopril 40 mg PO DAILY
8. NIFEdipine CR 120 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain/discomfort
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Gabapentin 600 mg PO TID
5. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate 10 mg PO QHS
7. Lisinopril 40 mg PO DAILY
8. NIFEdipine CR 120 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- Recurrent Clostridium difficile infection
- recurrent abdominal pain possibly secondary to abdominal
migraines
===================
SECONDARY DIAGNOSES
===================
- hypertension, uncontrolled
- type 2 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 caring for you at ___
___. You were admitted for abdominal pain and
vomiting. You were continued on your treatment for Clostridium
difficile, with antibiotics, with which you will go home. We
controlled your pain and nausea with medication, and you started
to have resolution of your symptoms. We did send some tests
which your primary care physician ___ continue to follow up
with to help identify the causative factor for your recurrent
symptoms.
Please take your discharge medications as described below. Your
follow-up appointments are also outlined below.
We wish you the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
10577647-DS-42 | 10,577,647 | 22,581,707 | DS | 42 | 2145-12-13 00:00:00 | 2145-12-16 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female with diabetes, GERD, h/o
chronic abdominal pain, chronic UTIs, urethral diverticulum, DM,
HTN, depression, obesity, anxiety, IV daptomycin for a blood
stream
infection, multiple admissions for chronic abdominal pain,
discharged one day ago who represents with abdominal pain and
reported hypertensive urgency.
Of note, patient has had four readmissions in past month d/t
abdominal pain. Continuing treatment with IV daptomycin for
___ Klebsiella UTI for which she remains asymptomatic.
Triage note this AM pt reported with hypertension BP is 225/137
with chest pain. Pt sweating and moaning in pain, referred to
ED.
In the ED, initial vitals were: 10 98.0 ___ 24 100% RA
- Labs were significant for continued leukocytosis (unclear
trend), stable anemia (9.3/30.1 from 7.6/24.3), thrombocytosis,
new mild transaminitis ALT 103, AST WNL, continued AP (193
mildly elevated from prior.
- Imaging deferred in ED
- The patient was given
1000 NS x 1
IV Ondansetron 4 mg x1
Aluminum-Magnesium Hydrox.-Simethicone 30 mL
IV Morphine Sulfate 5 mg x2
Donnatal ((Belladonna Alkaloids, Phenobarbital) 10 mL x1
Lidocaine Viscous 2% 10 mL x1
Vitals prior to transfer were: 98.3 86 151/81 17 99% RA
Upon arrival to the floor, VS: 97.9 178/88 104 22 100%RA
Patient moaning with pain on the floor. States that after her
discharge yesterday, went to sleep, awoke from sleep in a panic
attack and recurrent L chest pain that devolved into repeat
diffuse abdominal pain, similiar from prior. States that she
tried taking all her psych meds and tylenol, but that doesn't
work. States that she hasn't eaten, but says that she had NBNB
emesis x 5 when she tried. Denies fever, chills, diarrhea,
BRBPR, melena. Continues to pass flatus.
Past Medical History:
- IDDM (type 2): HbA1c 6.8% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections possibly related to
urethral diverticulum
- Chronic back pain
- IUD placement
Social History:
lives in ___ with dtr/son/grand-daughter and fob.
She also describes severe financial stressors such that once she
pays her bills from disability she is not able to buy food. Her
dtr just had a 2 month old baby, is on food stamps but still
things are difficult. Her son was just released after a month in
prison.
- on SSI (does not work). She has not worked since she was ___.
- smokes marijuana 1x/month ("when I can afford it" which is
once per month)
- denies alcohol use
- denies IVDU
- severe financial difficulties. Children assist with medication
management. She does not feel physically threatened by the
father of her grand-daughter. Son with bipolar disorder does
give her money.
Family History:
Mother - DM, breast cancer s/p treatment but now found to have
recurred in her liver in ___. Son with bipolar
disorder, on disability.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 178/88 104 22 100%RA
GEN: AAF, obese, grabbing her belly and moving in pain on the
bed. Inconsolable
HEENT: NCAT, inacteric, mmm
NECK: no JVP
CV: RRR, ___ SEM at ___
RESP: CTAB
ABD: +bs, soft, diffuse tenderness with palpation, no guarding
or rebound.
GU: No CVAT b/l
EXTR: no c/c/e 2+pulses
DERM: no rash
NEURO: cranial nerves grossly intact, MAE w purpose
PSYCH: inconsolable
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.2 BP: 121/60 P:68 R:18 O2:100% on RA
General: Alert, oriented, no acute distress
HEENT: MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: decreased heart sounds, RRR, nl S1 S2, no
murmurs/rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
___ 04:55AM BLOOD WBC-14.8* RBC-2.98* Hgb-7.6* Hct-24.3*
MCV-82 MCH-25.5* MCHC-31.3* RDW-15.4 RDWSD-45.8 Plt ___
___ 04:30PM BLOOD Glucose-252* UreaN-17 Creat-1.1 Na-135
K-4.6 Cl-102 HCO3-22 AnGap-16
___ 04:30PM BLOOD ALT-103* AST-23 AlkPhos-193* TotBili-0.2
___ 04:30PM BLOOD Albumin-4.2 Calcium-9.7 Phos-3.1 Mg-1.9
___ 04:30PM BLOOD Lipase-23
___ 03:31AM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 07:25AM BLOOD WBC-11.1* RBC-3.08* Hgb-7.6* Hct-25.0*
MCV-81* MCH-24.7* MCHC-30.4* RDW-15.5 RDWSD-45.9 Plt ___
___ 07:25AM BLOOD Glucose-168* UreaN-18 Creat-1.1 Na-134
K-4.7 Cl-100 HCO3-25 AnGap-14
___ 07:25AM BLOOD ALT-60* AST-15 LD(LDH)-154 CK(CPK)-37
AlkPhos-144* TotBili-0.2
IMAGING
___ RUQ ULTRASOUND
1. No evidence of biliary obstruction. Patient is s/p
cholecystectomy. There is no intrahepatic biliary dilatation.
Top-normal caliber of common bile duct is felt to be compatible
with post cholecystectomy state.
2. Normal sonographic appearance of the liver.
MICROBIOLOGY
___ Blood culture No growth to date
Brief Hospital Course:
___ year old female with h/o recurrent UTIs, chronic abdominal
pain, urethral diverticulum admitted with chronic abdominal pain
and reported hypertensive urgency.
# Chronic abdominal pain: Patient has had multiple (26 so far in
___ admissions for abdominal pain and has been evaluated by
multiple physicians. Extensive workup has been unremarkable and
etiology thought likely secondary to anxiety. Patient has had
action plan put in place by previous provider for which she is
recommended to take anxiolytics when she begins to develop
abdominal pain, but has not done so ___ difficulty obtaining
medications. She endorsed being unable to afford some of her
medications. On this admission exam was benign; patient endorsed
pain while awake but was able to sleep comfortably. She was
continued on outpatient carafate, peptobismol, and anxiety
medications. Abdominal pain resolved prior to discharge.
# Hypertensive Urgency: Patient has had repeated episodes of
hypertensive urgency frequently associated with anxiety. Also
denied taking all of her medications due to financial
difficulties as above. On admission she hypertensive to 225/137
with normal creatinine and troponin. She was restarted on her
home regimen of lisinopril, nifedipine, and imdur, and BP
normalized.
# Depression/anxiety: Patient has recurrent episodes of panic
attacks and thought to be major contributor to repeated
presentation with abdominal pain and hypertension. Seen by
psychiatry and social work last admission. She was continued on
home clonazepam, ativan, setraline. Recommend continued
outpatient follow up for anxiety if possible.
# Leukocytosis: To peak of 18 this admission. On chart review
patinet has chronic leukocytosis to teens without identification
of source. Possibly secondary to chronic stress. She was
continued on her previous outpatient antibiotics as below.
# Coag negative staph port associated bloodstream infection:
Patient has had port placed for venous access given repeated
hospitalizations. On prior admission had a bloodstream infection
likely due to the port and started on course of daptomycin per
ID. She was continued on daptomycin and daptomycin-heparin port
locks in house. She will cotninue this course until ___.
# History of C diff: On PO vancomycin. She was continued on this
in house with plan to extend the vancomycin 10 days past
completion of daptomycin course.
# DM: Held home metformin. Continued on glargine and sliding
scale insulin.
# CODE STATUS: Full code
# CONTACT: Health Care Proxy: ___
# TRANSITIONAL ISSUES:
- patient to continue home daptomycin therapy and lock therapy
through ___
- continue PO vancomycin for 10 days beyond daptomycin, until
___
- follow-up as previously scheduled
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H pain/discomfort
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Bismuth Subsalicylate 15 mL PO QID
4. ClonazePAM 0.5 mg PO QHS
5. Daptomycin 500 mg IV Q24H
6. Daptomycin-Heparin Lock ___SDIR port infection
7. Gabapentin 600 mg PO TID
8. Isosorbide Mononitrate 10 mg PO QHS
9. Lisinopril 40 mg PO DAILY
10. NIFEdipine CR 120 mg PO DAILY
11. Sertraline 200 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. Vancomycin Oral Liquid ___ mg PO Q6H
14. Daptomycin-Heparin Lock 10 mg LOCK ONCE
15. Propranolol 40 mg PO DAILY:PRN panic attack
16. Lorazepam 0.5 mg PO Q6H:PRN pain
17. MetFORMIN (Glucophage) 1000 mg PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Propranolol LA 120 mg PO DAILY
20. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
21. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain/discomfort
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Bismuth Subsalicylate 15 mL PO QID
4. ClonazePAM 0.5 mg PO QHS
5. Daptomycin 500 mg IV Q24H Duration: 4 Doses
through ___
RX *daptomycin [Cubicin] 500 mg 1 vial IV daily Disp #*4 Vial
Refills:*0
6. Daptomycin-Heparin Lock ___SDIR port infection
Duration: 4 Doses
Daptomycin 2mg/mL
+ Heparin 100 Units/mL
7. Daptomycin-Heparin Lock ___SDIR Duration: 4 Doses
Daptomycin 2mg/mL
+ Heparin 100 Units/mL
8. Gabapentin 600 mg PO TID
9. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
10. Lisinopril 40 mg PO DAILY
11. Lorazepam 0.5 mg PO Q6H:PRN pain
12. NIFEdipine CR 120 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Propranolol 40 mg PO TID:PRN panic attack
15. Propranolol LA 120 mg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO DAILY
17. Isosorbide Mononitrate 10 mg PO QHS
18. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. Sertraline 200 mg PO DAILY
20. Sucralfate 1 gm PO QID
21. Vancomycin Oral Liquid ___ mg PO Q6H
22. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
RX *heparin lock flush (porcine) 10 unit/mL 10 units IV daily
and prn Disp #*10 Syringe Refills:*0
23. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 mL IV daily and prn Disp #*10
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Abdominal pain
Hypertensive urgency
Secondary
Anxiety
Line-associated bacteremia
Leukocytosis
C diff
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for abdominal pain and very high blood
pressure. We restarted your home blood pressure medications and
your blood pressure returned to normal. The work up for your
abdominal pain was unrevealing and it is likely that your
anxiety led to some of your symptoms. Please be sure to follow
the plan set forth by Dr. ___ anxiety when you leave the
hospital. In addition, increased services have been set up at
home to help you with anxiety. It will be very important to see
a therapist.
It is very important that you pick up and take all your
medications as prescribed. Please continue your IV antibiotic
therapy and PO vancomycin for C.diff as already prescribed. You
should continue the vancomcyin therapy for 10 days after the
conclusion of your daptomycin therapy.
It was a pleasure taking care of you in the hospital.
- Your ___ Team
Followup Instructions:
___
|
10577647-DS-52 | 10,577,647 | 23,452,696 | DS | 52 | 2146-05-08 00:00:00 | 2146-05-11 12:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / aspirin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of chronic abdominal pain and IDDM presents
with abdominal pain and chest pain. Patient reports onset of
midsternal chest pain this morning. Her pain is easily
reproducible; associated with nausea and small amount of clear
sputum. Denies alcohol use today, does occasionally smoke
marijuana. Denies recent viral illness but has been diagnosed
with C. difficile diarrhea for which she was treated initially
with PO flagyl, on last hospital admission (discharged one day
ago) switched to PO vancomycin. Denies any recent exertional
chest pain/SOB.
In the ED, initial vitals were: T 97.9 HR 81 BP 133/85 RR 18
SpO2 100% RA. Initial labs most notable for leukocytosis 20.8,
Glucose 299, trop<0.01, lactate 1.9, lipase 19, LFTs unchanged
from baseline.
UA was notable for cloudy urine, large leuks, pyuria, and
bacteruria. EKG was notable for SR with old RBBB. In the ED, the
patient was given
IV Metoclopramide 10 mg x1, Propranolol 40 mg PO x1,IV
Lorazepam 1 mg x1, Ciprofloxacin HCl 500 mg PO x1, IV Lorazepam
1 mg x1, IV Acetaminophen IV 1000 mg x1.
On the floor, the patient was tearful and complaining of
diffuse abdominal pain and nausea and vomiting. She endorsed
ongoing diarrhea. She denied any chest pain, dyspnea, suprapubic
pain, dysuria, fevers, or chills.
Past Medical History:
- Abdominal pain with multiple admissions, extensive evaluation
without clear etiology identified. Attributed to poorly
controlled anxiety.
- IDDM (type 2): HbA1c 6.8% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections possibly related to
urethral diverticulum
- Chronic back pain
- IUD placement
- venous access device-related blood stream infection
Social History:
___
Family History:
Mother - DM, breast cancer s/p treatment but now found to have
recurred in her liver in ___. She is not doing well per
pt's dtr.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.5 HR 80 BP 136/65 RR 18 SpO2 97% RA
General: Tired appearing, tearful, but in NAD
HEENT: Sclera anicteric, MMM, no OP lesions
Neck: L-sided port appears clean, dry, and intact. Supple, no
lymphadenopathy, JVD.
CV: RRR, no m,r,g. Normal S1 and S2.
Lungs: No wheezing, crackles, or rhonci.
Abdomen: Obese, redundant skin folds, diffusely tender
throughout, no rigidity or rebound tenderness
Ext: No ___ edema
Neuro: Moving all extremities with purpose, no facial asymmetry
DISCHARGE PHYSICAL EXAM:
Vitals: 97.9 130/76 75 20 100 RA
___ 200s-329
General: alert, comfortable appearing
HEENT: Sclera anicteric, MMM, no OP lesions
Neck: L-sided port appears clean, dry, and intact. Supple, no
lymphadenopathy, JVD.
CV: RRR, no m,r,g. Normal S1 and S2.
Lungs: No wheezing, crackles, or rhonci.
Abdomen: Obese, redundant skin folds, non tender, no rigidity or
rebound tenderness
Ext: trace ___ edema
Neuro: grossly intact, moving all extremities, no facial
asymmetry
Pertinent Results:
ADMISSION LABS:
___ 06:12AM PLT COUNT-374
___ 06:12AM WBC-12.8* RBC-3.34* HGB-7.5* HCT-25.2*
MCV-75* MCH-22.5* MCHC-29.8* RDW-17.4* RDWSD-47.2*
___ 07:20PM PLT COUNT-444*
___ 07:20PM NEUTS-77.8* LYMPHS-17.2* MONOS-4.0* EOS-0.0*
BASOS-0.5 IM ___ AbsNeut-15.94* AbsLymp-3.52 AbsMono-0.82*
AbsEos-0.01* AbsBaso-0.10*
___ 07:20PM ALT(SGPT)-18 AST(SGOT)-15 ALK PHOS-144* TOT
BILI-0.2
___ 07:20PM GLUCOSE-232* UREA N-19 CREAT-0.8 SODIUM-133
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-25 ANION GAP-16
DISCHARGE LABS:
___ 07:20PM BLOOD WBC-20.5*# RBC-4.03 Hgb-9.3* Hct-30.3*
MCV-75* MCH-23.1* MCHC-30.7* RDW-17.5* RDWSD-47.2* Plt ___
___ 07:20PM BLOOD Glucose-232* UreaN-19 Creat-0.8 Na-133
K-4.7 Cl-97 HCO3-25 AnGap-16
IMAGING:
___ KUB
FINDINGS:
There is some air seen within the small and large bowels. There
are no
abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air. Osseous structures are
unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies. Surgical clips are seen within the right upper
quadrant.
IMPRESSION:
No evidence of ileus or obstruction.
Brief Hospital Course:
___ y.o. woman with anxiety/depression, DM, chronic abdominal
pain with multiple recent admissions, recurrent UTIs and ongoing
C diff colitis presenting with abdominal and chest pain, nausea,
vomiting, and inability to tolerate PO.
ACTIVE ISSUES:
# Acute on Chronic Abdominal Pain: She presented with recurrence
of her chronic abdominal pain, associated with chest pain,
nausea and vomiting, and diarrhea. She was admitted because she
was unable to tolerate POs. As below, she never picked up her
prescription for C. Diff (was supposed to start a 10 day course
of PO vanco on ___ which may have contributed to acute
worsening. In the past it's been thought that her abdominal pain
is closely tied to difficult psychosocial situation and home
stressors. She was treated for nausea with IV ativan given
prolonged qTC (487). On HD1 she tolerated a full diet without
nausea or vomiting. Diarrhea slowed on PO Vanco prior to
discharge. Of note we had her meds delivered to bedside prior to
discharge and we informed the patient that copays can be waived
on many of her medications.
#Recurrent C. diff: C diff was last positive on ___. She was
discharged on a 10 day course flagyl at that time. PO vanco
added ___ given ongoing leukocytosis, however she never picked
up her script. She was restarted on PO Vanco for a ___symptomatic pyuria: UA was grossly positive but she denied
symptoms and UAs have been recurrently positive. She was not
treated.
#hypoK: Hypokalemic on admission in setting of vomiting and
diarrhea. This resolved with repletion and improved PO intake,
as well as treatment of nausea/diarrhea as above.
CHRONIC ISSUES:
# Diabetes Mellitus: She was hypoglycemic on arrival in setting
of poor PO intake and vomiting. This resolved w/PO intake.
Continued home Gabapentin 600 mg PO TID for neuropathy.
# Anxiety/Depression: Continued home Sertraline, clonazepam,
propranolol.
# Hypertension: Continued home Nifedipine CR 120 mg PO QDaily,
Imdur 10 mg PO QHS
# GERD: Continued home Ranitidine 150 mg PO BID, Sucralfate 1
gm PO QID
TRANSITIONAL ISSUES:
[]C diff: continue vanco up to and including ___ (total 10 day
course)
[]medication refills - recommend future medication refills be
sent to ___ Careplus with instructions to wave co-pays as
patient has difficulty filling medication due to financial
burden
[] anemia: pt has chronic microcytic anemia which was at
baseline during this admission. Consider working up as an
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
2. ClonazePAM 0.5 mg PO QHS:PRN sleep
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Gabapentin 600 mg PO TID
5. Isosorbide Mononitrate 10 mg PO QHS
6. Lorazepam 0.5 mg PO Q6H:PRN pain
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
8. NIFEdipine CR 120 mg PO DAILY
9. Propranolol LA 120 mg PO DAILY
10. Sertraline 200 mg PO DAILY
11. Sucralfate 1 gm PO QID
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Propranolol 40 mg PO TID:PRN panic attack
17. RISperidone 0.5 mg PO QHS
18. Vancomycin Oral Liquid ___ mg PO Q6H
19. Ranitidine 150 mg PO BID
20. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 9 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*36 Capsule Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 patch once a day Disp #*30 Patch Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN pain/discomfort
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
5. ClonazePAM 0.5 mg PO QHS:PRN sleep
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gabapentin 600 mg PO TID
8. Isosorbide Mononitrate 10 mg PO QHS
RX *isosorbide mononitrate 10 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
9. NIFEdipine CR 120 mg PO DAILY
RX *nifedipine 60 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
10. Propranolol 40 mg PO TID:PRN panic attack
11. Sertraline 200 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. Lorazepam 0.5 mg PO Q6H:PRN pain
14. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*24 Tablet Refills:*0
15. Propranolol LA 120 mg PO DAILY
16. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
17. RISperidone 0.5 mg PO QHS
18. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
19. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
chronic abdominal pain
SECONDARY DIAGNOSES:
insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
You were admitted to ___ with abdominal pain. You were treated
with resting your bowels until you were no longer having pain.
You were also given some medications for nausea. Additionally
you were given antibiotics for an infection of your GI tract.
You improved clinically and it was determined you could be
discharged to home. Please take your medications as prescribed
and keep your follow up appointments as scheduled.
It was a pleasure to care for you!
Your ___ team
Followup Instructions:
___
|
10577647-DS-64 | 10,577,647 | 22,761,375 | DS | 64 | 2147-06-25 00:00:00 | 2147-06-25 11:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / daptomycin / Bactrim
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ PMHx GERD, HTN, depression, poorly
controlled T2DM, anxiety, chronic abdominal pain (unclear
etiology but felt to be possibly functional ___ anxiety),
recurrent ESBL UTIs, and multiple hospitalizations for abdominal
pain/UTIs (most recently ___ who re-presents with abdominal
pain.
She states that she has been having ongoing abdominal pain x 3
weeks a/w nausea and NBNB emesis. She endorses her typical
___ abdominal pain that is persistently in ___
severity of pain. She has no associated diarrhea or change in
her BMs. She also endorses increased urinary frequency and new
L sided flank pain which is new as well. She denies any chest
pain, SOB, fevers/chills/ns. Of note, given her recurrent
hospitalizations for abdominal pain of unclear etiology, there
is a care plan in place to avoid narcotic medications and trial
benzo's as able.
In the ED, initial VS 97.5, 90, 155/61, 19, 100% on RA, In the
ED, her exam was notable for diffuse abdominal tenderness w/o
peritoneal signs. Admission labs showed Na 127, K 4.8, Cr 1.2
(at baseline), LFTs/Tbili wnl, WBC 19.5, Hgb 10.2 (baseline ~
10), Plt 672, lactate 1.7. UA was grossly positive for large
leuks and pyuria although with 16 epi's. Repeat clean-catch UA
was still grossly positive with large leuks and pyuria. Of
note, while in the ED, her FSBG were elevated to 484 and her
chem panel showed AG of 17. However, her VBG was wnl and she
only had 10 ketones on her UA so was not felt to be in DKA. She
was given 10u regular insulin, gentamicin and Ativan prior to
transfer to the floor. A femoral line was placed given her poor
access.
Upon transfer to the floor, the patient is seen lying in bed in
tears and reporting diffuse ___ abdominal pain as
well as L-sided midline and back pain. She continues to feel
nauseous and is dry-heaving. Denies any fevers. No other acute
medical complaints but is requesting improved pain control.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Abdominal pain with multiple admissions, extensive evaluation
without clear etiology identified. Attributed to poorly
controlled anxiety.
- IDDM (type 2): HbA1c 6.8% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections possibly related to
urethral diverticulum
- Chronic back pain
- IUD placement
- venous access device-related blood stream infection
Social History:
___
Family History:
(per OMR, confirmed with patient)
Mother - DM, breast cancer s/p treatment but now found to have
recurred in her liver in ___ s/p surgery and she is
getting better.
Physical Exam:
ADMISSION EXAM:
Vitals- 98.6 194 / 78 113 22 96 RA
GENERAL: obese middle-aged female lying in bed in moderate
discomfort, in tears, wailing
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: regular tachycardic, nml S1 and S2, no m/r/g
LUNGS: CTAB, no w/r/r, unlabored respirations
BACK: bilateral CVAT L > R
ABDOMEN: soft, obese, nondistended, diffuse TTP worse at
___ region, no rebound/guarding, + bowel sounds
GU: no Foley, has L femoral line in place
EXTREMITIES: wwp, no c/c/e
SKIN: no rash or lesions
NEUROLOGIC: AOx3, grossly nonfocal
PSYCH: anxious, tearful
DISCHARGE EXAM:
Vitals: 98.6 145 / 82 79 18 97 Ra
GENERAL: obese middle-aged female sitting up in bed eating in
NAD
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: RRR, nml S1 and S2, no m/r/g
LUNGS: CTAB, no w/r/r, unlabored respirations
BACK: Nontender to palpation, lidocaine patch in place
ABDOMEN: soft, obese, nondistended, nontender, no
rebound/guarding, + bowel sounds
GU: no Foley
EXTREMITIES: wwp, no c/c/e. Left midline in place c/d/I.
SKIN: no rash or lesions
RECTAL: deferred
NEUROLOGIC: AOx3, motor and sensory exam grossly intact
PSYCH: calm, pleasant, restricted affect
Pertinent Results:
ADMISSION LABS:
___ 03:39PM ___ PO2-37* PCO2-46* PH-7.39 TOTAL
CO2-29 BASE XS-1 INTUBATED-NOT INTUBA
___ 10:37AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 10:37AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 10:37AM URINE RBC-2 WBC->182* BACTERIA-FEW YEAST-NONE
EPI-2
___ 09:22AM URINE UCG-NEGATIVE
___ 09:22AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 09:22AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 09:22AM URINE RBC-9* WBC->182* BACTERIA-FEW YEAST-NONE
EPI-16 TRANS EPI-<1
___ 09:22AM URINE AMORPH-RARE
___ 09:14AM LACTATE-1.7
___ 09:05AM GLUCOSE-530* UREA N-26* CREAT-1.2*
SODIUM-127* POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-21* ANION
GAP-22*
___ 09:05AM ALT(SGPT)-10 AST(SGOT)-9 ALK PHOS-157* TOT
BILI-0.3
___ 09:05AM LIPASE-20
___ 09:05AM ALBUMIN-3.6
___ 09:05AM WBC-19.5* RBC-4.50 HGB-10.2* HCT-34.0 MCV-76*
MCH-22.7* MCHC-30.0* RDW-16.3* RDWSD-44.6
___ 09:05AM NEUTS-85.4* LYMPHS-10.3* MONOS-2.9* EOS-0.3*
BASOS-0.6 IM ___ AbsNeut-16.67* AbsLymp-2.02 AbsMono-0.57
AbsEos-0.05 AbsBaso-0.11*
___ 09:05AM PLT SMR-VERY HIGH PLT COUNT-672*
DISCHARGE LABS:
___ 03:10PM BLOOD WBC-12.6* RBC-3.55* Hgb-8.4* Hct-27.3*
MCV-77* MCH-23.7* MCHC-30.8* RDW-17.2* RDWSD-48.4* Plt ___
___ 03:10PM BLOOD Glucose-178* UreaN-32* Creat-1.4* Na-134
K-4.3 Cl-100 HCO3-20* AnGap-18
___ 03:10PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0
Imaging/Studies:
___ CXR
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or
edema. There is no pneumothorax. The cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No pneumothorax.
Renal US ___:
Normal renal ultrasound. Specifically, no evidence of
hydronephrosis.
Brief Hospital Course:
Ms. ___ is a ___ PMHx GERD, HTN, depression, poorly
controlled T2DM, anxiety, chronic abdominal pain (unclear
etiology but felt to be possibly functional ___ anxiety),
recurrent ESBL UTIs, and multiple hospitalizations for abdominal
pain/UTIs (most recently ___ who re-presents with abdominal
pain, possible UTI, and hyperglycemia, now complicated by ___.
___ on CKD: Abrupt increase in Cr ___ from 1.2 to 2.5, which
was confirmed on repeat testing and rose to 2.8. Unclear
etiology, most likely prerenal given abrupt change and reduced
UOP per patient as well as associated hyponatremia, though BUN
stable and patient has been receiving fluids even when PO intake
was poor. Given improvement after IVF, this seems most likely.
Renal US was obtained and showed no e/o hydronephrosis or
stranding. Cr improved to 1.4 which is close to pt's baseline on
discharge.
#Hyponatremia: Pt presented with Na: 127, likely hypovolemic in
setting of limited PO intake over the past week related to her
abdominal/back pain as well as
osmotic effect from hyperglycemia especially given UNa <20.
This improved with IVF's to low 130's.
#Acidosis: HCO3 nadired at 15 though AG 13, lactate 1.3. This
was felt to be from diarrhea vs mild transient RTA from acute
renal injury. BG's in 200's range so DKA was not likely.
Resolved with improved renal function and resolution of
diarrhea.
# Hyperglycemia.
# T2DM.
Patient hyperglycemic to 484 in the ED with mild ketonuria and
small gap acidosis but resolved rapidly with insulin in ED and
VBG without acidosis, making DKA less likely. Likely poor
compliance with insulin as on past admissions, possibly
exacerbated in setting of infection. FSGs on discharge were in
the 200's range on home Lantus 54 u qhs and Humalog 10u with
meals.
# Acute on chronic abdominal pain.
# N/v
# Anxiety.
Patient presented with acute on chronic abdominal pain with
extensive work-up in the past without any obvious etiology.
Previously thought to be a manifestation of severe anxiety and
social stressors with clearly documented management plan on many
prior admissions (16 admissions in about 14 months). Her
LFTs/Tbili are wnl and she has been passing gas/moving her
bowels so suspicion for obstruction is low. She was started on
her pain management care plan (home amitriptyline, propranolol,
sertraline) with improvement in abdominal pain.
# Bacteruria/bacteremia: Patient with grossly positive UA and
leukocytosis, however, urine cultures were negative. Bcx from
admission also with ___ bottles with peptostreptococcus.
Patient was otherwise afebrile and appeared well so this was
felt to be contaminant. Femoral line removed ___ d/t concerns
about contamination and replaced with midline. She was not
treated with abx.
# HTN: Patient intermittently hypertensive to the 190s in the
setting of acute abdominal pain/anxiety. On admission she
states
that she only took some of her home meds (not her home
propranolol). BP elevation resolved after taking her medications
and improvement in anxiety. Her home lisinopril was held for
___ and ___ be restarted on discharge in addition to her other
home anti-hypertensives.
Transitional issues:
-Has had hyperglycemia during admission, would benefit from
adjustment of diabetes medications as outpatient
-Patient requires midline or PICC during admissions due to poor
access. Please avoid femoral central lines if possible as
patient has had multiple bouts of bacteremia.
-Please follow abdominal pain protocol as documented previously
when patient presents with abdominal pain
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Amitriptyline 25 mg PO QHS
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Isosorbide Mononitrate (Extended Release) 10 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lisinopril 20 mg PO DAILY
7. LORazepam 0.5 mg PO DAILY:PRN anxiety
8. NIFEdipine CR 120 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN n/v
10. Pregabalin 50 mg PO QHS
11. Propranolol 40 mg PO TID:PRN anxiety
12. Propranolol LA 80 mg PO DAILY
13. RisperiDONE 0.5 mg PO QHS
14. Sertraline 200 mg PO DAILY
15. Sucralfate 1 gm PO QID
16. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
17. Docusate Sodium 100 mg PO BID
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
19. Senna 8.6 mg PO BID:PRN constipation
20. Glargine 54 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 54 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Amitriptyline 25 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Isosorbide Mononitrate (Extended Release) 10 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lisinopril 20 mg PO DAILY
9. LORazepam 0.5 mg PO DAILY:PRN anxiety
10. NIFEdipine CR 120 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN n/v
12. Pregabalin 50 mg PO QHS
13. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q6H:PRN
SOB/wheezing
14. Propranolol LA 80 mg PO DAILY
15. Propranolol 40 mg PO TID:PRN anxiety
16. RisperiDONE 0.5 mg PO QHS
17. Senna 8.6 mg PO BID:PRN constipation
18. Sertraline 200 mg PO DAILY
19. Sucralfate 1 gm PO QID
20. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute on chronic abdominal pain
Secondary: Acute kidney injury, acidosis, hyperglycemia,
diabetes mellitus, hyponatremia, bacteruria, anemia,
hypertension, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to abdominal pain, nausea,
vomiting, and diarrhea. Your abdominal pain improved rapidly,
but your diarrhea persisted. As a result, you had some injury to
your kidneys from dehydration. You improved after receiving
fluids and as your diarrhea improved. You may have a had a viral
infection that led to these symptoms.
Your blood sugars were high during your admission. Please follow
up with your PCP regarding your diabetes.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
10577647-DS-66 | 10,577,647 | 24,037,785 | DS | 66 | 2147-08-24 00:00:00 | 2147-08-24 22:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / daptomycin / Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain and chest pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: ___
_
________________________________________________________________
PCP: ___.
CC:Abdominal pain
History obtained from daughter ___ as patient will not talk
to me and falls asleep during the encounter.
_
________________________________________________________________
HPI:
___ woman with GERD, HTN, depression, poorly controlled
T2DM, delayed gastric emptying, anxiety, chronic abdominal pain,
recurrent UTIs, and multiple hospitalizations for abdominal
pain/UTIs. She is brought in by EMS to ED with c/o n/v "for
days" pt with chronic ABD pain. Talking with ___ and
reviewing the EMS call in sheet she also reported pleuritic
chest pain which was different from her anxiety attacks.
Talking with ___, her mother has expressed depression along
with a lack of self worth. She does not report SI/HI. When she
has severe abdominal pain she will say, kill me now or let me
die but other than that she does not express such thoughts. She
does have recurrent vomiting and regurgitation of undigested
food. It is very hard for her to eat small frequent meals. She
often has abdominal pain. Her daughter worries that her pain may
have been worsened by IUD placement but she saw GYN in ___ for
this and they thought that she had abdominal pain prior to this
and it was so difficult to put in and it would be difficult to
remove it only to see that it did not have any effect on her
pain. Her daughter also notices that her abdominal sx, nausea
and vomiting get worse when she does not have regular bowel
movements so she keeps giving her her bowel medications to try
to keep her regular.
___ knows that her mother has been struggling with
depression for most of her adult life but refuses home ___ and
refuses a home therapist.
She had GI appointment last week but did not make appointment.
When I see her she is asleep but then she wakes up occasionally
in pain only to fall asleep again.
In ER: (Triage Vitals:8|97.0|87|144/98|22|100% RA
Today ___
Meds Given:
Ondansetron ODT 4 mg|SCInsulin 10 + 4 UNITS| LORazepam 1 mg and
2 MG| Zosyn 4.5 gm|
Plan in ED:
[x]basic labs- lactate elevation, no DKA
[x]EKG- RBBB still but morphology appears different, no acute ST
changes
[x]add on troponin, lipase -wnl
[x]Zofran odt
[x]insulin order
[x]UA grossly positive, has hx of resistant organisms
Will obtain IV access, get CBC/blood culture, IV zosyn for
treatment of UTI given persistent symptoms not controlled by
usual lorazepam treatment. Admit to medicine.
A ten point limited review of systems was negative except as
above. Review of systems markedly limited by her refusal to talk
with me.
.
Past Medical History:
- Abdominal pain with multiple admissions, extensive evaluation
without clear etiology identified. Attributed to poorly
controlled anxiety.
- IDDM (type 2): HbA1c 6.8% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections possibly related to
urethral diverticulum
- Chronic back pain
- IUD placement
- venous access device-related blood stream infection
Social History:
___
Family History:
From last time I admitted her but she will not talk to me now to
confirm this.
Mother - DM, breast cancer s/p treatment but now found to have
recurred in her liver in ___ s/p surgery and she is
getting better.
Physical Exam:
Vitals: 98.0 ___
Gen: Lying in bed, awake and alert, appears comfortable
HEENT: AT, NC, PERRL, EOMI, MMM, hearing grossly intact
CV: S1, S2, RRR no M/R/G
Pulm: CTA b/l, no wheeze, rhonchi, or rales
GI: (+) BS, soft, obese, mild generalized tenderness, ND, no HSM
Skin: No rashes or ulcerations evident
Neuro: A+O x4, speech fluent, face symmetric, moving all
extremities
Psych: calm mood, appropriate affect
Pertinent Results:
___ 05:41PM ___ PO2-100 PCO2-29* PH-7.52* TOTAL
CO2-24 BASE XS-1
___ 05:41PM LACTATE-1.9
___ 05:35PM WBC-16.9* RBC-3.92 HGB-9.3* HCT-30.6* MCV-78*
MCH-23.7* MCHC-30.4* RDW-16.2* RDWSD-46.2
___ 05:35PM PLT COUNT-572*
___ 03:30PM URINE HOURS-RANDOM
___ 03:30PM URINE UCG-NEGATIVE
___ 03:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 03:30PM URINE RBC-5* WBC-43* BACTERIA-FEW YEAST-NONE
EPI-3
___ 03:30PM URINE MUCOUS-RARE
___ 01:32PM ___ PO2-199* PCO2-32* PH-7.49* TOTAL
CO2-25 BASE XS-2 COMMENTS-GREEN TOP
___ 01:32PM LACTATE-2.8*
___ 01:32PM O2 SAT-95
___ 01:20PM GLUCOSE-200* UREA N-32* CREAT-1.2*
SODIUM-132* POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-22 ANION GAP-17
___ 01:20PM estGFR-Using this
___ 01:20PM ALT(SGPT)-14 AST(SGOT)-16 ALK PHOS-110* TOT
BILI-0.2
___ 01:20PM LIPASE-29
___ 01:20PM cTropnT-<0.01
___ 01:20PM ALBUMIN-3.7 CALCIUM-8.2* MAGNESIUM-1.6
+++++++++++++++++++++++++++++++
ABDOMINAL CT SCAN WITH IV AND PO CONTRAST ___
IMPRESSION:
1. No acute intra-abdominal or pelvic abnormality. No
abnormality identified to explain patient symptomatology.
2. Urethral diverticulum, previously described and unchanged.
3. Right Bartholin's gland cyst, partially imaged, also
previously present and unchanged.
==========================================================
RENAL ULTRASOUND ___:
FINDINGS:
The right kidney measures 10.3 cm. The left kidney measures 11.5
cm. Normal
cortical echogenicity and corticomedullary differentiation are
seen
bilaterally. Per technologist's note, the measured echogenic
focus in the
left inferior renal pole is artifactual. No shadowing renal
calculi or
hydronephrosis.
The bladder is moderately well distended.
IMPRESSION:
Unremarkable renal ultrasound as on ___
==============================================================
___ 07:10AM BLOOD WBC-15.4* RBC-4.17 Hgb-9.8* Hct-31.7*
MCV-76* MCH-23.5* MCHC-30.9* RDW-16.3* RDWSD-45.1 Plt ___
___ 07:10AM BLOOD Glucose-274* UreaN-24* Creat-1.0 Na-131*
K-4.4 Cl-95* HCO3-22 AnGap-18
___ 07:10AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ woman with GERD, HTN, depression,
poorly-controlled T2DM, delayed gastric emptying, anxiety,
chronic abdominal pain, recurrent UTIs, chronic leukocytosis,
and multiple hospitalizations for abdominal pain/UTIs. She is
brought in by EMS to ED with n/v "for days" and with acute on
chronic ABD pain.
Likely 'flare' of gastroparesis vs gastroenteritis. Pt did not
have significant vomiting thoughout since admission. UA was
equivocal in the setting of chronic bladder diverticulum and has
chronic leukocytosis so held off on antibiotics.
Managed with supportive care, advancing diet. Her daughter has
noticed that her abdominal sx, nausea and vomiting get worse
when she does not have regular bowel movements so we focused on
advancing her bowel regimen while inaptient (and successful BM
on ___. Also obtained ___ consult as her A1c is >10.
WBC downtrended and she was eventually tolerating PO intake.
Renal function and electrolytes are also improved.
Per problem:
#ABDOMINAL PAIN, NAUSEA: ? gastroenteritis vs gastroparesis
#DELAYED GASTRIC EMPTYING:
CT abdomen from ___ (during similar exacerbation of her
chronic ab pain) without acute pathology.
Pt with known delayed gastric emptying, which most likely caused
her recent symptoms. Also her daughter ___ reported that her
mother's sx are worsened when she is constipated so we have
continued an aggressive bowel regimen - with successful large BM
on ___. Work-up: lipase 29, urine hug negative. Urine culture
from ___ showed mixed bacterial flora - likely contaminant.
Remained afebrile and WBC downtrended despite no antibiotics.
#LIGHT HEADEDNESS
#ORTHOSTATIC HYPOTENSION
This may have been secondary to acute dehydration after emesis,
however, pt had been documented to have good PO fluid intake. DM
neuropathy and polypharmacy likely contributed. We scaled back
on all of her antihypertensives except propranolol and she still
remained orthostatic. Propranolol was stopped and orthostatic
hypotension resolved. ___ was d/w her PCP, ___, who is
aware she was discharged off all her antihypertensives. Pt is
scheduled to see her in 2 days, at which time, her BP will be
reevaluated. Despite being off her meds, her blood pressure
remained adequately controlled.
#URETHRAL DIVERTICULUM
#FREQUENT UTIS
The patient has a history of recurrent UTIs. She is colonized
with multi-resistant organisms (including MDR Kleb from the
urine, only S to gent, zosyn, and Bactrim). She also has chronic
leukocytosis (unchanged from her usual "baseline"). In the
absence of a fever or clear signs of infection, held abx out of
balance against concern risk for cdiff and the creation of even
more resistant abx. Regarding her diverticulum: d/w pt and dtr
that pt is not a good surgical candidate. She was seen by
urology and its not clear that surgical repair of the
diverticulum would help. Renal ultrasound was done to rule out
urinary obstruction or any signs to suggest pyelo, which would
push us to treat with antibiotics. Renal ultrasound ___ was
normal (no hydro, no inflammation seen).
#DEPRESSION AND ANXIETY
She has multiple medical co-morbidities which could help explain
the extent of her pain, nausea and vomiting eg gatroparesis and
chronic UTIS but there is probably also a huge component of
anxiety. Unfortunately, poor patient follow up has hindered
ideal longitudinal follow up for these issues. Social work
consulted for support and for help mobilizing outpatient mental
health resources.
#DIABETES MELLITUS: Poorly controlled, last HgbA1C = 10.3 in
___. She was continued lantus 50 units sq qhs while in
house. ___ had recommended lantus 40 units sq qhs and
glipizide XL 10 mg po qday. After speaking to her PCP, we
decided to continue her home regimen of lantus 54 units sq qhs
due to concerns about compliance and polypharmacy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine CR 120 mg PO DAILY
2. Ferrous Sulfate 325 mg PO BID
3. Propranolol LA 80 mg PO DAILY
4. TraMADol 50 mg PO TID:PRN Pain - Moderate
5. Sertraline 200 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 10 mg PO QHS
7. Docusate Sodium 100 mg PO BID
8. Lisinopril 20 mg PO DAILY
9. Amitriptyline 50 mg PO QHS
10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
13. Pregabalin 50 mg PO DAILY:PRN pain
14. Sucralfate 1 gm PO QID
15. Glargine 54 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. Senna 8.6 mg PO BID:PRN constipation
17. Ondansetron ODT 8 mg PO Q8H:PRN nausea
18. LORazepam Dose is Unknown PO Frequency is Unknown
19. Lidocaine 5% Ointment 1 Appl TP ONCE
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
4. Amitriptyline 50 mg PO QHS
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Glargine 54 Units Bedtime
9. Lidocaine 5% Ointment 1 Appl TP ONCE
10. LORazepam 1 mg PO BID:PRN anxiety
11. Ondansetron ODT 8 mg PO Q8H:PRN nausea
12. Pregabalin 50 mg PO DAILY:PRN pain
13. Senna 8.6 mg PO BID:PRN constipation
14. Sertraline 200 mg PO DAILY
15. Sucralfate 1 gm PO QID
16. TraMADol 50 mg PO TID:PRN Pain - Moderate
17. HELD- Isosorbide Dinitrate 10 mg PO QHS This medication was
held. Do not restart Isosorbide Dinitrate until seen by Dr.
___
18. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until seen by Dr. ___
19. HELD- NIFEdipine CR 120 mg PO DAILY This medication was
held. Do not restart NIFEdipine CR until seen by Dr. ___
20. HELD- Propranolol LA 80 mg PO DAILY This medication was
held. Do not restart Propranolol LA until seen by Dr. ___
___ blood pressure check
Discharge Disposition:
Home
Discharge Diagnosis:
-poorly controlled type 2 DM
-delayed gastric emptying
-chronic abdominal pain and nausea
-urinary diverticulum
-orthostatic hypotension
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 ___.
Why were you in the hospital?
=======================
-nausea, vomiting and abdominal pain
-high blood sugars
-blood pressure drop when going from sitting to standing
position
What did we do for you?
=======================
- The ___ diabetes team was consulted to help manage your
high blood sugars.
- you were given anti nausea medication and pain medication to
help your abdominal pain
- you were taken off your blood pressure medications to prevent
blood pressure dropping when standing
What do you need to do?
=======================
- it is extremely important that you attend your follow up
appointments with your primary care doctor.
It was a pleasure taking care of you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10577647-DS-67 | 10,577,647 | 23,170,006 | DS | 67 | 2147-09-16 00:00:00 | 2147-09-16 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / daptomycin / Bactrim
Attending: ___.
Chief Complaint:
n/v, abdominal pain, back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with GERD, HTN, depression,
poorly-controlled T2DM, delayed gastric emptying, anxiety,
chronic abdominal pain, recurrent UTIs, chronic leukocytosis,
and multiple hospitalizations for abdominal pain/UTIs p/w
recurrent abdominal pain, back pain, dysuria, and n/v.
Pt is a difficult historian and is reluctant to answer
questions, preferring to play games on her phone during our
interview.
Pt essentially reports that she's had nausea, vomiting,
worsening abdominal pain, back pain, and dysuria and frequency
for the last 1.5-2 weeks. Came in for further evaluation today
b/c "she couldn't stand it anymore". She states that her
abdominal pain and back pain are constant and worsened with
food. She also reports chills but no measured fever. At this
point, pt becomes teary and has difficulty providing more
history as she is quite upset.
Of note, pt recently admitted from ___ for similar symptoms,
thought to be d/t possible flare of gastroenteritis vs.
gastroparesis d/t constipation. She was also noted to be quite
lightheaded with positive orthostatics on discharge so many of
her home anti-hypertensives were held on discharge and gradually
restarted by Dr. ___ follow-up.
In the ED, VS: T:97.1, HR: 103, BP: 198/106, RR: 20, O2: 100% RA
Exam notable for R CVA tenderness and diffuse abdominal
tenderness
Labs notable for ___ with Cr: 2.6, elevated glucose of 459, and
WBC: 14.4
UA showed moderate leuk esterase and 7 WBC's
She was given tramadol, morphine, Zofran, and 18U regular
insulin
Admitted to medicine for further w/u and management ___
ROS: rest of 10-point ROS reviewed and is negative except as
noted above
Past Medical History:
- Abdominal pain with multiple admissions, extensive evaluation
without clear etiology identified. Attributed to poorly
controlled anxiety.
- IDDM (type 2): HbA1c 6.8% (___), complicated by proteinuria
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections possibly related to
urethral diverticulum
- Chronic back pain
- IUD placement
- venous access device-related blood stream infection
Social History:
___
Family History:
Mother - DM, breast cancer s/p treatment but now found to have
recurred in her liver in ___ s/p surgery and she is
getting better.
Physical Exam:
Vitals: T98.4, Bp 150/80
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: obese Soft, non-tender, non-distended, bowel
sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
.
Pertinent Results:
ADMISSION LABS:
___ 12:20PM BLOOD WBC-14.4* RBC-4.49 Hgb-10.6* Hct-34.3
MCV-76* MCH-23.6* MCHC-30.9* RDW-17.4* RDWSD-47.8* Plt ___
___ 12:20PM BLOOD Neuts-73.2* ___ Monos-5.0
Eos-0.2* Baso-0.6 Im ___ AbsNeut-10.55* AbsLymp-2.93
AbsMono-0.72 AbsEos-0.03* AbsBaso-0.08
___ 12:20PM BLOOD Glucose-459* UreaN-58* Creat-2.6*#
Na-129* K-4.4 Cl-91* HCO3-22 AnGap-20
___ 12:20PM BLOOD ALT-13 AST-12 AlkPhos-139* TotBili-0.2
___ 12:20PM BLOOD Albumin-3.7
MICRO:
Urine culture ___: pending
IMAGING:
Renal US ___: Unremarkable renal ultrasound.
Discharge Labs
___ 05:28AM BLOOD WBC-15.2* RBC-3.74* Hgb-8.8* Hct-28.8*
MCV-77* MCH-23.5* MCHC-30.6* RDW-17.2* RDWSD-48.0* Plt ___
___ 05:28AM BLOOD Glucose-148* UreaN-37* Creat-1.2* Na-134
K-4.2 Cl-100 HCO3-24 AnGap-14
___ 12:20PM BLOOD ALT-13 AST-12 AlkPhos-139* TotBili-0.2
___ 06:25PM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ woman with GERD, HTN, depression,
poorly-controlled T2DM, delayed gastric emptying, anxiety,
chronic abdominal pain, recurrent UTIs, chronic leukocytosis,
and multiple hospitalizations for abdominal pain/UTIs p/w
recurrent abdominal pain, back pain, dysuria, and n/v who
presents with ___ resolved with fluids.
___
# DSYURIA
# LEUKOCYTOSIS
___ likely from dehydration. Her UA only has 7 wbc which is
remarkably less than usual. Her leukocytosis is chronic and
stable. In the past her UTIs have all been resistant to
ceftriaxone, so it was stopped. Got x1 ceftriaxone in the
emergency room. Her final culture was contaminated. Her
lisinoipril was initially held but restarted after her renal
function normalized. She should have her Cr rechecked in 1 week.
# N/V/ABDOMINAL PAIN
# CHRONIC GASTROPARESIS
-- Continue supportive care with home tramadol, zofran
-- Continue home amitriptyline, lyrica
-- Continue PPI, sucralfate
#HTN: Bp's elevated on admission in the 190's
-- Continuing NIFEdipine/propranolol/isosorbide/lisinoipril
-- Monitor for worsening orthostasis after restarting home
anti-hypertensives
#DEPRESSION ANXIETY:
-- Continue sertraline/amitryptiline/lorazepam
#DIABETES MELLITUS: Poorly controlled, last HgbA1C = 10.3 in
___. BG's now very elevated possible iso infection per
above.
-- Continue home lantus of 54U + 10 U humalog coverage with
meals
#ASTHMA:
- continue fluticasone/albuterol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
3. Amitriptyline 50 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. LORazepam 1 mg PO BID:PRN anxiety
8. Ondansetron ODT 8 mg PO Q8H:PRN nausea
9. Pregabalin 50 mg PO DAILY:PRN pain
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 200 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. TraMADol 50 mg PO TID:PRN Pain - Moderate
14. Omeprazole 40 mg PO DAILY
15. Lidocaine 5% Ointment 1 Appl TP ONCE
16. Propranolol LA 80 mg PO DAILY
17. Lisinopril 20 mg PO DAILY
18. NIFEdipine CR 120 mg PO DAILY
19. Glargine 54 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
20. Isosorbide Mononitrate (Extended Release) 10 mg PO DAILY
Discharge Medications:
1. Glargine 54 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
4. Amitriptyline 50 mg PO QHS
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Isosorbide Mononitrate (Extended Release) 10 mg PO DAILY
9. Lidocaine 5% Ointment 1 Appl TP ONCE
10. Lisinopril 20 mg PO DAILY
11. LORazepam 1 mg PO BID:PRN anxiety
12. NIFEdipine CR 120 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Ondansetron ODT 8 mg PO Q8H:PRN nausea
15. Pregabalin 50 mg PO DAILY:PRN pain
16. Propranolol LA 80 mg PO DAILY
17. Senna 8.6 mg PO BID:PRN constipation
18. Sertraline 200 mg PO DAILY
19. Sucralfate 1 gm PO QID
20. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute on chronic abdominal pain
Secondary: Acute kidney injury, acidosis, hyperglycemia,
diabetes mellitus, hyponatremia, bacteruria, anemia,
hypertension, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for kidney injury. This was
likely from dehydration. ___ were given IV fluids and with this
your kidney function improved back to normal. it is extremely
important that ___ attend your follow up appointments with your
primary care doctor.
It was a pleasure taking care of ___. We wish ___ the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10577647-DS-74 | 10,577,647 | 20,941,842 | DS | 74 | 2148-04-19 00:00:00 | 2148-04-19 22:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / daptomycin / Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
Right hallux toenail avulsion on ___
Right hallux amputation ___
History of Present Illness:
Patient is a ___ female with history of IDDM2 with
gastroparesis, HTN, depression, asthma, morbid obesity, s/p
cholecystectomy, and multiple previous
admission for gastroparesis requiring IV meds for which
she has Port-A-Cath ___ place ___ left chest due to difficult
access due to difficult access who presents from home with
abdominal pain, concerning for HHS/DKA.
Of note, patient has had multiple admissions for abdominal pain
dating back several years. She was most recently admitted from
___ for abdominal pain. During that hospitalization,
she was bacteremic with port cultures x2 growing coag neg staph.
ID recommended 10 day course of daptomycin (___). UA was
grossly positive and patient initially was on CTX followed by IV
zosyn, though UCx returned unremarkable (contaminant). CT A/P
was negative for any acute process and ECG showed sinus rhythm
with baseline RBBB and QTc=0.45.
Three days prior to this admission, patient developed diffuse
abdominal pain and nausea/vomiting, consistent with prior
episodes. She also ran out of her insulin pen needles on
___ (had been reusing needles prior to this). Patient
endorses mild diarrhea over this time as well as poor PO intake.
She also denies dysuria, urinary frequency, or new back pain
(chronic lumbar pain). No fevers/chills. Patient denies any
ongoing chest pain or palpitations. She does say that she has
felt quite anxious over the past several days and routinely
experiences some chest tightness when having a panic attack. No
worsening SOB or cough.
On arrival to the ED, her initial vital signs were T 96.6, HR
128, BP 210/108 (improved to 149/72), RR 18, O2 100% RA, and
Glucose 518.
On exam, she was noted to be sleep but answering questions
appropriately. Her abdomen was diffusely tender to palpation.
Initial labs notable for WBC 30.7 (93.5% neutrophils), Hgb 9.3,
Plt 758, Cr 1.3 (baseline 1.1), AG 26, LFTs normal except alk
phos 175, Lipase 17, lactate 2.2, and VBG 7.34/35. Urinalysis
significant for WBC > 182, large leuks, 40 ketones, 1000 gluc.
CXR was NEGATIVE for any acute process. ECG at baseline (sinus
tachycardia, R axis deviation, RBBB, TWIs III/V1-V2).
Patient was given piperacillin-tazobactam, lorazepam,
metoclopramide, GI cocktail, and normal saline/LR. For
hyperglycemia, she was given glargine 25U and then 10U regular
insulin.
Upon arrival to the floor, patient recounts the history as
above.
She mainly complains of significant abdominal pain, consistent
with prior episodes. Last BM was yesterday, +flatus. She is
experiencing low level nausea, no recurrent bouts of emesis.
Still with decreased appetite. No ongoing fevers/chills.
Patient endorses copious urination, no dysuria or new back pain.
No active CP or SOB. No new skin rash or lesions.
Past Medical History:
- Abdominal pain with multiple admissions, extensive evaluation
without clear etiology identified. Attributed to poorly
controlled anxiety.
- IDDM (type 2): complicated by proteinuria, gastroparesis
- GERD
- Hypertension
- Depression
- Obesity
- Recurrent urinary tract infections possibly related to
urethral diverticulum
- Chronic back pain
- venous access device-related blood stream infection
- Asthma
Social History:
___
Family History:
FAMILY HISTORY:
Mother with breast CA.
Physical Exam:
ADMISSION EXAM:
===============
VITAL SIGNS: 99.4 144/76 107 18 99 RA
GENERAL: Sitting at edge of bed, uncomfortable appearing,
pleasant/appropriate ___ conversation.
HEENT: PERRL, EOMI. No scleral icterus. OP dry without signs of
thrush/lesions.
NECK: Unable to assess JVP ___ body habitus. No thyromegaly.
CARDIAC: Tachycardic, s1 s2, regular rhythm. ___ systolic
murmur heard throughout the precordium. No rubs/gallops/
LUNGS/CHEST: L POC without surrounding erythema, cdi. Lungs
CTABL, no wheezes.
ABDOMEN: Obese abdomen. Hypoactive BS throughout. Diffuse
tenderness to palpation with guarding. No palpable HSM.
EXTREMITIES: WWP, no lower extremity edema. 1+ radial pulses
b/l.
NEUROLOGIC: AOx3, moving all extremities equally, grossly
non-focal.
SKIN: No skin rash, no ecchymoses, no signs of infection.
DISCHARGE EXAM:
===============
VITALS: 98.7PO 155/78 117 18 98 Ra
GENERAL: Very uncomfortable appearing, crying, saying she has
abdominal pain
HEENT: NC/AT, PERRL
Lungs: L POC without surrounding erythema. Lungs clear to
auscultation no wheezes, rales, or rhonchi
CARDIAC: +S1/S2, RRR. ___ systolic murmur heard throughout the
precordium. No murmurs, rubs, or gallops
ABDOMEN: Soft, mild TTP ___ epigastrium. Normoactive bowel
sounds.
No organomegaly.
EXTREMITIES: WWP, no lower extremity edema. R foot dressing ___
place. Non-tender to palpation surrounding wrappings.
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-30.7*# RBC-4.00 Hgb-9.3* Hct-30.0*
MCV-75* MCH-23.3* MCHC-31.0* RDW-16.9* RDWSD-46.2 Plt ___
___ 05:00PM BLOOD Neuts-93.5* Lymphs-3.3* Monos-1.9*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-28.69*# AbsLymp-1.02*
AbsMono-0.57 AbsEos-0.00* AbsBaso-0.08
___ 05:00PM BLOOD Glucose-565* UreaN-30* Creat-1.3* Na-133*
K-5.1 Cl-90* HCO3-17* AnGap-26*
___ 05:00PM BLOOD ALT-13 AST-13 AlkPhos-175* TotBili-0.3
___ 05:00PM BLOOD Lipase-17
___ 05:00PM BLOOD cTropnT-0.01
___ 12:44AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:00PM BLOOD Albumin-3.6 Calcium-9.8 Phos-5.3* Mg-2.2
___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:14PM BLOOD ___ pO2-46* pCO2-35 pH-7.34*
calTCO2-20* Base XS--5
___ 08:24PM BLOOD ___ pO2-45* pCO2-38 pH-7.37
calTCO2-23 Base XS--2
___ 05:11PM BLOOD Lactate-2.2*
INTERVAL LABS
___ 06:35AM BLOOD ALT-72* AST-76* AlkPhos-271*
___ 04:32AM BLOOD ALT-40 AST-17 AlkPhos-209* TotBili-0.3
___ 08:55AM BLOOD Lipase-11
___ 04:32AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0 Iron-16*
___ 04:32AM BLOOD calTIBC-213* Ferritn-247* TRF-164*
___ 06:35AM BLOOD CRP-291.3*
___ 09:05AM BLOOD CRP-147.7*
DISCHARGE LABS
___ 04:45AM BLOOD WBC-21.5* RBC-3.48* Hgb-8.0* Hct-26.6*
MCV-76* MCH-23.0* MCHC-30.1* RDW-18.0* RDWSD-49.7* Plt ___
___ 04:45AM BLOOD Glucose-207* UreaN-22* Creat-1.0 Na-138
K-5.0 Cl-99 HCO3-24 AnGap-15
___ 04:45AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
MICRO
Urine (___) Mixed bacterial flora consistent with skin and/or
genital contamination
Blood (___) Negative
Blood (___) Negative
Urine (___) Negative
Stool C. Diff (___) Negative
Stool fecal culture (___) Negative
R hallux swab (___)
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED
R hallux tissue culture (___)
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
TISSUE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING:
RLE arterial NIAS (___):
Right:
Femoral artery: Triphasic waveform
Popliteal artery: Triphasic waveform
Posterior tibial artery: Triphasic waveform
Dorsalis pedis artery: Triphasic waveform
Right ABI (at rest): 1.23
Left:
Femoral artery: Triphasic waveform
Popliteal artery: Triphasic waveform
Posterior tibial artery: Triphasic waveform
Dorsalis pedis artery: Triphasic waveform
Left ABI (at rest): 1.1
Pulse volume recordings showed symmetric amplitudes at all
levels,
bilaterally.
IMPRESSION: No evidence of arterial insufficiency to the lower
extremities at rest.
R Foot XR (___): Three views of the right foot are compared
to pre amputation views. Right first toe has been amputated
distal to the metatarsal head. There is no subcutaneous gas.
Some soft tissue swelling is present as expected. Remainder of
the foot is unremarkable.
R hallux pathology results (___): PND
MRI R foot w/o contrast (___):
1. Irregularity of the soft tissues ___ the nail bed with
hyperemia and
circumferential edema of the great toe, ___ keeping with provided
history of
hallux toenail removal with ulceration and infection. Extensive
edema ___ the
distal phalanx resulting ___ effacement of normal marrow fat
signal is
concerning for osteomyelitis.
2. Diffuse edema ___ the subcutaneous tissues and intrinsic
musculature of the
foot without evidence of abscess formation.
3. Degenerative changes at the first MTP joint and a small joint
effusion.
CT A/P WO Contrast (___):
1. Thickened bladder wall could suggest cystitis to be
correlated with
urinalysis. No hydronephrosis or renal abnormality within
limits of this
noncontrast examination. No drainable fluid collection. Normal
appendix.
2. Redemonstrated urethral diverticulum.
3. Left breast calcification can be correlated with mammography.
4. Coronary artery calcifications.
Abdominal US (___):
1. No focal liver abnormalities or biliary dilatation
identified.
2. No hydronephrosis identified.
CXR (___) No acute intrathoracic process.
Brief Hospital Course:
This is a ___ year old female with past medical history diabetes
type 2, recurrent episodes of abdominal pain attributed to
gastroparesis and/or urinary tract infections, hypertension
admitted with hyperosmolar hyperglycemic state and acute R
first toe osteomyelitis, now status post R hallux amputation,
able to be discharged home
# Diabetes type 2 with hyperosmolar state without coma
# Anion gap metabolic acidosis
Patient initially presented with severe abdominal pain, found
to be hyperglycemic with a glucose of 565, anion gap 26, and
ketonuria on admission, admitted for HHS. Trigger likely
multifactorial ___ etiology including inadequate insulin
administration given that she ran out of insulin pen needles
prior to admission, ___ addition to underlying acute infection
including right great toe osteomyelitis per below, now status
post right great toe amputation. Patient received subcutaneous
insulin administration with aggressive IV fluid resuscitation
and anion gap subsequently closed. ___ was consulted and ___
addition to sliding scale insulin, home glargine was increased
to 48 units at bedtime with standing Humalog 10 units with
meals at time of discharge.
# Abdominal pain
# Bacteruria
Patient has a history of gastroparesis with multiple previous
admissions for severe abdominal pain, ___ the setting of
gastroparesis flares thought to be secondary to type 2
diabetes. Presented with severe abdominal pain likely worsened
___ the setting of HHS. Abdominal US was un-remarkable.
Subsequent CT A/P demonstrated thickened bladder wall
suggestive of possible cystitis. Also with re-demonstration of
urethral diverticulum. Otherwise no other intra-abdominal
findings. Abdominal pain improved with conservative management.
___ discussion with ID service (consulted for foot infection
below), it was felt that clinically patient did not have
evidence of a urinary tract infection. Patient continued to
have waxing and waning abdominal pain with periods of severe
epigastric pain alternating with periods of no abdominal pain,
thought to be ___ long-standing gastroparesis. Was continued on
home dicyclomine, ativan prn, sertraline, amitriptyline,
reglan, zofran, PPI/sucralfate, standing Tylenol.
# Acute R Right hallux osteomyelitis
# R foot pain
Patient presented with leukocytosis of 30.7 on admission, with
exam notable R hallux toenail purulent drainage, prompting
initiation of Zosyn.
Podiatry was initially consulted and performed a right hallux
toenail avulsion on ___. Hospital course was complicated by
recurrent fevers and persistent leukocytosis. MRI right foot
was obtained which showed right hallux osteomyelitis. Patient
subsequently underwent right great toe amputation by podiatry.
Patient received a 5 day course of zosyn, which was then
transitioned to 7 day course of augmentin per podiatry
recommendations. Pain and fevers resolved. Podiatry to
follow-intra-operative culture data and margins to determine if
additional management is indicated.
# Chronic Anemia and Thrombocytosis - Patient has a history of
chronic anemia and thrombocytosis. Hospital course complicated
by worsening microcytic anemia with hemoglobin 6.7 requiring 1
unit PRBC with post-transfusion hemoglobin 7.4 with no evidence
of hemolysis and no obvious source of bleeding. Found to have
mixed iron deficiency anemia and anemia of chronic disease with
Fe 16, ferritin 247, TIBC 213 and poor reticulocyte count. Was
previously followed by hematology on previous admissions
requiring IV iron given severe gastroparesis with likely poor
absorption of PO. Deferred starting iron supplementation given
acute infectious processes per above and received 1 unit PRBC.
Also thought to previously have reactive thrombocytosis given
recurrent gastroparesis flares.
# Vaginal discharge - Clear vaginal discharge possible vaginal
candidiasis treating with miconazole cream.
#Pseudohyponatremia - Sodium down trended to a low of 128 ___
the setting of severe hyperglycemia from HHS. Sodium corrected
to normal with improved glucose control.
# Hypertension - Continued home nifedipine 120mg QD and
lisinopril 20mg PO QD
# Anxiety/depression - Continued home amitriptyline 100mg qhs,
sertraline 200mg qd, propranolol 40mg prn, Ativan .5mg prn
# Asthma - Continue home Fluticasone Propionate 110mcg 220
mcg/actuation IH BID and Albuterol Inhaler 2 PUFF IH Q6H:PRN
SOB
# GERD - Continue home omeprazole 40mg PO QD
TRANSITIONAL ISSUES
[ ] NEW/CHANGED MEDICATIONS
- Started augmentin 875 mg PO Q12H x 7 days
- Increased home glargine to 48 units QHS
- Increased standing Humalog to 10 Units TID with meals
- Started Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
Duration: 7 Days
- Oxycodone 7 day prescription for R foot pain
[ ] Consider repeat CBC at PCP ___ appointment to ensure
WBC and platelets continues to down-trend
[ ] ___ wound care every other day betadine gauze, kerlix, ACE
dressing
changes
[ ] Podiatry to ___ intra-operative R hallux cultures and
margins. If margins return positive patient will require
extended course of zosyn
[ ] Consider outpatient urology workup for urethral
diverticulum likely leading to recurrent UTIs
[ ] Consider outpatient mammography given CT A/P showing left
breast calcifications recommended correlation with outpatient
mammography
[ ] Abnormal Labs on discharge
- WBC 21.5, previous baseline ___
- Hb 8.0, baseline ___
- PLT 971, baseline 400-500
#Contact
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
#Code Status: Full Code
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN PAIN
2. Amitriptyline 100 mg PO QHS
3. Cyanocobalamin ___ mcg PO DAILY
4. DICYCLOMine 10 mg PO QID
5. Lisinopril 20 mg PO DAILY
6. LORazepam 0.5 mg PO DAILY:PRN anxiety
7. Metoclopramide 10 mg PO TID W/MEALS
8. NIFEdipine (Extended Release) 120 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Sertraline 200 mg PO DAILY
11. Sucralfate 1 gm PO QID
12. TraMADol 50 mg PO Q8H:PRN Pain - Severe
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
14. fluticasone 220 mcg/actuation inhalation BID
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Propranolol 40 mg PO TID:PRN anxiety
18. Glargine 35 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth Twice Daily Disp #*14 Tablet Refills:*0
2. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
RX *miconazole nitrate [Miconazole 7] 2 % Apply Daily Daily Disp
#*1 Applicator Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth Three times
daily as needed Disp #*21 Tablet Refills:*0
4. Glargine 48 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
48 48 Units before BED Disp #*5 Syringe Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 30 10
Units before BKFT; 10 Units before LNCH; 10 Units before DINR;
Disp #*3 Syringe Refills:*0
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine]
31 gauge X ___ 4 times daily Disp #*2 Syringe Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN PAIN
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
7. Amitriptyline 100 mg PO QHS
8. Cyanocobalamin ___ mcg PO DAILY
9. DICYCLOMine 10 mg PO QID
10. fluticasone 220 mcg/actuation inhalation BID
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Lisinopril 20 mg PO DAILY
13. LORazepam 0.5 mg PO DAILY:PRN anxiety
14. Metoclopramide 10 mg PO TID W/MEALS
15. NIFEdipine (Extended Release) 120 mg PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. Propranolol 40 mg PO TID:PRN anxiety
19. Sertraline 200 mg PO DAILY
20. Sucralfate 1 gm PO QID
21. TraMADol 50 mg PO Q8H:PRN Pain - Severe
___ wedge forefoot offloader shoe
ICD 10 Code: 86.0 (Osteomyelitis) s/p amputation
23.walker
ICD Diagnosis: 86.0 (osteomyelitis)
Prognosis: Good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Diabetes type 2 with hyperosmolar state without coma
# Acute R Right hallux osteomyelitis
# Abdominal pain, generalized
# R foot pain
# Gastroparesis
# Pseudohyponatremia
# HTN
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 ___
___.
You initially came to the hospital because of severe abdominal
pain and you were admitted because of elevated blood sugars.
What happened during your hospitalization?
-You initially received IV fluids and insulin for better control
of your diabetes given your very elevated blood sugars
-Your right first toenail was removed because it was infected. A
subsequent MRI of the right foot showed that you had an
infection of the bone ___ your right big toe, which was later
amputated.
-You were treated with an antibiotic called zosyn for a possible
UTI and for your right big toe infection
-You also received 1 unit of blood for anemia
What to do when you leave the hospital?
-Continue to take all of your medications as prescribed
-Continue to take the antibiotic augmentin for 1 week
-___ with your primary care physician ___ 1 week
-Please keep all of your other health care appointments as
listed below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10577647-DS-81 | 10,577,647 | 22,561,517 | DS | 81 | 2149-06-07 00:00:00 | 2149-06-07 21:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / daptomycin / Bactrim /
azithromycin / Cipro / clindamycin / clarithromycin / Sulfa
(Sulfonamide Antibiotics) / latex
Attending: ___.
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with PMH of DMII c/b
gastroparesis, chronic abdominal pain, HFpEF presenting with 1
day of acute right flank pain.
Patient states that around 4 days ago she was having increased
urinary frequency - she notes that this is been an ongoing
problem ever since starting her torsemide, but that it is worse
than normal. She was seen in the emergency department, and a
urine was checked which was concerning for an infection. She
was
discharged on Cefpodoxime. She states that despite taking her
cefpodoxime, 2 days ago she developed pain over her right back.
Non-radiating. It was coming and going, at times severe,
associated with what she describes as a "slight fever". The
night prior to admission, this pain came back very severe, and
has been constant since that time. Reports that her abdominal
pain and nausea are similar to normal.
Four days ago patient endorsed increased urinary frequency. Was
discharged with Cefpodoxime. Last night, patient endorsed sudden
right flank pain that was sharp and stabbing in nature. Endorses
multiple bouts of nausea vomiting but denies any hematuria or
change in bowel movements. Denies any fevers or chills. She then
presented to the ED.
On review of records, patient last admitted from
___ with abdominal pain. She was treated
conservatively and was able to be discharged on her home pain
regimen.
ED Course:
VSS, exam notable for diffuse abdominal pain and CVAT
Labs notable for leukocytosis and positive UA. UCx pending.
CTU did not show any stones
Pt received Haldol for nausea, 3L of IVF, lorazepam and
meropenem. She was admitted to the hospital for pyelonephritis
and treatment failure with oral antibiotics.
Upon arrival to the floor, patient recounts history as above.
She does not feel like the pains at all changed.
Past Medical History:
Type 2 DM on insulin
HTN
Gastroparesis
Chronic abdominal pain
Asthma
GERD
Depression and anxiety
Chronic UTIs
Right toe amputation
Social History:
___
Family History:
Mother with breast CA.
Physical Exam:
Admission Physical Exam:
========================
VITALS: T 99.1, HR 100, BP 169/89, RR 19, 100 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation
without rebound or guarding. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
BACK: acutely tender to superficial palpation over right side
spine
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: see Eflowsheets
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation
without rebound or guarding. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
BACK: no tenderness to palpation throughout upper and lower back
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 05:17AM BLOOD WBC-14.2* RBC-3.47* Hgb-7.9* Hct-26.8*
MCV-77* MCH-22.8* MCHC-29.5* RDW-18.5* RDWSD-51.5* Plt ___
___ 05:17AM BLOOD Glucose-276* UreaN-21* Creat-1.2* Na-136
K-4.2 Cl-99 HCO3-26 AnGap-11
___ 05:17AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.8
Imaging:
========
CT Abd/Pelvis:
1. No acute intra-abdominal process.No renal or ureteral
calculus. No
perinephric abnormality.
2. Urethral diverticulum is and vaginal cyst as seen previously.
3. A 9 x 7 mm partially calcified soft tissue nodule in the
right breast.
Nonurgent mammographic imaging is suggested on a nonurgent basis
unless
performed elsewhere.
Renal US:
Normal renal ultrasound.
Discharge Labs:
===============
___ 05:17AM BLOOD WBC-14.2* RBC-3.47* Hgb-7.9* Hct-26.8*
MCV-77* MCH-22.8* MCHC-29.5* RDW-18.5* RDWSD-51.5* Plt ___
___ 05:17AM BLOOD Glucose-276* UreaN-21* Creat-1.2* Na-136
K-4.2 Cl-99 HCO3-26 AnGap-11
___ 05:17AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ female with diabetes, chronic
abdominal pain and a UTI treated with Cefpodoxime starting 4
days ago presenting with acute right flank pain. Pt was given IV
Meropenem and admitted to medicine given long list of allergies
to abx and failed outpatient treatment on cefpodoxime.
ACUTE/ACTIVE PROBLEMS:
# Flank pain
Pt was seen in ED on ___ with complaint of flank pain. She was
diagnosed with UTI and started on abx. Urine cultures from that
visit returned negative. On admission she reported that symptoms
had not improved.
At time of admission UA was again notable for large leukocytes.
She had a CT Abd/Pelvis without evidence of nephrolithiasis or
pyelonephritis. Labs were notable for a stable leukocytosis,
unchanged from prior.
There was low concern that her symptoms represented a UTI, as
practically all urines in the past year have had large
leukocytes, white blood cells, and at least some degree of
bacteria. Therefore, antibiotics were held and she was
monitored. Repeat urine culture returned negative.
Her right flank pain resolved without intervention and was
ultimately felt to be musculoskeletal.
# Incidental Finding
Transitional issue
A 9 x 7 mm partially calcified soft tissue nodule was
incidentally noted in the right breast.
Patient was made aware that she needs a mammogram and her
primary providers are working to arrange this
CHRONIC/STABLE PROBLEMS:
# Diabetic gastroparesis
Was recently admitted for a flare.
Continued home regimen:
-- ondansetron 4 mg PO/NG Q8H:PRN
-- oxycodone ___ mg PO/NG Q6H:PRN
-- tramadol 50 mg PO Q8H:PRN
-- Haldol 0.5 mg PO DAILY
-- omeprazole 40 mg PO DAILY
-- sucralfate 1 gm PO/NG QID
# DM2
Poorly controlled. On last admission was decreased given concern
for hypoglycemia I/s/o gastroparesis. At discharge she was
continued on Tresiba 68 units with 12 units of Novolog with
meals and insulin sliding scale
# Asthma
Continued home fluticasone, albuterol
# Primary prevention:
Continued home statin, aspirin
# Depression/Anxiety/Insomnia
Continued home sertraline 200 mg PO DAILY, lorazepam 0.5 mg PO
DAILY, Amitriptyline 100 mg PO QHS
# Recent proximal humerus fracture:
Seen in ___ clinic on ___ with plan for non-operative
management. Will need interval f/u films as outpatient.
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- needs mammogram to evaluate breast nodule incidentally found
on CT scan. Patient aware and primary office working to arrange
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin ___ mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN cough/wheeze
4. Senna 8.6 mg PO BID
5. Torsemide 10 mg PO DAILY
6. Acetaminophen 1000 mg PO Q8H
7. Amitriptyline 100 mg PO QHS
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Docusate Sodium 200 mg PO BID
11. Fluticasone Propionate 110mcg 1 PUFF IH BID
12. Haloperidol 0.5 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS
14. LORazepam 0.5 mg PO DAILY:PRN anxiety
15. NIFEdipine (Extended Release) 90 mg PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
19. Polyethylene Glycol 17 g PO BID
20. Sertraline 200 mg PO DAILY
21. Sucralfate 1 gm PO QID
22. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
23. Lisinopril 20 mg PO DAILY
24. Novolog 12 Units Breakfast
Novolog 12 Units Lunch
Novolog 12 Units Dinner
Tresiba 68 Units Lunch
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amitriptyline 100 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Cyanocobalamin ___ mcg PO DAILY
6. Docusate Sodium 200 mg PO BID
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Haloperidol 0.5 mg PO DAILY
10. Novolog 12 Units Breakfast
Novolog 12 Units Lunch
Novolog 12 Units Dinner
Tresiba 68 Units Lunch
Insulin SC Sliding Scale using Novolog Insulin
11. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS
12. Lisinopril 20 mg PO DAILY
13. LORazepam 0.5 mg PO DAILY:PRN anxiety
14. NIFEdipine (Extended Release) 90 mg PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
18. Polyethylene Glycol 17 g PO BID
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN cough/wheeze
20. Senna 8.6 mg PO BID
21. Sertraline 200 mg PO DAILY
22. Sucralfate 1 gm PO QID
23. Torsemide 10 mg PO DAILY
24. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Back pain
Secondary:
DM2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came in because you were having back pain. Fortunately we
did not find any evidence of a urinary tract infection. Your CT
scan also did not show any signs of infection or kidney stones.
Your pain was probably a muscle pain.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10577647-DS-9 | 10,577,647 | 23,166,430 | DS | 9 | 2145-03-05 00:00:00 | 2145-03-05 23:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with HTN, DM2 complicated by neuropathy and gastroparesis,
asthma who presents with R flank pain. Pt reports RUQ and flank
pain which developed yesterday. Says pain is excruciating ___
at its worst. Not radiating to groin. She has had some
associated nausea and had an episode of vomiting here in the ED.
She denies any hematuria or dysuria. No fevers, but she has had
chills. Hs has never experienced such symptoms in the past.
She typically gets her care at ___ though she has had a few
presentations to the ED here for epigastric pain attributed to
her gastroparesis, never requiring inpatient admission. Pt
recently seen at ___ and started on fluconoazole for oral thrush
from poor oral care with flovent use.
Workup in the ED notable for normal vitals. Leukocytosis to 18K
with pyuria. CTU showed no stones. LFT's normal except for
elevated alkaline phosphatase. Pt had groin TLC placed due to
poor access options in the ED.
ROS: negative except as above
Past Medical History:
Hypertension
IDDM2
Asthma
GERD
Depression
Physical Exam:
Admission Exam:
Vitals: 98.2 152/80 92 18 99%RA
Gen: NAD, uncomfortable appearing
HEENT: NCAT, moist mm, oral thrush
CV: RRR, no r/m/g
Pulm: clear b/l
Abd: soft, nontender, nondistended, +bs
Back: exquisite tenderness over R flank, no visible ecchymosis
Ext: no edema
Neuro: alert and oriented x 3
Discharge Exam:
Vital Signs: 98.0 140/74 87 18 100%RA
Glucose: ___
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: obese, S/NT/ND, BS present
EXT: pain on palpation of RLE (chronic per pt), trace pitting
edema bilaterally
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 04:40PM BLOOD WBC-18.0* RBC-5.01# Hgb-11.2* Hct-37.9#
MCV-76* MCH-22.3* MCHC-29.4* RDW-17.6* Plt ___
___ 04:40PM BLOOD Neuts-71.9* ___ Monos-3.1 Eos-1.2
Baso-0.6
___ 04:40PM BLOOD Glucose-344* UreaN-22* Creat-1.0 Na-132*
K-4.9 Cl-91* HCO3-27 AnGap-19
___ 04:40PM BLOOD ALT-21 AST-14 AlkPhos-173* TotBili-0.2
___ 04:40PM BLOOD Lipase-26
___ 04:40PM BLOOD Albumin-4.2
Discharge Labs:
___ 05:38AM BLOOD WBC-13.8* RBC-3.63* Hgb-8.1* Hct-26.4*
MCV-73* MCH-22.4* MCHC-30.8* RDW-17.8* Plt ___
___ 05:38AM BLOOD Glucose-119* UreaN-28* Creat-1.2* Na-135
K-4.7 Cl-99 HCO3-28 AnGap-13
___ 05:38AM BLOOD Calcium-8.6 Phos-4.9* Mg-2.2
___ 06:04AM BLOOD Iron-26*
___ 06:04AM BLOOD calTIBC-371 Ferritn-26 TRF-285
___ 04:48PM BLOOD Lactate-3.0*
___ 10:55AM BLOOD Lactate-2.9*
___ 06:01AM BLOOD Lactate-1.3
___ 04:40PM URINE Color-Straw Appear-Clear Sp ___
___ 04:40PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 04:40PM URINE RBC-3* WBC-91* Bacteri-FEW Yeast-NONE
Epi-1
C.Diff NEGATIVE
Urine Cx x 2 - contaminated
Blood Cx x 2 PENDING
ECG -
Sinus tachycardia. Right bundle-branch block. Compared to the
previous
tracing of ___ no change except that the rate is now
slightly faster.
CTU - IMPRESSION:
1. No evidence of acute intra-abdominal process
2. Coronary artery calcifications.
3. Cyst anterior to the vagina, probably a urethral
diverticulum, not
significantly changed, versus paravaginal cyst.
Brief Hospital Course:
___ yo F with DM2, HTN, asthma who presents with flank pain,
nausea/vomiting, and leukocytosis. Positive urinalysis with
negative CTU points towards likely pyelonephritis.
# UTI/Pylonephritis: 2 urine cultures sent and returned with
fecal contamination. She was initially treated with ceftraixone
with clinical improvement. She was transitioned to PO cipro. She
will complete a 2 week course of antibiotics.
# DM2, uncontrolled, with cx: On Lantus and premeal short acting
insulin. FSBS moderately elevated, likely in the setting of
acute infection. Gabapentin for neuropathy, metoclopramide for
gastroparesis.
# Hypertension: On lisinopril, nifedipine.
# GERD: On pantoprazole.
# Asthma: On PRN albuterol.
# Depression: On home sertraline.
# Anemia: Labs notable for mild iron deficiency. Pt was started
on iron supplementation.
# Thrush: Was continued on fluconazole in house. This was d/c'ed
at discharge, as pt had reportedly received 16 days of tx.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 34 Units Bedtime
Humalog Unknown Dose
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 40 mg PO DAILY
3. Labetalol 600 mg PO BID
4. Gabapentin 600 mg PO TID
5. Fluconazole 100 mg PO Q24H
6. Metoclopramide 10 mg PO QIDACHS
7. NIFEdipine CR 60 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Glargine 34 Units Bedtime
4. Metoclopramide 10 mg PO QIDACHS
5. Pantoprazole 40 mg PO Q24H
6. Sertraline 150 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. NIFEdipine CR 60 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. Ciprofloxacin HCl 500 mg PO Q12H
For a total 2 week course of antibiotics, ending ___.
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
12. Ferrous Sulfate 325 mg PO TID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
This is to prevent constipation that may be caused by your iron
pills.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
14. Senna 8.6 mg PO BID:PRN constipation
This is to prevent constipation that may be caused by your iron
pills.
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary Tract Infection / Pyelonephritis
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented with pain in your back. You were found to have a
urinary tract infection. You were treated with IV antibiotics
initially and then you were switched to oral antibiotics. You
are now being discharged home.
You are also being started on iron pills because of some anemia
that was noted during your admission. You should follow-up with
your PCP for further workup of your anemia.
You should follow up with your doctor as listed below.
Followup Instructions:
___
|
10577868-DS-20 | 10,577,868 | 27,272,884 | DS | 20 | 2182-09-04 00:00:00 | 2182-09-03 10:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex / Codeine / Valium / Phenobarbital /
Neosporin Scar Solution / Risperdal / adhesive
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Exploration of left forearm laceration, repair of flexor
tendons, median nerve left forearm, left carpal tunnel release
History of Present Illness:
___ is a ___ F RHD with complex medical
history including morbid obesity (s/p gastric bypass in ___ w/
200 lbs weight loss), CKD, kidney stones, bipolar disorder,
asthma, HTN, HLD, GERD, RA, fibromyalgia, chronic lower back
pain/spinal stenosis/disk herniation (s/p L4-5 and L5-S1
diskectomy and spinal fusion in ___ & L3-4 laminectomy for
spinal stenosis in ___, and CTS (s/p CTR and R thumb ___
arthroplasty ___ who presents to the ___ ED this evening
after a mechanical fall resulting in left volar forearm
lacerations. Patient states that she was carrying some glasses
for passover dinner when she accidentally tripped over a case of
water and landed on the shattered glass. Patient denies any
associated headstrike or loss of consciousness. She noted almost
an immediate change in the sensation of her left hand along with
deep forearm lacerations, prompting her presentation to the
___
ED for formal evaluation. PRS hand surgery is consulted to help
assist with management of the patient's hand and forearm
injuries. On presentation, the patient endorses sensory changes
in her radial 3 fingers of her left hand.
ROS:
-Negative unless otherwise stated in HPI
Past Medical History:
1. Bipolar Affective Disorder
2. Diabetes mellitus
3. Rheumatoid arthritis
4. Asthma
5. Chronic Renal Insufficiency, baseline Cr 1.8-2.0
6. h/o Multinodular goiter s/p Thyroidectomy ___ w/ postop
hypocalcemia
7. HTN
8. Fibromyalgia
9. Obesity s/p Gastric bypass
10. Herniated disc s/p laminectomy & spinal fusion
11. Nephrolithiasis s/p lithotripsy x2
___. Rheumatoid Arthritis on steroids and immunotherapy
12. Recent CAP (s/p levofloxacin ___
Social History:
___
Family History:
Father w/ h/o CAD s/p MI, DM; Mother w/ h/o arrhythmia.
Physical Exam:
98.6
PO 168 / 77 68 18 93 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities. Left arm with wrap
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
___ 06:28AM BLOOD WBC-8.2 RBC-3.10* Hgb-9.8* Hct-31.2*
MCV-101* MCH-31.6 MCHC-31.4* RDW-12.0 RDWSD-43.8 Plt ___
___ 06:25AM BLOOD WBC-7.2 RBC-3.26* Hgb-10.6* Hct-32.9*
MCV-101* MCH-32.5* MCHC-32.2 RDW-12.6 RDWSD-47.4* Plt ___
___ 06:00AM BLOOD Glucose-77 UreaN-13 Creat-0.9 Na-143
K-3.6 Cl-100 HCO3-28 AnGap-15
___ 08:15AM BLOOD Glucose-98 UreaN-17 Creat-1.6* Na-144
K-4.7 Cl-100 HCO3-34* AnGap-10
___ 08:15AM BLOOD CK-MB-2 cTropnT-0.01
___ 08:15AM BLOOD LD(LDH)-354*
___ 06:00AM BLOOD Albumin-3.1* Calcium-8.1*
___ 06:28AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8
___ Imaging FOREARM (AP & LAT) LEFT
IMPRESSION:
3 radiopaque foreign body fragments underlying the palmar distal
forearm
laceration measuring between 2-5 mm with a deepest fragment
roughly 1 cm deep
to the skin surface. No fracture.
___ Imaging FOOT AP,LAT & OBL LEFT
IMPRESSION:
Intra-articular minimally displaced fracture along the plantar
medial aspect
of the great toe proximal phalanx.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Increased ill-defined opacity in the left lower lobe, is
concerning for
pneumonia.
Right lung is clear. Cardiomediastinal and hilar silhouettes
are normal.
Mild calcification of the aortic arch. There is no pneumothorax
or pleural
effusion.
Brief Hospital Course:
___ year old woman with RA on abatacept and methylprednisolone,
bipolar disorder, chronic back pain and spinal stenosis, GERD,
HTN, hypothyroidism (post-thyroidectomy for benign nodule),
hypocalcemia due to
hypoparathyroidism after thyroidectomy, obesity s/p gastric
bypass in ___, OA s/p knee replacement, neuropathy who
presented
to the ED after falling onto glass and
sustained a deep laceration to the left arm with incomplete
median nerve injury and potential injury to the extrinsic
flexors, now s/p operative repair on ___, but course
complicated by sepsis, ___, respiratory failure due to narcotic
overuse. Transferred to ___ on ___ from surgery.
#Sepsis (resolved)
#Pneumonia (resolving)
-likely was from pneumonia and now rapidly improved.
-levofloxacin for 7 day course (last day to be ___
___ (resolved) - likely was prerenal from sepsis, improved with
IVF.
#Acute hypoxic respiratory failure with somnolence, narcotic
toxicity (resolved)
#Nausea (resolved)
#Vomiting (resolved)
#Ileus (resolved)
-KUB on ___ revealed ileus. Probably due to narcotic overuse
earlier in
her stay.
-She then had daily bowel movements as it resolved.
-Tolerated her diet without emesis for 48 hours prior to
discharge.
#Left forearm laceration and incomplete median nerve injury
#Left toe fracture, suspected
- Post-op shoe to LLE, WBAT
- NWB LUE, maintain elevation
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
#HTN
-Initiated losartan 100 mg once daily, this is new medication
for BP.
#hypocalcemia due to
hypoparathyroidism after thyroidectomy
-Ca is stable with albumin correction.
#RA on Orencia/methylprednisolone
-Stable, on home methylprednisolone.
-Hold abatacept for 4 weeks at minimum.
#Hypothyroidism
-Continue home synthroid
#Bipolar disorder
-Continue home lamotrigine, wellbutrin
TRANSITIONAL ISSUES:
-Orthopedics follow up on ___
-Follow up BP control with new losartan medication with PCP
within ___ month
-3 days of levofloxacin remaining after discharge
-Consider OSA evaluation with sleep study with PCP ___.
Greater than 30 minutes was spent on discharge planning and
coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. abatacept (with maltose) 125 mg injection 1X/WEEK
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. carisoprodol 350 mg oral TID:PRN muscle spasm
5. DICYCLOMine 20 mg PO QID
6. Famotidine 20 mg PO DAILY
7. Gabapentin 400 mg PO TID
8. LamoTRIgine 250 mg PO DAILY
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Methylprednisolone 4 mg PO DAILY
11. nystatin 100,000 unit/gram topical BID
12. Sucralfate 1 gm PO BID
13. Tizanidine 8 mg PO QHS:PRN muscle spasm
14. Aspirin 81 mg PO DAILY
15. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral BID
16. Vitamin D 7000 UNIT PO DAILY
17. Cyanocobalamin 1000 mcg PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Ibuprofen 400 mg PO BID:PRN Pain - Moderate
20. Loratadine 10 mg PO DAILY:PRN allergies
21. Multivitamins 1 TAB PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Riboflavin (Vitamin B-2) 200 mg PO BID
Discharge Medications:
1. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN
BREAKTHROUGH PAIN
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every eight (8) hours Disp #*18 Tablet Refills:*0
2. Levofloxacin 750 mg PO DAILY
Last day to take is on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Refills:*0
5. Prochlorperazine 5 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg 1 tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
6. abatacept (with maltose) 125 mg injection 1X/WEEK
Do not take for 4 weeks after discharge.
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
8. Aspirin 81 mg PO DAILY
9. BuPROPion (Sustained Release) 300 mg PO QAM
10. carisoprodol 350 mg oral TID:PRN muscle spasm
11. Cyanocobalamin 1000 mcg PO DAILY
12. DICYCLOMine 20 mg PO QID
13. Docusate Sodium 100 mg PO BID
14. Famotidine 20 mg PO DAILY
15. Gabapentin 400 mg PO TID
16. LamoTRIgine 250 mg PO DAILY
17. Levothyroxine Sodium 175 mcg PO DAILY
18. Loratadine 10 mg PO DAILY:PRN allergies
19. Methylprednisolone 4 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. nystatin 100,000 unit/gram topical BID
22. Omeprazole 20 mg PO DAILY
23. Riboflavin (Vitamin B-2) 200 mg PO BID
24. Sucralfate 1 gm PO BID
25. Tizanidine 8 mg PO QHS:PRN muscle spasm
26. Vitamin D 7000 UNIT PO DAILY
27.Walker Platform Attatchment
Dx: flexor tendon repair
NWB precautions
Length of need 13 months
Px; Good
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Partial median nerve injury with FDS/FDP and PL tending
injuries.
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after you injured your hand. You underwent
surgery. After surgery you had some trouble breathing and were
also found to have a pneumonia. You were started on antibiotics
and you improved. You also had slow down of your gut motility
called "ileus" due to pain medications (narcotics), but this
resolved.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing in left upper extremity in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
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:
___
|
10578209-DS-21 | 10,578,209 | 21,443,552 | DS | 21 | 2150-03-12 00:00:00 | 2150-03-12 10:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Zyprexa
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Blood transfusion ___
History of Present Illness:
___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion. She reports two weeks of
worsening dyspnea on exertion. This became significant worse on
___ and ___. She states that she now cannot walk from
one room to another without feeling very short of breath. She
felt some chest pain last week, which is now resolved. She also
notes intermittent nausea and vomiting. She is overall very
fatigued. She has had diarrhea recently which is not black or
bloody and was C. diff negative. She was recently set up for
home IVF.
On arrival to the floor, patient reports feeling tired. She
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, cough, hemoptysis,
chest pain, palpitations, abdominal pain, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: as above otherwise 10point ROS negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pancreatic cancer stage IV
- ___ Presented with 5 weeks of left buttock pain in the
setting of prior back surgery that did not respond to
conservative medical treatment.
- ___ Spine MR showed signal abnormalities/bony lesions
in sacrum and ilium.
- ___ Bone scan showed abnormal areas of activity in the
sacrum and approximately T5 concerning, both concerning for
metastatic disease. CT abdomen pelvis that day showed 20 x 34 mm
mass within the pancreas at the junction of body and tail c/f
adenocarcinoma. CT suggested left sacral involvement and
possibly L4 involvement. CT chest showed small lung nodules.
- ___ EUS showed a 2.6 cm X 2.1 cm ill-defined mass in
body of pancreas with suspicious for vascular invasion by the
mass. Pancreatic mass biopsy and FNA demonstrated
adenocarcinoma.
- ___ Biopsy of sacrum showed metastatic adenocarcinoma.
- ___ C1D1 Gemcitabine NAB paclitaxel
- ___ C2D1 Gemcitabine NAB paclitaxel
- ___ C3D1 Gemcitabine NAB paclitaxel
- ___ C4D1 Gemcitabine NAB paclitaxel
- ___ C5D1 Gemcitabine NAB paclitaxel
- ___ C6D1 Gemcitabine NAB paclitaxel
- ___ C7D1 Gemcitabine NAB paclitaxel
- ___ C8D1 Gemcitabine NAB paclitaxel
- ___ C9D1 Gemcitabine NAB paclitaxel
- ___ C1D1 FOLFIRINOX
- ___ C2D1 FOLFIRINOX
- ___ C3D1 FOLFIRINOX
- ___ C4D1 FOLFIRINOX
- ___ C5D1 FOLFIRINOX
- ___ C6D1 FOLFIRINOX
- ___ C7D1 FOLFIRINOX
- ___ C1D1 FOLFIRI
- ___ C2D1 FOLFIRI
- ___ C3D1 FOLFIRI
- ___ C4D1 FOLFIRI
- ___ C5D1 FOLFIRI
- ___ C6D1 FOLFIRI
- ___ Consent for ___ ___ the COMBAT Bioline trial
- ___ C1D1 BL8040 1.25 mg/kg loading week 1 D1,2,3,4,5
followed by MWF dosing with pembrolizumab 200 mg D8
- ___ C2D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ CT torso showed stable disease
- ___ C3D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C4D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C5D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ Reconsent for ___ ___, signed for data
collection and tissue banking but not optional biopsy
- ___ CT torso showed stable disease by RECIST criteria
with some increased in bone mets by size but not new lesions.
- ___ C6D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C7D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ C8D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ CT torso showed stable disease by RECIST criteria,
but increased size of bone mets, no new disease
- ___ C9D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ Start XRT to symptomatic bone mets
- ___ Complete XRT with 20 Gy to T2-5 and 20 to the
sacrum
- ___ CT for abdominal pain showed increase in adnexal
mass -unclear if metastatic disease or not
- ___ C10D1 BL8040 1.25 mg/kg MWF pembrolizumab 200 mg D1
- ___ Held therapy, admitted for symptomatic progression
of pelvic mass
- ___ Underwent resection of the enlarging symptomatic
pelvic mass
- ___ CT torso shows increase in size of pancreatic mass
- ___ C1D1 FOLFOX7 (LV @ 200 ___ cytopenias) +
Neulasta
- ___: C1D15 FOLFOX + Neulasta
- ___ - ___: Admitted for nausea/vomiting/abdominal pain.
CT a/p without new process and MRI head normal
- ___: Celiac plexus neurolysis
OTHER PAST MEDICAL HISTORY:
- Anal Fissure
- Neuropathy
Social History:
___
Family History:
Maternal aunt with ovarian cancer at ___. Paternal grandmother
with colon cancer.
Physical Exam:
-Vitals: reviewed
-General: NAD, laying comfortably in bed
-HENT: atraumatic, normocephalic, moist mucus membranes
-Eyes: PERRL, EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present
-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, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Discharge Exam:
-General: NAD, laying comfortably in bed
-HENT: atraumatic, normocephalic, moist mucus membranes
-Eyes: PERRL, EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present
-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, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 04:41PM BLOOD WBC-8.3 RBC-2.30* Hgb-7.4* Hct-22.4*
MCV-97 MCH-32.2* MCHC-33.0 RDW-19.9* RDWSD-70.0* Plt Ct-83*
___ 04:41PM BLOOD Neuts-81* Bands-7* Lymphs-7* Monos-5
Eos-0 Baso-0 ___ Myelos-0 NRBC-2* AbsNeut-7.30*
AbsLymp-0.58* AbsMono-0.42 AbsEos-0.00* AbsBaso-0.00*
___ 05:24PM BLOOD ___ PTT-24.6* ___
___ 04:41PM BLOOD Glucose-126* UreaN-10 Creat-0.4 Na-140
K-4.1 Cl-105 HCO3-20* AnGap-15
___ 04:41PM BLOOD ALT-14 AST-16 AlkPhos-294* TotBili-0.2
___ 04:41PM BLOOD Albumin-4.0 Calcium-8.3* Phos-1.5* Mg-2.1
___ 04:41PM BLOOD cTropnT-<0.01
___ 04:41PM BLOOD proBNP-75
DISCHARGE LABS
___ 05:02AM BLOOD WBC-6.0 RBC-2.36* Hgb-7.4* Hct-22.0*
MCV-93 MCH-31.4 MCHC-33.6 RDW-20.9* RDWSD-68.5* Plt Ct-65*
___ 05:02AM BLOOD Glucose-115* UreaN-5* Creat-0.3* Na-141
K-3.3* Cl-107 HCO3-22 AnGap-12
IMAGING
-CTA CHEST ___:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. New ___ opacification in the superior segment of the
left lower lobe, likely small airways infection, with slightly
increased airway wall thickening.
3. Persistent small left pleural effusion and slightly
increased left lower lobe perifissural atelectasis.
4. Multiple bilateral perifissural nodules are similar to the
prior exam, and metastases are not excluded.
5. Multiple osseous sclerotic metastases again noted.
Brief Hospital Course:
___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion and weakness found to have
anemia and pneumonia.
1. Acute on chronic normocytic anemia and thrombocytopenia
-s/p chemotherapy ___ with subsequent nadir as likely cause
of anemia. She essentially has pancytopenia with
thrombocytopenia and a relative leukopenia (drop in WBC from
30.8 ___ s/p Neulasta to 7.8 today). Transfused 1Unit PRBC ___
with improvement in hemoglobin to 7.4 to 7.6. Fecal occult
testing was negative. She noted improvement of her SOB even
prior to transfusion and felt better and requested to be
discharged home for further management as an outpatient
2. Community Acquired Pneumonia
-Potential small airway infection noted on CT. She has been
afebrile this admission. Was treated with a 5 day course of
levofloxacin that will continue through ___.
3. DOE and weakness
-Likely in setting of symptomatic anemia although potentially
mulficatorial in setting of pneumonia and poor PO intake. No PE
on CTA chest. She reported improvement in her SOB and symptoms
even prior to transfusion.
CHRONIC MEDICAL PROBLEMS
1. Metastatic pancreatitic cancer: Most recent treatment ___
with FOLFOX w/ Neulasta support. Continue oxycodone and
pancreatic supplementation.
2. Nausea/vomiting: Seems to be a side effect of chemotherapy on
antiemetics not currently an issue.
3. GERD: continue omeprazole
4. Opioid-induced constipation: continue bowel regimen
5. Hypophosphatemia: replete and monitor
>30 minutes spent on discharge
Transitional Issues:
[] f/u repeat CBC in a few days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon ___ CAP PO QIDWMHS
2. Docusate Sodium 200 mg PO BID
3. Milk of Magnesia 30 mL PO DAILY:PRN constipation
4. Omeprazole 20 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Bisacodyl 5 mg PO DAILY:PRN constipation
9. LORazepam 1 mg PO QHS:PRN insomnia/anxiety/nausea
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. Dexamethasone 2 mg PO AS DIRECTED WITH CHEMOTHERAPY
13. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Creon ___ CAP PO QIDWMHS
4. Dexamethasone 2 mg PO AS DIRECTED WITH CHEMOTHERAPY
5. Docusate Sodium 200 mg PO BID
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. LORazepam 1 mg PO QHS:PRN insomnia/anxiety/nausea
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Omeprazole 20 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
14. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic anemia
Pneumonia
Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with weakness and shortness of breath found to
have low blood counts (anemia) and received a blood transfusion
with improvement in your symptoms. You were also found to have
pneumonia treated with antibiotics.
Please continue to follow up with your oncology team.
It was a pleasure taking care of you.
-Your ___ team
Followup Instructions:
___
|
10578322-DS-17 | 10,578,322 | 29,510,782 | DS | 17 | 2118-06-18 00:00:00 | 2118-06-18 11:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left shoulder septic arthritis
Major Surgical or Invasive Procedure:
___: Left shoulder incision and debridement
___: Repeat Left shoulder incision and debridement
History of Present Illness:
___ male on Coumadin for atrial fibrillation who
presents with left shoulder pain, had arthrocentesis performed
as outpatient with arthrocentesis performed on ___ with WBC
count 92,898, cultures growing staph aureus. The patient states
that he has been experiencing progressive left shoulder pain
over approximately the last week and a half. He notes that over
the past 4 days he has had a little range of motion of his left
shoulder. He denies falls or trauma. He was raking leaves
before the pain started a week and a half ago. He does not have
any pain in any other joints. He has not been having any
fevers. He denies history of endocarditis or sepsis.
Past Medical History:
Coronary artery disease s/p CABG x ___, A. fib on Coumadin,
hyperlipidemia, hypertension, prediabetes, mild asthma
Social History:
___
Family History:
Noncontributory
Physical Exam:
General: Well-appearing, breathing comfortably
MSK: L shoulder incision c/d/I. Motor intact distally. Sensation
intact in
M/R/U/A distributions. WWP fingers.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have left shoulder septic arthritis and was admitted to the
orthopaedic surgery service. The patient was taken to the
operating room on ___ for left shoulder irrigation and
debridement, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report.
On postop day 2 there was concern for ___ erythema
and the patient was subsequently taken back to the OR for repeat
irrigation and debridement of the left shoulder. Following both
procedures, 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
anticoagulation per routine.
Intraoperative cultures obtained from the first surgery are
growing staph pansensitive Staphylococcus aureus. Per
recommendations of ID the patient is being treated with IV Ancef
which will be continued for 6 weeks. Cultures obtained from the
second operation were with no growth to date at the time of
discharge.
The patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with home ___ was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing range of motion as tolerated in the left
extremity, and will be discharged on home warfarin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV every
eight (8) hours Disp #*56 Intravenous Bag Refills:*1
4. Docusate Sodium 100 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
6. Senna 8.6 mg PO BID
7. Albuterol Inhaler 2 PUFF IH DAILY
8. Calcium Carbonate 500 mg PO TID
9. Fexofenadine 120 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Lisinopril 10 mg PO DAILY
12. Metoprolol Tartrate 75 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Simvastatin 60 mg PO QPM
15. Vitamin D 400 UNIT PO DAILY
16. Warfarin 4 mg PO DAILY16
RX *warfarin 4 mg 4 mg by mouth once a day Disp #*10 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left septic shoulder
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 (nothing over 5lbs), range of motion as
tolerated, Left upper 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:
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 continue with your home warfarin. Your dose has been
decreased to 4mg daily as your INR remained high. Please follow
up as soon as possible with your anticoagulation specialist.
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 greater than 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please call ___ to schedule a follow up with your
Orthopaedic Surgeon, Dr. ___. You will have follow up with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Followup Instructions:
___
|
10578325-DS-48 | 10,578,325 | 21,157,506 | DS | 48 | 2142-02-27 00:00:00 | 2142-02-27 21:22:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with morbid obesity (BMI >70), chronic lymphedema and
cellulitis, HTN, depression w h/o suicide attempts,
schizoaffective disorder, and asthma who presents with chest
pain that started at 10 am while he was on the phone with his
girlfriend. Patient describes the pain as ___ with radiation
across his left chest and into his back. He denies associated
N/V, abdominal pain, shortness of breath or diaphoresis. Pain is
not affected by position but is somewhat worse with deep
breaths. Pain is not reproducible with palpation. At baseline
the patient only minimally ambulates. He has been at rehab on
and off since last ___ due to recurrent cellulitis. Patient
notes similar pain last week which resolved after approximately
___ hour. This time pain failed to resolve and he presented to
the ED. Pain decreased to ___ with nitro and has remained
stable since.
.
In the ED, initial VS: 61 136/85 20 99% 4L NC. Trop was negative
x1, EKG did not show signs of ischemia. CXR was without PNA. D
Dimer was noted to be elevated at 811. Pt denies personal or
family hx of clots, he is at rehab where he ambulates daily.
Given patients size is not a candidate for CTA he was therefore
admitted to medicine for VQ scan. He was given morphine for pain
without improvement in his pain. Vitals on transfer were HR 47,
RR: 18, BP: 105/62, O2Sat: 99 on room air.
.
REVIEW OF SYSTEMS:
(+) Per HPI, some cough and dysnea due to asthma
(-) chills, night sweats, loss of appetite, fatigue, chest pain,
palpitations, rhinorrhea, nasal congestion, sputum production,
hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, nausea,
vomiting, diarrhea, constipation, hematochezia, melena, dysuria,
urinary frequency, urniary urgency, focal numbness, focal
weakness, myalgias, arthralgias
Past Medical History:
Hypertension
morbid obesity (BMI ~___)
Osteoarthritis w knee difficulties
Asthma
Microcytic anemia with known hemoglobin AC disease, baseline HCT
mid 30___s
OSA, refuses CPAP
Chronic lower extremity edema c/b cellulitis
Mild MR ___ of ___)
Schizoaffective disorder with history of suicide attempts
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
Vitals: Afebrile, 144/78 48 18 96%RA
General: Alert, oriented, no acute distress
HEENT: slight esotropia of L eye, MMM, oropharynx clear
Neck: supple, unable to assess JVD due to habitus
Lungs: CTAB
CV: bradycardic regular rhythm, non-displaced PMI, normal S1 +
S2, no murmurs, rubs, gallops, no ttp of the chest wall
Abdomen: soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
Ext: Both legs show chronic lymphedema changes, RLE>>LLE. Cannot
appreciate erythema. 1+ DP pulses bilaterally
Neuro: CN II-XII intact. Strength ___ throughout, sensation in
tact to light touch
DISCHARGE PHYSICAL EXAM:
unchanged
Pertinent Results:
ADMISSION LABS
___ 12:15PM BLOOD WBC-5.7 RBC-4.90 Hgb-10.6* Hct-34.1*
MCV-70* MCH-21.6* MCHC-31.1 RDW-17.7* Plt ___
___ 12:15PM BLOOD Neuts-54.3 ___ Monos-4.1 Eos-6.0*
Baso-0.7
___ 12:15PM BLOOD Glucose-84 UreaN-11 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-27 AnGap-14
___ 12:15PM BLOOD ALT-9 AST-14 AlkPhos-73 TotBili-0.2
___ 12:15PM BLOOD Lipase-37
___ 12:15PM BLOOD D-Dimer-811*
.
CARDIAC ENZYMES
___ 12:15PM BLOOD cTropnT-<0.01
___ 07:39PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:39PM BLOOD CK(CPK)-46*
.
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-5.8 RBC-5.04 Hgb-11.3* Hct-35.6*
MCV-71* MCH-22.3* MCHC-31.6 RDW-17.7* Plt ___
___ 07:05AM BLOOD Glucose-77 UreaN-10 Creat-1.0 Na-142
K-4.3 Cl-104 HCO3-30 AnGap-12
___ 07:05AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.6
.
IMAGING:
.
CXR-IMPRESSION: Suboptimal study without evidence for acute
process.
.
CXR, PA and Lat: IMPRESSION: Suboptimal study due to patient
body habitus, as above. Given
this, no acute cardiopulmonary process seen.
.
LENIS- Examination limited by body habitus, as the calf veins
could not
be visualized. Otherwise, no DVT seen.
.
VQ SCAN:
Low probability
Brief Hospital Course:
___ yo M with morbid obesity (BMI >70), chronic lymphedema and
cellulitis, HTN, depression w h/o suicide attempts,
schizoaffective disorder, and asthma presents with chest pain
with elevated d-dimer, admitted for V/Q scan.
.
ACTIVE ISSUES BY PROBLEM
# Chest pain: The etiology of the patient's chest pain is
unclear. Acute coronary syndrome was felt to be unlikely given
EKG without ischemic changes and 2 sets of negative troponins.
Pain was not reproducible to palpation to suggest MSK etiology.
CXR without signs of PNA. Also without fevers or elevated WBC.
Pt did have elevated D=dimer in 800s, however ___ Dopplers were
negative. He is mimimally mobile which could put him at risk but
states he has been ambulating regularly. Given his body habitus,
a CTA was not possible. He had a V/Q scan which was low
probability, so pulmonary embolism was essentially ruled out. It
is possible that his symptoms could be GI in origin, such as
from intermittent esophageal spasm or stricture. He does also
endorse easily choking on foods at times and spitting up,
especially with steak. He was started on therapeutic trial of
calcium channel blocker with nifedipine, which will also help
control his blood pressure. Should be monitored at rehab for BP
and see if this makes any difference in his chest pain.
Recommend outpatient EGD for further evaluation.
.
# Bradycardia: Patient was noted to have sinus bradycardia
throught admission with HR dipping to the mid ___ while
sleeping. The patient was asymptomatic with stable blood
pressure. He was monitored on telemetry as above.
.
STABLE ISSUES
# Asthma: Uses advair and albuterol at home (says he uses a neb
nightly). He was continued prn albuterol nebulizer treatments
and his home advair.
.
# HTN: Patient was continued on his home lisinopril and started
on nifedipine CR 30 mg for therapeutic trial for esophageal
spasm.
.
# Psychiatric disorders: Patient has a history of
schizoaffective and depression. He was continued on his
outpatient regimen of abilify and wellbutrin.
.
# Anemia: Microcytic, at baseline. Has known hemoglobin C trait.
Hct was at baseline throughout admission.
.
TRANSITIONAL ISSUES
- Chest pain: started therapeutic trial of nifedipine for
possible esophageal spasm, should assess affect on chest pain.
- Recommend EGD to rule out esophageal stricture, possible
esophageal manometry to futher assess for esophageal spasm.
- BP: should have BP monitored at least twice daily for the
first week after starting nifedipine.
- FULL CODE this admission
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
3. aripiprazole 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) disk Inhalation BID (2 times a day).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): ___ hold for loose stools.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): ___ hold for loose stools.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
2. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
10. nifedipine 30 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath .
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Atypical Chest pain
SECONDARY DIAGNOSIS
Asthma
Hypertension
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because you were having chest pain.
Reassuringly both your EKG (test of the electrical activity) of
your heart and blood test demonstrated that you did not have a
heart attack. There was some concern that you may have had a
blood clot in your lungs, so a special scan was done and showed
no clot.
The cause for your chest pain is still not clear, but it is
unlikely to be anything serious. Sometimes problems with your
esophagus can cause pain like this, so we are starting you on a
new medicine called nifedipine to see if this might help the
pain. This will also help control your blood pressure. Your
primary doctor should schedule an endoscopy to take a closer
look at your esophagus to evaluate for this problem.
Changes to your medications:
START nifedipine CR 30 mg daily
Please continue to take all other medications as instructed.
Please feel free to call for any questions or concerns.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure to take care of you at ___ Deaconess!
Followup Instructions:
___
|
10578325-DS-53 | 10,578,325 | 29,590,117 | DS | 53 | 2144-06-04 00:00:00 | 2144-06-04 19:14:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
Presumed Pulmonary Embolus
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with h/o schizoaffective disorder, morbid obesity (BMI 73),
L sided chest pain, asthma, lymphedema who presents with left
sided chest pain. Pt was sleeping this evening and a left-sided,
squeezing chest pain woke him up. It was located to the left of
the sternum around his left breast, constant, lasted ~ 6hrs,
non-radiating, worsens with deep breathing and palpation, ___
in severity, not associated with dyspnea, diaphoresis, or N/V.
He has left sided chest pain in the same location with multiple
admissions and ED visits but he states that this pain is
different as it is squeezing in quality. He is not active at
home at all and is wheelchair bound. He lives alone with ___ x2
hrs daily. He has not had anything to eat or drink x2 days as he
ran out of food. He has not taken any of his medications x2
days. Denies increased ___ edema, orthopnea, wheezing, dyspnea,
syncope, palpitations, N/V, abd pain, diarrhea. Endorses
dysuria.
Pt states that he's had two "mild heart attacks" in the past,
most recent one in ___ in ___. They recommended c.
cath but could not find a bed big enough given pt's body
habitus.
In the ED initial vitals were: 98.3 76 140/90 18 98% RA.
- Labs were significant for D-dimer 1160 (1719 on last admission
in ___, trops x1 negative, normal CHEM7, H&H 12.3/___, UA
with leuks moderate, WBC 44, few bacteria. CXR unremarkable. EKG
with no new ischemic changes. Unable to perform CTA given his
large body habitus.
- Patient was given ASA 325mg and started on heparin gtt for
presumed PE given elevated D-dimer.
Vitals prior to transfer were: 97.2 73 128/76 20 100% RA.
On the floor, VS are: 98.5 125/75 62 20 99% on RA. Pt is in no
acute distress. He is chest pain free and states that it
resolved about 20 minutes ago.
Of note, pt was admitted in ___ for left sided chest pain
with D-dimer elevated to 1719. His body habitus is not
compatible with CTA or V/Q scan. Received lovenox in ED but
d/c'd on the floor. He underwent ETT-MIBI. Stress test notable
for angina like symptoms but no ST changes. Nuclear imaging poor
quality but with no defects.
Past Medical History:
Hypertension
CHF
lymphedema
lower extremity cellulitis
morbid obesity (BMI ~___)
Osteoarthritis - s/p multiple knee and hip surgeries
Asthma- no bronchodilator response on PFTs
Microcytic anemia w hemoglobin AC dz
OSA - previously refuses CPAP (uses 2L NC at night)
Mild MR ___ of ___)
Schizoaffective disorder with history of suicide attempts
Social History:
___
Family History:
Father died of complications from CHF. Otherwise, no family hx.
of MI or early sudden cardiac death. No hx of bleeding or
clotting disorders in the family
Physical Exam:
ADMISSION
Vitals - 98.5 125/75 62 20 99% on RA
GENERAL: morbidly obese AA male in no acute distress, breathing
comfortably
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, reproducible
chest pain with paplpation along left breast border
LUNG: mild wheezes anteriorly
ABDOMEN: distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: significant venous insufficiency changes, 4+ edema
above knees
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE
PHYSICAL EXAM
Vitals: 97.6 137/57 73 20 100%RA
General: Morbidly obese man laying comfortably in hospital bed
HEENT: NCAT, EOMI, MMM
Lymph: No cervical LAD
Lungs: CTAB
Chest: RR S1/S2 No M/R/G No tenderness on palpation of L
anterior chest wall
Abdomen: +BS protuberant, soft, NT/ND
Ext: B/l ___ stasis changes, b/l non-pitting edema difficult to
quantify in setting of habitus
Neuro: AAOx3, no focal neuro deficits observed
Skin: Warm, dry throughout
Pertinent Results:
LABS
ADMISSION
___ 08:45PM BLOOD WBC-7.4 RBC-5.26 Hgb-12.3* Hct-37.0*
MCV-70* MCH-23.4* MCHC-33.3 RDW-17.6* Plt ___
___ 08:45PM BLOOD Neuts-56.7 ___ Monos-6.2 Eos-4.6*
Baso-0.6
___ 08:45PM BLOOD Plt ___
___ 08:45PM BLOOD Glucose-107* UreaN-14 Creat-1.0 Na-141
K-3.8 Cl-105 HCO3-28 AnGap-12
___ 08:45PM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD Calcium-8.8 Phos-3.5 Mg-1.7
___ 08:45PM BLOOD D-Dimer-1160*
___ 06:45AM BLOOD ___ PTT-45.9* ___
___ 04:06AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:43PM BLOOD cTropnT-<0.01
DISCHARGE
___ 06:30AM BLOOD WBC-6.3 RBC-5.30 Hgb-12.1* Hct-37.5*
MCV-71* MCH-22.9* MCHC-32.4 RDW-17.6* Plt ___
___ 08:45PM BLOOD Neuts-56.7 ___ Monos-6.2 Eos-4.6*
Baso-0.6
___ 06:10AM BLOOD ___ PTT-79.9* ___
___ 06:30AM BLOOD Glucose-88 UreaN-13 Creat-1.1 Na-137
K-4.5 Cl-101 HCO3-31 AnGap-10
___ 04:30PM BLOOD Iron-40*
___ 06:45AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.7
___ 12:43PM BLOOD %HbA1c-5.6 eAG-114
MICROBIOLOGY
___ 10:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 10:00PM URINE RBC-1 WBC-44* Bacteri-FEW Yeast-NONE
Epi-<1
___ 10:00PM URINE Mucous-RARE
IMAGING
___ CHEST PA + LATERAL IMPRESSION:
No acute cardiopulmonary process.
___ Bilateral ___ dopplers IMPRESSION:
Technically limited study. No evidence of deep venous thrombosis
in the
bilateral lower extremity veins. The right popliteal vein and
the bilateral calf veins were not visualized.
Brief Hospital Course:
___ with h/o schizoaffective disorder, morbid obesity (___ 73),
recent NSTEMI in ___ at ___, asthma,
lymphedema who presents with left sided chest pain that resolved
upon admission to the floor. He was found to have negative ACS
work-up w/ negative EKGs, troponin negativex3, an elevated
d-dimer, and a CXR with no evidence of acute abnormality. On
further review during admission, the patient was found to have
two types of chest pain, one "squeezing" which brought him into
the ED and ultimately was determined to be a presumed PE and was
not like previous chest pain and one "burning" which was akin to
previous episodes of GERD flares. The patient was started on a
heparin drip and bridging to warfarin started on hospital day 3
for presumed PE, as well as, for documented hx of pAfib with
CHADS2-vasc score of 3. INRs will be checked every day until
goal of ___ is reached at outpatient facility. The patient's
PPI, which he had not been taking, was restarted and helped the
"burning" pain.
#Presumed PE:
Patient had elevated D-dimer during low-risk workup for PE.
Patient could not undergo CTA or V/Q scan given body habitus.
His Wells score is 1.5 (immobility), so low probability, howver,
his DDimer is significantly elevated and given obesity this is
concerning. We could not explain the DDimer otherwise. Empiric
heparin drip was started. EKGs were negative with no acute
changes, TnT negative x3, recent MIBI in ___ was negative, and
patient was monitored on Tele for his first and second nights of
admission without event concerning for ischemia or event
requiring reflex EKG. Outside hospital reports from ___ in
___ showed NSTEMI (TnI 3.22). Here, Bilateral lower
extremity dopplers could not image lower calf or popletial veins
due to habitus, but no DVTs were observed b/l. Given history,
risk factors, inability to rule out, as well as, documented
history of Afib with CHADS2vasc score of 3, the patient was
started on anticoagulation therapy with warfarin, while
continuing to bridge with heparin drip. The patient's PCP was
___ with idea but had concerns with patient adherence. After
discussion between our attending, pt's PCP, ___, additional
support services were put in place to ensure adherence. The
patient found placement at rehabilitation facility that can
continue INR checks and titrate warfarin appropriately.
#symptomatic GERD:
"burning" chest pain noted first morning after admission,
described as similar to episodes where patient consumed large
amount of greasy food in the past, resolved after medication
dosage (including PPI). Patient reports not taking PPI due to
lack of availability. Loss of prior authorization lead to lack
of medicaiton. Given above negative chest pain work up, as well
as, classic history, determined to be acute GERD flare. SW was
consulted regarding resources and patient encouraged to continue
PPI as outpatient to prevent these symptomatic episodes.
# UTI:
UA notable for leuks moderate, WBC 44, few bacteria in ED, Epi
0. Patient endorsed dysuria. Complicated UTI given patient is a
male. Patient was started on ceftriaxone IV 1 g q 24h to
continue x 7 day until ___.
# CAD with recent NSTEMI (___):
Patient reports h/o MI's x2. ETT-MIBI with angina symptoms but
no EKG changes or perfusion defects in our hospital in ___. Known NSTEMI at ___ ___ (no EKG changes but +TnI
elevation to 3.22). We contined lisinopril 2.5, nifedipine
30mg/d, ASA 81mg/d, Atorvastatin 80mg and ordered PRN SL nitro
for chest pain (did not require)
# morbid obesity-- 568lbs on discharge
The patient mentioned he was considering bariatric intervention
and would like to find out if he's a candidate. Please ensure
follow-up with bariatric specialist to have patient discuss
options following recovery from acute issues.
# Dizziness--
Patient reported feeling dizzy the morning after admission,
which he attributed to lack of food for past few days. He
reports his SSI check was stolen. There was a positional
component, ?BPV. ___ was not performed ___ difficulty
given habitus. Neurologic emergency was deemed much less likely.
Social work was consulted for resource issues.
# HTN: normotensive. Continued lisinopril and nifedipine.
# OSA:
Patient reports not using CPAP at home ___ to lack of machine
which ___ is working on obtaining per patient. Used CPAP
machine while inpatient.
# Asthma: No wheezes on exam as inpatient. Continued home
regimen of asthma medications.
TRANSITIONAL ISSUES
- Monitor INR daily until >=2. Cont heparin bridge during this
time. Increase warfarin dose, adjust dosing as necessary.
- Day 1 of Warfarin = ___, INR 1.1 on ___
- Cont IV ceftriaxone 1 mg IV q 24hrs, to compelte 7 day course
(up to and on ___
- f/u Bariatric surgery
- Ensure continuation of PPI as outpatient to prevent "burning"
chest pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. NIFEdipine CR 30 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Divalproex (DELayed Release) 1000 mg PO HS
6. Metoprolol Succinate XL 50 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Polyethylene Glycol 17 g PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Divalproex (DELayed Release) 1000 mg PO HS
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO BID
6. NIFEdipine CR 30 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Polyethylene Glycol 17 g PO DAILY
9. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
chest discomfort
10. Aspirin 81 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Warfarin 10 mg PO DAILY16
13. CeftriaXONE 1 gm IV Q24H UTI
DAY ___ ON DISCHARGE. PLEASE CONTINUE DAILY UP TO AND ON ___.
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
15. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
16. Dakins ___ Strength 1 Appl TP ASDIR
17. Heparin IV per Weight-Based Dosing Guidelines
Continue existing infusion at 2250 units/hr
Start: Today - ___, First Dose: ___
Target PTT: 60 - 100 seconds
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pulmonary Embolism
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 treating you at ___
___. You were admitted because of your chest pain. During
your time in our hospital, you were evaluated for potential
causes of your chest pain. Heart attack was ruled out with both
electrical tests of your heart and blood tests. You had an
elevated test that indicated you may have clots in your lungs as
the source of your chest pain. In conjunction with your primary
care provider, it was decided you would continue on oral blood
thining medication (warfarin) after discharge to prevent harmful
clot formation. You were also found to have symptomatic heart
burn during your admission and restarted on your home
anti-reflux medication, which you should continue after
discharge. During your emergency department workup, we found
signs of a urinary tract infection, for which you were put on
antibiotic medications, which you should continue after
discharge. You also have history of Atrial Fibrillation, a heart
rhythm that can cause clots. This will also be helped by the
blood Warfarin.
Best of health,
___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10578325-DS-55 | 10,578,325 | 28,014,657 | DS | 55 | 2145-09-27 00:00:00 | 2145-10-04 06:07:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
Chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with a history of morbid obesity, asthma, and hip
and back pain who presented to the ED with fever, malaiase and
cough. The symptoms started yesterday. He has felt dehydrated
and dizzy with standing. He feels his shortness of breath is at
baseline.
In the ED, initial VS were 98.8 88 148/76 18 96% RA
He then triggered for tachycardia to the 180s, with afib with
RVR that improved with IVF and a 'partial adminisitration' of
10mg diltiazem given with calcium gluconate.
Labs showed WBC 17.5, Hgb 12.5 MCV 68, Plt 176. Lacatate of
2.2. Electrolytes at his baseline (Cr 1.1). CXR showed minimal
bibasilar atelectasis without focal consolidation. The patient
refused flu swab so was empiricly treated for flu and CAP.
He received:
___ 13:40 PO Acetaminophen 1000 mg
___ 13:40 IH Albuterol 0.083% Neb Soln 1 NEB
___ 13:40 IH Ipratropium Bromide Neb 1 NEB
___ 13:40 IVF 1000 mL NS 1000 mL
___ 14:12 IVF 1000 mL NS 1000 mL
___ 14:15 IV Levofloxacin 750 mg
___ 14:15 PO/NG OSELTAMivir 75 mg
___ 14:15 PO Ibuprofen 600 mg
___ 16:19 IV Diltiazem 10 mg Partial Administration
___ 16:49 IV Calcium Gluconate 1 gm
Transfer VS were 98.2 113 96/62 22 96% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient confirms above story, stating
he felt fevers up to 100.2 at home, and felt chills and hence
came in to ED. He denied travel or sick contacts. He did not get
the flu shot this year. He denies frequent pneumonias or
respiratory infections, and has not used his albuterol inhaler
recently. He denies cp, sob, abdominal pain, does report some
back pain, no new rashes, no dysuria. He is sexually active with
one female partner, has not noted any penile discharge or new
symptoms or sores. He says he has a non productive cough,
otherwise unchanged from baseline cough with no sore throat.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Hypertension
CHF
lymphedema
lower extremity cellulitis
morbid obesity (BMI ~___)
Osteoarthritis - s/p multiple knee and hip surgeries
Asthma- no bronchodilator response on PFTs
Microcytic anemia w hemoglobin AC dz
OSA - previously refuses CPAP (uses 2L NC at night)
Mild MR ___ of ___)
Schizoaffective disorder with history of suicide attempts
Social History:
___
Family History:
Father died of complications from CHF. Otherwise, no family hx.
of MI or early sudden cardiac death. No hx of bleeding or
clotting disorders in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS 98.5 BP 120/65 R 85-124 RR18 98 RA
GENERAL: NAD, morbidly obese gentleman lying in bed, limited
mobility, general malodor around body concerning for possible
wound infection
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD
CARDIAC: distant heart sounds, S1/S2, no murmurs, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: large abdomen, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema
SKIN: warm and well perfused, Skin exam did not reveal any clear
rashes, ulcers
Back skin fold with skin tag without erythema or tenderness
No sacral ulcers
Patients inner thighs/genitalia with mucous like discharge,
malodorous, no discoloration
DISCHARGE PHYSICAL EXAM:
VS 98.0 121/49 65 21 95%
GENERAL: NAD, morbidly obese gentleman lying in bed, limited
mobility, general malodor around body probably from poor hygiene
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD
CARDIAC: distant heart sounds, S1/S2, no murmurs, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: large abdomen, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema
SKIN: warm and well perfused, Skin exam did not reveal any
clear rashes, ulcers
Back skin fold with skin tag without erythema or tenderness
No sacral ulcers
Patients inner thighs/genitalia with mucous like discharge,
malodorous, no discoloration.
Pertinent Results:
ON ADDMISSION:
___ 01:23PM LACTATE-2.2*
___ 01:15PM GLUCOSE-89 UREA N-14 CREAT-1.1 SODIUM-135
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-13
___ 01:15PM estGFR-Using this
___ 01:15PM WBC-17.5*# RBC-5.60 HGB-12.5* HCT-37.9*
MCV-68* MCH-22.3* MCHC-33.0 RDW-19.9* RDWSD-44.8
___ 01:15PM NEUTS-86.7* LYMPHS-7.7* MONOS-4.4* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-15.13*# AbsLymp-1.35 AbsMono-0.76
AbsEos-0.02* AbsBaso-0.04
___ 01:15PM PLT COUNT-176
ON DISCHARGE:
___ 06:20AM BLOOD WBC-12.1* RBC-4.79 Hgb-10.6* Hct-32.6*
MCV-68* MCH-22.1* MCHC-32.5 RDW-18.7* RDWSD-45.0 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-90 UreaN-14 Creat-1.0 Na-137
K-4.8 Cl-100 HCO3-28 AnGap-14
Brief Hospital Course:
This is a ___ with a history of morbid obesity, asthma, and hip
and back pain who presented to the ED with fever, malaise found
to have RLE cellulitis.
## cellulitis: The patient presented with new right swollen
right leg associated with itching. He also had a new
leukocytosis with afib/RVR on presentation. Blood cultures were
collected and the patient was started on clindamycin. During his
hospital stay his right leg swelling and redness improved and he
was discharged home with ___ on clindamycin until ___.
## Afib with RVR: The patient suffered from Afib with RVR during
his ED stay which was treated with IV diltiazem resulting in
brief hypotension which was corrected with fluids. During his
hospital stay the patient was given fluids and started on
metoprolol for rate control with no complications. With regards
to his anticoagulation, the patient was previously on warfarin
as an outpatient, but then his anticoagulation was stopped as an
outpatient due to prior difficulties in optimizing his INR
levels given his morbid obesity and dietary habits. We discussed
with pharmacy regarding the possibility of starting him on a
novel anti-coagulant. However, due to morbid obesity warfarin
was preferred. Given the patient's history of uncontrolled INR's
in the past and difficult to keep therapeutic, warfarin was not
restart despite a CHADS2 score of ___. We felt that it is
better if the patient would follow up with his primary care
provider regarding the risk and benefits of starting him on
warfarin as an outpatient.
## Asthma: The patient had no evidence of exacerbation on exam,
no wheezes and appears comfortably
## Schizoaffective Disorder: was stable without complication
during admission.
## History of CAD: The patient reported a history of MI twice in
the past. We continued the patient aspirin, statins, and
adjusted increased his home metoprolo to 100 PO daily (see
above)
# OSA: The patient refused using CPAP during admission.
# Hypertension: His home antihypertensive medication were
initiall held to allow uptitration of metoprolo but then
restarted upon discharge.
TRANSITIONAL ISSUES:
============================
- consider starting the patient on warfarin for AF after having
a risk and benefit discussion.
- continue clindamycin till ___ and reassess for
resolusion of cellulitis
- order miconazole powder for severe ___ intertrigo of groin
and pannus
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Atorvastatin 80 mg PO QPM
4. Divalproex (DELayed Release) 1000 mg PO QAM
5. Vitamin D ___ UNIT PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Naproxen 500 mg PO Q12H
9. NIFEdipine CR 30 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
11. Nystatin Ointment 1 Appl TP QID:PRN Rash
12. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
13. Pantoprazole 40 mg PO Q24H
14. Topiramate (Topamax) 50 mg PO DAILY
15. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
nausea
16. Aspirin 81 mg PO DAILY
17. Magnesium Oxide 800 mg PO BID
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
nausea
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Divalproex (DELayed Release) 1000 mg PO QAM
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Magnesium Oxide 800 mg PO BID
8. Nystatin Ointment 1 Appl TP QID:PRN Rash
9. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Topiramate (Topamax) 50 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Clindamycin 600 mg PO Q8H
RX *clindamycin HCl [Cleocin] 300 mg 2 capsule(s) by mouth three
times a day Disp #*17 Capsule Refills:*0
15. Miconazole Powder 2% 1 Appl TP BID fungal infection of the
groin
RX *miconazole nitrate [Anti-Fungal] 2 % apply on groin and skin
folds of the lower abdomen and thighs twice a day Refills:*3
16. Lisinopril 5 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
18. Naproxen 500 mg PO Q12H
19. NIFEdipine CR 30 mg PO DAILY
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
cellulitis of the right foot, dehydration, atrial fibrillation,
fungal infection of the groin.
SECONDARY DIAGNOSIS:
====================
morbid obesity, hypertension, hyperlipidemia, coronary artery
disease, asthma, obstructive sleep apea, anemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___
___ was a pleasure taking care of you at the ___. You were
admitted because of fever, chills, cough and lower limbs
redness. you were found to have a condition called cellulitis
which is an infection of the skin of your right leg. We started
you an a oral antibiotic called clindamycin which you will
continue taking till ___.
During you hospital stay you were also noted to have atrial
fibrillation, a condition in which the heart beats fast and in a
irregular manner. You heart rate was controlled with medication.
At the time of your discharge we increase your home metoprolol
to 100mg. Since you have atrial fibrillation, you have a higher
risk of developing clots in the heart that might travel to other
parts of your body which puts you at risk of developing a stoke.
To prevent clots from forming you primary care provider might
start you on blood thinners. Please discuss starting a blood
thinner medication with your primary care doctor.
Also during your hospital stay, you were found to have a fungal
infection in our skin fold of your groin and under your belly.
We prescribed you miconizole which is an antifungal powder that
helps get rid on the infection.
Please continue to take your medication as prescribed.
Again it was a pleasure taking care of you at the ___.
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
10578325-DS-56 | 10,578,325 | 27,795,021 | DS | 56 | 2146-09-26 00:00:00 | 2146-09-28 14:25:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
Wound Evaluation
Major Surgical or Invasive Procedure:
I&D and debridement of necrotic tissue ___
History of Present Illness:
___ yo male with a PMH of asthma, HTN, morbid obesity, a-fib,
fungating right flank skin mass who presents with increasing
pain and yellow pus drainage for the past month from a chronic
back wound but has worsened in the last 2 days. He has a history
of cellulitis in his lower extremities, last treated in ___.
He states that he has a history of wounds in the skin folds of
his back, and states that they typically get worse in the
summer. He has noted worsening pain to the left mid-back and has
had drainage from the area. He has not been able to visualize
the area due to body habitus. Reports subjective fevers.
He also has a fungating skin mass to the right flank for some
time.
Of note he was in ___ clinic on ___ for a
fungating lesion on his right flank. However given his weight
~500-600 Ibs, he reports they were unable to turn him to
evaluate
his back.
Labs were notable for WBC of 21.6 and 6 bands.
He was given 600 mg of clindamycin x 2, acetaminophen, and
tramadol.
He was seen by surgery, no surgical intervention needed.
In the ED, initial vitals were: T 97.2 87 134/68 20 93% RA
On the floor, patient is feeling well except complaining of
shortness of breath, but not more than usual. Denies cough. Not
reporting any pain. States that he has had loss of appetite over
the last 4 days and unable to eat.
Past Medical History:
Hypertension
CHF
lymphedema
lower extremity cellulitis
morbid obesity (BMI ~___)
Osteoarthritis - s/p multiple knee and hip surgeries
Asthma- no bronchodilator response on PFTs
Microcytic anemia w hemoglobin AC dz
OSA - previously refuses CPAP (uses 2L NC at night)
Mild MR ___ of ___)
Schizoaffective disorder with history of suicide attempts
Social History:
___
Family History:
Father died of complications from CHF. Otherwise, no family hx.
of MI or early sudden cardiac death. No hx of bleeding or
clotting disorders in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.7 PO 105 / 64 81 28 87 ra
General: Alert, oriented, no acute distress. Morbidly obese.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished in anterior fields; unable to listen in
posterior fields.
Abdomen: Soft, non-tender, non-distended, morbidly obese, bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused. Difficult to appreciate edema. Skin is
very dry. Toe nails are long. No ulcers noted
Neuro: CNII-XII intact, difficult to assess strength
DISCHARGE PHYSICAL EXAM
========================
Vital Signs: 98.5 PO 135 / 72 99 21 95 RA
General: Somnolent. Alert to person but not place or time.
Speech is much clearer this AM. No dysarthria.
HEENT: Sclerae anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: mildly tachycardic, no murmurs, rubs, or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, no cyanosis. Left hip has adaptiq bandage over
Neuro: moving all extremities spontaneously and to commands
Pertinent Results:
ADMISSION LABS
==============
___ 06:00AM BLOOD WBC-21.6*# RBC-4.60 Hgb-9.7* Hct-30.4*
MCV-66* MCH-21.1* MCHC-31.9* RDW-19.6* RDWSD-44.9 Plt ___
___ 06:00AM BLOOD Neuts-67 Bands-6* Lymphs-12* Monos-12
Eos-3 Baso-0 ___ Myelos-0 AbsNeut-15.77*
AbsLymp-2.59 AbsMono-2.59* AbsEos-0.65* AbsBaso-0.00*
___ 06:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:00AM BLOOD Glucose-92 UreaN-9 Creat-1.2 Na-136 K-3.8
Cl-97 HCO3-25 AnGap-18
___ 06:00AM BLOOD ALT-5 AST-13 AlkPhos-154* TotBili-0.7
___ 12:50PM BLOOD CK(CPK)-27*
___ 06:00AM BLOOD proBNP-5494*
___ 07:19AM BLOOD Calcium-8.1* Phos-4.8* Mg-1.9 Iron-29*
___ 07:19AM BLOOD calTIBC-129* Ferritn-594* TRF-99*
___ 07:19AM BLOOD CRP->300
IMAGING
=======
BILATERAL HIPS:
IMPRESSION:
Limited evaluation. No displaced fracture identified.
CXR:
IMPRESSION:
Underpenetrated study due to patient body habitus.
Right lung parenchyma not well-visualized in the periphery
concerning for
pneumothorax.
1.5 cm nodular opacity seen in the right upper lung.
Recommend chest CT for further evaluation as assessment on chest
radiograph is limited.
SOFT TISSUE U/S:
IMPRESSION:
Markedly limited exam with very poor visualization of the
subcutaneous soft tissues.
DISCHARGE LABS
==============
___ 06:21AM BLOOD WBC-11.9* RBC-4.49* Hgb-9.4* Hct-30.0*
MCV-67* MCH-20.9* MCHC-31.3* RDW-21.1* RDWSD-47.6* Plt ___
___ 06:42AM BLOOD Neuts-65 Bands-4 Lymphs-14* Monos-10
Eos-4 Baso-0 ___ Metas-1* Myelos-2* AbsNeut-13.80*
AbsLymp-2.80 AbsMono-2.00* AbsEos-0.80* AbsBaso-0.00*
___ 06:21AM BLOOD Plt ___
___ 06:21AM BLOOD Glucose-111* UreaN-25* Creat-1.2 Na-129*
K-5.1 Cl-91* HCO3-28 AnGap-15
___ 06:42AM BLOOD ALT-10 AST-17 AlkPhos-150* TotBili-0.4
___ 06:21AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.5
___ 07:19AM BLOOD calTIBC-129* Ferritn-594* TRF-99*
___ 07:19AM BLOOD CRP->300
Brief Hospital Course:
Providers: ___ yo male with a PMH of asthma, HTN, morbid obesity,
a-fib, fungating right flank skin mass who presents with
increasing pain and yellow pus drainage for the past month from
a chronic back wound that has worsened in the last 2 days,
concerning for cellulitis and abscess formation.
# Cellulitis with Abscess s/p I&D: Patient has increasing
drainage and pain from a chronic back wound, with elevated
leukocytosis and bandemia consistent with cellulitis. Patient
has had chronic wounds in the past with unclear MRSA history.
Ultrasound was difficult to assess for abscess ___ to habitus.
ACS debrided necrotic tissue and drained any abscesses on ___
however reports that abscess had significant tracking within the
fat and unclear if all infected tissue is removed. Patient
initially received IV clindamycin (___) and then
transitioned to daptomycin on ___. Course was determined after
debridement and it was decided to continue daptomycin for 7 more
days after source control. Last day was ___ for total of 13
days. He will need BID wet to dry dressing changes until follow
up in ___ clinic in ___ weeks s/p discharge.
This wound is located on his left flank. It is about 4-5cm with
pink granulation tissue. Mild induration and no fluctuance at
time of discharge.
#Acute on Chronic Hypoxic Respiratory Failure
#Acute on Chronic CHF: Patient with known hx of CHF but no echo
because of habitus. Patient is on 2L of O2 at home at nighttime
for unclear reasons but likely asthma (reports does not always
wear). BNP is elevated to ~4500 and has orthopnea. Also may have
a component of restriction, asthma/COPD. We initially
aggressively diuresed him with IV Lasix starting at 40 mg and
then at had him on a Lasix gtt at 10 mg/hour with 100 mg
boluses. However, he was likely overdiuresed and this was
discontinued. His volume status was difficult to interpret ___
to habitus. He was continued on home dose of metoprolol.
#Acute Kidney Injury: Discharge Cr is 1.2 today and baseline
seems around ~1.0. Likely ___ to CHF exacerbation and infection.
#Microcytic Anemia: Below baseline which seems to be ___.
Normal ferritin in ___ and has been worked up in the past.
Former electrophoresis showed hemoglobin c trait. No melena or
BRBPR. Zinc was low and we repleted.
#Fall: The day prior to discharge, he was being transferred onto
a stretcher by the EMS service and accidentally fell onto the
floor. X-ray of his left hip was performed but was negative for
fracture. The following day he was discharged without issue.
CHRONIC ISSUES:
===============
# Fungating Mass: Patient has had chronic fungating mass on
right flank for many years that was attempted to be biopsied two
weeks ago. Touched base with dermatology who said he will need
outpatient follow up with derm surgery.
# Atrial Fibrillation (Not on anticoagulation ___ to difficult
to control INR from obesity): Continued on metoprolol succinate
ER 50 mg
# Asthma/COPD: Continued on albuterol PRN, advair.
# Hx of CAD: Continued on atorvastatin, aspirin
# Hypertension: Continued on lisinopril
# GERD: Continued pantoprazole
# Schizoaffective Disorder
# Unclear diagnosis: Continue Topamax and Depakote.
TRANSITIONAL ISSUE
==================
[] Diuresis: Unclear CHF history but has received Lasix 20 mg in
the past for leg swelling. Not discharged on diuretic, please
assess renal function at follow up appointment and consider
starting oral furosemide.
[] Cellulitis with Abscess: Will need twice daily wet to dry
dressing changes until surgery follow up in ___ weeks
[] Please re-check ___ and BMP on ___.
[] Fungating Mass: Patient will need outpatient follow up with
dermatology surgery.
[] Morbid Obesity: Patient said that he would like outpatient
information on bariatic surgery. Please provide him with times
of information sessions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Divalproex (DELayed Release) 500 mg PO BID
4. Topiramate (Topamax) 50 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Pantoprazole 40 mg PO Q24H
9. Vitamin D ___ UNIT PO 1X/WEEK (___)
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
11. NIFEdipine CR 30 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
3. TraMADol 100 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 2 tablet(s) by mouth every 6 hours Disp #*28
Tablet Refills:*0
4. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
RX *zinc sulfate [Zinc-220] 220 mg (50 mg zinc) 1 capsule(s) by
mouth daily Disp #*10 Capsule Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Divalproex (DELayed Release) 500 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Lisinopril 5 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. NIFEdipine CR 30 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Topiramate (Topamax) 50 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Cellulitis with abscess
Acute on Chronic Heart Failure (unspecified)
Acute Renal Failure
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You came to the hospital for worsening back pain with a wound
with increasing pus and blood drainage and your kidneys were
injured.
WHAT DID WE DO FOR YOU IN THE HOSPITAL?
We gave you antibiotics and surgery came by to remove infected
tissue. We also gave you a medication to help you urinate to
remove some fluid that we thought might be due to congestive
heart failure.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
You should follow up with your doctor at healthcare associates
and the surgery doctors. ___ is important that they look at your
wounds.
We wish you the best,
Your care team at ___
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10578325-DS-58 | 10,578,325 | 20,206,823 | DS | 58 | 2147-06-17 00:00:00 | 2147-06-17 18:16:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / vancomycin / Erythromycin Base
Attending: ___.
Chief Complaint:
Left lower extremity pain
Major Surgical or Invasive Procedure:
Right neck abscess incision and drainage
History of Present Illness:
Mr. ___ is a ___ y/o man with h/o super obesity, recurrent
cellulitis, afib on warfarin, asthma, HTN, CAD who presented to
the ED via EMS for worsening of chronic LLE pain. He notes
increased discharge today and his ___ was unable to change the
dressing due to his pain.
In the ED, initial vitals were: T 97.3, HR 88, BP 133/65, RR 24,
O2 95% RA
- Exam notable for: Purulent discharge from L medial thigh with
apparent tract. Multiple areas of purulent discharge and skin
breakdown in interdigitating spaces of bilateral ___
- Labs notable for: CBC 19.2>8.3<467, lactate 2.9
- Imaging was notable for: US w/ no fluid collection
- Seen by surgery who recommended abx and admission to medicine
as no drainable collection
- Received: clindamycin 600mg IV, zosyn 4.5g, ondansetron 4mg,
valproic acid ___ PO, topiramate 50mg PO, 1L NS
Upon arrival to the floor, patient reports worsening L lateral
hip pain with movement over the last few days, and requested to
be brought to the hospital. Notes ___ has been dressing skin
wounds daily. Denies fevers/chills, dyspnea, chest pain,
abdominal pain, diarrhea. Notes he cannot see out of L eye for
last few months, attributes this to his eyelid not opening.
Denies any pain or discharge
Past Medical History:
Hypertension
Diastolic CHF, EF >55% ___, mild diastolic dysfxn
lymphedema
lower extremity cellulitis
Super obesity
Osteoarthritis - s/p multiple knee and hip surgeries
Asthma- no bronchodilator response on PFTs
Microcytic anemia w hemoglobin AC dz
OSA - previously refuses CPAP (uses 2L NC at night)
Mild MR ___ of ___)
Schizoaffective disorder with history of suicide attempts
Social History:
___
Family History:
Family hx of DM. Father died of complications from CHF.
Otherwise, no family hx of MI or early sudden cardiac death. No
hx of bleeding or clotting disorders in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: T 98.5, HR 87, BP 137/83, RR 20, O2 95% RA
GENERAL: Morbidly obese man lying in bed, NAD unless being moved
HEENT: L cornea cloudy with probable cataract, injected sclera.
No blink to confrontation
NECK: Unable to assess JVP ___ habitus
CARDIAC: ___, normal S1, S2, no m/r/g
LUNGS: Distant breath sounds anteriorly
ABDOMEN: Obese, soft, non-tender
EXTREMITIES: Obese, with chronic scale, lymphedema
NEUROLOGIC: A&O x3, EOMI, no blink to confrontation L eye
MSK: Significant L leg pain with passive movement, unable to
clearly localize to specific joint but reports pain most
significant in L hip.
SKIN: Diffuse skin breakdown and ulcers throughout skin folds on
back, chest, axilla, buttocks, legs with serosanguinous
drainage. No purulent drainage observed on admission. Large
pedunculated mass on R flank. Extremities with diffuse xerosis
and scale.
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM:
VITALS: T:97.5 BP:106 / 59 HR:73 RR:20 SaO2:97 Ra
GENERAL: Sitting up in bed this morning, well appearing man
speaking to me comfortably
LUNGS: Clear to auscultation on anterior and lateral lung
fields, no use of accessory muscles and no sign of respiratory
distress
HEART: Very distant heart sounds, irregular rate
ABDOMEN: Large, soft, non-tender with positive bowel sounds and
rebound or guarding
Hand: L ___ and ___ digit tender to palpation with extension
limited to pain in the ___ digit, and mild erythema and redness
in both digits
Extremity: L knee no longer tender to palpation
Skin: Scant bleeding from superficial abrasion on occiput of
head beneath hair.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:49AM BLOOD WBC-19.2*# RBC-4.54* Hgb-8.3* Hct-27.6*
MCV-61* MCH-18.3* MCHC-30.1* RDW-23.7* RDWSD-48.2* Plt ___
___ 03:49AM BLOOD Neuts-77.3* Lymphs-10.7* Monos-7.6
Eos-2.3 Baso-0.4 NRBC-0.3* Im ___ AbsNeut-14.83*#
AbsLymp-2.05 AbsMono-1.46* AbsEos-0.44 AbsBaso-0.08
___ 06:20AM BLOOD ___ PTT-41.7* ___
___ 03:49AM BLOOD Glucose-97 UreaN-31* Creat-1.1 Na-131*
K-5.6* Cl-97 HCO3-26 AnGap-14
___ 09:35PM BLOOD CRP-254.6*
DISCHARGE LABS:
===============
___ 06:12AM BLOOD WBC-12.0* RBC-4.49* Hgb-8.3* Hct-28.1*
MCV-63* MCH-18.5* MCHC-29.5* RDW-24.4* RDWSD-51.8* Plt ___
___ 09:05AM BLOOD ___ PTT-32.8 ___
___ 06:12AM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-138
K-4.7 Cl-101 HCO3-25 AnGap-12
Microbiology:
=============
___ Urine culture:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Blood culture: No growth
___ Urine Culture: No growth
___ Blood Cx: No growth
___ Catheter Tip Cx: No growth
___ Blood Cx: ESCHERICHIA COLI
___ Urine Cx: ESCHERICHIA COLI. >100,000 CFU/mL.
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-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ Blood Cx: ESCHERICHIA COLI.
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ Abscess:
GRAM STAIN (Final ___:
1+(<1 per 1000X FIELD):POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ Blood Cx: Negative
___ MRSA Screen: negative
___ Blood Cx:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
___ Blood Cx: negative
IMAGING/STUDIES:
================
----- ___ L ___ digit hand ultrasound-----
Transverse and sagittal images were obtained of the superficial
tissues of the left ring finger PIP joint. There is a tiny
joint effusion. No echogenic structures to suggest crystals.
There is soft tissue swelling of the subcutaneous tissues around
the left ring finger PIP. No fluid collections were identified.
IMPRESSION:
1. No fluid collections.
2. Tiny joint effusion with soft tissue swelling.
--___ FINGER(S),2+VIEWS LEFT PORT of L ___ digit hand
-----
No fracture or dislocation seen. The digit is held flexed at
the proximal
interphalangeal joints on all available views. The long finger
and small
finger are also flexed at the proximal interphalangeal joints,
likely
correlating with fibroid history of contracted fingers. No bony
abnormality seen. No radiopaque foreign body or unexplained
soft tissue calcification appear
--___ Renal Ultrasound-----
1. Technically suboptimal study due to patient discomfort,
immobility, and poor acoustic windows. No right hydronephrosis.
2. Left kidney not visualized.
--___ US EXTREMITY LIMITED SOFT TISSUE-----
No subcutaneous edema or collection identified in the left
gluteal and thigh soft tissues.
--___ LEFT HIP XR-----
No gross evidence of fracture or dislocation. Bilateral hip
osteoarthritis.
--___ Echo-----
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). There
is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate to severe global left ventricular
hypokinesis. Quantitative (biplane) LVEF = 24 %. No masses or
thrombi are seen in the left ventricle. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with moderate to severe global
hypokinesis in a pattern most suggestive of a non-ischemic
cardiomyopathy. Mild pulmonary artery systolic hypertension.
--___ Chest XR-----
In comparison with the study ___, there again is
substantial
enlargement of the cardiac silhouette, though improvement in
pulmonary
vascular status and no definite acute focal pneumonia. The tip
of the right
IJ catheter now is at the level of the mid SVC.
--___ Carotid Duplex----
IMPRESSION:
Right ICA no stenosis.
Left ICA no stenosis.
--___ US R POSTERIOR NECK MASS-----
3.8 x 1.8 x 3.2 cm fluid collection in the right posterior neck
with extension to the skin surface compatible with clinical
history of recurrent abscess.
----- ___ US L HIP JOINT-----
Slightly limited study, no hip effusion identified.
----- ___ US L MEDIAL THIGH-----
No fluid collection identified.
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
___ year old man with super obesity, recurrent cellulitis, afib,
asthma, HTN, CAD who presented to the ED via EMS for worsening
of chronic LLE pain and over a 62 day hospital course was
treated for a right neck abscess, cellulitis and skin ulcers,
left hip septic arthritis, E Coli UTI with sepsis, heart
failure, and atrial fibrillation.
============
ACUTE ISSUES
============
#LEFT HIP SEPTIC ARTHRITIS WITH POSSIBLE FRACTURE:
Interventional radiology and orthopedic surgery were consulted
for possible biopsy; however, given the patient's habitus, it
was felt that biopsy would not be possible. His hip XR reveals
possible fracture, but would be a poor surgical candidate.
Instead, he was treated empirically with 6 weeks of daptomycin
for presumed septic arthritis. His hip pain resolved.
#ANEMIA: Stable anemia, possible secondary to GI losses given
guaiac positivity. He is very high risk for any procedure, and
will therefore defer endoscopy.
#ACUTE SYSTOLIC HEART FAILURE:
Known mild diastolic dysfunction from ___, developed reduced
EF to 24%, which increased to 40%. The most likely etiology was
felt to be stress cardiomyopathy from sepsis and new atrial
fibrillation; thus the patient was rate controlled with
metoprolol and diuresed with IV lasix. Volume status difficult
to assess and bed weights unreliable. After overdiruesing the
patient and developing ___ on ___, he was found to be stable
on furosemide 20mg orally and lisinopril 2.5mg daily.
#E. ACUTE BLOODSTREAM INFECTION:
Developed E. coli UTI and bacteremia and transferred to MICU
requiring short course of pressors. Completed treatment of
bacteremia on ___ with CTX 14 day course, In setting of new E.
Coli UTI and bacteremia. ID following, currently on Ceftriaxone.
No further sign of infection.
#ATRIAL FIBRILLATION:
New atrial fibrillation while hospitalized. Intermittent RVR
while in ICU, but now well rate controlled on Metoprolol
Tartrate 50 mg every 6 hours which will be transitioned to
Metoprolol Succinate XL 200mg PO. Anticoagulated with warfarin
with goal INR ___.
#CELLULITIS, SKIN ULCERS AND ABSCESS:
Initial concern for lower extremity cellulitis given
leukocytosis and multiple ulcers. Regardless, his bacteremia was
treated with daptomycin, as above, and resolved. He received
wound care throughout hospitalization, but still has some
chronic bleeding from skin folds.
#ACUTE GOUT: L ___ digit pain at PIP, does not follow flexor
tendon, cannot assess full ROM given baseline flexion
monoarthritis. Ultrasound without obvious crystal arthropathy
and no drianbale fluid collection. Uric acid elevated to 11.6.
DDX: gout vs pseudogout, doubt septic joint given ultrasound
findings, doubt tenosynovitis. Suspect gout, especially given
elevated uric acid continue empiric colchicine for seven days
(___). Would continue Occupation Therapy for
chronic finger flexion.
Transitional issue: recheck urate level two weeks after
resolution of potential flare on ___.
#OPIOID OVERODSE:
Reduced renal function, combined with increased doses of opioids
for control of his hip pain, resulted in opioid induced apnea on
___ requiring a total of 1.2mg naloxone to improve the
patient's breathing. On oxycodone 10mg q6hrs and only requiring
___ doses daily by the end of his admission.
==============
CHRONIC ISSUES
==============
#HYPERTENSION: On metoprolol tartrate 50mg Q6hr and lisinopril
2.5mg daily, as above, with excellent blood pressure control.
#LEFT EYE VISION LOSS: Seen by ophthalmology who feel that
ocular vascular event likely responsible for visual disturbance,
favoring central retinal artery occlusion. Initially treated
with atropine sulfate and brimonidine tartrate eye drops. Will
follow up with ophthalmology as an outpatient on routine basis.
#ASTHMA: Reportedly on home advair, albuterol nebs, and
albuterol inhalers but again does not appear to have filled
prescriptions recently. No shortness of breath by the end of his
hospitalizations.
#OSA: Not on home CPAP (had been on years ago but gets "phobia"
to it). Will desaturate into the 80's at night, but saturates in
high 90's on room air during the day.
#DEPRESSION: Continued home topiramate, valproic acid
#HLD: Continued home atorvastatin
#GERD: Continued home pantoprazole
====================
TRANSITIONAL ISSUES:
====================
[]continue colchicine for seven day course ending ___, if joint
pain does not resolve would obtain rheumatology evaluation
[]Opthalmology follow up for ultrasound of L eye with vision
loss in three months
[]Re-check uric acid level ___ to establish baseline for
future management of gout flares
[]Consider echocardiogram as an outpatient for interval change
in stress cardiomyopathy by ___
[]Monthly comprehensive metabolic panel
[]Discuss regular use of CPAP with patient
[]INR monitoring on warfarin, goal ___. Next INR should be drawn
___.
[]Weight loss plan with patient, as this is main barrier to
going home
# Communication: HCP: ___, friend. ___
# Code: Full, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO 2X/WEEK (MO,FR)
2. Warfarin 5 mg PO 5X/WEEK (___)
3. Gabapentin 300 mg PO BID
4. Vitamin D 1000 UNIT PO DAILY
5. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
8. Furosemide 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Topiramate (Topamax) 50 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Divalproex (DELayed Release) 500 mg PO BID
13. Lisinopril 5 mg PO DAILY
14. NIFEdipine CR 30 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Colchicine 0.6 mg PO DAILY Duration: 4 Days
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Miconazole Powder 2% 1 Appl TP TID:PRN panus breakdown
6. OxyCODONE (Immediate Release) 10 mg PO TID:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Sarna Lotion 1 Appl TP QID:PRN prutitis
9. Senna 8.6 mg PO BID constipation
10. Acetaminophen 650 mg PO Q8H
11. Lisinopril 2.5 mg PO DAILY
12. Warfarin 2.5 mg PO DAILY16
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Divalproex (DELayed Release) 500 mg PO BID
16. Furosemide 20 mg PO DAILY
17. Gabapentin 300 mg PO BID
18. Pantoprazole 40 mg PO Q24H
19. Topiramate (Topamax) 50 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Super obesity
Urinary tract infection with sepsis requiring vasopressors
Acute heart failure with reduced ejection fracture on top of
chronic diastolic heart failure
New onset atrial fibrillation on warfarin
Septic arthritis of the left hip
Cellulitis
Anemia with possible gastrointestinal blood loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
DISCHARGE WORKSHEET INSTRUCTIONS:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were having pain in your hip and leg and we were concerned
you had an infection
WHAT HAPPENED IN THE HOSPITAL?
-You were treated with antibiotics for a skin and hip infection
-You had an abscess on your neck that the surgeons drained
-You were seen by an eye doctor because you couldn't see out of
your left eye. They felt this was likely caused by an artery
being blocked and that your sight may not come back.
-You had an infection of your urinary tract that spread to your
blood. You want to the ICU to have this treated.
-Your heart started beating irregularly rather than at a steady
beat. We gave you blood thinners so you don't get a clot from
your heart.
WHAT SHOULD YOU DO AT HOME?
- Keep losing weight! You've lost weight here, and losing more
will be the best thing for your health.
- Take all of your medications
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10578544-DS-20 | 10,578,544 | 21,002,145 | DS | 20 | 2117-05-24 00:00:00 | 2117-06-22 17:48:00 |
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 memory change
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with no significant past medical
history who presents with acute memory change.
Mr. ___ was in his usual state of health the morning of ___ and
performed his typical 1.5 hour cardio and strength workout. He
was able to drive home(although he doesn't remember this), but
then went to his wife and said that
he "felt funny." His wife reports some slurring of his speech.
He started making additional comments such as "I feel like
something is wrong with my head" and "I don't know what day it
is". He did not know the month, and repeatedly asked questions
such as "Where do we live?" "Are we in a house?" "Is it by
rocks?" "Do we live in ___. He became very upset by
his lack of knowledge and was quite agitated and crying. He
received lorazepam (unknown
dose) at OSH for this and his wife states the agitation then
improved. He was then transferred to ___.
After arrival to ___, he started to be able to remember some
things. He remembered working out (though hadn't remembered that
earlier in the day) and remembered where he worked (also new
from earlier), but continued to ask questions.
His wife said that his pupils look different today, saying that
the left one looks larger than normal.
On neuro ROS, he denied headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denied difficulties
producing or comprehending speech. Denied focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denied difficulty with gait.
Past Medical History:
HLD
Traumatic amputation of RUE below elbow
Social History:
___
Family History:
Father died of nasal cancer and lung cancer, also with stroke.
Sister with a different type of nasal cancer and HLD
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___, ___.
Able to register 3 objects and recall ___ at 5 minutes. Recalls
his own phone number, DOB, high school, college, first address
after college, and current address. Attentive, able to name ___
backward without difficulty. Speech is fluent with normal
grammar and syntax. No paraphasic errors. Naming intact to low
frequency words. Repetition intact. Comprehension intact to
complex, cross-bodycommands. Normal prosody.
-Cranial Nerves: R miosis (L 0.5mm larger than R in bright
light,
1mm larger than R in low light). No ptosis. VFF to
confrontation. EOMI with ___ beats of bilateral end-gaze
nystagmus. Facial sensation intact to light touch. Face
symmetric at rest and with activation. Hearing intact to
conversation.
Palate elevates symmetrically. ___ strength in trapezii
bilaterally. Tongue protrudes in midline and moves briskly to
each side. No dysarthria.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis. RUE amputated below elbow.
-Sensory: Proprioception intact BLE. Intact to LT throughout.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
EXAM ON DISCHARGE:
Neuro:
MS ___ intact. Recall ___ -> ___ with multiple choice. Can't
spell ___ backwards, get's stuck after ___ backwards
intact. Reverse digit span 4. Recall of 7 digits with 1 error,
10 digits with 3 errors.
CN: intact
Motor: full strength
Sensation: no deficits to light touch
Reflexes: deferred
Coord: FNF intact
Pertinent Results:
___ 07:05AM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-142
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 07:05AM ALT(SGPT)-28 AST(SGOT)-27 ALK PHOS-65
___ 07:05AM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.9
MAGNESIUM-2.1
___ 07:05AM %HbA1c-5.0 eAG-97
___ 07:05AM WBC-6.7 RBC-4.71 HGB-14.9 HCT-42.7 MCV-91
MCH-31.6 MCHC-34.9 RDW-13.6 RDWSD-45.2
___ 07:05AM PLT COUNT-239
___ 07:05AM ___ PTT-32.9 ___
___ 11:33PM ___ COMMENTS-GREEN TOP
___ 11:33PM LACTATE-1.0
EEG:
OBJECT: ___ -year-old male presenting with suspected transient
global amnesia.
Medications: Aspirin, atorvastatin, Cyanocobalamin,
This is a 23 electrode EEG ___ placement with T1/T2) recorded
with video,
with additional EOG and EKG electrodes.
REFERRING DOCTOR: ___. ___
___:
BACKGROUND: Waking background is characterized by a symmetric 10
Hz posterior
dominant rhythm that attenuates with eye opening. Symmetric ___
mcV beta
activity is present, maximal over bilateral frontal regions.
HYPERVENTILATION: Hyperventilation is performed for 180 seconds
with good
cooperation, and produces no effect.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from
___ flashes
per second (fps) produces no activation of the record.
SLEEP: The patient progresses into drowsiness but does not reach
stage N2
sleep.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm with an
average rate of 60-70 bpm.
IMPRESSION: This is a normal waking and drowsy EEG. No focal
abnormalities or
epileptiform discharges are present.
INTERPRETED BY: Electronically signed by ___.
(___)
IMAGES:
Final Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with transient global amnesia.
Evaluate for
stroke.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR,
gradient echo,
and diffusion-weighted images of the brain were obtained.
COMPARISON: ___ head CT/CTA.
___ head CT.
FINDINGS:
There is no acute infarction, edema, mass effect, or evidence
for blood
products. There are scattered small foci of high signal on T2
weighted and
FLAIR images in the subcortical, deep, and periventricular white
matter of the
cerebral hemispheres. Ventricles, sulci, and basal cisterns are
normal in
size for age. Major vascular flow voids appear grossly
preserved.
There is a small mucous retention cyst in the right maxillary
sinus and
minimal mucosal thickening in the ethmoid air cells.
IMPRESSION:
1. No acute infarction.
2. Scattered small T2 hyperintense foci in the supratentorial
white matter are
nonspecific, though most likely sequela of mild chronic small
vessel ischemic
disease in this age group. Sequela of prior inflammation or
trauma, or
migraine related lesions, may also be considered in appropriate
clinical
setting.
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with acute onset confusion and slurred
speech at
5pm// cva?Cr 1.1 at OSH today
TECHNIQUE: Contiguous MDCT axial images were obtained through
the brain
without contrast material. Subsequently, helically acquired
rapid axial
imaging was performed from the aortic arch through the brain
during the
infusion of mL of Omnipaque intravenous contrast material.
Three-dimensional
angiographic volume rendered, curved reformatted and segmented
images were
generated on a dedicated workstation. This report is based on
interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy
(Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy
(Head) DLP =
27.2 mGy-cm.
3) Spiral Acquisition 5.4 s, 42.5 cm; CTDIvol = 31.1 mGy
(Head) DLP =
1,323.3 mGy-cm.
Total DLP (Head) = 2,254 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass.
The ventricles and sulci are normal in size and configuration.
Submucosal retention cyst right maxillary sinus with adjacent
minimal mucosal
thickening.. Otherwise, the visualized portion of the paranasal
sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion
of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm
formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches
appear normal with
no evidence of stenosis or occlusion. There is no evidence of
internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. There is 1.7 cm
hypervascular
nodule posterior left thyroid lobe, best seen on sagittal
reformatted images.
There is no lymphadenopathy by CT size criteria. Degenerative
changes
cervical spine.
IMPRESSION:
1. Normal head and neck CTA.
2. 1.7 cm hypervascular nodule left thyroid lobe. Follow-up
ultrasound
recommended.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up
recommended.
___ College of Radiology guidelines recommend further
evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5
cm in patients age ___ or ___, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White
Paper of the ACR Incidental Findings Committee". J ___
___ ___
12:143-150.
Brief Hospital Course:
Mr. ___ is a ___ man with no significant past medical
history who presented with transient global amnesia after
exercise. Neurologic examination was significant for no recall
following the event and decreased working memory with recall ___
at five minutes, ___ with category cues, and ___ with multiple
choice. He demonstrated intact recall of remote history, as well
as intact executive function, attention, and comprehension of
complex commands. CT head showed no acute intracranial
abnormality and CTA head and neck normal intracranial, carotid,
and vertebral arteries without stenosis, occlusion, or aneurysm
formation. MRI also showed no acute intracranial process. Given
normal imaging, carotid dissection was unlikely. Although his
presentation was unlikely to be caused by a stroke, he was
started on aspirin 81mg, which he should continue taking.
Additionally, seizure was unlikely given that his neurologic
exam was significant for working memory defects with minimal
confusion or executive function defects. Extended routine EEG
showed no evidence of seizure activity. His mental status on
discharge improved to ___ registration and free recall, digit
span 6, serial 7 from 100-51 within one minute.
Transitional Issues:
- Follow up Vitamin B1 level
- Continue repletion with Vitamin B12
- Continue Aspirin 81 mg daily
Follow-up with your PCP and with ___ as directed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*12
2. Cyanocobalamin 500 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) [B-12 DOTS] 500 mcg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*12
3. Atorvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Global Amnesia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
You were admitted to the neurology service for trouble with your
memory. We have performed imaging of your brain and the blood
vessels in your neck with a CT and MRI, which did not show any
abnormalities as we discussed. We think that this is likely an
episode of transient global amnesia, which is a brief loss of
memory that can occur after strenuous exercise and improves in a
few hours to days. Your memory showed remarkable improvement
during your hospital stay.
Your memory loss is most consistent with Transient Global
Amnesia given the acuity of short-term memory loss, the rapid
improvement within ___ days, and the absence of findings to
suggest that you have suffered from a stroke. However, some
components of your presentation are slightly atypical for
Transient Global Amnesia. These include 1) not knowing how to
use a phone ("Apraxia") 2) forgetting your children's birthdates
3) slurred speech. These symptoms are also found in seizures and
strokes, but your MRI brain imaging showed no evidence of stroke
and your EEG recordings of brain activity was normal, without
evidence of seizure activity.
In the scenario that you may have had a Transient Ischemic
Attack (temporary decrease in blood supply to the brain that is
like a "mini-stroke"), you were started on aspirin in the
hospital. We also checked your stroke risk factors. We recommend
that you continue taking aspirin 81 mg daily at home. Your LDL
was 89 and we recommend that you continue your atorvastatin to
reduce your risk of stroke. We will contact you for a follow-up
appointment with a neurologist in ___ months.
Part of your memory work-up included evaluation of Vitamin B12
and B1 (thiamine) levels, which can cause memory problems if
low. We found that your vitamin B12 level was low and started
you on Vitamin B12 supplementation.
MEDICATION CHANGES ON THIS ADMISSION:
- continue Aspirin 81 mg once a day
- continue Vitamin B12 500ucg once a day
Please take all remaining medications as prior to your hospital
admission.
It has been a pleasure caring for you,
___ Neurology Team
Followup Instructions:
___
|
10578633-DS-10 | 10,578,633 | 26,557,514 | DS | 10 | 2128-08-22 00:00:00 | 2128-09-11 11:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Left renal colic
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F well known to the urology service who
presents with flank pain. She initially presented ___ with
renal colic and was found to have a 7mm left ureteral stone. She
failed two days of medical trial of passage and underwent laser
lithotripsy ___. She was seen again in the ED POD1 for
continued left-sided flank pain, nausea, and vomiting. She
represents today for the same complaints, this time with
inadvertent removal of her left ureteral stent. She was
discharged from the ED with empiric antibiotics for a urinalysis
that was suggestive of a urinary tract infection, however no
cultures have demonstrated an isolated organism. Her pain
control had improved, though she continued to have flank pain
with urination. Yesterday she
inadvertently removed the stent, which resulted in worsening
left flank pain, nausea, vomiting and poor PO. Post-operative
dysuria and gross hematuria has improved. She denies any fevers,
chills, urinary urgency or frequency.
Past Medical History:
PMH: BMI 43.2, reflux/heartburn, hypertension, hyperlipidemia,
fatty liver s/p biopsy in ___, borderline type 2 diabetes with
hemoglobin A1c of 6.1%, depression.
PSH: lap gastric banding ___
Social History:
___
Family History:
Her family history is noted for both parents living father age
___
with heart disease and obesity; mother age ___ with
hyperlipidemia, asthma and obesity; brother living age ___ with
asthma.
Physical Exam:
Afebrile, vital signs stable
No acute distress
Warm and well-perfused
Non-labored breathing
Abdomen soft, non-tender, non-distended
Mild left CVA tenderness
Pertinent Results:
___ 10:18PM GLUCOSE-123* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
___ 10:30PM URINE RBC->182* WBC-29* BACTERIA-FEW
YEAST-NONE EPI-5
___ 10:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-TR
___ 10:18PM WBC-12.5* RBC-4.49 HGB-13.3 HCT-40.8 MCV-91
MCH-29.6 MCHC-32.5 RDW-13.1
Brief Hospital Course:
Ms. ___ is a ___ year old obese female with multiple medical
problems and poor tolerance of renal colic presenting to the ED
for the fourth time in a week
reporting flank pain, nausea and vomiting secondary to a left
ureteral stone.
She is POD4 status post laser lithotripsy and ureteral stent
placement but she inadvertent self-removed the stent yesterday.
She was afebrile with
stable vitals but presented to ED with pain. Her labs were
negative for significant leukocytosis or elevated creatinine.
Imaging negative for obstruction. Urinalysis
consistent with recent urologic instrumentation. Cultures
contaminated. Given poor
tolerance of pain and multiple readmissions to the ED, she was
admitted to urology for pain control and observation. She was
continued on tylenol, narcotics for pain control as necessary
but NSAIDs were avoided due to history of gastric banding. She
was given a regular diet and continued all of her home
medications. On Hospital day two her symptoms had markedly
improved so she was discharged home. On discharge she was
tolerating a regular diet and on all of her home medications.
She was voiding independently and tolerating oral analgesics
without nausea. She was discharged home and will follow up as
directed.
Medications on Admission:
ARIPIPRAZOLE [ABILIFY] - Abilify 5 mg tablet. 1 Tablet(s) by
mouth at bedtime - (Prescribed by Other Provider)
HYDROMORPHONE [DILAUDID] - Dilaudid 2 mg tablet. 1 tablet(s) by
mouth every four (4) hours as needed for pain do not drink
alcohol or drive while taking this medication
LEVONORGESTREL [MIRENA] - Dosage uncertain - (Prescribed by
Other Provider)
LORAZEPAM - lorazepam 0.5 mg tablet. 1 Tablet(s) by mouth twice
a
day as needed for Anxiety - (Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. two
capsule,delayed ___ by mouth daily - (Prescribed
by Other Provider)
PHENAZOPYRIDINE - phenazopyridine 100 mg tablet. 1 tablet(s) by
mouth three times a day as needed for bladder pain can turn
urine
orange
TAMSULOSIN [FLOMAX] - Flomax 0.4 mg capsule. 1 capsule(s) by
mouth at bedtime
VENLAFAXINE - venlafaxine ER 225 mg tablet,extended release 24
hr. 1 tablet extended release 24hr(s) by mouth daily -
(Prescribed by Other Provider)
Medications - OTC
CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] - Dosage
uncertain - (Prescribed by Other Provider)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit capsule. one Capsule(s) by mouth once a day - (Prescribed
by Other Provider)
DIPHENHYDRAMINE HCL - diphenhydramine 25 mg capsule. 1
Capsule(s)
by mouth daily - (Prescribed by Other Provider)
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s)
by
mouth twice a day as needed for constipation
MULTIVITAMIN WITH MINERALS - multivitamin with minerals capsule.
one Tablet(s) by mouth once a day - (Prescribed by Other
Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Aripiprazole 5 mg PO HS
3. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
4. Lorazepam 0.5 mg PO BID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Tamsulosin 0.4 mg PO HS
8. Venlafaxine XR 225 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Renal colic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications, except HOLD any
aspirin until you see your urologist in follow-up
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
Followup Instructions:
___
|
10578633-DS-12 | 10,578,633 | 21,735,438 | DS | 12 | 2130-09-22 00:00:00 | 2130-09-22 23:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Topamax / Dilaudid / hydromorphone / metformin
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ gastroparesis, fatty liver disease, hypertension presents
with three days of nausea worse than usual and ___ hours
of bilateral uppre back pain over her "kidneys" and today while
at work at ___ she could not understand the words she was
speaking, experienced blurry/tunnel vision, shortness of breath
and lightheadedness and her boss sent her to the ED.
bilateral upper back/flank pain, and generalized abdominal pain.
Initial ED vitals notable for temp 99.4, HR 100, BP 61/46 but
repeated 10 minutes later BP was 137/70. She received two
liters IVF, ceftriaxone for possible pyelonephritis though UA
showed 10 epis with ___bdomen pelvis showed no acute
pathology to explain her symptoms.
She started hydrochlorothiazide 3 days prior to presentation for
hypertension.
ROS: chronic nausea. pain over upper back/flanks, one prior
episode of syncope during ILI, no syncope during this current
illness, no dysuria, no burning or frequency, no cough, low
grade headache is present, no trouble w speech, her pain is
improved and she currently has appetite, otherwise 13pt is
negative unless noted above
Past Medical History:
PAST MEDICAL HISTORY:
- BMI ___ s/p lap gastric banding ___
- Hypertension
- Hyperlipidemia
- Borderline type 2 diabetes with hemoglobin A1c of 6.3%
- Reflux/heartburn
- Fatty liver s/p biopsy in ___ (as per GI records, has hx of
elevated transaminases in setting of this)
- IBS
- Cholecystectomy ___
- Left ureteral stone ___
- Lower back pain
- Migraines
- Dyslexia (per pt)
PTSD
anxiety/depression
gastroparesis
eating disorder
Social History:
___
Family History:
not pertinent to current admission
Physical Exam:
nontoxic, awake, alert, not confused
orthostatic vitals (after 2 L IVF in Ed)
supine 130/56 74
standing ___ HR 85
face symmetric, perrl, eomi,
clear BS no wheezes
obese abdomen, no focal tenderness, rebound or guarding
no CVA tenderness
no suprapubic tenderness
no peripheral edema
speech fluent
moves all extremities equally, stands on her own, balance normal
Discharge exam:
AF, HR 99, BP 120s-130s/90s, RR 18, SpO2 97% RA
face symmetric, perrl, eomi,
clear BS no wheezes
tachycardic, regular rhythm
obese abdomen, no focal tenderness, rebound or guarding
mild R CVA tenderness
no suprapubic tenderness
no peripheral edema
speech fluent
no rashes
moves all extremities equally, stands on her own, balance normal
Pertinent Results:
___ 10:15AM BLOOD WBC-13.2* RBC-5.37* Hgb-15.6 Hct-45.8*
MCV-85 MCH-29.1 MCHC-34.1 RDW-13.8 RDWSD-42.5 Plt ___
___ 10:15AM BLOOD Neuts-59.5 ___ Monos-7.6 Eos-0.8*
Baso-0.8 Im ___ AbsNeut-7.85* AbsLymp-4.02* AbsMono-1.00*
AbsEos-0.10 AbsBaso-0.11*
___ 10:15AM BLOOD Glucose-113* UreaN-21* Creat-1.2* Na-136
K-4.6 Cl-97 HCO3-27 AnGap-17
___ 10:15AM BLOOD ALT-44* AST-31 AlkPhos-108* TotBili-0.4
___ 10:15AM BLOOD Lipase-63*
___ 10:15AM BLOOD Albumin-5.0
___ 10:29AM BLOOD Lactate-2.1*
___ 06:35AM BLOOD WBC-8.0 RBC-4.40 Hgb-12.8 Hct-37.3 MCV-85
MCH-29.1 MCHC-34.3 RDW-13.4 RDWSD-41.6 Plt ___
___ 06:35AM BLOOD Glucose-161* UreaN-18 Creat-0.6 Na-134
K-4.5 Cl-99 HCO3-24 AnGap-16
CT abdomen/Pelvis
Final Report
EXAMINATION: Noncontrast CT abdomen and pelvis.
INDICATION: ___ woman with abdominal pain and
hypotension. Evaluate
for evidence of appendicitis or nephrolithiasis.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were acquired
without intravenous contrast. Non-contrast scan has several
limitations in
detecting vascular and parenchymal organ abnormalities,
including tumor
detection.Oral contrast was not administered. Coronal and
sagittal
reformations were performed and reviewed on PACS.
DOSE: 879.81 mGy-cm. DLP
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous
hypoattenuation throughout,
consistent with steatosis. There is no evidence of focal
lesions within the
limitations of an unenhanced scan. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically
absent.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions within the limitations of an unenhanced scan.
There is no
pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size. There is
no evidence
of focal renal lesions within the limitations of an unenhanced
scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no
perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber and wall thickness throughout. The colon and
rectum are within
normal limits. The appendix is not definitively seen, but there
are no
secondary signs to suggest appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus contains an appropriately
positioned IUD
within the fundus. There are multiple, small subserosal
fibroids. The
adnexae are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
There are mild degenerative changes at L5-S1.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No CT findings in the abdomen or pelvis to correlate with
patient's
symptoms. Specifically, no hydronephrosis or renal/ureteral
stone.
2. Hepatic steatosis.
CXR: no infiltrate
Brief Hospital Course:
___ with transient hypotension in ED 72hrs after starting
hydrochlorothiazide. She also experienced non specific abdominal
discomfort and nausea that are not explained by imaging and she
has reassuring exam and CT findings with no stones and no
hydronephrosis. Her volume status is now improved after 2
Liters in ED of IVF. UA initially with moderate bacteria and
large amount of leuk esterase and WBCs, but also with some
squamous cells. Repeat UA showed a few bacteria, trace leuk
esterase but this was after she had received 1 dose of
ceftriaxone. She had mild CVA tenderness on exam on day of
discharge. She endorsed increased urinary frequency overnight
on ___ night before starting HCTZ on ___. Her WBC was
elevated on admission and normalized on hospital day 2/ day of
discharge, but all cell lines also decreased, indicating that
her initial CBC may have been c/w contraction due to severe
dehydration. This is underscored by the fact that her Cr
improved from 1.2 to 0.6 with 2.5 L IVF.
Her hypotension was likely due to dehydration from HCTZ despite
inceasing her oral fluid intake. HOwever, it may have been
compounded by a UTI and as we have a UA with possible infection
with cultures pending at time of discharge, an initial
leukocytosis which has improved with fluids and after 1 dose
ceftriaxone, and flank pain that has improved with the same
treatment, we will treat empirically with a 7 day course-- 2
doses of ceftriaxone to be followed by bactrim BID x 5 days
which will not affect her QTc as do several of her home meds.
She requested ativan for nausea since she is not supposed to
take zofran in addition to her home promethazine and so she was
given a 12 pill prescription for 1 mg ativan. She has PCP ___
arranged for early next week. She was instructed to not take
HCTZ and to drink ___ L of water and gatorade every day and to
eat at least 2 full meals and discuss with her food coach as
previously scheduled on ___ to ensure that she is eating
adequately to maintain her nutrition as she recovers from
hypotension and possible infection.
#Migraine/Anxiety/PTSD/Depression
--continue home meds including atenolol, venlafaxine, abilify
Answered all her ?s and reviewed above plan with her. She will
be notified if her cultures become positive.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Sucralfate 1 gm PO TID
3. Atenolol 50 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Promethazine 25 mg PO Q8H:PRN nausea
7. Cyclobenzaprine 10 mg PO BID:PRN spasm
8. ARIPiprazole 2.5 mg PO BID
9. Gabapentin 200 mg PO BID
10. Venlafaxine XR 225 mg PO QPM
Discharge Medications:
1. ARIPiprazole 2.5 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Cyclobenzaprine 10 mg PO BID:PRN spasm
4. Gabapentin 200 mg PO BID
5. Omeprazole 40 mg PO BID
6. Promethazine 25 mg PO Q8H:PRN nausea
7. Sucralfate 1 gm PO TID
8. Venlafaxine XR 225 mg PO QPM
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO BID
start on ___ in the morning, take through evening dose on ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
11. LORazepam 1 mg PO Q12H:PRN nausea
only take as needed
RX *lorazepam [Ativan] 1 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. hypotension, likely due to hydrochlorothiazide and
2. possible UTI, pyelonephritis unlikely
Discharge Condition:
Good: ambulatory: walking. Mental status: alert and oriented,
no deficits.
Discharge Instructions:
___, you were admitted with low blood pressure and
lightheadedness, worsening nausea and were found to have signs
of being severely dehydrated. This may have been due to two
things: the new hydrochlorothiazide and you also likely had a
urinary tract infection. We do not have concrete proof of a
urinary tract infection but cultures are still pending.
Nevertheless, because of the severity of your low blood
pressure, the nausea and the pain in your flank we will treat
you empirically for a urinary tract infection. The CT did not
show signs of inflammation around the kidneys and did not show
any signs of stones. You received 2 doses of IV ceftriaxone, an
antibiotic, and should take 5 more days of Bactrim and follow up
as scheduled with your PCP next week. If your urine culture
becomes positive, we will call you at home.
Bactrim is well tolerated and does not interfere with the heart
rhythm as some other antibiotics can. You should continue to
drink at least ___ liters of water and Gatorade/ powerade each
day and should eat AT LEAST two full meals a day as nutrition is
very important for maintaining blood pressure and for healing
from an infection. To help with nausea, you are being given a
very small prescription for lorazepam/ Ativan.
Please follow up with your eating counselor as scheduled on
___.
PLEASE DO NOT TAKE HYDROCHLOROTHIAZIDE ANY LONGER
Followup Instructions:
___
|
10578633-DS-9 | 10,578,633 | 22,401,609 | DS | 9 | 2126-05-13 00:00:00 | 2126-05-13 19:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided chest and abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ year-old female with obesity s/p recent
uncomplicated laparoscopic gastric band 3 days ago on ___ who presents with left sided chest pain and dyspnea for
one day. The patient states that symptoms came on suddenly
without any clear triggers; exacerbating factors including deep
inspiration and movement of the left side. She does have a
history of asthma but denied any wheezing or asthma-like
symptoms
at the time or at present. She notes she has been diligently
using her incentive spirometer at home. She also has a history
of
anxiety disorder and noted that she felt 'panicky' during the
last 24 hours and that this may have exacerbated her symptoms.
She denied any fevers or chills, noted some nausea with her
current diet (protein shakes) but no vomiting. She denied any
leg
swelling or leg pain and has been able to ambulate frequently
with ease at home.
Review of systems was otherwise unremarkable.
ED course: given IVF, kept NPO, pain controlled with IV
medications, CTA-chest and CXR ordered.
Past Medical History:
PMH: BMI 43.2, reflux/heartburn, hypertension, hyperlipidemia,
fatty liver s/p biopsy in ___, borderline type 2 diabetes with
hemoglobin A1c of 6.1%, depression.
PSH: lap gastric banding ___
Social History:
___
Family History:
Her family history is noted for both parents living father age
___
with heart disease and obesity; mother age ___ with
hyperlipidemia, asthma and obesity; brother living age ___ with
asthma.
Physical Exam:
Upon discharge:
VS: Tm 96.8 Tc 96.8 HR 79 BP 122/74 RR ___ O2sat 98-100%RA
General:in no acute distress, non-toxic appearing.
HEENT:mucus membranes moist, nares clear, no perioral cyanosis
or nasal flaring. Trachea at midline.
CV:regular rate, rhythm. No appreciable murmurs, rubs or gallops
PULM:CTAB, good inspiratory effort
Chest:Mild tenderness, improved, to palpation and compression of
left chest
ABD:soft, obese, incisions clean, dry, intact. Resolving
erythema at infero-lateral aspect of left lower port incision.
No induration or drainage.
MSK:warm, well perfused. Compartments soft.
Neuro:alert, oriented to person, place, time.
Pertinent Results:
___ 10:40PM ___ PTT-34.1 ___
___ 10:40PM WBC-11.7* RBC-4.16* HGB-12.9 HCT-35.7* MCV-86
MCH-30.9 MCHC-36.0* RDW-13.6
___ 10:40PM NEUTS-62.8 ___ MONOS-4.1 EOS-1.9
BASOS-0.7
___ 10:40PM PLT COUNT-315
___ 10:40PM ALT(SGPT)-43* AST(SGOT)-43* ALK PHOS-79 TOT
BILI-0.4
___ 10:40PM ALBUMIN-4.5
___ 10:40PM GLUCOSE-86 UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
___ 10:46PM URINE RBC-21* WBC-4 BACTERIA-FEW YEAST-NONE
EPI-1
___ 10:46PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:46PM URINE COLOR-Yellow APPEAR-Clear SP ___
___: CXR PA/Lat:
No prior. The lungs are clear.
There is no pleural effusion or pneumothorax. Cardiomediastinal
silhouette is within normal limits. Osseous and soft tissue
structures are grossly
unremarkable noting laparoscopic band in the left upper
quadrant.
___: CTA Chest: The pulmonary arterial tree is well
opacified and no filling defect to suggest pulmonary embolism is
seen. The aorta is normal in caliber and configuration without
evidence of acute aortic syndrome.
The lungs demonstrate mild bilateral dependent atelectatic
changes. A
calcified granuloma or calcified lymph node is noted at the
right hilum.
There are subcarinal and right paraesophageal calcified lymph
nodes. The
heart and great vessels are grossly unremarkable. No evidence of
endobronchial lesion is seen. No pathologically enlarged lymph
nodes are
identified.
___: UGI: within normal limits. Band in place with no
perforation, leak or slippage.
Brief Hospital Course:
The patient was admitted to the ___ surgery service on
___ for left sided chest and abdominal pain after a recent
laparoscopic gastric band placement on ___, which was
uncomplicated. The patient initially underwent a CXR and CTA
chest to rule-out effusion, pneumonia or PE; both were
unremarkable. She was thus admitted for further observation and
for an UGI, which did not demonstrate any band slippage,
perforation or free air.
Neuro: The patient noted a reaction to Percocet elixir at home
and was switched to Dilaudid IV with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: As noted, imaging was negative for pulmonary
embolism. The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. She maintained excellent
oxygen saturations without supplementation and was ambulating
well prior to discharge without complaints of shortness of
breath. She did note left sided chest pain with movement and
increased inspiration, which was reproducible on exam,
suggesting musculoskeletal etiology.
GI/GU: The patient was initially kept NPO with IV fluids, and
given an unremarkable UGI, was re-started on her stage III diet,
which she tolerated. Intake and output were closely monitored.
ID: The patient was noted to have minimal erythema, blanching,
of her lower left port site, and was started on cephalexin for a
total 7 day course. The patient's temperature was closely
watched for signs of infection, of which she had none.
Prophylaxis: The patient received subcutaneous heparin and wore
pneumatic compression boots during this stay, and was encouraged
to get up and ambulate as early as possible.
MSK: given the likely musculoskeletal nature of the patient's
pain, she was given one dose of cyclobenzaprine with good
effect, and was discharged on a limited, low-dose course of 14
days. She noted previous history of muscle spasms with good
response from the medication.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled.
Medications on Admission:
1. oxycodone-acetaminophen ___ mg/5 mL Solution Sig: ___ MLs
PO Q4H (every 4 hours) as needed for Pain for 10 days.
Disp:*250 ML(s)* Refills:*0*
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation for 10 days.
3. venlafaxine 75 mg Capsule twice daily
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. Abilify 5 mg Tablet Sig: One (1) Tablet PO once a day: please
crush.
6. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. topiramate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
9. multivitamin with minerals Tablet Sig: One (1) Tablet PO
once a day: crushable.
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*28 Capsule(s)* Refills:*0*
3. aripiprazole 1 mg/mL Solution Sig: One (1) PO DAILY (Daily).
4. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every four (4) hours
as needed for pain for 5 days.
Disp:*40 Tablet(s)* Refills:*0*
6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation for 10 days.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
8. atenolol 50 mg Tablet Sig: Two (2) Tablet PO once a day.
9. topiramate 25 mg Tablet Sig: Three (3) Tablet PO twice a day.
10. multivitamin with minerals Tablet Sig: One (1) Tablet PO
once a day: crushable.
11. cyclobenzaprine 5 mg Tablet Sig: ___ Tablets PO twice a day
as needed for muscle spasms for 14 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided chest pain and abdominal pain with negative work-up
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for observation for your left
sided pain. You underwent several studies, including a chest
x-ray, CT scan of the chest, as well as a swallow-study, which
did not show any abnormalities, including a pulmonary embolism
or problems with your recent laparoscopic gastric band
placement.
Your pain has been well controlled, you have not needed
supplemental oxygen, and are now ready to go home.
You were noted to have minimal redness ('erythema') around your
left lower port site, and were started on Keflex, an antibiotic,
for a total 7 day course. You were also given Flexeril, a muscle
relaxant, for what appears to be muscle spasm of your left upper
back/side.
There were otherwise no changes to your medications prior to
admission.
Followup Instructions:
___
|
10578743-DS-17 | 10,578,743 | 28,855,100 | DS | 17 | 2172-07-17 00:00:00 | 2172-07-17 19:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
Right Hip Hemiarthroplasty (___)
History of Present Illness:
___ W/ PMH of IDDM, CKD (Cr 1.6), MGUS, Crohns (s/p
iliocolectomy), CAD s/p stents, CVAx2 with residual right sided
weakness who presents s/p mechanical fall. Patient states he was
standing next to his car when a dog was being walked by and
began barking aggressively at him. He was trying to get away and
fell on his hip. He denies HS/LOC. He denies any pre-syncopal
symptoms and had no preceding hip pain on that side.
Of note, he was hospitalized in ___ for an illeocectomy.
This hospitalization was complicated by pneumonia, sepsis, a fib
with rvr, and ___, with creatinine rising to 4.3 during but
eventually recovered to 1.3 upon discharge. Cr has since risen
to 1.6.
Mr. ___ is able to ambulate at baseline with a Cane. He
states he can walk ___, but stops after a block ___ to back
pain. He is able to walk up one flight of stairs without
difficulty. He denies DOE, Orthopnea, or PND.
Patient endorses slight nonproductive cough and occasional ___
edema but denies fevers, chills, sweats, nausea, Vomiting, SOB,
PND, Orthopnea, numbness, paresthesias and pain in other
extremities.
Past Medical History:
CARDIAC HISTORY:
CAD, w/ 2 VD and NSTEMI ___ with DES to major pOM1, and DES to
dOM1.
Atrial Fibrillation
OTHER PAST MEDICAL HISTORY:
- Multiple past CVA, ___ L pontine infarct, ___ L pontine
infarct, history of cerebellar infarcts, chronic L ICA occlusion
with residual R sided weakness
- HTN
- HLD
- DM II
- PVD
- Chronic Kidney Disease (baseline Cr 1.6)
- Crohns Disease - Last flare ___ per patient
- Left parotid mass resection
- Pyodermal gangrenosum.
- Hypothyroidism.
- Depression
- MGUS
PAST SURGICAL HISTORY:
- s/p open ileocecectomy secondary to stricture ___
Social History:
___
Family History:
Father - rectal cancer
Mother- DM, CAD
Sister- cancer
Sister- ___
Physical Exam:
ADMISSION PHYSICAL:
=======================
Vitals: 98.1 75 176/68 16 97% 2L Nasal Cannula
General: A&Ox3, NAD
CAM/MINICOG: Negative
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Abdomen: soft, non-distended, non-tender. Well healed surgical
scars.
Right/ Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless active/passive ROM of shoulder, elbow, wrist,
and digits
- EPL/FPL/DIO (index) fire
- Sensation intact to light touch in
axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, fingers warm and well perfused
Right Lower extremity:
- Skin intact, leg slightly shortened, externally rotated.
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and lower leg
- Pain with any ROM of hip. Full, painless active/passive ROM of
knee, and ankle
- ___ fire
- Sensation intact to light touch in
SPN/DPN/Tibial/saphenous/Sural distributions
- 1+ ___ pulses, foot warm and well perfused
DISCHARGE PHYSICAL:
=======================
Vitals: T:98 ___ 80 20 96%RA
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mildly decreased breath sounds on LLL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 1+ Pitting edema up to knee
(confirmed with ortho this is a normal finding s/p right hip
arthroplasty)
Pertinent Results:
ADMISSION LABS:
====================
___ 09:00AM BLOOD WBC-12.7* RBC-3.86* Hgb-9.9* Hct-34.1*
MCV-88 MCH-25.6* MCHC-29.0* RDW-21.1* RDWSD-65.4* Plt ___
___ 09:00AM BLOOD Neuts-82.6* Lymphs-8.0* Monos-7.3
Eos-0.9* Baso-0.6 Im ___ AbsNeut-10.45* AbsLymp-1.01*
AbsMono-0.92* AbsEos-0.11 AbsBaso-0.08
___ 09:00AM BLOOD ___ PTT-39.6* ___
___ 09:00AM BLOOD Glucose-138* UreaN-24* Creat-1.5* Na-139
K-4.3 Cl-108 HCO3-22 AnGap-13
___ 04:40AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.6
PERTINENT LABS:
====================
___ 02:20AM BLOOD CK-MB-5 cTropnT-0.18* ___
___ 08:30AM BLOOD CK-MB-4 cTropnT-0.16*
___ 01:10AM BLOOD ALT-9 AST-22 LD(LDH)-213 AlkPhos-58
TotBili-0.2
___ 02:20AM BLOOD CK(CPK)-136
DISCHARGE LABS:
====================
___ 06:20AM BLOOD WBC-17.0* RBC-3.11* Hgb-8.0* Hct-27.6*
MCV-89 MCH-25.7* MCHC-29.0* RDW-20.9* RDWSD-67.7* Plt ___
___ 06:20AM BLOOD Glucose-146* UreaN-34* Creat-1.3* Na-136
K-4.9 Cl-105 HCO3-21* AnGap-15
MICROBIOLOGY:
====================
Urine Cultures x 2 - Negative
Blood Cultures x 4 - Negative
C. Diff (___) - Negative
STUDIES:
====================
CXR ___:
IMPRESSION:
Left basilar opacity could be any combination of atelectasis,
infection, or effusion. Consider PA/lateral chest radiograph if
patient is amenable.
R HIP X-RAY ___:
IMPRESSION:
There is a a right hemiarthroplasty in place that appears well
seated. Further information can be gathered from the procedure
report.
CTA CHEST ___:
IMPRESSION:
1. Eccentric, nonocclusive filling defects in the right upper
lobe subsegmental arteries may be due to subacute or chronic
pulmonary emboli. No pulmonary emboli identified elsewhere.
Right upper lobe opacity distal to the pulmonary emboli is
concerning for pulmonary infarction, although this may represent
infection given that it appears similar to heterotogenous
opacity in the left upper lobe which is concerning for
infection.
2. Left lower lobe collapse with small to moderate left pleural
effusion. No obstructing lesion seen in the left lower lobe
bronchus.
3. Partial right lower lobe collapse with small right pleural
effusion.
4. Mild mediastinal lymphadenopathy without axillary
lymphadenopathy is likely reactive to the intrathoracic
findings. Recommend repeat chest CT after treatment of acute
issues to evaluate for resolution.
5. 11 mm left thyroid nodule could be evaluated by non-urgent
thyroid ultrasound, if clinically warranted.
BILATERAL ___ ULTRASOUND ___:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
ECHOCARDIOGRAM ___:
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The 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. Moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate mitral regurgitation with mild leaflet
thickening. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild pulmonary artery hypertension.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is increased and pulmonary
artery hypertension is now identified. However, the prior study
was of suboptimal technical quality and this may account for
some of the differences.
Foot/Ankle XRay ___:
There are mild degenerative changes with some well-defined
osteophytes off the talus vascular calcifications are noted
there is patchy osteopenia involving the distal fibula. Soft
tissue swelling is noted about the distal fifth toe. The
alignment is normal there is no fracture or dislocation.
___: Doppler of LEs
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
Brief Hospital Course:
___ W/ PMH of IDDM, CKD (Cr 1.6), CVAx2 with residual right
sided weakness who presented with a mechanical fall now s/p R
hip hemiarthroplasty. After his surgery, he was transferred to
the medicine service for a new oxygen requirement where his
course was complicated by AF with RVR.
# Hypoxia: Patient was s/p R hip hemiarthroplasty when new O2
requirement developed and was transferred to medicine service.
Most likely this was due to multiple factors including moderate
left sided pleural effusion with LLL collapse, atelectasis
possibly ___ operation, chronic upper lobe emphysematous
changes, and pneumonia. CTA also showed concern for areas of
infection and subacute or chronic pulmonary emboli. Patient
continued to have improved oxygenation with aggressive chest ___
and standing atrovent and fluticasone. He is being discharged on
Levofloxacin to complete a 10 day course given his persistent
leukocytosis. Last day is ___.
#A-fib with RVR: Has hx of afib with RVR after prior operations.
He was transferred to the MICU for a dilt gtt with stabilization
of his tachycardia and was transitioned to dilt 90 mg PO/NG QID.
Will initiate diltiazem 360 ER prior to discharge. Patient was
started on apixiban 5 mg BID for AF with RVR and
chronic/subacute PEs noted on CTA.
#s/p Mechanical Fall with displaced femoral neck fracture. Right
hip hemiarthroplasty on ___. Pain control with oxycodone 2.5-5
mg Q3H PRN. WBAT on RLE. On apixaban as above.
#CKD: (baseline 1.5) being followed by renal as outpatient.
Increased to 2.0 following contrast for CT but returned to
baseline prior to discharge.
#IDDM: Continued Lantus w/ Humalog Sliding scale while in
house.
#CAD: patient w/ 2VD s/p DES x2 in ___. Currently stable.
Continued home atorvastatin, metoprolol succinate 50 mg daily
stopped for diltiazem. Dipyridamole-Aspirin stopped.
#HTN: stable. Held home HCTZ, amlodipine. Pressures controlled
with diltiazem and lisinopril. Home antihypertensives can be
restarted as needed as an outpatient.
TRANSITIONAL ISSUES:
[ ] f/u CBC in 1 week (___) to ensure resolution of
leukocytosis
[ ] f/u with ortho for post-op management
[ ] rate and BP control per outpatient cardiology and PCP. Note
that beta blocker and HCTZ were held once adequate rate control
was achieved with diltiazem and BP control with lisinopril.
[ ] note that apixiban was started for AFib and chronic/subacute
PE, Dipyridamole-Aspirin was stopped
[ ] Consider repeat CT chest to ensure resolution of LLL
collapse and mediastinal LAD. No obstructing lesion or mass were
seen on CTA here. Should have IP (___) follow up in ___ weeks
(___)
[ ] Consider thyroid ultrasound to evaluate thyroid nodule
incidentally noted on CTA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Atorvastatin 20 mg PO QPM
4. Fenofibrate 134 mg PO DAILY
5. Gabapentin 100 mg PO BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Aspart (NovoLog) 5 Units Breakfast
Aspart (NovoLog) 6 Units Dinner
Glargine 8 Units Bedtime
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. TraMADOL (Ultram) 100 mg PO BID
12. Venlafaxine 75 mg PO BID
13. Zolpidem Tartrate 5 mg PO QHS insomnia
14. Aspirin 81 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. LOPERamide 2 mg PO TID:PRN diarrhea
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Gabapentin 100 mg PO BID
3. Aspart (NovoLog) 5 Units Breakfast
Aspart (NovoLog) 6 Units Dinner
Glargine 8 Units Bedtime
4. Levothyroxine Sodium 125 mcg PO 6X/WEEK (___)
5. Multivitamins 1 TAB PO DAILY
6. Venlafaxine 75 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 Puffs Inhaled
twice a day Disp #*1 Inhaler Refills:*0
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*24 Tablet Refills:*0
11. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
12. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
13. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
Capsule(s) Inhaled Daily Disp #*30 Capsule Refills:*0
14. Lisinopril 20 mg PO DAILY
15. Levofloxacin 500 mg PO Q24H CAP Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
fall with right femoral neck fracture
hypoxemia
atrial fibrillation with rapid ventricular response
pneumonia
SECONDARY:
acute kidney injury on chronic kidney disease
insulin dependent diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a fall where you
fractured your right hip. You had surgery to repair the hip, but
after surgery we noticed your oxygen level was low. We think
this is because part of your left lung was collapsed, which can
happen when mucous gets stuck in your lungs. We did a CT scan of
your chest to look for any other causes of your low oxygen and
it showed that you may have a pneumonia so we started you . To
help re-expand your lung, we did chest physical therapy and
breathing exercises, which you should continue.
You also developed a rapid heart rate called atrial fibrillation
or A-Fib. This type of heart rate can put you at risk for having
a stroke, so we started you on a blood thinner called apixaban
and a medicine called diltiazem to slow your heart rate.
You will be discharged to a rehab facility to continue to regain
your strength. After you are discharged from there, you will
follow up with your primary care physician. All of your
medication changes are detailed in your discharge medication
list. You should review this carefully and bring it with you to
upcoming appointments.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10578807-DS-25 | 10,578,807 | 26,264,376 | DS | 25 | 2211-04-10 00:00:00 | 2211-04-10 19:00:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Citalopram / codeine
Attending: ___
Chief Complaint:
Bleeding per rectum | Abdominal Pain
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
Ms. ___ is a ___ female with history of disseminated
tuberculosis (treated ___ years ago), seizure activity due to CNS
TB, hx of ischemic colitis (unclear etiology), anxiety, who now
presents with 1 day of bright red blood per rectum.
She was seen in the ED yesterday for left lower quadrant
abdominal pain and had a CT abdomen pelvis that was negative.
She
was discharged from the ED after feeling better. Today she
noticed blood in her stool and a significant amount of blood
after a second bowel movement. It was bright red blood with some
clots. This was associated with LLQ crampy pain. This prompted
presentation to urgent care where a rectal exam was performed
and
she was referred to the ED. She denies fever, chills, nausea,
vomiting. She has a history of ischemic colitis about ___ years
ago, unclear what precipitated that event, and she states that
this presentation is very similar to that one.
In the ED, her vital signs are stable. Exam is notable for left
lower quadrant abdominal tenderness. Labs are notable for an
unremarkable BMP and CBC, hemoglobin 11.2 which is baseline. She
is evaluated by GI who recommended checking C. difficile and
stool culture and observation, as she continued to have bright
red blood per rectum she was admitted with plan for colonoscopy
on ___.
On the floor, she reports feeling ok. Has mild LLQ pain but
denies nausea, loss of appetite, vomiting.
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:
SEIZURES
ANXIETY
DISSEMINATED TB - EXTRAPULM DZ
PSORIASIS
*S/P GLOMANGIOPERICYTOMA REMOVED FROM RT FOREARM. BENIGN. ___. ___
BACK PAIN
CELIAC DISEASE
S/P TAH/BSO
SKIN NODULE
SEBORRHEIC KERATOSIS
H/O THYROID CANCER s/p thyroidectomy
Cervical Myelopathy with paraparesis
Social History:
___
Family History:
Mother - TB (pleural effusions, urinary retention, tuberculoma,
myelodysplasia)
Father - ___ Disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
Vital Signs: ___ Temp: 98.4 PO BP: 137/69 L Sitting
HR: 79 RR: 16 O2 sat: 93% O2 delivery: RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, 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, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAMINATION:
===============================
Temp: 97.6 (Tm 97.9), BP: 108/64 (102-112/57-68), HR: 64
(64-73), RR: 18 (___), O2 sat: 95% (94-97), O2 delivery: RA
General: pleasant, interactive, not in pain
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, left abdominal tenderness to deep palpation,
non-distended, 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, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:25PM BLOOD WBC-9.6 RBC-4.06 Hgb-11.8 Hct-35.6 MCV-88
MCH-29.1 MCHC-33.1 RDW-12.2 RDWSD-39.6 Plt ___
___ 11:25PM BLOOD ___ PTT-28.0 ___
___ 11:25PM BLOOD Glucose-186* UreaN-19 Creat-0.9 Na-137
K-3.5 Cl-98 HCO3-22 AnGap-17
___ 11:25PM BLOOD ALT-18 AST-19 AlkPhos-88 TotBili-0.2
___ 11:25PM BLOOD Albumin-4.7 Calcium-10.4* Phos-4.5 Mg-2.3
___ 11:30PM BLOOD Lactate-2.3*
___ 01:06AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
DISCHARGE LABS:
===============
___ 06:08AM BLOOD WBC-7.1 RBC-3.92 Hgb-11.2 Hct-35.1 MCV-90
MCH-28.6 MCHC-31.9* RDW-12.6 RDWSD-41.0 Plt ___
___ 04:50AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-143 K-3.6
Cl-109* HCO3-23 AnGap-11
MICROBIOLOGY:
==============
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
REPORTS:
========
Colonoscopy - ___
There was patchy erythema, friability, purplish erosions seen
starting distal sigmoid colon up to mid descending colon. The
rest of colon including 10 cm of terminal ileum appeared normal.
CT A/P with contrast - ___
LOWER CHEST: With the exception of bibasilar atelectasis, the
lung bases are clear. No pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. Focus of calcification in the
gallbladder
walL fundus most likely reflects adenomyomatosis.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: 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 not definitely
seen.
Scattered surgical clips are re-demonstrated throughout the
abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not seen. No adnexal mass.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Trace
atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Unchanged sclerotic focus in the right ilium.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
No acute findings in the abdomen or pelvis to explain the
patient's left lower
quadrant pain.
Brief Hospital Course:
Ms. ___ is a ___ female with history of treated
disseminated tuberculosis (treated ___ years ago), seizure
activity due to CNS TB, hx of ischemic colitis (unclear etiology
in ___, anxiety, who now presents with bright red blood per
rectum and found to have ischemic colitis on colonoscopy.
DISCHARGE H/H: ___
DISCHARGE Cr: 0.8
ADVANCE CARE PLANNING
- Surrogate/emergency contact: ___ cell ___,
home ___
- Code Status: DNR/DNI
TRANSITIONAL ISSUES:
====================
[] If abdominal pain recurs or if bleeding per rectum, patient
was advised to come back to the ED for possible surgical
evaluation.
ACUTE ISSUES
=============
# BRBPR:
# Ischemic colitis:
Patient present with BRBPR and abdominal pain similar to prior
pain experienced in ___ when she had ischemic colitis. CT A/P
from ___ showed patent vasculature with good arterial phase.
Per radiology, CTA would add info as ___ branches are small.
Colonoscopy from ___ showed mucosal involvement upto the mid
right colon with patchy erythema and friable mucosa consistent
with ischemic colitis. It is a bit odd as this is the same area
involved in ___, making a thromboembolic phenomena less common
but still possible. There might be a stricture/stenosis in one
of the braches of the ___. During her hospital stay, H/H was
stable 11.2/35.1.
CHRONIC ISSUES
===============
# Seizure
Secondary to disseminated TB (treatment completed).
-continue home Keppra and lamotrigine
# Anxiety
-continue home lorazepam
# Hypothyroidism
-continue home levothyroxine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 500 mg PO BID
2. LORazepam 0.5 mg PO QAM anxiety
3. Levothyroxine Sodium 88 mcg PO DAILY
4. LamoTRIgine 200 mg PO BID
Discharge Medications:
1. LamoTRIgine 200 mg PO BID
2. LevETIRAcetam 500 mg PO BID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. LORazepam 0.5 mg PO QAM anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Ischemic colitis
SECONDARY DIAGNOSES:
====================
# Seizure
# Anxiety
# Hypothyroidism
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 came to the hospital because you had abdominal pain and
bloody stool.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent colonoscopy, which showed evidence of ischemic
colitis.
- You were given IV fluids to maintain good hydration.
- Your abdominal pain improved. No did not experience another
episode of bloody bowel movement. You also tolerated food intake
without pain.
- You were ready to leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience increased abdominal pain, fever, dizziness
or bloody bowel movement, please call your primary care doctor
or go to the emergency department immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10578880-DS-8 | 10,578,880 | 22,062,774 | DS | 8 | 2129-09-11 00:00:00 | 2129-09-15 10:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial pain
Major Surgical or Invasive Procedure:
ORIF right PS fracture, CRMMF Left subcondylar fracture
History of Present Illness:
This patient is a ___ year old male who complains of
MANDIBLE FX. Patient transferred from OSH with open mandible
fx. Mixed martial fighter got hit in the face. Got morphine
at OSH. Complains of jaw pain, headache. Denies neck pain.
Denies chest pain or shortness of breath. Denies abdominal
pain. Given ampicillin at OSH.
Timing: Sudden Onset
Past Medical History:
mandible fx
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION
Temp: 98.4 HR: 56 BP: 144/67 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Appears uncomfortable
HEENT: Malocclusion of jaw, tender palpation over the
medial mandible, Pupils equal, round and reactive to light,
Extraocular muscles intact
No C-spine tenderness
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Skin: Warm and dry
Neuro: Strength equal upper and lower extremities
Supplements
Physical examination upon discharge: ___:
vital signs: 97.6, HR=63, BP=136/82, RR=18, 97% room air
General: Sitting comfortably in bed, NAD
HEENT: Jaw wired
CV: ns1, s2, -s3, -s4, no murmurs
LUNGS: clear, no adventitious
ABDOMEN: soft, non-tender, no masses
EXT: no calf tenderness bil. no pedal edema bil.
NEURO: alert and oriented x 3, speech mumbled related to jaw
wiring
Pertinent Results:
___ 06:50AM BLOOD WBC-12.2* RBC-4.65 Hgb-14.8 Hct-43.1
MCV-93 MCH-31.9 MCHC-34.4 RDW-11.7 Plt ___
___:50AM BLOOD Neuts-80.9* Lymphs-11.2* Monos-7.2
Eos-0.3 Baso-0.5
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-25.3 ___
___ 06:50AM BLOOD Glucose-101* UreaN-16 Creat-1.4* Na-136
K-4.0 Cl-103 HCO3-24 AnGap-13
___: cat scan of the head:
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical
spine.
3. Non-displaced fracture at the left ramus of the mandible is
fully assessed
on the CT facial bones performed earlier the same day.
___: cat scan of the c-spine:
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical
spine.
3. Non-displaced fracture at the left ramus of the mandible is
fully assessed
on the CT facial bones performed earlier the same day
___: cat scan of the head:
IMPRESSION:
1. No acute intracranial injury.
2. No acute fracture or traumatic malalignment of the cervical
spine.
3. Non-displaced fracture at the left ramus of the mandible is
fully assessed on the CT facial bones performed earlier the same
day.
___: Sinus films:
IMPRESSION:
1. Mildly displaced obliquely oriented fracture through the
right mental
tubercle of the mandible extending between the right central and
lateral
incisors with 5-mm anterior displacement and 3-mm overriding of
the right
fracture fragment.
2. Non-displaced fracture through the left ramus of the
mandible extending to the coronoid process.
3. No additional facial bone fractures.
Brief Hospital Course:
___ year old gentleman admitted to the hospital after being
punched in the face. He was reported to have sustained an
isolated mandible fracture. He was transferred here for further
management. Upon admission, he was made NPO, given intravenous
fluids, and underwent additional imaging. On cat scan imaging
of the head he was reported to have no acute intra-cranial
injury. C-spine imaging showed no mal-alignment of the spine.
Because of his injury, he was evaluated by the Oral Maxillary
service who recommended surgery. The patient was taken to the
operating room on HD #2 where he underwent an open reduction
internal fixation of right parasymphysis fracture and a closed
reduction maximum mandibular fixation of the left subcondylar
fracture. The operative course was stable with a 50cc blood
loss ( please see operative note). The patient was extubated
after the procedure and monitored in the recovery. His
post-operative course has been stable. He has been afebrile and
his pain has been controlled with oral analgesia. He has resumed
a full liquid diet withiout any difficulty in swallowing. He
has been instructed to continue antiobiotic coverage for 1 week
and peridex rinses for 2 weeks. He will follow- up with ___
surgeons in ___. A copy of the discharge summary and
operative note were given to the patient at discharge.
Medications on Admission:
none
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate [Peridex] 0.12 % Swish and spit 15mL
Twice a day Disp #*500 Milliliter Refills:*0
RX *chlorhexidine gluconate [Peridex] 0.12 % Mouth rinse twice a
day Disp #*1 Bottle Refills:*0
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 250 mg/5 mL 10 mL by mouth Four times a day Disp
#*300 Milliliter Refills:*0
RX *cephalexin 250 mg/5 mL 280 Suspension for Reconstitution(s)
by mouth every six (6) hours Disp #*1 Bottle Refills:*0
3. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ cc
by mouth every four (4) hours Disp #*400 Milliliter Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose stool
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Mandible Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgery service after
suffering a jaw fracture in order the Oral and Maxofacial
Surgery (OMFS) could repair your jaw. They left the following
instructions for you:
1. Take antibiotics for 1 week
2. Wash your mouth with Peridex 2x a day for 2 weeks
3. Please review jaw instructions placed in your chart.
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Showering: You may shower ___ days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick to the braces and can cause gum disease and damage teeth.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better. If your jaws are wired shut with elastics and you
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If you feel that you cannot safely expel the vomitus in
this manner, you can cut elastics/wires and open your mouth.
Inform our office immediately if you elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.
___ Instructions: If you have had a bone ___ or soft tissue
___ procedure, the site where the ___ was taken from (rib,
head, mouth, skin, clavicle, hip etc) may require additional
precautions. Depending on the site of the ___ harvest, your
surgeon will instruct you regarding specific instructions for
the care of that area. If you had a bone ___ taken from your
hip, we encourage you to ambulate on the day of surgery with
assistance. It is important to start slowly and hold onto stable
structures while walking. As you progressively increase your
ambulation, the discomfort will gradually diminish. If you have
any problems with urination or with bowel movements, call our
office immediately.
Elastics: Depending on the type of surgery, you may have
elastics and/or wires placed on your braces. Before discharge
from the hospital, the doctor ___ instruct you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.
Followup Instructions:
___
|
10579175-DS-9 | 10,579,175 | 28,110,821 | DS | 9 | 2123-05-07 00:00:00 | 2123-05-07 13:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old women who was diagnosed with
bulbar-predominant ALS in ___ in the setting of progressive
speech, swallowing and gait difficulty over the last ___ years who
is presenting from home with respiratory issues.
History was obtained with the help of Mrs. ___, who also lives with her. At this time, Mrs. ___
is extremely dysarthric, but she does communicate effectively
with writing on a board.
He states that for the last couple days there has been an
increased caregiver burden associated with her respiratory care.
They just started using a cough assist machine for the last
couple of days, but it has not been very effective. He denies
any
large mucous plugs or heavy secretions. It seems like the only
thing that has provided relief is supplemental oxygen, but it is
not clear that she was ever hypoxemic. No fevers. No obvious
aspiration event. No sick contacts.
Patient was actually scheduled to have a PEG tube placed on the
day of admission, but this was cancelled in light of the
presentation.
At the moment the patient is comfortable and in no respiratory
distress, stating "I just have to use the bathroom".
In the ED, initial VS were: 96.3 82 130/80 22 100% 2L NC
Exam notable for: NIF -40
ECG: TWI in III and VI
Labs showed: unremarkable
Imaging showed: Patchy atelectasis in the lung bases.
Consults: Neuro
Patient received: LR 100/hr
Transfer VS were: 97.8 67 149/64 20 97% 1L NC
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Hypertension
Macular degeneration
Hearing loss
Social History:
___
Family History:
No family history neurologic disease
Physical Exam:
ADMISSION PHYSICAL
==================
VS: 98.2 152/73 67 20 98 Ra
Gen: alert to name, place, date. Communicates with writing. No
resp distress
Lungs: minimal anterior rhonchi that clear with cough
CV: RRR. S1S2, no m/r/g
Abd: soft, NTND
Neuro: very dysarthric, ___ strength in major muscle groups of
arms and legs
DISCHARGE PHYSICAL
==================
GENERAL: Elderly female, NAD.
HEAD: NC/AT.
NECK: Supple, no JVP.
CARDIAC: S1S2 w/o m/r/g.
RESPIRATORY: CTABL.
ABDOMEN: Soft, NT, +BS. PEG site clean, dry, intact.
EXTREMITIES: Warm, no edema.
Pertinent Results:
ADMISSION LABS
==============
___ 05:35PM BLOOD WBC-7.4 RBC-3.89* Hgb-11.3 Hct-35.3
MCV-91 MCH-29.0 MCHC-32.0 RDW-13.2 RDWSD-43.6 Plt ___
___ 05:35PM BLOOD Neuts-64.0 ___ Monos-7.5 Eos-3.2
Baso-0.5 Im ___ AbsNeut-4.75 AbsLymp-1.81 AbsMono-0.56
AbsEos-0.24 AbsBaso-0.04
___ 05:35PM BLOOD Glucose-98 UreaN-19 Creat-0.7 Na-137
K-4.6 Cl-101 HCO3-26 AnGap-10
___ 06:54AM BLOOD Calcium-10.2 Phos-2.9 Mg-2.3
___ 05:35PM BLOOD cTropnT-<0.01
___ 05:41PM BLOOD Lactate-1.1
MICRO
=====
Blood Culture ___ x1: Pending - No Growth to Date
STUDIES
=======
CXR PA and LAT ___
Patchy atelectasis in the lung bases. No focal consolidation to
suggest
pneumonia.
CT A/P:
IMPRESSION:
1. Percutaneous gastrostomy tube in situ which appears
appropriately
positioned within the stomach. Patient was unable to tolerate
further
scanning, therefore no oral contrast was administered via the
percutaneous
gastrostomy tube.
2. Small volume pneumoperitoneum, likely within normal limits
post insertion
of percutaneous gastrostomy tube.
3. Marked fecal loading of the rectum, with equivocal areas of
mural
thickening and perirectal fat stranding which may be suggestive
of early
stercoral colitis. Consider disimpaction.
4. Mild apparent thickening of the endometrium, measuring up to
10 mm.
RECOMMENDATION(S): Follow-up with non urgent dedicated
gynecologic ultrasound is recommended.
DISCHARGE LABS
==============
___ 05:30AM BLOOD WBC-9.2 RBC-3.74* Hgb-11.0* Hct-34.4
MCV-92 MCH-29.4 MCHC-32.0 RDW-13.1 RDWSD-43.8 Plt ___
___ 05:30AM BLOOD Glucose-94 UreaN-19 Creat-0.8 Na-137
K-4.6 Cl-95* HCO3-27 AnGap-15
Brief Hospital Course:
SUMMARY:
=========
Ms. ___ is an ___ w/ bulbar-predominant ALS
(diagnosed ___, HTN, insomnia, & depression, presenting w/
respiratory distress.
ISSUES ADDRESSED:
=================
# Dyspnea
# Bulbar-predominant ALS
There was no evidence of pneumonia, aspiration, or ACS on
laboratory testing, chest x-ray, and EKG. Patient w/ known ALS &
cause of dyspnea (w/ no noted hypoxia) consistent w/ respiratory
muscle weakness due to ALS. Patient was maintained on nasal
cannula with supplemental O2 for comfort. The patient's
outpatient ALS Neurologist recommended BiPAP for further comfort
although the patient did not want to trial this in the hospital.
She was maintained on hyoscyamine for secretion management. She
had no hypoxia or other respiratory concerns throughout
hospitalization.
# Goals of Care
A family meeting was arranged in conjunction with the primary
team, the patient, the patients daughter/HCP (___) and the
patient's outpatient ALS Neurology team. The patient and her
daughter understood that the patient's illness was terminal.
They were also aware of progressive nature of ALS and understood
that she may be best served at an extended care facility. The
patient confirmed that she was DNAR/DNI during this
conversation. She stated that noninvasive ventilation such as
BiPAP would be okay with her moving forward. Patient also
preferred to continue eating as she derives pleasure from it.
She and daughter were acutely aware of aspiration risk but
prefer to continue dysphagia diet. A MOLST form was filled
signed and placed in the patient's chart.
# Nutrition:
Patient underwent successful PEG tube placement ___. On ___ w/
initiation of tube feeds the patient complained of acute,
diffuse abdominal pain ___ hours after tube feed initiation. A
CT of the abdomen showed PEG in situ which appeared
appropriately positioned within the stomach. There was also
small volume pneumoperitoneum within normal limits post
insertion of the PEG tube. Her abdominal pain was felt to be
related to constipation and after bowel movements she had no
further abdominal pain. She tolerated tube feeds at goal rates
the remainder of her hospitalization.
# Constipation:
Patient with known constipation at baseline related to ALS &
immobility. On hospital day 5 she developed acute, diffuse
abdominal pain with initiation of tube feeds (see above). CT of
the abdomen revealed marked fecal loading of the rectum, with
equivocal areas of mural thickening and perirectal fat stranding
which may be suggestive of early stercoral colitis. She
underwent successful manual disimpaction ___ with increase in
bowel regimen. She had a successful bowel movement and will be
maintained on aggressive bowel regimen given propensity for
constipation. (Polyethylene Glycol 17 g PO/NG BID + bisacodyl PR
PRN + senna 8.6 mg PO/NG BID)
# Hypertension
Patient was continued on home dose of metoprolol.
# Insomnia
The patient was continued on home trazodone.
# Pain
The patient was continued on home tramadol.
# Depression
The patient was continued on her home sertraline.
TRANSITIONAL ISSUES
===================
[] Continue aggressive bowel regimen as prescribed. If the
patient does not have a bowel movement every ___ days her bowel
regimen should be escalated as she is at risk for fecal
impaction.
[] Patient communicates via writing board so keep encouraging
this use!
[] Patient can use non-invasive ventilation for respiratory
support but is DNR/DNI. She is not currently interested in
non-invasive ventilation.
#CODE: DNR/DNI (confirmed)
#HCP: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. TraZODone 75 mg PO QHS
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
4. Celecoxib 100 mg oral DAILY
5. Sertraline 100 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO QHS
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation failing to
resolve with Miralax
Give if failure to have a bowel movement with polyethylene
glycol and senna.
2. Hyoscyamine 0.125 mg SL QID
3. Polyethylene Glycol 17 g PO BID
4. Senna 8.6 mg PO BID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Metoprolol Succinate XL 25 mg PO QHS
8. Sertraline 100 mg PO DAILY
9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
10. TraZODone 75 mg PO QHS
11. HELD- Docusate Sodium 100 mg PO BID This medication was
held. Do not restart Docusate Sodium until instructed by your
physician.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Bulbar predominant ALS
Respiratory distress
Secondary Diagnoses
===================
Hypertension
Constipation
Insomnia
Chronic pain
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital!
WHY WERE YOU ADMITTED?
-You came to the hospital because you had difficulty breathing.
WHAT HAPPENED WHEN YOU WERE HERE?
-You were evaluated with chest x-ray that did not show any
infection or cause of your trouble breathing.
-Your trouble breathing is probably related to your ALS.
-You had a goals of care conversation alongside your daughter
___, the Neurologist, and us to decide that you woul not want
to be resuscitated or intubated and would prefer to continue
eating because it is a pleasurable activity with the
understanding that there is a risk that you may get food into
your lungs.
-We had a feeding tube placed in your stomach to help you with
nutrition.
-You became very constipated and needed help going to the
bathroom.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Please continue taking all of your medications as prescribed.
-Keep all of your appointments as scheduled.
-Keep smiling :)
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10579198-DS-10 | 10,579,198 | 25,906,148 | DS | 10 | 2190-02-23 00:00:00 | 2190-02-23 20:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old woman with a history of Stage IV bladder cancer, who
most recently received C2D1 of carboplatin/gemcitabine on
___ presenting with diarrhea, UTI, and AMS. On ___, patient
had low grade temp 100.0 in addition to diarrhea and poor oral
intake over the course of the evening. She was referred to the
emergency department where she was found to have leukocytosis to
13.5 and UTI. Patient's daughter also notes that patient was
saturating low on room air and there was question of pna on CXR.
She was discharged on a 7 day course of levofloxacin. Daughter
notes that levofloxacin was changed to ?ciprofloxacin by
pharmacy because of interaction with another medication.
Patient had some diarrhea after her first cycle of chemotherapy.
She had mild diarrhea on ___ and ___. Last night, she had
worsening diarrhea. She also noted associated lower abdominal
pain and intermittent chills. It is difficult to quantify how
much diarrhea since she has a diaper which she has been
staining. Review of systems was negative for cough, shortness of
breath, dysuria. She denies any altered mental status.
Her daughters reported ongoing agitation after discharge. Of
note, patient's daughter had contacted outpatient oncologist on
___ worried that patient was having personality changes. They
deferred on workup temporarily because patient's husband had
just died and the wake/funeral was on ___. Unfortunately,
patient missed her husband's funeral today because had to come
to the hospital.
Patient is currently on chemotherapy with last treatment last
___ with gemcitabine. Patient is next due for chemotherapy
on ___.
In ED/Clinic, initial vitals were: Pain ___ T98.3 HR77
BP116/50 RR18 95% RA
Exam was significant for no acute neurological change. Patient
was awake and alert but c/o abd pain with poor appetite and
malaise.
Labs were significant for wbc 42, K 3.1, all other labs are at
baseline.
C diff stool assay was sent. U/a is unchanged from prior with no
urine culture obtained at prior ED visit.
Patient was given ceftriaxone for UTI.
Patient underwent head CT for which metastatic disease has not
been ruled out.
Final vitals prior to transfer were Pain ___ 99.0 80 121/62 16
97%
Review of Systems:
(+) Per HPI
Patient has had left lower extremity swelling for the last few
motnhs. She has had 2 prior LENIs which have been negative for a
DVT.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Stage IV high-grade urothelial carcinoma of the bladder with
squamous differentiation
--Bladder cancer (transitional cell carcinoma of bladder) in
___ s/p BCG therapy and fulgration
--___: routine cystoscopy by Dr. ___ with cystoscopy
showed abnormal areas consistent with TCC, red patches, and a
small papillary lesion posteriorly and on the right wall of the
bladder - diagnosed with UTI
--Left leg swelling in the interim: ___ negative X 2
--Urinary incontinence
--___: ___ noted (Cr 0.7 to 2.1)- CT a/p showed bilateral
UVJ obstruction and a bladder tumor measuring 7.5 x 6.8
x 2.4 cm probably extending beyond the posterior bladder wall to
involve the vaginal cuff. There was also aggregated external
iliac adenopathy, left greater than right, as well as
paraaortic,
aortocaval, and retroperitoneal lymph nodes
--___: Presented with new hematuria and left leg
swelling who was found to have urinary obstruction and ___ from
bladder tumor: right ureteral stent was placed. Left stent could
not be inserted due to obstruction by tumor. Cr improved from
peak 3.6 to 1.5. CT scan showed UVJ obstruction and biltaeral
hydronephrosis with worsening renal fx from 0.9 to 3.2
Continues to have urinary incontinence and urine clots.
--Patient declined fulgration for multiple reasons including
anticoagulation with coumadin and care responsbilities for her
husband
--Memory and behavior issues since diagnosis
--Radiation is not thought to be a useful treatment at this time
--___: C1D1 Carboplatin/gemcitabine
--___: C2D1 Carboplatin/gemcitabine
PAST MEDICAL HISTORY:
--Atrial fibrillation, initially noted in ___ prompting
admission to ___ with volume overload, s/p
cardioversion with amiodarone on board in ___
--Heart failure with preserved EF
--Hypertension
--COPD
--s/p hysterectomy
--CCY
--GI bleed ___- warfarin briefly stopped
--Diet controlled Type II diabetes
--Colonic stricture
--Macular degeneration
SURGICAL HISTORY: Total abdominal hysterectomy and BSO in ___,
and cholecystectomy at ___ in ___.
Social History:
___
Family History:
Father deceased in his ___ of prostate cancer.
Mother died at the age of ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:98.4 BP:126/50 HR: 85 RR:24 02 sat:92%RA
GENERAL: oriented X 3, elderly female sitting up in bed, nad
CARDIAC: rrr, no m/r/g, loud S1
LUNG: ctab except mild crackles in right lower base
ABDOMEN: soft, nondistended, normoactive bowel sounds, no
guarding, mild tenderness to palpation worse in the right lower
quadrant
EXTREMITIES: 2+ pitting edema in LLE extending halfway up calf,
1+ pitting edema in RLE to shins; no overlying erythema
PULSES: 2+ ___
NEURO: CNII-XII intact, sensation and motor strength grossly
intact throughout
SKIN: no rashes observed on limited exam
BACK: no CVA tenderness
DISCHARGE PHYSICAL EXAM
VS: Tm 97.6, Tc 97.5, 140/60 (130-140/42-60), 60, 18, 96% RA
I/O: 170/inc, 2BM
GENERAL: comfortable in NAD
HEENT: sclera anicteric MMM
CARDIAC: rrr, no m/r/g
LUNG: ctab bilaterally
ABDOMEN: soft, normoactive bowel sounds, distended, NTTP,
typanitic
EXTREMITIES: b/l ___ elevated and in teds
NEURO: moving all extremities
SKIN: no rashes observed on limited exam
Pertinent Results:
ADMISSION LABS
___ 11:45AM BLOOD WBC-42.4*# RBC-2.72* Hgb-8.8* Hct-26.4*
MCV-97 MCH-32.4* MCHC-33.4 RDW-12.7 Plt ___
___ 11:45AM BLOOD Neuts-96.8* Lymphs-1.4* Monos-1.3*
Eos-0.4 Baso-0.1
___ 11:45AM BLOOD Plt ___
___ 11:45AM BLOOD Glucose-123* UreaN-18 Creat-1.2* Na-128*
K-3.1* Cl-93* HCO3-21* AnGap-17
___ 11:45AM BLOOD ALT-10 AST-16 AlkPhos-121* TotBili-0.2
___ 11:45AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.5 Mg-1.8
___ 11:52AM BLOOD Lactate-1.4
___ 06:09PM BLOOD Lactate-1.3
PERTINENT LABS (___ trend)
___ 07:45AM BLOOD WBC-58.1*
___ 08:20AM BLOOD WBC-76.9*
___ 06:55AM BLOOD WBC-48.7*
___ 06:06AM BLOOD WBC-29.0*
___ 06:35AM BLOOD WBC-17.3*
___ 06:35AM BLOOD WBC-11.2*
___ 07:05AM BLOOD WBC-8.1
DISCHARGE LABS
___ 07:00AM BLOOD WBC-8.5 RBC-3.06* Hgb-9.7* Hct-30.6*
MCV-100* MCH-31.6 MCHC-31.6 RDW-14.7 Plt ___
___ 07:00AM BLOOD Glucose-118* UreaN-27* Creat-1.4* Na-138
K-3.7 Cl-108 HCO3-19* AnGap-15
URINE
___ 12:35PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 12:35PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:35PM URINE RBC-99* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 12:35PM URINE Hours-RANDOM Na-24 K-18 Cl-22
___ 12:35PM URINE Osmolal-322
MICROBIOLOGY
___ C diff
___ 12:40 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ 1010AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ Blood culture No growth
___ 12:05 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
VANCOMYCIN Sensitivity testing confirmed by Etest.
LINEZOLID Sensitivity testing per ___
___.
Daptomycin = 0.75 MCG/ML, Daptomycin Sensitivity
testing performed
by Etest.
ENTEROCOCCUS SP.. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = 3.0 MCG/ML, Daptomycin Sensitivity testing
performed
by Etest. VANCOMYCIN Sensitivity testing confirmed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 16 R =>32 R
DAPTOMYCIN------------ S S
LINEZOLID------------- 2 S 2 S
PENICILLIN G---------- 16 R =>64 R
VANCOMYCIN------------ <=0.5 S =>32 R
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS.
Reported to and read back by ___ ___ 11:24AM
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS.
___ Blood cx no growth
___ Blood cx no growth
___ Blood cx pending at discharge
PERTINENT IMAGING
___ CT head w/o contrast
Area of hypodensity in the right temporoparietal region, which
most likely
represents an old infarct with area of cortically based
hyperdensity that
likely represents pseudolaminar necrosis however MR is
recommended for further
evaluation for possibility of metastatic disease.
___ KUB
No evidence of toxic megacolon or free air.
___ CXR
1. Decreased bilateral lower lung opacities, likely atelectasis,
although
infection is not excluded.
2. Mild interstitial pulmonary edema, unchanged.
3. Unchanged mild cardiomegaly.
4. Unchanged small bilateral pleural effusions.
___ MR head w/o contrast
1. Decreased bilateral lower lung opacities, likely atelectasis,
although
infection is not excluded.
2. Mild interstitial pulmonary edema, unchanged.
3. Unchanged mild cardiomegaly.
4. Unchanged small bilateral pleural effusions.
___ CT a/p with contrast
1. Small to moderate bilateral pleural effusions and bilateral
lower lobe
atelectasis.
2. Left hydroureteronephrosis. The left ureter is dilated to
the level of the
ureterovesicular junction. The degree of hydroureteronephrosis
appears
similar compared to the outside hospital CT of ___.
The cause is
presumably the patient's known bladder cancer. The cancer is
difficult to
evaluate due to underdistention of the bladder, however,
enhancement in the
right greater than left posterior wall of the bladder is
identified.
Abdominal and aggregated bilateral inguinal lymphadenopathy is
again
identified.
3. Pancolonic mucosal hyper enhancement, wall thickening and
surrounding fat
stranding is concerning for colitis of infectious, ischemic or
inflammatory
etiology. There is moderate volume ascites. No free air or
drainable fluid
collections identified.
Brief Hospital Course:
Ms. ___ is an ___ year-old woman with a history of Stage IV
bladder cancer, who most recently received C2D1 of
carboplatin/gemcitabine on ___ presented with diarrhea, UTI,
and altered mental status found to have Clostridium difficile
colitis and vancomycin-resistant enterococcal bacteremia.
ACTIVE DIAGNOSES:
#. C diff colitis. Patent was found to have a positive C diff
stool assay for which she was started on po vanc. She had
recently been treated with a course of flouroquinolones in the
setting of UTI. Given rising leukocytosis with persistent
abdominal pain despite antibiotics, patient was also started on
IV flagyl and PR vancomycin. Abdominal pain and leukocytosis
improved with these antibiotics. Imaging showed no evidence of
perforation and only showed colonic mucosal hyper enhancement,
wall thickening and surrounding fat stranding concerning for
colitis and moderate volume ascites. The surgical team was
consulted but surgical intervention was not indicated. Patient
was discharged home on po vancomycin to be taken for a total 14
days after completion of linezolid (last dose: ___.
# VRE bacteremia: Likely secondary to microperforation in the
setting of colitis and recent chemotherapy. Patient was started
on daptomycin and narrowed to linezolid (last dose ___. TTE was
not performed since ID did not recommend it.
#. UTI: Patient had a positive urinalysis and mild abdominal
pain. Her abdominal pain persisted after 4 days of levofloxacin,
so treatment was switched to ceftriaxone. She completed a 7 day
course. There was no evidence of perinephric abscess in the
setting of obstruction of the left ureter on imaging. Patient
may also have positive u/a from necrosis of bladder tumor, if
present (though not noted on CT abdomen/pelvis).
# Renal insufficiency: Improved since last hospitalization at
which time unilateral ureteral stent was placed for bilateral
UVJ obstruction and a bladder tumor measuring 7.5 x 6.8.
Baseline Creatinine was 0.6-0.7 prior to obstruction. During
hospitalization, creatinine worsened in the setting of poor po
intake and persistent diarrhea and urine lytes were suggestive
of hypovolemia. Renal function improved with fluid boluses PRN.
Creatinine on the day of discharge was 1.4.
#. Encephalopathy: Most likely secondary to psychological
stressors in the setting of husband's recent death and recent
diagnosis of cancer. Other etiologies that were considered
include metastatic bladder cancer, medication induced in the
setting of recent floroquinolone administration, and/or
infection (UTI/diarrhea). MR ___, however, had no evidence of
metastatic disease. Patient was intermittently delirious
especially overnight in the setting of poor sleep and fatigue.
No deliriogenic medications were identified. Patient and her
family were in contact with social work for social support
during hospital stay. She was mentating at her baseline for
several days prior to discharge.
# Increased O2 requirement: Asymptomatic, likely secondary to
deconditioning - patient initially required supplemental O2 but
was saturating well on room air by day 6 of hospitalization.
Prior CXR was concerning for possible pneumonia though patient
denied cough/shortness of breath and repeat CXR had no evidence
of new pneumonia.
#. Weakness: in the setting of acute illness. Underlying illness
was treated as above. Patient was seen by physical therapy who
advised discharging the patient to home with physical therapy
services.
CHRONIC, INACTIVE DIAGNOSES:
#. Stage IV high-grade urothelial carcinoma of the bladder with
squamous differentiation. Palliative carboplatin and gemcitabine
were held in the setting of acute illness.
#. LLE edema: Patient has had multiple prior LENIs which have
been negative for a DVT. Exam nor clinical history was not
consistent with infection. LLE swelling was thought to be
secondary to lymphadenopathy and venous compression. Swelling
improved with ACE wrapping and leg elevation for conservative
management.
# Atrial fibrillation: Initially noted in ___ prompting
admission to ___ with volume overload, s/p
cardioversion with amiodarone on board in ___. Patient
in normal sinus rhythm throughout hospital stay. Patient was
continued on diltiazem, amiodarone, and aspirin during hospital
stay.
TRANSITIONAL ISSUES:
# Continue po vancomycin for total 14 days AFTER completion of
linezolid (last dose: ___
# Continue linezolid for 14 days from last positive blood
cultures (last dose ___
# Consider checking CBC at oncology follow-up visit to monitor
for cytopenias while on linezolid
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Amiodarone 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Vancomycin Oral Liquid ___ mg PO Q6H
last dose: ___
RX *vancomycin 125 mg 1 capsule(s) by mouth q6 Disp #*90 Capsule
Refills:*0
8. Linezolid ___ mg PO Q12H
last dose ___
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth every 12 hours
Disp #*16 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Clostridium difficile colitis
Vancomycin-resistant enterococcus bacteremia
Urinary tract infection
Secondary diagnosis:
Stage IV high-grade urothelial carcinoma of the bladder
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 here at ___. You were
found to have worsening diarrhea caused by a bacteria called C.
difficile. You were started on an antibiotic for C. difficile
called vancomycin, which you should continue taking until ___. You were also found to have bacteria in the blood, likely
from a small tear in intestines from the chemotherapy and
bacterial infection of your intestines for which we treated you
with an antibiotic called linezolid (last dose ___. For a
urinary tract infection, you completed a course of antibiotics
while in the hospital. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10580148-DS-10 | 10,580,148 | 25,044,023 | DS | 10 | 2119-09-20 00:00:00 | 2119-09-24 09:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right calf pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p EVAR ___ referred to the ER from PCP office with
known pop arterial occlusion and ischemic right foot. Mr.
___ notes right sided calf pain for 5 months and says this
gradually worsened to the point where he couldn't walk without
having calf pain. He also started having numbness and tingling
of his toes.
He mentioned this to PCP at office visit for BP check today.
PCP did ___ ultrasound to rule out DVT where the pop occlusion was
noted. He was asked to present to ___ ER for further
evaluation.
Past Medical History:
HTN, HLD, ___ Syndrome, Diverticulosis, AAA,
ectatic iliac arteries.
PSH: EVAR ___
Physical Exam:
VS: 98.6, 60, 178/96, 18, 99% RA
Gen: NAD
CV: RRR
Pulm: breathing comfortably on room air
Abd: soft, nondistended, nontender
Ext: no edema. right toes are cool to the touch and pale. left
___ Pulses:
L all palpable;
R femoral palp, pop dopp, DP venous, ___ nondopplerable
Pertinent Results:
___ 04:07AM BLOOD WBC-5.7 RBC-4.94 Hgb-12.9* Hct-39.1*
MCV-79* MCH-26.1 MCHC-33.0 RDW-14.3 RDWSD-40.8 Plt ___
___ 04:07AM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-137
K-3.5 Cl-103 HCO3-23 AnGap-15
___ 04:07AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
Lower extremity CTA:
1. Status post endovascular repair of an infrarenal abdominal
aortic aneurysm with unchanged size of the aneurysm sac and
similar appearance of known type 2 endoleaks.
2. Nonocclusive thrombus in the iliac portion of the stent graft
bilaterally, new on the right and slightly changed in
configuration on the left.
3. New nonocclusive thrombus in the right proximal and mid deep
femoral
artery.
4. Abrupt cut off of the right superficial femoral artery in
the mid thigh compatible with occlusion with non opacification
of the superficial femoral and popliteal arteries distal to this
level. Distal reconstitution of the anterior tibial and
tibioperoneal trunk below the knee via collaterals with
three-vessel runoff into the foot.
5. Nonvisualization of a short segment of the distal right
peroneal artery may be due to distal thrombus.
6. New moderate amount of thrombus within the proximal left
deep femoral
artery resulting in high-grade narrowing.
7. Normal three-vessel runoff to the left foot.
Brief Hospital Course:
___ s/p EVAR ___ referred to the ER from ___ office with
known pop arterial occlusion and ischemic right foot. Mr.
___ notes right sided calf pain for 5 months and says this
gradually worsened to the point where he couldn't walk without
having calf pain. He also started having numbness and tingling
of his toes.
He mentioned this to PCP at office visit for BP check today.
PCP did ___ ultrasound to rule out DVT where the pop occlusion was
noted. He was asked to present to ___ ER for further
evaluation.
A heparin infusion was started and CTA of the lower extremities
was obtained. CTA of the right lower extremity showed
nonocclusive thrombus in the iliac portion of the stent graft
with new nonocclusive thrombus in the right proximal and mid
deep femoral
artery and occlusion of the superficial femoral and popliteal
arteries. There was distal reconstitution of the anterior tibial
and tibioperoneal trunk below the knee via collaterals with
three-vessel runoff into the foot.
On the left there was new moderate amount of thrombus within the
proximal left deep femoral artery resulting in high-grade
narrowing.
Given his history of months of right leg symptoms, we did not
feel intervention or lysis was warranted as this thrombus was
likely not acute. Xarelto and cilostazol were started. We will
follow up in 2 weeks with ___ arterial duplex. He is instructed
to call with wosening symptoms ie: rest pain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Cilostazol 50 mg PO BID
RX *cilostazol 50 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
4. Acetaminophen 650 mg PO Q4H:PRN pain, fever
5. Rivaroxaban 15 mg PO BID
For the next 3 weeks.
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) ___ tablets(s)
by mouth as directed Disp #*1 Dose Pack Refills:*0
6. Rivaroxaban 20 mg PO DAILY
to start after 15mg twice daily dosing for 3 weeks
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
Arterial Thrombosis Right Lower Extremity.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for further evaluation of your
right leg pain which was felt to be secondary to a blood clot in
your popliteal artery that was found at the ___ ___.
We did a CT scan that showed the clot was extensive, from the
right groin arteries to the knee. Some areas were totally
blocked and other were only partially blocked. We feel this
clot has been accumulating over time and is not new so you are
not a good candidate for clot removal or lysis.
We started you on blood thinners which will hopefully improve
the blood flow over time to allow you to walk without pain. We
will follow your symptoms closely for the next few months to
determine a final plan.
Followup Instructions:
___
|
10580148-DS-9 | 10,580,148 | 27,450,601 | DS | 9 | 2118-10-19 00:00:00 | 2118-10-19 14:52:00 |
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 chills, lightheadedness, recently s/p EVAR
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male recently s/p EVAR on
___ for 5.5cm AAA, discharged home on ___ after an
uncomplicated overnight stay.
Of note, the patient has had ongoing vague right > left lower
abdominal pain, which was in fact the presenting complaint which
led to CT scan and discovery of his AAA. Upon evaluation today,
he reports that he began to feel chills and had a low-grade
fever
(100.4*) today, as well as persistence and slight worsening of
his vague abdominal pain. This is in the bilateral lower
quadrants, unchanged by food or OTC pain medications. He
reported
no nausea or vomiting, and although he has a decreased appetite,
he has no issues with PO tolerance. He has had normal appearing
bowel movements, with no melena, no BRBPR. He has been able to
ambulate and function per normal at home. He reports no CP/SOB,
no dysphagia, no malaise/fatigue.
Past Medical History:
HTN, HLD, ___ Syndrome, Diverticulosis, AAA,
ectatic iliac arteries.
Social History:
___
Family History:
FAMILY HISTORY: Mother with thyroid disorder. Father with
thyroid disorder and a biopsy that was negative. Three brothers
and a sister are well. The patient denied history of AAA or
rupture.
Physical Exam:
At discharge:
Vitals: 98.1 97 143/72 18 96%RA
GEN: A&O, NAD, interactive and cooperative
HEENT: No scleral icterus
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, small hematoma palpable ~1cm in
subcutaneous fat in RLQ likely related to heparin shot (with
overlying small ecchymosis), slightly tender with deep palpatin
in RLQ > LLQ, no rebound/rigidity, no pulsatile mass
Groins: bilateral groins soft, with no drainage from puncture
sites, mild degree of bruising/ecchymoses over both groins
Ext: No ___ edema, ___ warm and well perfused, no wounds or ulcers
Pulses: R: p/p/p/p L: p/p/p/p
Pertinent Results:
___ 07:55AM BLOOD WBC-8.4 RBC-3.67* Hgb-10.4* Hct-29.2*
MCV-80* MCH-28.3 MCHC-35.5* RDW-12.5 Plt ___
CXR ___: No acute cardiopulmonary process.
CTA Abdomen/Pelvis: 1. Moderate-sized hematoma in the
retroperitoneum on the right as above. There
is no active extravasation. While retroperitoneal hematoma is
possible after
groin access, rupture of the aortic aneurysm or from the
tortuous, aneurysmal
right common iliac artery (noting that most significant hematoma
seen
surrounding the vessel in this location) is a distinct
possibility. Close
clinical followup will be necessary.
2. Type 2 endoleak status post EVAR of and infrarenal aortic
aneurysm. The
aneurysm sac itself is unchanged in size as compared to ___.
Brief Hospital Course:
Mr. ___ was admitted to ___ s/p EVAR, POD4, with
complaints of abdominal pain. He had a temperature of 100.4 in
the ED, CXR, UA were all negative and WBC was normal. He was
tender on exma in the RLQ, similar to his pain he complained of
post-operatively after his EVAR which was unexplained at the
time. He has some mild bruiding in his right femoral groin site,
but no udnerlying mass or hematoma. A CT A was obtained which
showed the graft in good position, a type 2 endoleak, a small
retroperitoneal hematoma, and a small left renal pole infarct.
The retroperitoneal hematoma, based on the difficulty to
perc-close the R femoral groin site and the amount of time
pressure was held post-op at the site, most likely is tracking
from the femoral groin site. His Hct is stable and his vitals
are all within normal limits. There is no sign of active
bleeding. The patient was made aware of all this information and
reassured that a type 2 endoleak seen this soon post-operatively
is nothing to be concerned about. He is scheduled to have his
routine follow-up CT scan in 1 month. He remained afebrile after
admission to the floor. WBC continued to be normal. His vitals
were monitored and he continued to be stable throughout his
hospital stay. He was advised that if he wished to be seen in
the clinic sooner, he can call to make an appointment to see Dr.
___. The patient verbalized understanding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ following your EVAR procedure when
you presented to the Emergency Room with abdominal pain. CT scan
did not show anything that was not to be expected in the
post-operative period. Unfortunately, we did not find a reason
to explain your pain. However, you were advised to follow-up in
your scheduled follow-up visit period with a repeat CT scan and
call the clinic if you would like to be seen within the next
week with any questions.You were discharged in good condition
with the following instructions:
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
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
Take all the medications you were taking before surgery,
unless otherwise directed
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over 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
over the area
CALL THE OFFICE at ___ FOR:
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 101.5F for 24 hours
Bleeding from incision
New or increased drainage from incision or white, yellow or
green drainage from incisions
Thank you,
Your ___ Vascular Surgery Team
Followup Instructions:
___
|
10580201-DS-39 | 10,580,201 | 21,341,420 | DS | 39 | 2140-04-15 00:00:00 | 2140-04-15 17:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with a history of hypertension,
hyperlipidemia, diabetes mellitus, chronic migraine headaches,
pseudotumor now presenting with a episode of syncope followed by
persistent lightheadness and difficulty walking. She felt
lightheaded yesterday afternoon like she was going to pass out,
she called her neighbor and neighbor found her laying on the
floor. She believes she was out for ___. She reports poor
po intake for the previous 24 hours. She took her glyburide that
morning even though she hadnt eaten but she said it did not feel
like her typical hypoglycemic episodes. She continued to have
lightheadness and had difficulty ambulating, saying "it feels
like I am drunk." EMS was called and she was brought to ___ ED
for further evaluation. This has never happened before. Also had
moderate HA on left side of head. Not worst HA of her life.
Denied CP, SOB, vision changes, dizziness, sensory changes,
weakness, N/V.
.
On arrival to the ED, her initial VS were 99.1 62 155/85 18 98%
RA.
It was thought she had dehydration and possible cardiac origin
of syncope. An EKG showed new T-wave inversions in V5, V6 but
cardiac enzymes were negative x2. She was placed in observation
in the ED. A stress test was planned yesterday morning but then
she was noted to have bilateral horizontal nystagmus, unsteady
gait and became concerned for a central etiology of her symptoms
given her risk factors. Neurology was consulted and recommended
MRI/MRA which showed no acute process. CT head was also negative
for bleed. She was complaining of headache and was given her
home migraine meds. She was admitted for further work-up of
vertigo. VS prior to transfer were 137/73 58 16 100% RA.
.
.
Currently, she is complaining of a ___ headache which feels
similar to her migraines. She thinks it will feel better after
she sleeps.
.
REVIEW OF SYSTEMS:
(+) per HPI, +cough, nasal congestion
Denies fever, chills, night sweats, vision changes, rhinorrhea,
sore throat, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-- chronic HA's: has both migraines and pseudotumor cerebri.
She
is not able to tell difference between the two. Has always had
right-sided HA's. Has been on TPM, propanolol for migraine ppx
and diamox for the last three to four months for pseudotumor
treatment(was previously on it for several years then taken off
and then restarted for unclear reasons). Followed in clinic by
Dr. ___, but last saw her in ___.
.
.
Other PMH:
1. Diabetes mellitus, type 2 (complicated by gastroparesis)
2. Depression
3. Hypertension - primary hyperaldosteronism
4. Paradoxical vocal fold motion disorder
5. Hyperlipidemia (due to primary hyperaldosteronism)
6. Left ventricular hypertrophy (grade II diastolic dysfunction
by last 2D-Echo in ___
7. Pulmonary hypertension
8. GERD
9. Obesity
10. OSA not on CPAP, had a uvulectomy several years ago
11. ? lung nodule on CT (being followed by PCP)
.
.
PSurgHx:
s/p appendectomy
s/p cholecystectomy
s/p hysterectomy (for uterine fibroids)
s/p septoplasty
s/p right tympanic cyst removal
s/p uvulectomy
Social History:
___
Family History:
Denies neurologic disorder. Father with stroke in his ___,
subsequently deceased of a "hiatal hernia" in his ___. Maternal
aunts with strokes in their ___. Migraines in niece and nephew.
Hypertension and Diabetes on maternal side.
Physical Exam:
Admission Physical Exam:
VS - Temp 98.7 F, BP 172/100, HR 60, R 22, O2-sat 98% RA, ___ 121
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, ___, CNs II-XII grossly intact, muscle strength
___ throughout, sensation intact throughout. Ataxic with finger
to nose. Unsteady gait falling to the right side.
Discharge Physical Exam:
Afebrile, SBP 132 after taking home anti-hypertensive
medications. ___, CNs II-XII grossly intact, muscle strength
___ throughout, sensation intact throughout. Ataxic with finger
to nose. Unsteady gait falling to the right side.
Pertinent Results:
Admission Labs:
___ 05:00PM BLOOD WBC-6.8 RBC-4.28 Hgb-11.2* Hct-36.6
MCV-86 MCH-26.2* MCHC-30.6* RDW-15.6* Plt ___
___ 05:00PM BLOOD Neuts-74.1* ___ Monos-2.9 Eos-1.6
Baso-0.4
___ 05:00PM BLOOD Glucose-120* UreaN-11 Creat-1.0 Na-143
K-3.3 Cl-113* HCO3-20* AnGap-13
Discharge Labs:
___ 09:00AM BLOOD WBC-5.4 RBC-4.12* Hgb-11.0* Hct-34.5*
MCV-84 MCH-26.7* MCHC-31.8 RDW-15.2 Plt ___
___ 09:00AM BLOOD Glucose-120* UreaN-8 Creat-0.9 Na-142
K-2.9* Cl-110* HCO3-22 AnGap-13
___ 09:00AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.7
Imaging:
PA AND LATERAL VIEWS OF THE CHEST: The cardiac, mediastinal and
hilar
contours are normal. The lungs are clear and the pulmonary
vascularity is
normal. No pleural effusion or pneumothorax is seen. There are
no acute
osseous abnormalities. IMPRESSION: No acute cardiopulmonary
process.
CT HEAD: There is no evidence of hemorrhage, edema, mass, mass
effect, or
infarction. The ventricles and sulci are normal in size and
configuration. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Allowing for technical limitations, the structures of
the otic capsule are grossly symmetric and unremarkable.
IMPRESSION: No evidence of acute intracranial process, with
unremarkable appearance of the posterior fossa.
MRI/MRA HEAD:
MRI HEAD: There is no acute intracranial hemorrhage, infarction,
edema, mass or mass effect seen. There are multiple scattered
T2/FLAIR high signal foci seen in bilateral periventricular
white matter and in the central pons likely represents sequelae
of small vessel ischemic disease. Ventricles and sulci appear
age appropriate. No diffusion abnormalities are seen. There are
no foci of abnormal susceptibility. The visualized orbits,
paranasal sinuses and mastoid air cells are unremarkable.
MRA BRAIN: Bilateral intracranial internal carotid arteries,
vertebral
arteries, basilar artery and their major branches are patent
with no evidence of stenosis, occlusion, dissection or aneurysm
formation. Left vertebral artery is dominant.
MRA NECK: Bilateral common carotid arteries, vertebral arteries,
internal
carotid arteries in the neck are patent with no evidence of
stenosis,
occlusion, dissection or pseudoaneurysm formation. There is mild
stenosis of the origin of the right vertebral artery.
IMPRESSION:
1. No acute intracranial abnormality.
2. Small vessel ischemic disease.
3. Unremarkable MRA of the head.
4. Mild stenosis at the origin of the right vertebral artery.
Otherwise,
unremarkable MRA of the neck.
___ 10:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:50PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
Brief Hospital Course:
Patient is a ___ year old female with a history of hypertension,
hyperlipidemia, diabetes mellitus, chronic migraine headaches,
pseudotumor now presenting with a episode of syncope followed by
persistent lightheadness and ataxia with negative head CT/ MRI
and EKG changes but negative cardiac enzymes.
# Ataxia: Patient developed ataxia after staying in the ED
overnight. She had a CT head which was negative for bleed.
MRI/MRA negative for infarction, though it did show mild
stenosis of the right vertebral artery. She was seen by the
neurology consult team in the emergency department, who did not
believe that the findings supported stroke. Full neurological
exam showed no focal deficits aside from gait instability. No
nystagmus was visible on exam, and ___ was negative
bilaterally. She was evaluated by ___ who felt the patient was
safe to be discharged home with home ___ and a walker. Given
recent URI symptoms, the etiology was thought to be due to
labyrinthitis in the absence of other findings on exam or
imaging.
# Syncope: Patient had episode of syncope in the setting of poor
oral intake for 24 hours. Cause of the patient's syncope was
thought to be due to vasovagal episode. Other possible causes
include hypoglycemia in the setting of taking glyburide with
poor oral intake, though the patient denied having her typical
symptoms of hypoglycemia. EKG in the ED showed new T wave
inversions in V5, V6. Because of these new EKG changes, cardiac
enzymes were cycled and negative. Patient was monitored on
telemetry through the admission, and there were no arrythmias
noted. Patient did not ultimately undergo stress testing given
that she had a normal stress test in ___.
# Chronic headaches: Patient with a history of migraines and
pseudotumor cerebri. Upon admission to the floor, patient
developed a headache similar to prior headaches. CT and MRI of
the head were negative for acute process. Her home topamax was
continued. Her home propranolol was discontinued given her
postive urine tox screen for cocaine. Patient was instructed
not to take propranolol for headaches given her use of cocaine.
# Cocaine use: Patient's urine toxicology screen returned
positive for cocaine. Patient admits to remote cocaine use. She
was counsuled on the deleterious health effects of cocaine
including myocardial infarction. Her propranolol was
discontinued given her positive urine tox screen.
# Depression/ anxiety: Patient's home citalopram and lorazepam
were continued.
# Diabetes mellitus: Patient on glyburide at home; her home
glyburide was held during the admission. She was placed on an
insulin sliding scale while in house. She is being discharged
home on her previous home dose of glyburide.
# Hypertension: Upon admission to the floor, patient's blood
pressure was elevated, but the patient did not receive home BP
medications. She was given home dose of enalapril and
amlodipine, and her blood pressure normalized.
# Hyperlipidemia: Continued home simvastatin.
# Gastroesophageal reflux/ vocal cord dysfunction: Continued
home omeprazole and ranitidine.
# Transition of Care:
- Home ___ for gait training and dynamic balance training.
Medications on Admission:
-Diamox 500mg BID
-Topiramate 100mg BID
-Tizanidine 4mg BID
-Citalopram 20mg daily
-Advair 500mcg/50mcg 2 puffs BID
-Propranolol 20mg BID
-Simvastatin 20mg daily
-Omeprazole ___ 40mg BID
-Amlodipine 10mg daily
-Enalapril 10mg daily
-Aspirin 81mg daily
-Glyburide 2.5 mg po daily
-Ranitidine
-Lorazepam 1 mg po qHS prn insomnia
Discharge Medications:
1. acetazolamide 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
Two (2) puffs Inhalation BID (2 times a day).
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Labyrinthitis
Diabetes Mellitus
Hypertension
Migraine Headaches
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 to the hospital for further work-up of gait
instability. Your work-up included an MRI of the head and a CT
scan of the head which returned negative.
You initially presented to the emergency department because of
an episode of loss of consciousness. We think that the cause of
your loss of consciousness may have been due to a vasovagal
episode. The work-up of your heart as a cause for your loss of
consciousness was negative.
Refrain from using cocaine and other illegal drugs. Cocaine may
have influenced you to develop your symptoms. You are encouraged
to seek help from community programs to help stop your cocaine
use.
Please take all medications as instructed. *STOP* taking your
propranolol as this medication in combination with cocaine use
can have deleterious effects on your heart.
Please keep all ___ medical appiontments as scheduled
below.
Followup Instructions:
___
|
10580201-DS-40 | 10,580,201 | 29,006,330 | DS | 40 | 2140-05-28 00:00:00 | 2140-05-29 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
"Headache."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with a history of hypertension,
hyperlipidemia, diabetes mellitus, chronic migraine headaches,
disatnt history of pseudotumor who presents with persistent
headache. She was seen on on ___ in the ED for same headache,
evaluated by Neurology at that time. They felt there were no
acute "red flag" signs/symptoms that warranted further follow up
given her recent imaging of MRI/MRA and CTA in the past month.
She was discharged after receiving pain control with narcotic
medications. She was discharged with oxycodone which she said
was not helping at all. She is now representing with same
headache.
.
Her symptoms began on ___ evening and are described as
"typical" migraine symptoms. She reports a pain behind her right
eye with minimal radiation. She denies any neurologic symptoms.
She tried taking oxycodone with only minimal relief of her
symptoms. Of note there is a record of a conversation between
the pt and her PCP in which she called reporting RLQ pain and
was told to go to the ED. She reported going to ___
because it was closer. She did not mention any of this during
her history.
.
Given that they persisted into ___ AM, she went to the ED for
further evaluation. As mentioned, her pain improved so she was
discharged with plans to follow-up with Dr. ___ in the
headache clinic as an outpatient. However, her symptoms returned
so she represented to the ED for further evaluation. She has
photophobia, but no neck stiffness, mild nausea without
vomitting no d/f/s/c, no visual chgs, no urinary symptoms, no
abd pain, no incontinence of bowels/bladder, no
numbness/tingling.
.
In the ED, T- 98.7, HR-64, BP- 116/77, RR- 8, SaO2- 100% RA.
Exam was unremarkable. Labs showed Cr of 1.2. She was given
dilaudid 1mg IV x2 with minimal improvement. She then responded
transiently to reglan, benadryl, caffeine, and zofran cocktail,
but pain rebounded so she is being admitted for pain control and
further evaluation. She was also found to have a UTI, for which
she received ciprofloxacin.
.
On arrival to the floor, vital signs were T- 98.6, BP- 140/80,
HR 64, RR 12, SaO2 97% on RA. Patient continues to experience
headache.
Past Medical History:
-- chronic HA's: has both migraines and pseudotumor cerebri. .
.
Other PMH:
1. Diabetes mellitus, type 2 (complicated by gastroparesis)
2. Depression
3. Hypertension - primary hyperaldosteronism
4. Paradoxical vocal fold motion disorder
5. Hyperlipidemia (due to primary hyperaldosteronism)
6. Left ventricular hypertrophy (grade II diastolic dysfunction
by last 2D-Echo in ___
7. Pulmonary hypertension
8. GERD
9. Obesity
10. OSA not on CPAP, had a uvulectomy several years ago
11. ? lung nodule on CT (being followed by PCP)
.
.
PSurgHx:
s/p appendectomy
s/p cholecystectomy
s/p hysterectomy (for uterine fibroids)
s/p septoplasty
s/p right tympanic cyst removal
s/p uvulectomy
Social History:
___
Family History:
Denies neurologic disorder. Father with stroke in his ___,
subsequently deceased of a "hiatal hernia" in his ___. Maternal
aunts with strokes in their ___. Migraines in niece and nephew.
Hypertension and Diabetes on maternal side.
Physical Exam:
Admission PE
VS - T- 98.6, BP- 140/80, HR 64, RR 12, SaO2 97% on RA.
GENERAL - NAD, appropriate, AAO x 3
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, ___ systolic murmur at LUSB no RG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, ___, CNs II-XII grossly intact, muscle strength
___ throughout, sensation intact throughout. No focal deficits
noted.
.
Discharge PE
Tm 99.0 Tc 97.8 HR 61 BP 118/75 RR 18 SaO2 100 on RA
GENERAL: AAOX3, in mild discomfort
HEENT: vision grossly normal, CN ___ grossly intact, PERRLA,
NECK: no lad, no thyromegaly
___: RRR, no RMG
LUNGS: distant BS, CTAB no wrr
ABDOMEN: obese, TTP, mild to moderate in nature in rlq (while
auscultating has no pain in same area), no palpable mass, active
BS X4, no HSM, no rebound
SKIN: no obvious rashes
Extremities: WWP, 1+ pulses in BUE and BLE, trace edema
NEURO: MS and ___ wnl, strength ___ in bue and ble, reflexes 1+
and equal in patellar and biceps, sensation grossly intact
Psych: mood and affect wnl
Pertinent Results:
ADMISSION LABS:
___ 05:20AM GLUCOSE-145* UREA N-11 CREAT-0.9 SODIUM-140
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
___ 05:20AM ALT(SGPT)-16 AST(SGOT)-14 ALK PHOS-156* TOT
BILI-0.1
___ 05:20AM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.1
MAGNESIUM-1.6
___ 05:20AM WBC-5.9 RBC-4.06* HGB-10.8* HCT-34.5* MCV-85
MCH-26.5* MCHC-31.2 RDW-13.7
___ 05:20AM NEUTS-70.1* ___ MONOS-3.9 EOS-2.2
BASOS-0.4
___ 05:20AM PLT COUNT-141*
___ 05:20AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 09:42AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 09:42AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 09:42AM URINE RBC-<1 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-4
.
DISCHARGE LABS:
___ 07:24AM BLOOD WBC-4.3 RBC-3.74* Hgb-9.8* Hct-32.8*
MCV-88 MCH-26.3* MCHC-29.9* RDW-13.6 Plt ___
___ 07:24AM BLOOD Glucose-104* UreaN-11 Creat-1.1 Na-139
K-3.8 Cl-109* HCO3-21* AnGap-13
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
KUB:
FINDINGS: There is a non-obstructive bowel gas pattern with no
dilated loops of small or large bowel. Clips overlie the right
upper quadrant. There is no evidence of pneumoperitoneum,
pneumatosis or portal venous gas. There are no abnormal soft
tissue calcifications. Visualized osseous structures are intact.
IMPRESSION: Non-obstructive bowel gas pattern.
Brief Hospital Course:
Patient is a ___ year old female with a history of hypertension,
hyperlipidemia, diabetes mellitus, chronic migraine headaches,
pseudotumor cerebri who presents with recurrent headaches.
.
# Headache- Patient with persistent symptoms not fully
responsive to pain medications in the ED. She was thoroughly
evaluated by neurology who recommended follow-up with neurology
headache clinic. She was discharged home with oxycodone however
she re-presented to the ED with simlar complaints and she was
admitted to meedicine. She was weaned off Dilaudid and was given
sumatriptan sc and uptitration of her acetazolamide with
complete resolution of her headache. She does have a history of
cocaine use and hypertenison. Her blood pressure was very well
controlled while in the hospital. Her tox screen was negative
for cocaine and she was cautioned to avoid cocaine when using
imitrex.
.
#Abdominal pain: She developed RLQ abdominal pain in area of
prior appendectomy and hernia repair while admitted. She had
recently been admittd at ___ for abdominal pain
where a CT scan did not show any acute abnormalities. She
underwent a KUB here which did not show any suggestion of
obstruction. She was also constipated in the context of
significant opiate use. She was instructed that opiate use was
leading to her constipation and would likley only worsen her abd
pain. Alternately she may have abdominal pain from her old
surgical scar tissue. She still had some pain on discharge but
was able to tolerate PO intake and stated that she preferred to
go home and follow up with her pain clinic and primary doctor.
.
# UA- She had a urinalysis that appeared positive found on
routine studies in the ED. Patient asymptomatic but she is being
treated with ciprofloxacin given possibility that infection is
exacerbating migraines per neurology. After she received two
days of ciprofloxacin her urine culture returned negative so
antibiotics were stopped.
.
# Depression/ anxiety: stable
- continue home citalopram and lorazepam
.
# Diabetes mellitus: on glyburide at home. Sliding scale
insulin was used while admitted and her glyburide was restarted
on discharge.
.
# Hypertension: Well controlled during this admission. continued
home enalapril, imdur and amlodipine.
.
# Hyperlipidemia:
- cont simvastatin 20mg daily
.
# Gastroesophageal reflux/ vocal cord dysfunction: stable
- cont omeprazole 40mg BID
.
# Transitional Issues:
-Needs close follow up with PCP, ___ and Pain clinic
.
Medications on Admission:
1. Topiramate- 100mg BID.
2. Acetazolamide- 500mg BID
3. P.r.n. acetaminophen.
4. Lorazepam 1 mg tablets for anxiety as needed. The patient
says she takes fewer than one per day.
5. Citalopram 20 mg daily.
6. Aspirin 81 mg daily.
7. Advair Diskus 500/50, two puffs b.i.d.
8. Simvastatin 20 daily.
9. Omeprazole 40 b.i.d.
10. Glyburide 2.5 daily.
11. Amlodipine 10 mg daily.
12. Albuterol inhaler, two puffs as needed for shortness of
breath.
13. Imdur 30 mg daily.
14. Tizanidine 4 mg for "muscle spasms" b.i.d.
15. Enalapril- 10mg daily
Discharge Medications:
1. Imitrex ___ mg Tablet Sig: One (1) Tablet PO PRN Migraine: ___
repeat once if migraine does not resolve in 2 hours. Do not take
more than twice in one day. Do not use cocaine while taking this
medication.
Disp:*10 Tablet(s)* Refills:*0*
2. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. acetazolamide 250 mg Tablet Sig: Four (4) Tablet PO twice a
day.
Disp:*240 Tablet(s)* Refills:*2*
4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for anxiety.
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every ___ hours as needed for shortness of
breath or wheezing.
11. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
16. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Migraine
abdominal pain likely realted to constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ you for coming to the ___
___. You were in the hospital because you had a severe
migraine. We are glad that you are feeling better. You can take
imitrex (sumatriptan) for migraines in the future. It is very
important you do not use cocaine while taking this medication.
We also increased your acetazolamide. We did not make any other
changes to your medications.
.
Medication Recommendations:
Please START
-Imitrex (sumatriptan) 50mg may repeat dose in one hour if pain
not resolved.
.
Please Increase acetazolamide to 1000mg twice daily
.
Please Continue taking all other medications as you have been
Followup Instructions:
___
|
10580201-DS-43 | 10,580,201 | 22,148,712 | DS | 43 | 2140-08-29 00:00:00 | 2140-08-30 22:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
Fall and headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with hx chronic migraine, pseudotumor
cerebri, and with multiple admissions for headaches who presents
following a fall yesterday evening.
She notes that she has had her current headache for
approximately 5 weeks and was recently discharged on ___ with
new prescription for amitryptiline. Due to persistent headache,
she took tizanidine yesterday afternoon and laid down for
several hours. Upon waking up, at 9pm, she stood up and the room
immediately became dizzy. The next thing she remembers is her
daughter waking her up from the floor. She approximately LOC for
1 minute and is unsure if she hit her head. She denies
antecedent CP or SOB. She denies loss of bowel or bladder
continence. She denies confusion upon waking up. She note recent
nausea with poor po intake but denies vomiting or diarrhea. She
notes she doesn't drink much fluid at baseline. Due to the fall,
she presented to the ED.
In the ED, initial vitals were: 98.6 88 160/91 18 100%. Exam in
the was notable for being very uncomfortable with neuro exam
intact, and no meningismus. Initial labs showed persistent
anemia stable from recent admission. CT head was negative for
acute process or bleed and CXR negative for PNA. She was given
2L IVF, 1mg IV dilaudid x2, and 4mg IV zofran for headache. She
was admitted to the medicine floor for further management. Most
recent vitals prior to transfer were: 96.9, 70, 16, 154/98,
100%ra
Currently, she denies any dizziness. Her only complaint is her
persistent headache. She reports chronic headache since ___,
most of which last only a few days. Her current headache has
been persistent for weeks, she rates as ___ bifrontal and
throbbing with associated right eye pain and photophobia. She
was recently admitted to medicine for same headache, and
discharged ___. Most recent LP on ___ did not improve her
symptoms. She has seen a headache specialist recently, and she
thinks she may need a shunt for persisently elevated pressures.
She saw neurosurgery in consultation on ___, and was told
that they do not think she needs shunt immediately. She is
scheduled for MRA end of ___ and she has ___ appointment with
neurology in ___. However she presents because she cannot
continue with this pain for that long.
ROS: Positive as above and endorses occasional night sweats.
Denies recent fever, chills, vision changes, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Migraine headache
- Pseudotumor cerebri
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- Depression
- Pulmonary hypertension
- Cocaine abuse
- s/p appendectomy
- s/p cholecystectomy
- s/p hysterectomy (for uterine fibroids)
- s/p septoplasty
- s/p right tympanic cyst removal
- s/p uvulectomy
Social History:
___
Family History:
Father with CVA in his ___ or ___. Maternal aunt with CVA.
Niece and nephew with migraines.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: Tc 98.0 BP 142/92 HR 76 RR 14 O2 99% RA
GENERAL: Well developed middle age woman, appears slightly
uncomforatble and holding her hand over her eyes. Pleasant,
appropriate.
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, dry MM, OP clear.
NECK: Thick, no apparent JVD. No LAD
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Non labored on room air. Scattered expiratory wheeze with
good air movement.
ABDOMEN: Obsese, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES: WWP, no c/c/e, palpaple DP and radial pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout, cerebellar exam
intact to FTN, gait deferred.
PHYSICAL EXAM ON DISCHARGE:
VS: Tm 98.7 Tc 98.1 BP 104/54 HR 54 RR 20 O2 98%RA
GENERAL: Well developed middle age woman, sitting up in bed
eating breakfast
HEENT: PERRL, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Thick, no apparent JVD. No LAD.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Non labored on room air. CTAB with good air movement
ABDOMEN: Obese, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES: WWP, no c/c/e, palpaple DP and radial pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, no gross change to motor
or sensory fxn
Pertinent Results:
ADMISSION LABS:
___ 12:34AM BLOOD WBC-6.5 RBC-4.07* Hgb-9.9* Hct-33.5*
MCV-82 MCH-24.3* MCHC-29.6* RDW-15.6* Plt ___
___ 12:34AM BLOOD ___ PTT-27.6 ___
___ 12:34AM BLOOD Glucose-201* UreaN-15 Creat-1.0 Na-142
K-3.4 Cl-105 HCO3-25 AnGap-15
___ 07:55AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-7.2 RBC-4.26 Hgb-10.5* Hct-35.7*
MCV-84 MCH-24.8* MCHC-29.5* RDW-15.6* Plt ___
___ 06:00AM BLOOD Glucose-198* UreaN-19 Creat-1.0 Na-138
K-4.1 Cl-106 HCO3-20* AnGap-16
___ 06:00AM BLOOD Calcium-9.2 Phos-1.6*# Mg-1.9
TROPONIN TREND:
___ 12:34AM BLOOD cTropnT-<0.01
___ 04:40PM BLOOD cTropnT-<0.01
___ 10:15PM BLOOD cTropnT-<0.01
URINE:
___ 05:10AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG
REPORTS:
___ RadiologyMRV HEAD W/O CONTRAST
Patent major venous sinuses without significant change from
prior. Narrow left transverse sinus and anterior part of
Superior sagittal sinus as before. MRI with and without
contrast is suggested if clinically warranted for complete
assessment given the h/o pseudotumor cerebri.
___ RadiologyCT HEAD W/O CONTRAST
There is no acute intracranial hemorrhage, edema, mass effect
or
major vascular territorial infarction. There is no shift of
normally midline structures. The ventricles and sulci are
normal in size and configuration. Gray-white matter
differentiation is preserved. No fracture is seen. The imaged
paranasal sinuses and mastoid air cells are well aerated.
___ RadiologyCHEST (PA & LAT)
The lungs are well expanded and clear. There is no pleural
effusion or pneumothorax. The heart is normal in size with
normal
cardiomediastinal contours aside from prominence of the right
mediastinal
border which is due to a tortuous brachiocephalic vein as shown
on previous
chest CTs.
___ Cardiovascular ECG
Sinus rhythm. Left ventricular hypertrophy. Left anterior
fascicular block.
Right bundle-branch block. Compared to the previous tracing of
___ no
diagnostic interim change
Brief Hospital Course:
ASSESSMENT & PLAN:
Ms. ___ is a ___ with hx chronic migraine, pseudotumor
cerebri, and with multiple admissions for headaches who presents
following a fall evening prior to admission.
#Headache: Unclear if patient suffers from pseudotumor, chronic
migraine, or medication overuse and rebound. Patient was
initially rehydrated with IVF's and provided dilaudid for pain
relief. Nausea was controlled with zofran. MRV was obtained to
evaluate for sinus thrombosis, which it did not demonstrate,
although cavernous sinus not well visualized in the study. Given
concern for component of narcotic overuse and subsequent rebound
headaches, an attempt was made to break the patient's use of
opiates. She was started on high dose methyprednisolone 250mg IV
every 6 hours for 6 doses before transitioning to 60mg
prednisone with rapid taper. During this time, patient did not
receive any analgesic medications. Patient was discahrged 2 days
into her steroid course with ___ pain the morning of discharge.
Notably, she did have increasing pain throughout the day prior
to discharge, and HA's may increase throughout the day.
Additionally, patients standing medications were decreased as
well. Her topirimate dose was lowered with plan to taper off
following discharge and amitryptiline was discontinued.
Propranolol was decreased to 60mg daily. She was continued on
tizanidine 4mg twice daily and lorazepam 0.5-1mg three times
daily as needed for anxiety and nausea. She was discharged with
plan to follow up in pain management clinic with her headache
specialist, Dr. ___.
# Fall: Suspect vasovagal sycope due to pain +/- orthostatic
hypotension compounded by polypharmacy with oversedating
medications, including lorazepam, tizanidine, and amitryptiline.
Orthostatics were not measured in ED, and she did receive 2L NS
prior to admission to floor. Orthostatics on the floor following
admission were negative. Very low concern for cardio-pulmonary
process. Troponins were negative x3 and she had no significant
events on telemetry monitoring.
# Prolonged QTc: Prolonged during last hospitalization (~480)
while on celexa. Celexa was discontinued last hospitialization.
Amitryptiline was discontinued this hospitalization. Her QTc
remained stably prolonged in the 460ms range.
# Hypertension: Patient was mildly hypertensive in the setting
of pain. She was continued on her home amlodipine and enalapril.
Propranolol dose was decreased to 60mg daily.
# Depression: At baseline. Amitryptiline was discontinued as
above. Patient also recently discontinued celexa. Her depression
would most likely benefit from control of her pain rather than
add'l medications which will add to her polypharmacy.
# Anxiety: Continued on judicious use of PRN lorazepam.
# DM2: Well-controlled, last HbA1c 6.6 in ___. Her blood
sugars were noted to be elevated in setting of steroid taper,
and she was placed on HISS while in house. Her glyburide was
restarted on discharge.
# GERD: Continued her home omeprazole. Did have one episode of
substernal chest pain without EKG changes or troponin elevation
that responded quickly to maalox.
# HLD: Continued her home simvastatin and ASA 81.
TRANSITIONAL ISSUES:
- Attempt to avoid or minimize analgesics, if possible
- Discharged to taper off topiramate given history of renal
stones
- Would monitor depressive symptoms given recent discontinuation
of celexa and amitryptiline
- Would monitor sugars to ensure adequate glycemic control
following steroid taper
- Would avoid QTc prolonging agents, if possible
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
4. Enalapril Maleate 10 mg PO DAILY
5. GlyBURIDE 2.5 mg PO DAILY
6. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
7. Omeprazole 40 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN
headache: Ran out on ___
9. Propranolol 120 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Tizanidine 4 mg PO BID
12. Topiramate (Topamax) 100 mg PO BID
13. Amitriptyline 25 mg PO HS
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for anxiety.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. tizanidine 4 mg Capsule Sig: One (1) Capsule PO twice a day.
9. topiramate 25 mg Tablet Sig: As directed Tablet PO according
to taper for 4 days: See attached taper.
Disp:*8 Tablet(s)* Refills:*0*
10. prednisone 10 mg Tablet Sig: As directed Tablet PO according
to taper for 5 days: See attached taper instructions.
Disp:*15 Tablet(s)* Refills:*0*
11. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One
(1) Capsule,Extended Release 24 hr PO once a day.
Disp:*30 Capsule,Extended Release 24 hr(s)* Refills:*2*
12. Prednisone Taper
Take 5 (10mg) tabs ___, 4 tabs on ___, 3 tabs on ___, 2
tabs on ___ and 1 tab on ___, then stop.
13. Topiramate taper
___: Take 2 (25mg) tabs in the evening
___: Take 2 tabs in the morning and one tab in the evening
___: Take 1 tab in the morning and 1 in the evening
___: Take 1 tab in the morning then STOP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Syncope
2. Chronic migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you passed out at
home. After taking a thorough history and physical, and running
several tests including blood work and radiology studies, we
think the reason you passed out due to pain and excessive use of
sedating medications. We gave you IV fluids and changed some of
your medications and you began feeling better. Because your
headaches likely have an element of medication overuse, we
started a trial to decrease the number of medications you take.
We discontinued all pain medications and began giving you
steroids. We also stopped your amitryptiline and are tapering
you off of your topamax. Please note the following changes to
your medications:
1. START Prednisone 10mg tablets: Take 5 tablets tomorrow, then
decrease by one tab daily until ___ when you will take 1
tablet. Stop this medication after your dose on ___.
2. DECREASE Topamax (topirimate) according to the following
taper: Take 2 (25mg) tabs the evening of ___. Take two tabs the
morning of ___ and one tab that evening. Take one tab in the
morning and in the evening of ___. Take one tab in the morning
of ___ then stop this medication.
3. DECREASE Propranolol to 60mg once daily
4. STOP amitryptiline
5. STOP Percocet
We made no other changes to your medications. Please note the
following appointments which we have already scheduled for you.
If you have worsening pain and cannot make it until your
appointment with Dr. ___ may call the Neurology ___
___ clinic at ___. It has been a pleasure taking care
of you.
Followup Instructions:
___
|
10580201-DS-46 | 10,580,201 | 25,468,205 | DS | 46 | 2140-10-21 00:00:00 | 2140-10-23 19:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
Abdominal ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady who is s/p VP shunt placement on
___ for pseudotumor cerebri who presented to the ED with RLQ
abdominal ___.
Since the operation her headaches have gotten much better but
one and a half weeks later she developed abdominal ___ and she
is concerned that it has to do with the shunt. ___ is sharp,
located in the RLQ and non-radiating. Not worse with eating. No
N/V, no loose stools. Worse with movement/walking or when her
legs are sraight, and it feels slightly better when she puts
light pressure on the area. She presented to ___ on ___ and
was referred to the ___ ED where she was evaluated by
Neurosurgery who felt this did not represent a complication of
the shunt, and also CT abdomen was reassuring so she was
discharged home. She has had continued ___ however, since
___ (3 days prior to this presentation) when she was walking
in the park so she came back to the ED.
In the ED, initial VS were 10 98. 79 146/83 100% RA. Labs were
notable for normal CBC, BUN/Cr ___ (baseline Cr 0.8), LFTs
with AP 183. ACS was consulted and felt there was no concerning
features and recommended pelvic exam/US. She received percocet
x3 and then Morphine 2mg IV for ___. She was admitted for ___
control. VS prior to transfer were Temperature 98.2 °F (36.8
°C). Pulse 63. Respiratory Rate 16. Blood Pressure 134/91. O2
Saturation 100
REVIEW OF SYSTEMS:
Notes weight gain recently, and she would like to lose weight.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest ___, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Migraine headache
- Pseudotumor cerebri
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- Depression
- Pulmonary hypertension and nodules
- Cocaine abuse
- kidney stones
- s/p appendectomy
- s/p cholecystectomy
- s/p hysterectomy (for uterine fibroids)
- s/p septoplasty
- s/p right tympanic cyst removal
- s/p uvulectomy
Social History:
___
Family History:
Stroke. Migraines.
Physical Exam:
Admission exam:
VITALS: 97.8, 167/105, 76, 18, 97%RA
GENERAL: obese lady in NAD, lying in bed with her knees bent
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: obese but nondistended, (+)bowel sounds, no fluid wave,
tender to deep palpation of RLQ but no rebound
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, gait normal
Discharge exam:
VITALS: 98.0 - 79 - 121/71 - 18 - 98RA
GENERAL: obese lady in NAD, comfortable, lying in bed
HEENT: NC/AT, right calvarial incision intact
LUNGS: CTAB no r/r/w
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: obese but nondistended, (+)bowel sounds, nontender to
palpation of RLQ, no rebound tenderness, no guarding
EXTREMITIES: No c/c/e
NEUROLOGIC: appropriate, alert, oriented to place, time, person.
No gross motor deficits (moves all 4), gait WNL, without tremor
Pertinent Results:
___ 01:30PM BLOOD WBC-6.0 RBC-4.47 Hgb-11.3* Hct-36.8
MCV-82 MCH-25.3* MCHC-30.7* RDW-15.9* Plt ___
___ 09:15AM BLOOD ___ PTT-28.6 ___
___ 01:30PM BLOOD Glucose-148* UreaN-14 Creat-1.2* Na-141
K-3.9 Cl-104 HCO3-23 AnGap-18
___ 07:37PM BLOOD Glucose-150* UreaN-13 Creat-1.0 Na-136
K-4.0 Cl-98 HCO3-29 AnGap-13
___ 01:30PM BLOOD ALT-9 AST-19 AlkPhos-183* TotBili-0.5
___ 09:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7
Urine Cx negative
Shunt Series: SKULL: There is a right-sided shunt with the
proximal tip in the right ventricle. The shunt is intact as it
courses along the right skull, along the right neck and enters
into the upper thorax. The paranasal sinuses are normal.
Orbital contours are preserved. The visualized lung apices are
clear. There are degenerative changes of the cervical spine
with some disc space narrowing at several mid cervical vertebral
levels. Prevertebral soft tissues are normal. AP CHEST: The
heart size is within normal limits. Lungs are grossly clear.
The right-sided shunt is seen coursing along the right upper
chest as it
extends medially crossing the mediastinum. It is poorly
visualized. The
shunt is then seen to course towards the lateral aspect into the
right
abdomen. ABDOMEN: Single view of the abdomen demonstrates a VP
shunt with the distal tip at the right lower abdomen. The more
proximal portion is projecting over the spine and the heart is
poorly visualized. Large amount of stool is seen throughout the
colon with a prominent amount of stool seen within the right
colon and cecum which may account for the patient's abdominal
___.
Pelvic U/S: transabdominal and transvaginal exams were
performed, the latter to better assess the adnexal structures.
The uterus is surgically absent. Ovaries are not visualized. A
16-mm calcification in the mid pelvis corresponds to lesion,
better assessed on the CT exam of ___. No adnexal mass
is present. There is no free fluid. IMPRESSION: 1. The uterus
is surgically absent. Ovaries are not visualized. No adnexal
mass or free fluid. 2. A 16-mm calcified nodule is better
assessed on CT exam of ___, which may represent
calcified lymph nodes or remote hematoma.
CT abdomen/pelvis: LUNG BASES: There is a small amount of
stable left basilar scarring. There is no evidence of
consolidation, pleural effusion, or nodule. The base of the
heart is unremarkable. There is no pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There are
no focal hepatic lesions. The portal veins are patent. There
is no intra- or extrahepatic biliary duct dilation. The patient
is status post cholecystectomy. The spleen, pancreas, adrenal
glands, and left kidney are unremarkable. There is a stable
simple right renal cyst which measures 3.8 cm in diameter (3,
32). There is no evidence of hydronephrosis. The kidneys
enhance symmetrically. There is no abdominal or mesenteric
lymphadenopathy. The abdominal vasculature is normal in course
and caliber. There is a small hiatal hernia. The stomach and
small bowel are otherwise unremarkable without evidence of
obstruction or inflammatory changes. There is no free air or
free fluid in the abdomen. A ventriculoperitoneal shunt is seen
coursing adjacent to the liver and into the right lower
quadrant. There are no surrounding fluid collections or
inflammatory changes. PELVIS: There are small scattered
diverticula without evidence of diverticulosis. The large bowel
is otherwise unremarkable without evidence of inflammatory
changes, masses, or obstruction. The patient is status post an
appendectomy. A calcified lesion in the mid pelvis overlying
the bladder (2,75) is unchanged in appearance from the oldest
available CT from ___. This is of unclear etiology,
and may represent a calcified duplication cyst, hematoma, or a
lymph node. The patient is status post a hysterectomy.
There are no adnexal masses. There is no pelvic or inguinal
lymphadenopathy. There is no free fluid in the pelvis. OSSEOUS
STRUCTURES: There are no concerning lytic or sclerotic bone
lesions.
There are no severe degenerative changes of the lumbar spine.
Flowing
anterior osteophytes are noted in the lower thoracic spine. No
fracture is
identified. IMPRESSION: 1. Unchanged appearance of
ventriculoperitoneal shunt terminating in the right lower
quadrant without evidence of surrounding fluid collections or
inflammatory changes. 2. Stable calcified lesion in the pelvis
is of unclear etiology, and may represent a calcified
duplication cyst, lymph node, or old hematoma. 3. Stable right
renal cyst. No evidence of hydronephrosis. 4. Status post
cholecystectomy and appendectomy.
Brief Hospital Course:
Ms. ___ is a ___ lady who is s/p VP shunt placement on
___ for pseudotumor cerebri who presented to the ED (for the
sixth time since shunt placement) with RLQ abdominal ___.
Active issues:
#. RLQ ___: The etiology of the abdominal ___ is of unclear
etiology. The patient is s/p appendectomy and the clinical
picture did not fit. Furthermore, She had abdominal imaging
including CT abdomen/pelvis, transvaginal ultrasound and shunt
series without an cause for the ___ found. She was afebrile
throughout with a normal white blood cell count. She was having
bowel movements without bleeding. Upon investigation of prior
notes, imaging studies and residents who previously have taken
care of the patient, it appears that she has had chronic
abdominal ___ (this was denied by the patient). She was
evaluated by surgery who did not feel that surgical intervention
was indicated. Neurosurgery evaluated her as well and believed
the VP shunt was very unlikely to be causing her abdominal ___.
She was initially treated with morphine for ___ control, which
was changed to oxycodone and acetaminophen. She was also started
on neurontin and a bowel regimen, both with good effect. She was
tolerating food, walking and had improved ___ control (although
it was still present) at the time of discharge. She was
encouraged to follow-up with outpatient ___ clinic management
and her PCP upon discharge.
Inactive Issues:
#. Pseudotumor cerebri & Migraine: stable. Shunt series showed
VP shunt distal tip in the RLQ, but without inflammation. No
migraines during stay.
#. Hypertension: stable. No change in management.
#. ___: Presented with mild ___, likely pre-renal and secondary
to decreased PO intake. She was given IV fluids and her
enalapril was held briefly until her elevated creatinine
resolved. She was resumed on enalapril at the time of discharge.
#. Hyperlipidemia: stable. No change in management.
#. Diabetes mellitus: stable. No change in management.
#. GERD: stable. No change in management.
#. Depression and Anxiety: stable. No change in management.
Transitional Issues:
- ___ need further evaluation regarding etiology of abdominal
___, as well as follow up to ensure ___ control as an
outpatient
- follow-up with ___ psychology at the ___
___
- follow-up with primary care physician
___ on ___:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amitriptyline 5 mg PO HS
2. Amlodipine 10 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Divalproex (EXTended Release) 500 mg PO DAILY
5. Enalapril Maleate 10 mg PO DAILY
6. GlyBURIDE 2.5 mg PO DAILY
7. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/insomnia
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Tizanidine 4 mg PO BID
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amitriptyline 5 mg PO HS
2. Amlodipine 10 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Divalproex (EXTended Release) 500 mg PO DAILY
5. Enalapril Maleate 10 mg PO DAILY
6. GlyBURIDE 2.5 mg PO DAILY
7. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/insomnia
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Tizanidine 4 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Gabapentin 300 mg PO Q8H
RX *gabapentin 300 mg Please take 1 capsule(s) by mouth Q 8
hours (every 8 hours) Disp #*20 Capsule Refills:*0
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN ___
hold for RR < 12, sedation
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4hours (every four
hours) Disp #*30 Capsule Refills:*0
14. Senna 1 TAB PO BID constipation
RX *Natural Senna Laxative 8.6 mg 1 tablet by mouth twice daily
Disp #*30 Tablet Refills:*0
15. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth daily Disp #*15 Tablet
Refills:*0
16. Acetaminophen 1000 mg PO Q8H ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal ___
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 while you were hospitalized at
the ___. ___ after you were admitted, a CT
scan and an ultrasound indicated that there were no acute
processes going on in your abdomen or pelvic that required
emergency surgery. We did a series of X rays to make sure that
the shunt was not blocked off and found no indication that it
might be working improperly. The CT scan did show that the tip
of the shunt had migrated to the area where you were having
___. However, you have been having similar abdominal ___ since
before you had your shunt placed, at least over one year ago.
Because of this, we do not think that the shunt is causing your
___. In addition, the neurosurgery and surgery services both
examined you, and their exams were reassuring. The ___ that you
feel is real, but we are not able to find a physical source for
the ___ you are having. We believe that follow-up with your PCP
and your ___ psychology therapy will help you manage your ___.
The following changes were made to your medications.
1. Please START gabapentin 300mg every 8 hours.
2. Please START oxycodone ___ tablets every 4 hours ONLY as
needed for abdominal ___.
3. Please START tylenol ___ every 8 hours. USE THIS
FIRST.
4. Please START senna 8.6mg ___ times daily as needed for
constipation while on narcotics.
5. Please START colace 100mg daily as needed for constipation
while on narcotics.
It is very important that you follow-up with your primary care
physician in addition to the ___ Clinic to discuss chronic
management of your abdominal ___. Your primary care physician
is aware of your hospitalization.
Followup Instructions:
___
|
10580201-DS-48 | 10,580,201 | 22,880,421 | DS | 48 | 2140-11-24 00:00:00 | 2140-11-24 20:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ - Diagnostic laparoscopy
History of Present Illness:
Briefly, patient is a ___ yo female with a history of pseudotumor
cerebri s/p VP shunt ___, HTN, DM, and depression who
presents with worsening of her RLQ pain. Patient states she
developed the RLQ pain about a week after having the VP shunt
placed. The pain has been intermittent since that time, sharp,
___ in severity ("feels like someone is stabbing her from
the inside"), but acutely worsened in severity yesterday
prompting her to present to the ED. She denies any associated
fevers, chills, nausea, vomiting, diarrhea, dysuria, hematuria
or vaginal bleeding. Patient does endorse a history of kidney
stones. No issues eating, drinking, having bowel movements or
urinating.
Of particular note, patient had 2 prior admissions for the
similar right lower quadrant pain and 1 presentation to the ED.
The first admission was from ___ where she had a 1)
dedicated shunt series, 2) pelvis ultrasound, 3)CT abdomen and
pelvis, 4) surgical and 5) neurosurgical evaluations without any
clear etiology of her pain. Her second admission was from ___ -
___. CT head negative.
In the ED, initial VS were: 10 98.5 72 153/93 22 100% RA. A Chem
7 and CBC were unremarkable. Pt was given 5 mg of IV morphine x
4 in the ED without relief of her pain. She was therefore
admitted to medicine for pain control. On arrival to the floor,
pt was sleeping, but when aroused complaining of continued right
lower quadrant abdominal pain, ___ in severity.
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.
Past Medical History:
- Migraine headache
- Pseudotumor cerebri
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- Depression
- Pulmonary hypertension and nodules
- Cocaine abuse
- kidney stones
- s/p appendectomy
- s/p cholecystectomy
- s/p hysterectomy (for uterine fibroids)
- s/p septoplasty
- s/p right tympanic cyst removal
- s/p uvulectomy
- s/p hernia repair
Social History:
___
Family History:
Stroke and migraines.
Physical Exam:
ADMISSION PHYSICAL EXAM (___):
VITALS: 8 98.6 65 142/81 18 98%
GENERAL: sleeping comfortably
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, nondistended, moderate right lower quadrant
tenderness with voluntary guarding, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
DISCHARGE PHYSICAL EXAM (___) - unchanged from above,
except as below:
ABDOMEN: two laparoscopic incision sites on abdomen are c/d/i.
Mild TTP to palpation in the area of surgery, but minimal RLQ
pain to palpation, improved from admission.
Pertinent Results:
ADMISSION LABS:
___ 07:10PM BLOOD WBC-6.9# RBC-4.17* Hgb-10.2* Hct-33.4*
MCV-80* MCH-24.4* MCHC-30.4* RDW-15.7* Plt ___
___ 07:10PM BLOOD Glucose-175* UreaN-16 Creat-1.0 Na-142
K-3.4 Cl-103 HCO3-26 AnGap-16
___ 07:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 07:15PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-3
___ 07:15PM URINE Mucous-RARE
DISCHARGE LABS:
___ 07:40AM BLOOD Hgb-9.6* Hct-31.7*
IMAGING:
___ KUB
Distal aspect of the VP shunt catheter is noted to terminate
within the right mid hemi abdomen and where visualized appears
intact. Please note that a dedicated shunt series should be
obtained to assess for discontinuity proximally.
Brief Hospital Course:
___ with a history of pseudotumor cerebri s/p VP shunt 2 months
ago (___), HTN, DM, depression who presents with worsening
of her RLQ pain of unclear etiology
#RLQ pain: Patient has experienced intermittent, severe RLQ pain
since placement of the VP shunt on in ___. Since, she has
had two separate admission to the hospital for evaluation and
management of the pain (___). She has had
extensive work-up including a dedicated shunt series, pelvic
ultrasound, CT head/abdomen/pelvis as well as neurosurgical and
general surgical evaluations, which did not reveal a cause for
her pain. Patient re-presented after worsening RLQ pain on
___. KUB in the ED was negative for acute pathology.
Patient's vital signs were stable and not concerning for any new
infectious etiology. Her pain was managed with PO oxycodone and
Tylenol. She was able to tolerate PO intake without pain and
reported no other symptoms. Her PCP ___ management
(___), Dr. ___. surg), and Dr. ___
were all contacted. She was evaluated by General Surgery and
taken to the OR on ___ for a diagnostic laparoscopy which
showed that the catheter was lying against the peritoneum in the
area of her pain. Her VP shunt catheter was shortened and
repositioned to the right upper quadrant. Note was also made of
significant pelvic adhesions, which were not intervened upon.
Her prior pain had improved significantly after the procedure.
She was discharged with PO oxycodone and Tylenol for pain
management after overnight observation. On the morning of
discharge, she had only mild post-surgical discomfort in her
abdomen. She was arranged for follow-up with her PCP, ___,
and pain management provider.
#Headaches: She did not have significant headaches this
admission, they have improved since her VP shunt was placed.
#Chronic issues: All of her chronic medical issues (migraines,
depression/anxiety, HLD, GERD, DM2, HTN) were managed with home
medications as previously prescribed.
#Code status: She was FULL CODE throughout admission.
#Transitional issues:
-Given prescription for oxycodone for pain control after her
laparoscopy
-Will follow-up with her PCP, surgeon and pain management
provider after discharge
___ on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amitriptyline 10 mg PO HS
2. Amlodipine 10 mg PO DAILY
please hodl for sbp<100
3. Citalopram 20 mg PO DAILY
4. Divalproex (DELayed Release) 500 mg PO DAILY
5. Enalapril Maleate 10 mg PO DAILY
please hold for sbp<100
6. GlyBURIDE 2.5 mg PO DAILY
7. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
please hold for rr<12 or increased somnolence
8. Omeprazole 40 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Simvastatin 20 mg PO DAILY
11. Tizanidine 4 mg PO BID
12. Aspirin 81 mg PO DAILY
13. Gabapentin 600 mg PO TID
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Amlodipine 10 mg PO DAILY
please hodl for sbp<100
3. Aspirin 81 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Divalproex (DELayed Release) 500 mg PO DAILY
6. Enalapril Maleate 10 mg PO DAILY
please hold for sbp<100
7. Gabapentin 600 mg PO TID
8. GlyBURIDE 2.5 mg PO DAILY
9. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
please hold for rr<12 or increased somnolence
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Simvastatin 20 mg PO DAILY
13. Tizanidine 4 mg PO BID
14. Acetaminophen 650 mg PO TID:PRN pain
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for worsening abdominal pain
in your right lower abdomen. We think this pain may have been
related to the cetheter in your abdomen. You underwent a
diagnostic procedure in the OR through General Surgery in which
your catether was re-positioned. We are discharging you with
oxycodone and Tylenol to manage your pain. Please be sure to
follow-up with your PCP ___ pain management with
Dr. ___ general surgeon Dr. ___ your
neurosurgeon Dr. ___ in the outpatient setting
Followup Instructions:
___
|
10580201-DS-49 | 10,580,201 | 28,288,538 | DS | 49 | 2140-11-30 00:00:00 | 2140-12-01 20:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo F with a history of pseudotumor cerebri s/p VP shunt
___, with laparoscopic adjustment of intraabdominal shunt
___ secondary to pain, presenting with persistent RLQ pain.
Patient noted resolution of her pain following surgery, but her
pain returned on the day prior to her current presentation.
Patient states she has progressive sharp RLQ pain accompanied by
nausea, no vomiting.
In the ED, initial vital signs were 99.4 69 147/82 18 98%. Labs
including CBC, electrolytes and LFTs were wnl, unchanged from
prior except for mildly elevated alk phos to 188. U/A was
negative. KUB showed no evidence of obstruction. Surgery was
consulted and felt there was no surgical issue, and recommended
pain control. Patient was given tylenol, zofran, 1mg dilaudid IV
x 2, 4mg dilaudid po x 2 without improvement in pain. She was
admitted to medicine for pain control.
On arrival to the floor, initial vital signs were T98.3 BP
144/76 HR 70 RR 18 O2 99% RA. Patient reported significant pain
in the RLQ. She is passing flatus and having bowel movements
without blood/black stool. She notes worsening stomach
distension. Pain is worse with urination, but denies dysuria.
Pain is not worsened with food intake and she has been able to
eat. She denies fevers.
Past Medical History:
- Migraine headache
- Pseudotumor cerebri
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- Depression
- Pulmonary hypertension and nodules
- Cocaine abuse
- kidney stones
- s/p appendectomy
- s/p cholecystectomy
- s/p hysterectomy (for uterine fibroids)
- s/p septoplasty
- s/p right tympanic cyst removal
- s/p uvulectomy
- s/p hernia repair
Social History:
___
Family History:
Stroke and migraines.
Physical Exam:
ADMISSION PHYSICAL EXAM (___)
VS: T98.3 BP 144/76 HR 70 RR 18 O2 99% RA
GEN: Obese female, visibly uncomfortable but in NAD
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, grade II/VI systolic murmur best heard at
___.
ABD: 2 portal sites with steristrips, no drainage/erythema.
Abdomen is mildly distended with +BS, tenderness along right in
upper and lower quadrants without rebound. Tenderness
significantly less when patient is distracted.
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: no ulcers or lesions
DISCHARGE PHYSICAL EXAM (___) - unchanged from above,
except as below:
ABD: soft/obese. Mild tenderness to palpation in the RLQ/RUQ, no
tenderness to palpation when patient is distracted.
Pertinent Results:
ADMISSION LABS:
___ 09:30PM BLOOD WBC-7.0 RBC-3.74* Hgb-9.3* Hct-30.4*
MCV-81* MCH-25.0* MCHC-30.7* RDW-16.0* Plt ___
___ 09:30PM BLOOD Neuts-59.7 ___ Monos-4.7 Eos-3.3
Baso-0.3
___ 09:30PM BLOOD Glucose-170* UreaN-18 Creat-1.1 Na-136
K-3.8 Cl-99 HCO3-25 AnGap-16
___ 09:30PM BLOOD ALT-13 AST-14 AlkPhos-188* TotBili-0.2
___ 09:30PM BLOOD Lipase-20
___ 09:30PM BLOOD Albumin-3.9
___ 10:40AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.8
___ 10:52AM BLOOD Lactate-1.5
___ 09:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
DISCHARGE LABS:
___ 10:40AM BLOOD WBC-8.8 RBC-3.89* Hgb-9.7* Hct-32.2*
MCV-83 MCH-24.9* MCHC-30.0* RDW-15.9* Plt ___
___ 10:40AM BLOOD Glucose-153* UreaN-22* Creat-1.1 Na-139
K-4.2 Cl-101 HCO3-28 AnGap-14
IMAGING:
___ KUB
Cholecystectomy clips are noted within the right upper quadrant.
Distal aspect of right VP shunt catheter is noted terminating
within the right hemi-abdomen and appears unchanged from the
prior examination. There is moderate amount of stool within the
right colon. Non-obstructive bowel gas pattern is noted. There
is no free air under the diaphragm.
MICRO:
___ UCxr: NGTD
Brief Hospital Course:
___ with a history of pseudotumor cerebri s/p VP shunt ___,
recently s/p shunt repositioning ___ for persistent RLQ pain
who presents with severe RLQ pain associated with nausea.
#RLQ pain: Patient has experienced intermittent, severe RLQ pain
since placement of the VP shunt on ___. She has had three
separated admission for evaluation and management of the pain
(___). She has had extensive
work-up including a dedicated shunt series, pelvic ultrasound,
CT head/abdomen/pelvis as well as neurosurgical and general
surgical evaluations, which did not reveal a cause for her pain.
Patient re-presented after worsening RLQ pain on ___.
Patient underwent a diagnostic laparoscopy on ___ with
re-positioning of shunt to above the liver. Patient again
developed RLQ pain on ___ after discharge associated with
nausea but no vomiting. She reports that the pain was the same
as her prior pain before the catheter was repositioned. Her labs
in the ER were unremarkable and KUB showed no signs of
obstruction, ileus, or transiation point. Her pain was initally
managed with IV/PO dilaudid but transited to PO oxycontin and
oxycodone prn for breakthrough. Surgery was consulted in the ED,
but no acute intervention was deemed necessary. Her abdominal
exam is inconsistent, she reports severe TTP in the RLQ during
the exam, but does not show evidence of any tenderness or
discomfort when abdomen is palpated and she is distracted. A
potential etiology for her pain is the dense pelvis adhesions
which were noted on recent laparoscopy.
Her outpatient providers, including PCP ___
management Dr. ___ surgeon Dr. ___ neurosurgeon
Dr. ___ all contacted. There is suspicion that her
symptoms may be psychosomatic in nature and not due to any
identifiable pathology. On multiple occasions, the patient would
report ___ pain and ask for pain medication, only to be found
sleeping comfortably when staff returned a few minutes later
with her pain medication. She was transitioned to Oxycontin
10mg twice daily (a lower total dose than the short acting
oxycodone she was recently prescribed) and reported an
improvement in her pain with this. She was instructed not to
drive or operate heavy machinery while on this medication.
#OSA: The patient was found to be loudly snoring on multiple
occasions and she states she was previously diagnosed with OSA.
Given that she was started on long acting narcotics this
admission, there is concern that her OSA may worsen with this
sedation. She was advised to wear CPAP at night, which she has
not been doing for many years.
#Chronic issues: All of her chronic medical issues (migraines,
depression/anxiety, HLD, GERD, DM2, HTN) were managed with home
medications as previously prescribed.
#Code status: She was FULL CODE throughout admission.
#Transitional issues:
-Will follow-up with her PCP and pain clinic provider regarding
medication titration
-Encouraged her to wear CPAP and will likely need re-titration
of her CPAP settings
-Started on Oxycontin 10mg bid this admission
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amitriptyline 10 mg PO HS
2. Amlodipine 10 mg PO DAILY
please hodl for sbp<100
3. Aspirin 81 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Divalproex (DELayed Release) 500 mg PO DAILY
6. Enalapril Maleate 10 mg PO DAILY
please hold for sbp<100
7. Gabapentin 600 mg PO TID
8. GlyBURIDE 2.5 mg PO DAILY
9. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
please hold for rr<12 or increased somnolence
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
12. Simvastatin 20 mg PO DAILY
13. Tizanidine 4 mg PO BID
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. Senna 1 TAB PO BID:PRN constipation
16. Acetaminophen 1000 mg PO TID
Discharge Medications:
1. GlyBURIDE 2.5 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Laxative PEG 3350] 17 gram 1
packet by mouth Daily Disp #*30 Packet Refills:*0
3. Oxycodone SR (OxyconTIN) 10 mg PO Q12H pain
Please hold for rr<12 or sedation.
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth Every 12
hours Disp #*10 Tablet Refills:*0
4. Tizanidine 4 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.8 mg/5 mL 1 tablet by mouth Twice daily
Disp #*60 Tablet Refills:*0
7. Omeprazole 40 mg PO DAILY
8. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
please hold for rr<12 or increased somnolence
9. Gabapentin 600 mg PO TID
10. Enalapril Maleate 10 mg PO DAILY
please hold for sbp<100
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily
Disp #*60 Capsule Refills:*0
12. Divalproex (DELayed Release) 500 mg PO DAILY
13. Citalopram 20 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Amlodipine 10 mg PO DAILY
16. Amitriptyline 10 mg PO HS
17. Acetaminophen 1000 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hi Ms. ___,
You were admitted to the hospital on ___ due to pain in
your right abdomen. You recently had a procedure on ___
where your VP shunt was repositioned. There was no evidence of
an infectious process or intestinal obstruction. You were given
pain and nausea medications. We are discharging you with
oxycontin (a long acting pain medication), gabapentin and
Tylenol to manage your pain. Please do not drive or operate
heavy machinery while you take the Oxycontin.
It will likely not be possible to eliminate your pain, the goal
is to reduce the pain to a level such that you can perform your
normal daily activities without difficulty.
We have arranged for follow-up with your PCP ___
pain management with Dr. ___.
Followup Instructions:
___
|
10580201-DS-50 | 10,580,201 | 27,671,075 | DS | 50 | 2140-12-22 00:00:00 | 2140-12-23 08:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with a history of pseudotumor cerebri
s/p VP shunt ___, with laparoscopic adjustment of
intraabdominal shunt ___ secondary to pain, presenting with
persistent RLQ pain. The patient presented similarly on ___
and was treated with pain control only at that time.
Pain is presently described as sharp. Denies N/V/D. Prior w/u
has included CT head/chest/abdomen, shunt series and multiple
laboratory testing. Per notes from outpatient providers, it
appears that depression may be playing a large role in this
patient's somatic complaints. Patient reports she was told her
shunt 'flipped' on most recent KUB however this is not noted in
radiology's read.
In the ED, initial vital signs were9 9.5 93 147/94 18 100% ra.
Labs
including CBC and electrolytes were unremakrable. UA
unremarkable and UCG negative. KUB was unremarkable and shows
the shunt in largely unchanged position. Received 3mg IV
dilaudid and lorazepam without relief. Seen b surgery who denied
surgical intervention and recommended f/u with N/ Surg for
possible removal of the shunt. Admitted to medicine for pain
control.
Past Medical History:
- Migraine headache
- Pseudotumor cerebri
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- Depression
- Pulmonary hypertension and nodules
- Cocaine abuse
- kidney stones
- s/p appendectomy
- s/p cholecystectomy
- s/p hysterectomy (for uterine fibroids)
- s/p septoplasty
- s/p right tympanic cyst removal
- s/p uvulectomy
- s/p hernia repair
Social History:
___
Family History:
Stroke and migraines.
Physical Exam:
VS - 98.2 145/93 78 20 99%RA
GENERAL - Walking around room when I first enter. Subsequently
lies down in bed and c/o severe pain.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - TTP in RLQ, + gaurding, BSx4
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
Pertinent Results:
Laboratory Studies
------------------
___ 08:18PM BLOOD WBC-7.9 RBC-4.21 Hgb-10.5* Hct-33.4*
MCV-79* MCH-24.9* MCHC-31.4 RDW-15.7* Plt ___
___ 08:25PM BLOOD Glucose-104* UreaN-16 Creat-1.0 Na-142
K-3.6 Cl-103 HCO3-24 AnGap-19
___ 08:25PM BLOOD ALT-13 AST-16 LD(LDH)-190 AlkPhos-231*
TotBili-0.3
___ 05:25AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.7
Radiology
---------
CT Abdomen - IMPRESSION: Unchanged appearance of
ventriculoperitoneal shunt terminating in the right lower
quadrant of the abdomen without evidence of fluid collection or
mass.
KUB - IMPRESSION: Normal shunt position. No evidence of bowel
obstruction or free air.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a VP shunt for
pseudotumor and persistent right lower quadrant (RLQ) pain since
shunt placement who presented ___ with worsening of RLQ
pain.
#. RLQ pain - The patient presented with worsening of her
chronic RLQ pain. In the ED, initial labs were unremarkable. A
KUB showed unchanged position of the patient's VP shunt. She
received pain control however remained in ___ abdominal pain.
Seen by surgery who declined operative intervention. Admitted to
medicine for pain control. On the floor the patient continued to
c/o ___ pain. Seen by N. Surg and Surgery who agreed to CT
abdomen. This showed unchanged position of VP shunt. A decision
was made not to surgically intervene. The patient's
amytriptiline was uptitrated and she was given a short course of
vicodin. Discharged on ___.
#. Elevated Alk phos - The patient has had persistently elevated
alk phos over the past year. Her alk phos was > 200 on this
admission. GGT and remainder of LFTs are within normal limits.
Unclear etiology of alk phos elevation but could consider
medication effect. This can be evaluated further on an
outpatient basis.
#. Iron deficienct - Patient with notably low iron checked at
PCPs office recently. Started on iron supplementation here.
#. Vitamin D Deficiency - Vitamin D levels low at PCPs office
recently. Started on vitamin D supplementation.
#. Depression/anxiety - Continued home citalopram and icnreased
amytriptiline
#. IDDM - Held orals and placed on ISS. Restartd orals on
discharge.
#. HTN/HLD - Continued home amlodipine, ACE-I and simvastatin.
#. GERD - Continued home omeprazole HLD, GERD, DM2, HT.
TRANSITIONAL ISSUES:
- Follow-up on elevated alk-phos
- Can continue to uptitrate amytriptiline as tolerated
- F/u vitamin D and iron levels
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amitriptyline 10 mg PO HS
2. Amlodipine 10 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Divalproex (EXTended Release) 500 mg PO DAILY
5. Enalapril Maleate 10 mg PO DAILY
6. Gabapentin 600 mg PO TID
7. GlyBURIDE 2.5 mg PO DAILY
8. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Omeprazole 40 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Tizanidine 4 mg PO BID
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO HS
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Divalproex (EXTended Release) 500 mg PO DAILY
6. Enalapril Maleate 10 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety
9. Omeprazole 40 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Tizanidine 4 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
13. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN
Pain
RX *hydrocodone-acetaminophen 2.5 mg-325 mg 1 tablet(s) by mouth
Every 6 hours Disp #*30 Tablet Refills:*0
14. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
Daily Disp #*30 Capsule Refills:*0
15. GlyBURIDE 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain, Unspecified
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 due to abdominal pain. This has been an
ongoing and difficult problem you have been struggling with. In
the hospital we treated your pain with strong pain medications.
In addition, we determined that there were no emergent medical
problems causing your abdominal pain. You were seen by
neurosurgery and general surgery who felt there was no
intervention indicated at this time. You will be discharged with
close outpatient follow-up.
New Medications:
- INCREASED Amytriptiline
- STARTED Vicodin for a short course until you can be seen by
your outpatient doctors
___ below for instructions regarding follow-up care:
Followup Instructions:
___
|
10580201-DS-51 | 10,580,201 | 27,591,902 | DS | 51 | 2141-05-07 00:00:00 | 2141-05-08 16:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___
Chief Complaint:
Headache, chest pain, "heart racing"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with diabetes mellitus
type 2, hypertension, obstructive sleep apnea, and smoking
abuse who was doing well until two days ago. She has had
intermittent chest pressure and burning sensation over the past
years for which she has received multiple stress test and a
"normal cardiac catheterization one year ago at ___".
She noticed her heart started racing two days ago and then
developed her usual chest pressure though she had radiation to
her jaw and right hand which is the first time she has had that
which prompted her to present to the ED eventually after one
day. She reports her blood pressure was high at home along with
headaches. She does not report nausea/vomiting/shortness of
breath/syncope.
In the ___ ED, 191/107 99%4LNC. She was given nitroglycerin
and IV morphine in the ED which helped a little bit with her
chest pain. CXR and CTA were normal. She was given HCTZ along
with her home carvediolol and admitted to ___ for
further evaluation.
On the floor, she reports her chest pain is essentially
resolved. She had no other complaints.
Past Medical History:
1. Atypical chest pain.
2. Hypertension.
3. Diabetes mellitus.
4. Headaches, migraine.
5. Pseudotumor cerebri status post VP shunt.
6. Obstructive sleep apnea, does not use CPAP machine.
7. Depression.
8. Obesity.
9. Tobacco use, ongoing.
10. Echocardiogram in ___ showed normal left ventricular
wall thickness and regional and global systolic function with
mild elevation of the pulmonary artery systolic pressure. No
significant valvular regurgitation seen.
Social History:
___
Family History:
Stroke and migraines.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS: 98.5 ___ 98%RA
GENERAL: Female in no acute distress
HEENT: NC. NT. Anicteric. MMM
NECK: JVP 8 cm
CHEST: CTAB. No crackles or wheezing noted
HEART: RRR. No murmurs appeciated
ABDOMEN: Obese, normal bowel sounds, soft and nontender.
EXTREMITIES: No edema. No rash
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS: 98.3F, BP 134/83 (sbp 107-134/69-83) HR 76, RR 18,
99% RA
GENERAL: Obese woman in NAD, A&Ox3, appropriate
HEENT: NC. NT. Anicteric. MMM
NECK: JVP difficult to assess due to habitus
CHEST: CTAB. No crackles or wheezing noted. Upper airway noises
obscuring lung sounds
HEART: RRR. No murmurs appeciated
ABDOMEN: Obese, normal bowel sounds, soft and nontender.
EXTREMITIES: No edema. No rash. Bilateral hypopigmentation over
shins
Pertinent Results:
ADMISSION LABS:
___ 07:07PM BLOOD WBC-7.4 RBC-4.59 Hgb-11.7* Hct-37.0
MCV-81* MCH-25.5*# MCHC-31.7 RDW-18.0* Plt ___
___ 07:07PM BLOOD Neuts-65.0 ___ Monos-4.3 Eos-1.1
Baso-0.4
___ 07:07PM BLOOD ___ PTT-22.2* ___
___ 07:07PM BLOOD Glucose-278* UreaN-17 Creat-0.9 Na-139
K-3.5 Cl-99 HCO3-26 AnGap-18
___ 07:40AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.4*
___ 08:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 08:20PM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-4
PERTINENT LABS:
___ 07:07PM BLOOD cTropnT-<0.01
___ 12:15AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:40AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:15PM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-4.6 RBC-4.47 Hgb-11.2* Hct-36.6
MCV-82 MCH-25.0* MCHC-30.6* RDW-17.7* Plt ___
___ 07:40AM BLOOD Glucose-388* UreaN-17 Creat-0.9 Na-137
K-4.2 Cl-96 HCO3-30 AnGap-15
___ 07:40AM BLOOD Calcium-9.8 Phos-3.4 Mg-1.9
EKG ___
Sinus rhythm. Left axis deviation. Right bundle-branch block
with left anterior fascicular block. Left ventricular
hypertrophy with associated ST-T wave changes, although ischemia
or myocardial infarction cannot be excluded. Compared to the
previous tracing of ___ there is no significant change.
IMAGING:
CTA chest ___
IMPRESSION:
1. No evidence of aortic dissection or central pulmonary artery
embolism.
The study is not technically adequate for assessment of
subsegmental pulmonary arteries.
2. Small hiatal hernia.
CXR ___
FINDINGS: A ventriculoperitoneal shunt courses across the right
side of the thorax. Its distal course is very difficult to
delineate because of underpenetration. The mediastinal and
hilar contours appear unchanged. There is similar mild
cardiomegaly. The lungs appear clear. There are no pleural
effusions or pneumothorax.
IMPRESSION: No evidence of acute disease.
Brief Hospital Course:
Ms. ___ is a ___ year old female diabetes mellitus type 2,
hypertension, obstructive sleep apnea, and tobacco abuse who
presents with 4 days of headache, one day of palpitations and
chest pressure, found to have hypertensive urgency which
resolved with adjustment in home medications.
# Atypical chest pain: Multiple cardiac risk factors including
HTN, HL, DM, but extensive work up in multiple admissions has
been negative for ischemia or CAD. Per report, has had normal
coronary cath in the last year at ___, last cath here ___
showed minimal disease. Report from ___ was
requested but unavailable at the time of this discharge summary.
Has been seen by cardiology in the past (Dr. ___ ___ who
described similar pain episodes, wich was not felt to be cardiac
in nature at that time. It is possible she could have developed
clincially significant coronary disease since prior work up, but
given the fact that she has had multiple stress tests, coronary
caths, and four sets of troponins negative since this
presentation, other etiologies more likely. Hypertensive urgency
could be causing demand ischemia, but would expect to see some
troponins. Noncardiac causes such as GERD or reactive airway
disease also possible, however no relief with antacids or
bronchodilators. CT angiogram of the chest was negative for
pulmonary embolism. Symptomatic relief has been challenging as
patient reports tongue swelling and rash with any NSAIDS, and
severe headache with nitroglycerin. She was discharged with
reassurance that her recurrent pain is unlikely cardiac, and
given instructions to seek medical attention if the pain
episodes should change in character or intensity.
# Hypertensive urgency: Headache, chest pain concerning for
symptomatic hypertension with BPs 170s-180s on admission. Has
had extensive work up in the past that has been negative,
including ultrasound with dopplers for renal artery stenosis,
urine metanephrines. No aortic coarctation on echo. Untreated
OSA, genetic predisposition, diet, and obesity remain likely
contributing factors. Continued enalipril 10mg QAM and 20mg QPM,
imdur 30mg daily, propanolol LA 120mg daily (thought to be
possibly also for migraine prophylaxis, but unclear), amlodipine
10mg daily. Her carvedilol was increased from 6.25mg BID to
12.5mg BID with good effect.
# Headache: Most likely from hypertensive urgency. Also possibly
chronic migraines. Treated hypertension as above, gave standing
acetaminophen with little effect, and continued other home
medications including divalproex ER 500mg daily, gabapentin
600mg TID, amitriptyline 10mg QHS. She was encouraged to try to
reschedule her headache clinic appointment (currently in ___, and a message was left over the weekend by the medical
team at the clinic to request an earlier appointment as well
within a month. She was also encouraged to seek referral to
sleep medicine again for repeat fitting for CPAP for OSA if
necessary, as could be contributing to both headaches and
hypertension.
# Hyperlipidemia: continued atorvastatin 20mg daily
# Type 2 DM: Held home metformin, glyburide and covered with
insulin sliding scale as inpatient; sugars were noted to be
difficult to control, frequently in 300s and asymptomatic.
Patient was encouraged to discuss with her PCP.
# GERD: continued omeprazole 40mg daily and calcium carbonate
# Nutrition: continued iron supplementation
TRANSITIONAL ISSUES:
- Code status: Full; Daughter ___ is intended HCP
___ or ___ but patient has not filled out form
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY Start: In am
2. Carvedilol 6.25 mg PO BID
Hold for SBP < 95 or HR < 65
3. GlyBURIDE 1.25 mg PO BID
4. Divalproex (EXTended Release) 500 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Hold for SBP < 90
6. Calcium Carbonate 500 mg PO BID
7. Amlodipine 10 mg PO DAILY
Hold for SBP < 95
8. MetFORMIN (Glucophage) 250 mg PO BID
9. Enalapril Maleate 10 mg PO QAM
Hold for SBP < 95
10. Enalapril Maleate 20 mg PO QPM
Hold for SBP < 95
11. Omeprazole 40 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. Amitriptyline 10 mg PO HS
14. Ferrous Sulfate 325 mg PO DAILY
15. Propranolol LA 120 mg PO DAILY Start: In am
Hold for SBP < 95
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Divalproex (EXTended Release) 500 mg PO DAILY
7. Enalapril Maleate 10 mg PO QAM
8. Enalapril Maleate 20 mg PO QPM
9. Ferrous Sulfate 325 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Propranolol LA 120 mg PO DAILY
RX *propranolol 120 mg 1 capsule by mouth once a day Disp #*30
Capsule Refills:*0
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Gabapentin 600 mg PO TID
14. GlyBURIDE 1.25 mg PO BID
15. MetFORMIN (Glucophage) 250 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertensive urgency
Secondary: atypical chest pain, migraine heachaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with headache and chest pain and were found to
have a very high blood pressure. Your medications were adjusted
and your blood pressure and symptoms improved and you were able
to be discharged home. Your blood tests and EKGs show that your
chest pain was NOT from a heart attack.
Please follow up with your primary care doctor regarding your
headaches and your high blood sugars. You may need some
adjustments to your diabetes medications. Please consider
rescheduling your appointment at the headache clinic for sooner
than ___ if possible. We have called and left a message asking
them to accomodate you within a month if they are able. Also
consider asking your primary care doctor for another sleep
medicine referral to see about CPAP options for your obstructive
sleep apnea.
Followup Instructions:
___
|
10580201-DS-54 | 10,580,201 | 23,978,253 | DS | 54 | 2144-10-29 00:00:00 | 2144-10-30 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with CAD, HTN, T2DM, and
recent admission for chest pain deemed noncardiac, who presents
with chest and abdominal pain.
The patient shares that on ___ she began to experience central
chest pressure that was worsened with movement. The pain was a
___, radiated to her back, associated with diaphoresis but no
shortness of breath, no nausea or vomiting, no paresthesias. Of
note, she was recently discharged ___ for chest pain, during
which she had negative troponins, no EKG changes, and a normal
stress test. She also had a coronary angiogram at that time that
was unrevealing. CTA at that admission was negative for PE.
In the ED, initial vitals were: T:98.8 HR:69 BP:114/83 RR:16 99%
RA. Pain was unrelieved by 3 doses of nitroglycerin, ECG
unchanged from baseline, trops negative x2, proBNP 113. CTA
chest negative for PE. Patient shares that around the time she
was having the CTA, her pain migrated to her abdomen. She was
having ___ stabbing pain in her left and right abdomen, but
worse in the RUQ. This pain was exacerbated by deep breaths, and
she has never had anything like it before. She says the pain was
somewhat relieved with dilaudid. Labs were notable for normal
lipase and LFTs (expected elevated AP, that was stable), and
normal lactate. She had a CT AP that was unrevealing for the
source of her pain. As above, she was given dilaudid for the
pain. She was also given viscous lidocaine and normal saline.
On the floor, the patient shares her pain had gone down to ___.
She also shares that over the past month she has been having
watery nonbloody diarrhea in the morning. She has had no melena
or hematochezia. She did have one episode of nausea and vomiting
1 week ago, but this lasted for one day and resolved.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY: CAD with no history of stent. Cardiac cath
at ___ in ___
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Migraines
- Pseudotumor cerebri status post VP shunt.
- Obstructive sleep apnea, does not use CPAP
- Depression
- Obesity
Social History:
___
Family History:
DMII in mother, sister, brother. CAD in mother, grandmother. HTN
in multiple family members.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vital Signs: T98.5 BP162/86 HR65 RR18 O296 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly distended, epigastrum and RUQ tender
GU: No foley
Ext: Warm, well perfused, no edema
Neuro: AOx3, grossly intact.
PHYSICAL EXAM ON DISCHARGE:
===========================
Vital Signs: T98.5 BP162/86 HR65 RR18 O296 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, submandibular and sublingual
lymphadenopathy
CV: Exam somewhat difficult due to body habitus; regular rate
and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Poor inspiratory effort
Abdomen: Soft, non-distended, tender to palpation in epigastrum
and RUQ, referred pain to RUQ on LLQ palpation.
GU: No foley. No CVAT tenderness but discomfort from 'vibration'
Ext: Warm, well perfused, no edema
Neuro: AOx3, grossly intact.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 08:14PM WBC-6.7 RBC-4.04 HGB-10.1* HCT-33.6* MCV-83
MCH-25.0* MCHC-30.1* RDW-16.4* RDWSD-49.0*
___ 08:14PM NEUTS-64.7 ___ MONOS-5.4 EOS-2.1
BASOS-0.3 IM ___ AbsNeut-4.34 AbsLymp-1.82 AbsMono-0.36
AbsEos-0.14 AbsBaso-0.02
___ 08:14PM ___ PTT-27.7 ___
___ 08:14PM proBNP-113
___ 08:14PM cTropnT-<0.01
___ 08:14PM ALT(SGPT)-13 AST(SGOT)-29 ALK PHOS-130* TOT
BILI-0.4
___ 08:14PM LIPASE-36
___ 08:14PM GLUCOSE-147* UREA N-15 CREAT-1.1 SODIUM-140
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-22 ANION GAP-18
___ 08:19PM LACTATE-1.8
___ 02:20AM cTropnT-<0.01
___ 09:54PM K+-3.7
MICRO:
=====
None
STUDIES:
========
KUB ___:
1. No free intraperitoneal air.
2. Nonobstructive bowel gas pattern.
Abdominal US ___:
IMPRESSION:
1. Limited exam secondary to patient body habitus.
2. Slightly 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.
3. Otherwise, normal abdominal ultrasound.
CT ABDOMEN/PELVIS ___:
IMPRESSION:
1. No CT evidence to explain patient's symptoms. Specifically,
no free fluid or colitis.
2. Partially visualized ventriculoperitoneal shunt with its tip
located along the right anterior abdominal wall between the
transverse colon and abdomen
CTA CHEST ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Dilated main pulmonary artery is suggestive of pulmonary
artery
hypertension.
ECG:
NSR. LAD, RBBB and LAFB (stable). LVH.
LABS ON DISCHARGE:
===================
___ 05:00PM BLOOD WBC-6.4 RBC-3.94 Hgb-9.9* Hct-32.9*
MCV-84 MCH-25.1* MCHC-30.1* RDW-15.9* RDWSD-48.6* Plt ___
___ 05:00PM BLOOD Glucose-236* UreaN-14 Creat-1.0 Na-140
K-3.8 Cl-102 HCO3-23 AnGap-19
___ 05:00PM BLOOD ALT-12 AST-11 AlkPhos-134* TotBili-0.4
___ 05:00PM BLOOD Albumin-3.7 Calcium-8.3* Phos-3.1 Mg-2.1
___ 05:12PM BLOOD Lactate-1.5
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with CAD, HTN, T2DM, and
recent admission for chest pain deemed noncardiac, who presented
to the ED by EMS initially with chest pain and subsequently with
abdominal pain. Pt's pain on presentation was noted to be
central sternal, radiating to the back. However, ECG and
troponins x2 were negative for ACS, and recent workup had
revealed no concerning cardiac pathology. CT PE did not reveal
any evidence of pulmonary embolism, aortic dissection or other
process. The chest pain resolved during the patient's stay in
the ED, but she simultaneously developed intermittent cramping
abdominal pain, worse in the RUQ and epigastrium. Pt is s/p
cholecystectomy ___ years ago. She did not endorse any nausea or
vomiting, hematochezia, melena, hematemesis. LFTs were only
notable for isolated elevated ALP, and lipase was normal. UA was
unremarkable, specifically no RBCs to raise suspicion for
nephrolithiasis. Abdominal US was unremarkable. CT A/P with
contrast was unremarkable. Stool was guaiac negative. Lactate
was normal. Pain did not limit the patient's ability to ambulate
or eat, but persisted throughout the hospitalization. Because of
ongoing symptoms, repeat imaging with KUB was obtained, which
did not show evidence of free air in the peritoneum or
obstruction. Ultimately, pain was attributed to gastritis given
h/o gastritis in past with prior EGD in ___. Patient's
pantoprazole was increased to BID, famotidine was added qhs for
symptom management.
Finally, pt had reported history of month-long ongoing watery
diarrhea, C diff negative. She stated her last episode of
diarrhea was in the ED yesterday. Last colonoscopy was performed
___ year ago and per pt was normal. Given guaiac negative stool,
no evidence of infection, no pain or evidence of dehydration
secondary to diarrhea, further workup was deferred to outpatient
setting.
CHRONIC ISSUES:
===============
#CAD: Continued home carvedilol, aspirin, atorvastatin
#T2DM: held home metformin. Placed pt on ISS. Continued home
gabapentin
#HTN: continued home amlodipine
#Depression: continue home sertraline
TRANSITIONAL ISSUES:
====================
[ ] Increase home pantoprazole to 40 mg BID
[ ] Add famotidine 20 mg qhs
[ ] Recommend pt follows up with PCP within ___ week of discharge
to review symptoms and any improvement with medical management
[ ] Recommend pt follows up with Gastroenterology for workup of
her epigastric pain and diarrhea. Consider obtaining an EGD to
rule out gastritis or PUD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 25 mg PO BID
5. Cetirizine 10 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Famotidine 20 mg PO QHS
RX *famotidine 20 mg 1 tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Carvedilol 25 mg PO BID
7. Cetirizine 10 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
===================
Non-cardiac chest pain
Abdominal pain
Secondary diagnoses:
====================
Hypertension
Hyperlipidemia
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 at ___
___!
Why were you hospitalized?
-You were hospitalized because you developed pain in your chest
and your abdomen.
What was done in the hospital?
-You had labs and EKG that showed you were not having a heart
attack.
-You had a scan of your chest that showed you were not having a
pulmonary embolism or dissection, or tear, in your aorta.
-You had ultrasound of your liver that was normal
-You had CT scan of your abdomen and X-ray of your abdomen that
were also normal.
-You had lab tests that showed your blood counts and
electrolytes were all normal. Additional lab tests (lactate)
were normal and showed that enough blood was reaching all of
your internal organs.
-You were started on new medication for possible gastritis or
stomach ulcer, and your pantoprazole dose was increased to twice
a day.
What should you do after leaving the hospital?
-Take your pantoprazole twice daily, and start an additional
medicine (famotidine) in the evenings to reduce your stomach
acid.
-We recommend that you follow-up with you PCP in ___ within
a week of your hospitalization.
-We recommend that you discuss with your PCP getting ___ referral
to see a Gastroenterologist (GI doctor), who can evaluate your
abdominal pain, as well as your diarrhea.
We wish you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10580201-DS-56 | 10,580,201 | 20,308,499 | DS | 56 | 2145-10-24 00:00:00 | 2145-10-26 07:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
Chest pain/ weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ PMH CAD s/p stenting to
RCA
(unclear when placed), T2DM, HTN, HLD, anxiety, depression &
pseudotumor cerebri presenting w/ CP and weight gain. She
states
that the CP began 2 days w/ no inciting factor. Has been
consistent w/o aggravating or alleviating factors, described as
___ substernal squeezing w/ radiation to the neck and left arm,
not responsive to nitroglycerin. Admits associated nausea, SOB
and light-headedness. States this pain is similar to when she
had
her MI and similar to the pain she has experienced
intermittently
over the last 3 months. She denies fevers, chills, HA, vomiting,
abdominal pain, dysuria, syncope.
In addition, the patient states that she had a 14-pound weight
gain over the past 2 days, although per chart she weighed
233.91-lb on ___ and current weight is 239.2. She states that
her PCP stopped her HCTZ ___ due to hypokalemia. She notes no
other medication changes or non-compliance, no dietary changes,
no recent illnesses.
Of note, she had a recent admission ___ ___uring
which she underwent cardiac catheterization that showed 30%
proximal & mid-RCA disease w/ patent distal RCA stent. She
otherwise had no grade flow-limiting lesions or microvascular
dysfunction. On that admission, per GI, the CP was ultimately
felt to be esophageal in nature, and a trial of PPI & antacids
was recommended w/ outpatient EGD. She never received this EGD.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY: CAD with no history of stent. Cardiac cath
at ___ in ___
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Migraines
- Pseudotumor cerebri status post VP shunt.
- Obstructive sleep apnea, does not use CPAP
- Depression
- Obesity
Social History:
___
Family History:
DMII in mother, sister, brother. CAD in mother, grandmother. HTN
in multiple family members.
Physical Exam:
ADMISSION PHYSICAL EXAM
===============================
T 98.3 BP 127/80 HR 56 RR 20 O2 94%
General: Middle-aged female, sitting in bed, endorsing CP,
pleasant, cooperative.
Head: NC/AT, sclera anicteric, conjunctiva clear.
Neck: JVP to earlobe, +HJR.
Cardiac: Normal S1, S2 w/o m/r/g.
Respiratory: Poor air movement, end-expiratory wheezing, no
crackles.
Abdomen: Soft, NT, ND, no organomegaly.
Extremities: 1+ edema, WWP, intact distal pulses.
DISCHARGE PHYSICAL EXAM
===============================
VITALS: Tc 98.1 134/84 70 21/ 99% RA
Weight: 107.9 kg
Admission weight: 108.5 kg
GENERAL: lying in bed, A/Ox3, NAD
HEENT: PERRLA, EOMI, sclera anicteric, no facial drooping
CV: RRR, no murmurs, crackles, or rubs, 2+ radial and distal
pulses, JVP difficult to appreciate given body habitus
RESP: no breath sounds bilaterally posteriorly, no wheezes,
crackles, bilateral rhonchi with expiration anteriorly,
decreased
respiratory effort, not using accessory muscles for respirations
GI: soft, non-distended, no tenderness to palpation, +BS
MSK: moving all extremities freely, history of R TKR
SKIN: acanthosis nigricans present bilaterally at base of neck
NEURO: no pronator drift, CN II-XII grossly intact, moving all
extremities freely
EXTREMITIES: No lower extremity edema or venous stasis changes
Pertinent Results:
ADMISSION LABS
==========================
___ 03:52AM BLOOD Neuts-71.7* ___ Monos-5.9 Eos-1.8
Baso-0.2 Im ___ AbsNeut-4.48 AbsLymp-1.24 AbsMono-0.37
AbsEos-0.11 AbsBaso-0.01
___ 03:52AM BLOOD ___ PTT-25.5 ___
___ 03:52AM BLOOD Glucose-208* UreaN-11 Creat-0.9 Na-141
K-4.0 Cl-99 HCO3-28 AnGap-14
___ 03:18PM BLOOD ALT-18 AST-15 AlkPhos-180* TotBili-0.4
___ 03:18PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.5*
PERTINENT LABS
==========================
___ 03:52AM BLOOD cTropnT-<0.01
___ 09:00AM BLOOD cTropnT-<0.01
___ 03:18PM BLOOD cTropnT-<0.01 proBNP-487*
___ 05:45AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:30AM BLOOD D-Dimer-694*
RELEVANT STUDIES
==========================
___ CT HEAD W/O CONTRAST: 1. No evidence of large vascular
territory infarction, hemorrhage, edema, or mass. No evidence of
fracture. 2. Right ventriculostomy shunt the terminates at the
level of the third ventricle. Ventricle size remains unchanged
from prior CT head ___.
___ CTA CHEST: 1. No evidence of pulmonary embolism or
aortic abnormality. 2. Unchanged dilation of the main pulmonary
artery, which can be seen in pulmonary arterial hypertension. 3.
Stable 4mm right middle lobe nodule.
___ Unilateral Lower Extremity Veins: No evidence of deep
venous thrombosis in the right lower extremity veins.
MICRO STUDIES
==========================
___ Urine Cx: URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS
==========================
___ 05:35AM BLOOD WBC-4.6 RBC-3.99 Hgb-10.1* Hct-33.2*
MCV-83 MCH-25.3* MCHC-30.4* RDW-16.8* RDWSD-49.7* Plt ___
___ 05:35AM BLOOD ___ PTT-27.9 ___
___ 05:35AM BLOOD Glucose-224* UreaN-18 Creat-1.1 Na-141
K-4.2 Cl-100 HCO3-27 AnGap-14
___ 05:35AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.2
Brief Hospital Course:
___ is a ___ yo F w/ ___ CAD s/p RCA stent, DM
II, HTN, HLD, anxiety, depression, pseudotumor cerebri s/p VP
shunt who presented with chest pain and weight gain. She had
been recently hospitalized in ___ for chest pain and had
coronary angiography with no intervention. Her home Lasix had
been switched in ___ to HCTZ, which was stopped one week prior
to presentation due to hypokalemia. She had gained six pounds
from baseline when she presented. Her chest pain was
unresponsive to nitroglycerin and her troponins were negative
x3. She had an EKG which was initially unchanged but then repeat
EKG showed inverted T waves in III, aVF on the floor. These EKG
changes were felt to be non-specific. D-dimer was mildly
elevated. She was diuresed with IV Lasix, which did not improve
her symptoms.
Suddenly on ___ AM she developed voice hoarseness, shortness of
breath, and somnolence on ___ and was triggered. She had a
normal respiratory rate and was not hypoxemic during this
episode. CTA chest was negative for PE. CT head was
unremarkable. CXR did not show any abnormalities. She had
similar episodes on ___ and ___. ENT was consulted and scoped
her vocal cords which had findings consistent with GERD. They
felt that although no evidence was seen on scope, her episodes
were potentially consistent with paradoxical vocal fold motion.
With deep breathing and a nebulizer these episodes improved, and
the patient never had any desaturation during them.
Her chest pain was not thought to be cardiac in nature. She was
instructed to follow-up with GI for evaluation of GERD with
outpatient EGD. Additionally, she had a history of requiring
albuterol inhaler and was scheduled for pulmonology follow-up
for possible undiagnosed COPD or asthma. Both of these were
thought to be potentially etiologies.
Acute issues:
#RLE swelling: Patient's right leg circumference was greater
than her left and her popliteal fossa was tender to palpation.
She had a history of right total knee replacement. She had a
lower extremity U/S which showed no evidence of DVT.
Chronic issues:
#HFpEF: Patient was initially diuresed with IV Lasix as she
presented with weight gain. However, she did not appear volume
overloaded and diuresis was held for the rest of her admission.
TRANSITIONAL ISSUES:
============================
Health care proxy: Proxy name: ___
___: Daughter Phone: ___
Code status: Full presumed
Discharge weight: 107.9 kg (237.87 lb)
[ ] Please follow-up on recent weight gain. Consider re-starting
furosemide if patient appears volume overloaded. Her weight was
stable here, so diuretics were held at discharge.
[ ] Please follow-up on patient's acute onset SOB/voice
hoarseness. Differential included paradoxical vocal cord
movement v. allergic reaction, although nothing in the hospital
or immediate vicinity was identified. ENT recommended prn Ativan
which can sometimes improve paradoxical vocal cord movement.
[ ] Obtain PFTs. There was suspicion of undiagnosed COPD given
chest pain and very poor air movement in the lungs. Patient sent
home with Spiriva and albuterol inhaler.
[ ] Follow-up on patient's GERD, chest pain, and any improvement
while on PPI/H2 blocker.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY
2. Clopidogrel 75 mg PO DAILY
3. Carvedilol 25 mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. TraZODone 50 mg PO QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. GlipiZIDE 10 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Furosemide 20 mg PO DAILY
13. Atorvastatin 80 mg PO QPM
14. ClonazePAM 0.5 mg PO BID:PRN anxiety
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
RX *albuterol sulfate [Proventil HFA] 90 mcg 2 puffs INH every
four hours Disp #*1 Inhaler Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Furosemide 20 mg PO DAILY:PRN Weight gain
Weigh yourself daily in the morning. If you gain more than 3
pounds, call your PCP.
RX *furosemide 20 mg 1 tablet(s) by mouth PRN Disp #*30 Tablet
Refills:*0
4. Ranitidine 300 mg PO QHS
RX *ranitidine HCl 300 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
5. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule INH daily Disp #*30 Capsule Refills:*0
6. amLODIPine 10 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Carvedilol 25 mg PO DAILY
9. ClonazePAM 0.5 mg PO BID:PRN anxiety
10. Clopidogrel 75 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. GlipiZIDE 10 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
14. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY
15. Levothyroxine Sodium 75 mcg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Pantoprazole 40 mg PO Q24H
18. TraZODone 50 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Atypical chest pain, non-cardiac in origin
Acute onset dysphonia
Secondary diagnosis:
Coronary artery disease
Heart failure with preserved ejection fraction
Hypertension
Anxiety
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 having chest pain and recent weight gain.
What was done for me while I was here?
- You had CT scans which showed no evidence of blood clots in
your lung or your legs.
- You had tests to see if your chest pain was due to a heart
attack. These tests showed you were not having a heart attack.
- You were given nebulizers to decrease your acute shortness of
breath.
What should I do when I go home?
- You should take all of your medications as prescribed.
- You should follow up with GI, pulmonology, and your PCP.
- You should weigh yourself daily. Your discharge weight is
107.9 kg (237.87 lb) . If you gain more than 3 pounds, you
should call your primary care doctor and ask them how much Lasix
to take.
We wish you the best.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10580201-DS-59 | 10,580,201 | 23,658,578 | DS | 59 | 2146-01-05 00:00:00 | 2146-01-05 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F HTN, DM, CHF, newly diagnosed Afib on rivaroxaban, CAD
w/
recent MI in ___ s/p RCA stent with LHC ___ showing no
obstructions but watershed/small vessel disease.
She presented to the ED with substernal chest pressure since ___
pm last night, ___ at its worst, not relieved by SLN,
improving
to ___, now back to ___. Pain feels like a general pressure,
occurs at rest, radiates to arm and back, and even jaw
sometimes,
made worse with activity. Took nitro x3 last night, pain
improved
from ___ to ___. Sometimes her chest pain is relieved by
nitro, sometimes not. The pain feels distinct from her acid
reflux, which she describes as "sour" pain. Is associated with
nausea, but has not vomited. Denies fever/chills, headache,
cough, abdominal pain, changes in bowel habits, melena/BRBPR, or
urinary symptoms. No SOB/diaphoresis. She denies feeling anxious
about her heart health, states she does not spend a lot of time
ruminating or worrying about having a heart attack. Denies that
the recent increase in her IMDUR dose from 90 to 120 mg daily
had
any effect. Was unable to fill her ranolazine due to a high
copay.
Seen by cards in ED, given negative troponins thought to be
likely microvascular ischemic disease vs non-cardiac chest pain.
Had appt for cardiology after previous hospitalization, but
missed appointment for a reason she cannot recall, now has
cardiology appt on ___.
Of note, has been evaluated for chest pain multiple times
recently as below:
-___ admitted to ___ for chest pain work up
-___ admitted ___ for CP, negative cardiac workup,
d/c
with ranolazine and uptitration of imdur
-___ ___ negative cards workup
-___ ___ ED negative cards workup
Upon review of OMR notes, multiple nursing phone calls to
patient
show numerous other episodes of chest pain, sometimes relieved
by
nitro and sometimes not.
Past Medical History:
1. CARDIAC RISK FACTORS
- HTN, HLD, T2DM
2. CARDIAC HISTORY
- DES to RPL ___ @ ___ on DAPT
3. OTHER PAST MEDICAL HISTORY
- Migraines
- Pseudotumor cerebri status post VP shunt.
- Obstructive sleep apnea, does not use CPAP
- Depression
- Obesity
- Hypothyrodism
- ?TIA early ___ per pt
- CCY
- Appendectomy
- Right knee replacement
Social History:
___
Family History:
DM, CAD, HTN all in multiple family members
Physical ___ Physical Exam:
Vitals- 98.2
PO 157 / 74 59 18 98 RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival
pallor or injection, sclera anicteric and without injection. ___
clear bilaterally with normal light reflex. Turbinates
non-edematous with clear discharge. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: Thyroid is normal in size and texture, no nodules. 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. No wheezes, rhonchi or rales.
Resonant to percussion.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait is
normal.
Discharge Physical Exam:
VITALS: 97.9 PO 135 / 76 Sitting 59 18 97 Ra
GENERAL: AOx3, NAD
EYES: PERRLA, EOMI
ENT: oropharynx clear, normocephalic, atraumatic, anicteric
sclera
CV: RRR, no m/r/g, no JVD
RESP: diffuse mild wheezes
GI: S, NTND
MSK: no ___ edema
SKIN: wwp
Pertinent Results:
Admission Labs:
___ 02:15AM BLOOD WBC-5.9 RBC-3.90 Hgb-10.2* Hct-32.5*
MCV-83 MCH-26.2 MCHC-31.4* RDW-16.2* RDWSD-48.1* Plt ___
___ 02:15AM BLOOD Neuts-75.4* Lymphs-15.3* Monos-6.3
Eos-2.4 Baso-0.3 Im ___ AbsNeut-4.44 AbsLymp-0.90*
AbsMono-0.37 AbsEos-0.14 AbsBaso-0.02
___ 05:45AM BLOOD ___ PTT-28.6 ___
___ 02:15AM BLOOD Plt ___
___ 02:15AM BLOOD Glucose-138* UreaN-14 Creat-0.9 Na-141
K-5.2* Cl-101 HCO3-26 AnGap-14
___ 02:15AM BLOOD cTropnT-<0.01
___ 02:15AM BLOOD proBNP-903*
___ 07:32AM BLOOD Glucose-176* Na-140 K-3.3 Cl-101
calHCO3-30
___ 05:01AM BLOOD K-4.5
___ 07:32AM BLOOD Hgb-10.7* calcHCT-32
Discharge and Notable Labs:
___ 06:40AM BLOOD WBC-4.5 RBC-4.13 Hgb-10.6* Hct-34.6
MCV-84 MCH-25.7* MCHC-30.6* RDW-16.2* RDWSD-48.5* Plt ___
___ 12:00AM BLOOD ___ PTT-37.1* ___
___ 06:40AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-142
K-4.1 Cl-101 HCO3-29 AnGap-12
___ 11:02AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:08AM BLOOD cTropnT-<0.01
___ 08:01AM BLOOD cTropnT-<0.01
___ 02:15AM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0
___ 02:57PM BLOOD TSH-0.69
Studies:
CTA Chest ___
FINDINGS:
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. The main pulmonary artery is persistently
enlarged,
measuring up to 3.8 cm (series 2: Image 46), which can be seen
in pulmonary
artery hypertension. There is bovine arch configuration, a
normal anatomic
variant. The heart appears prominent in size, but unchanged.
There is no
pericardial effusion. Atherosclerotic calcifications are again
seen along the
coronary arteries.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is a nonspecific focus of ground-glass
opacity in the
right upper lobe, which may be of infectious or inflammatory
etiology (series
2: Image 37) and is new. There is mild atelectasis dependently
in the lung
bases. A 4 mm pulmonary nodule seen along the right minor
fissure, unchanged,
likely perifissural lymph node (series 3: Image 115). A
calcified granuloma
is also noted in the right middle lobe. Otherwise, there is no
focal
parenchymal opacification. The airways are patent to the level
of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
Incidental note is made of a presumed VP shunt extending along
the anterior
chest wall and into the right upper quadrant.
ABDOMEN: Included portion of the upper abdomen is remarkable
for an accessory
spleen and a small hiatal hernia.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. There is a nonspecific focus of ground-glass opacity in the
right upper
lobe, which may be of infectious or inflammatory etiology.
3. Unchanged enlargement of the main pulmonary artery, measuring
up to 3.8 cm,
which can be seen in pulmonary artery hypertension.
4. Stable appearance of a 4 mm pulmonary nodule along the right
major fissure,
likely perifissural lymph node.
CHEST (PA & LAT) Study Date of ___ 3:00 AM
FINDINGS:
Again seen is shunt catheter projecting over the chest wall
anteriorly, the
full course of which is not fully visualized. The lung volume
is small,
exaggerating bronchovascular markings. No focal consolidation
to suggest
pneumonia. There is bibasilar atelectasis. The pulmonary
vasculature is
unremarkable. No pleural effusion or pneumothorax. The
cardiomediastinal
silhouette is unchanged. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
Ms ___ is a ___ YO F with PMH HTN, DM, HFpEF, recently
diagnosed AFib on ___ on xarelto, CAD with MI s/p stent to RCA
in ___ and LHC showing microvascular disease,
anxiety/depression, and numerous ED visits and hospitalizations
in the past several weeks for chest pain, presenting with
typical
chest pain, negative troponins/EKG, admitted to medicine for
management of her pain. EKGs repeatedly showed no ischemic
changes and cardiac biomarkers were negative. Cardiology was
consulted, pain felt to likely be a combination of microvascular
disease, musculoskeletal disease, stress and anxiety, and poorly
controlled hypertension. She was discharged and will follow up
with cardiology, GI, and her PCP.
ACUTE/ACTIVE PROBLEMS:
#Chest Pain
Patient has history of CAD with recent MI in ___. Had stent to
RCA done at ___ ___. Cath in ___
showed
patent stent and significant microvascular disease. Recently
hospitalized here one month prior, had IMDUR dose increased and
started on ranolazine (although too expensive for patient to
fill). Over the past several weeks, has had multiple ED visits
and hospitalizations for chest pain, each time ruled out for
ACS. During this admission she had multiple EKGs performed
without ST segment changes, nitro did not improve pain, and
cardiac biomarkers were negative. Cardiology was consulted
during this admission as well. It was felt that chest pain was
likely a combination of microvascular disease, musculoskeletal
disease, stress and anxiety, and poorly controlled hypertension.
She had no evidence of restenosis or in stent thrombosis. She
also had no evidence of pericarditis or coronary dissection. Her
coreg was split to 12.5 mg bid from 25 mg daily. Her nifedipine
was increased to 60 mg daily from 30 mg daily. She has a known
history of gastritis,and EGD was recommended previously but not
done. She was given GI cocktail and ranitidine with little
relief. Pt will follow up with PCP, ___, and GI for
further evaluation and long term management of symptoms.
#Atrial Fibrillation
Newly diagnosed on prior ED visit on ___. EKG at that time
shows AFib (in OMR). CHADSVASC 7 (F, HTN, DM,
CHF, TIA hx, MI). Home xarelto was continued. Coreg was modified
as above. She remained in sinus rhythm during admission.
CHRONIC/STABLE PROBLEMS:
# CAD s/p stent ___.
Continued Aspirin, Plavix, atorva as above.
# HFpEF. TTE showed preserved systolic function.
Conitnued Lasix 20 mg PO QD
# HTN
Patient's HTN was uncontrolled during this admission. Split
Carvedilol 25mg BID. Increased nifedipine to 60 mg daily from 30
mg daily and BP improved. Continued Losartan 50mg daily
# Normocytic Anemia:
Near baseline, Continued home iron
# T2DM
Held metformin, glipizide, gave ISS. Resume home meds on d/c.
# Anxiety/depression
Continued ClonazePAM 0.5 mg PO BID:PRN anxiety, Sertraline 200
mg PO DAILY
# GERD
Reduced home pantoprazole to 40 mg po daily from bid dosing.
Referred to GI for OP f/u to consider EGD.
# Hypothyroidism
TSH wnl. Continued levothyroxine.
# Asthma
Continued Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing. Patient
had wheezing requiring nebulizer while hospitalized. Of note, on
two occasions her voice became high and tight, although she did
not describe any SOB or difficulty breathing, and this resolved
on its own within an hour or so. Patient would likely benefit
from PFTs as an outpatient.
Transitional Issues:
#Chest Pain
-f/u with PCP
-___ with cardiology
-f/u with GI
#H/o gastritis
-f/u with GI
-may benefit from EGD
-CHANGED pantoprazole to 40 mg once daily from bid dosing
-STARTED ranitidine 150 mg bid prn heartburn/chest pain
#HTN
-CHANGED coreg to 12.5 mg bid from 25 mg daily
-CHANGED nifedipine to 60 mg daily
#Asthma
-may benefit from repeat PFTs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 25 mg PO BID
5. ClonazePAM 0.5 mg PO BID:PRN anxiety
6. Clopidogrel 75 mg PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. NIFEdipine (Extended Release) 30 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Sertraline 200 mg PO DAILY
14. TraZODone 50 mg PO QHS
15. Fluticasone Propionate NASAL 2 SPRY NS DAILY congestion
16. GlipiZIDE 10 mg PO DAILY
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
19. Ranolazine ER 500 mg PO BID
20. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Ranitidine 150 mg PO BID:PRN heartburn or chest pain
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*2
2. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*2
3. NIFEdipine (Extended Release) 60 mg PO DAILY
RX *nifedipine [Adalat CC] 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q24H Disp #*30
Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. ClonazePAM 0.5 mg PO BID:PRN anxiety
9. Clopidogrel 75 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Fluticasone Propionate NASAL 2 SPRY NS DAILY congestion
12. Furosemide 20 mg PO DAILY
13. GlipiZIDE 10 mg PO DAILY
14. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
15. Levothyroxine Sodium 75 mcg PO DAILY
16. Losartan Potassium 50 mg PO DAILY
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Rivaroxaban 20 mg PO DAILY
19. Sertraline 200 mg PO DAILY
20. TraZODone 50 mg PO QHS
Note: The patient is not taking Ranolazine due to inability to
afford prescription, therefore, it was removed from her
discharge medication lsit
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-----------------
CHEST PAIN, NOS
SECONDARY DIAGNOSES
-------------------
ATRIAL FIBRILLATION
CAD
GERD
HYPERTENSION
TYPE II 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 ___.
Why was I here?
-You were having chest pain similar to prior episodes of chest
pain.
What was done while I was in the hospital?
-Blood tests showed that you are not having a heart attack.
Pictures of your heart did not show concern for a heart attack
either. Our Cardiology team felt reassured that you were not
having a heart attack
What should I do once I go home?
-You should go to your appointment with your PCP
-___ should go to your appointment with the GI doctors
-___ should go to your appointment with the heart doctor
-___ should take the prescriptions given to you
Be well!
-Your ___ Care Team
Followup Instructions:
___
|
10580201-DS-61 | 10,580,201 | 22,284,386 | DS | 61 | 2147-01-31 00:00:00 | 2147-01-31 21:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Motrin / Compazine / Voltaren / albuterol
Attending: ___
Chief Complaint:
Loss of consciousness
Major Surgical or Invasive Procedure:
Coronary angiogram ___
ICD implantation ___
History of Present Illness:
Ms. ___ is a ___ with h/o hypertension, hyperlipidemia,
type 2 diabetes mellitus, atrial fibrillation with ? TIA, CAD
S/P DES to RCA ___ ___ who presented to ___
for evaluation of diarrheal illness and syncope. She collapsed
and was found to be in ventricular fibrillation arrest. She was
defibrillated once with 200 Joules. Epinephrine 1 mg was
administered and ROSC was obtained within ___ minutes. During
the code, she was also intubated. After the arrest, she was
following commands and tracking with her eyes, so targeted
temperature management was deferred. She was transferred to BID
for medical management and likely coronary angiography. Of note,
patient fell in the ___.
In the ___ ___, initial vitals were HR 56, BP 151/69, RR 18,
SaO2 96%. EKG notable for ? ST elevation in III and aVF but
difficult to interpret in the setting of atrial flutter and
RBBB. Bedside echocardiogram (difficult windows) without clear
evidence of inferior wall motion abnormality. Labs notable for
troponin-T 0.21. CT head showed no bleed. Patient was given: ASA
600 mg pr.
On arrival to the CCU, the patient was intubated and sedated.
She withdraws to pain.
ROS: Unable to obtain.
Past Medical History:
1. CAD RISK FACTORS
- Hypertension, hyperlipidemia, type 2 diabetes mellitus
2. CARDIAC HISTORY
- DES to RPL ___ at ___
3. OTHER PAST MEDICAL HISTORY
- Migraines
- Pseudotumor cerebri now S/P VP shunt.
- Obstructive sleep apnea, does not use CPAP
- Depression
- Obesity
- Hypothyroidism
- ? TIA early 2000s
- S/P CCY
- S/P Appendectomy
- S/P Right knee replacement
Social History:
___
Family History:
DM, CAD, hypertension all in multiple family members. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
On admission
GENERAL: Elderly black female intubated and sedated, withdraws
to pain
HEENT: Sclera anicteric. PERRL.
NECK: Supple. JVP difficult to detect.
CARDIAC: bradycardic, irregular. ___ systolic murmur.
LUNGS: intubated, CTAB on anterior auscultation
ABDOMEN: Soft, non-tender, not distended. No palpable
hepatomegaly or splenomegaly. +BS
EXTREMITIES: cool extremities with pitting peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
GENERAL: NAD
VS: Temp: 98.6 PO BP: 108/59 HR: 64 RR: 16 O2 sat: 96% FSBG: 166
NECK: JVD flat
CARDIAC: ICD site clean, dry and itact with no erythema, no
surrounding edema. ___ holosystolic murmur at left upper
sternal border, no gallops no rubs.
LUNGS: Decreased breath sounds bilaterally. No crackles,
wheezes, or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. Bowel sounds present.
EXTREMITIES: Warm and well perfused. No clubbing, cyanosis, or
peripheral edema.
PULSES: Distal pulses palpable and symmetric.
NEURO: A&Ox3 to person, place and time. Good attention and
recall.
Pertinent Results:
___ 01:11AM BLOOD WBC-16.4* RBC-3.49* Hgb-9.4* Hct-31.7*
MCV-91 MCH-26.9 MCHC-29.7* RDW-15.4 RDWSD-50.7* Plt ___
___ 05:00AM BLOOD WBC-8.8 RBC-2.20* Hgb-5.9* Hct-20.0*
MCV-91 MCH-26.8 MCHC-29.5* RDW-15.6* RDWSD-50.7* Plt ___
___ 07:00AM BLOOD WBC-10.6* RBC-2.83* Hgb-7.9* Hct-26.3*
MCV-93 MCH-27.9 MCHC-30.0* RDW-17.0* RDWSD-55.5* Plt ___
___ 01:11AM BLOOD ___ PTT-20.5* ___
___ 01:11AM BLOOD Glucose-245* UreaN-18 Creat-1.1 Na-144
K-3.7 Cl-109* HCO3-18* AnGap-17
___ 04:56PM BLOOD Glucose-220* UreaN-21* Creat-1.4* Na-139
K-3.9 Cl-106 HCO3-18* AnGap-15
___ 07:00AM BLOOD Glucose-153* UreaN-27* Creat-1.3* Na-146
K-4.5 Cl-102 HCO3-26 AnGap-18
___ 05:22AM BLOOD ALT-125* AST-154* AlkPhos-151*
TotBili-0.8
___ 02:00AM BLOOD ALT-66* AST-43* LD(LDH)-375* AlkPhos-103
TotBili-1.0 DirBili-0.4* IndBili-0.6
___ 05:00AM BLOOD ALT-48* AST-26 AlkPhos-99 TotBili-0.7
___ 03:52AM BLOOD ALT-43* AST-20 AlkPhos-110* TotBili-1.0
___ 06:00AM BLOOD ALT-36 AST-17 AlkPhos-124* TotBili-1.2
___ 05:32AM BLOOD ALT-26 AST-12 CK(CPK)-284* AlkPhos-113*
TotBili-1.2
___ 05:21AM BLOOD ALT-24 AST-16 LD(LDH)-444* AlkPhos-126*
TotBili-0.8
___ 07:53AM BLOOD freeCa-1.07*
___ 01:11AM BLOOD Calcium-8.4 Phos-3.3 Mg-0.8*
___ 05:22AM BLOOD Calcium-8.3* Phos-3.5 Mg-3.4*
___ 07:00AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.6
___ 01:11AM BLOOD proBNP-___*
___ 01:11AM BLOOD cTropnT-0.21*
___ 05:22AM BLOOD CK-MB-23* cTropnT-0.40*
___ 10:38PM BLOOD CK-MB-13* cTropnT-0.12*
___ 07:30AM BLOOD TSH-0.93
___ 06:00AM BLOOD ___
___ 01:01PM BLOOD HIV Ab-NEG
___ 01:30AM BLOOD Lactate-2.9*
___ 07:53AM BLOOD Lactate-1.5
___ 05:39PM BLOOD Lactate-2.6*
___ Detailed urine tox screen
Codeine-by LC-MS/MS: Negative
Dihydrocodeine-by LC-MS/MS: Negative
Hydrocodone-by LC-MS/MS: Negative
Norhydrocodone-by LC-MS/MS: Negative
Hydromorphone-by LC-MS/MS: Negative
Oxycodone-by LC-MS/MS: 2909 ng/mL
Noroxycodone-by LC-MS/MS: 2881 ng/mL
Oxymorphone-by LC-MS/MS: 566 ng/mL
Noroxymorphone-by LC-MS/MS: 124 ng/mL
Naloxone-by LC-MS/MS: Negative
Morphine-by LC-MS/MS: Negative
CHEST (PORTABLE AP) ___ 1:27 AM
An endotracheal tube terminates 3.6 cm above level of carina. A
right central line terminates in the right distal SVC/cavoatrial
junction. An orogastric tube curls within the body of the
stomach, with the distal tip flipped up near the
gastroesophageal junction. There is moderate cardiomegaly. Mild
perihilar vascular fullness is demonstrated with at least mild
pulmonary edema. There are bilateral patchy pulmonary opacities.
No pleural effusion. No pneumothorax. The included osseous
structures are unremarkable. Cholecystectomy clips project over
the right upper quadrant.
IMPRESSION: 1. Endotracheal tube terminating 3.6 cm above the
level of the carina. Orogastric tube coiled within the stomach
with the tip flipped up near the gastroesophageal junction.
Recommend repositioning. 2. Mild perihilar vascular fullness
with least mild pulmonary edema. Bilateral patchy opacities
could represent pulmonary edema, however aspiration or
infectious process cannot be completely excluded.
Head CT ___
There is no evidence of infarction, hemorrhage, edema, or
mass. The ventricles and sulci are normal for age.
Periventricular and subcortical white matter hypodensities are
demonstrated, which are nonspecific but likely reflect chronic
microangiopathy.
There is no evidence of fracture. There is mild thickening of
the bilateral ethmoid air cells and right maxillary sinus, which
may be secondary to intubation. The bilateral mastoid air cells
and inner ear cavities are clear. The visualized portion of the
orbits are unremarkable. A ventriculostomy tube via a right
frontal approach is demonstrated, terminating near the septum
pellucidum.
IMPRESSION: 1. No acute intracranial process. 2. VP shunt via
right frontal approach terminating near the septum pellucidum.
CHEST (PORTABLE AP) ___ 4:55 AM
In comparison with the earlier study of this date, the
monitoring and support devices are stable, with the nasogastric
tube coiling back on itself so that the tip lies close to the
esophagogastric junction pointing upward. Diffuse bilateral
pulmonary opacifications could well represent pulmonary edema.
However, in the appropriate clinical setting, superimposed
aspiration/pneumonia or even ARDS would have to be considered.
CHEST (PORTABLE AP) ___ 6:13 ___
The tip of the right internal jugular central venous catheter
projects over the distal SVC. A partially evaluated VP shunt
catheter is seen over the right chest.
There is improved aeration of the upper lobes. Small bilateral
pleural effusions with subjacent atelectasis/consolidation is
again noted. No pneumothorax. The size of the cardiac silhouette
is mildly enlarged but unchanged.
IMPRESSION: Improved aeration of the upper lungs. Persisting
small bilateral pleural effusions with subjacent
atelectasis/consolidation.
Coronary angiogram ___
LM: The left main coronary artery is without significant
disease.
LAD: The left anterior descending coronary artery is with mild
irregularities and wraps around the apex.
Circ: The circumflex coronary artery is without significant
disease.
RCA: The right coronary artery is with mild diffuse disease
throughout. The RPDA is a high bifucation. There is a patent mid
RPL stent.
Findings
No significant coronary artery disease
Patent RCA stent.
CXR ___
The tip of the right internal jugular central venous line
projects over the mid to distal SVC. There is a small to
moderate right pleural effusion with subjacent
atelectasis/consolidation. Atelectasis is also present at the
left lung base. No pneumothorax. The size of the
cardiomediastinal silhouette is unchanged.
IMPRESSION: Mildly increased right pleural effusion. Bibasilar
opacities are consistent with atelectasis and/or consolidation.
CTA Torso ___
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. 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. No
mediastinal hematoma.
PLEURAL SPACES: There are a small right and trace left pleural
effusions. No pneumothorax.
LUNGS/AIRWAYS: Enhancing consolidations adjacent to the pleural
effusions are compatible with atelectasis. There is faint
ground-glass haziness throughout the lungs in a central
distribution most likely reflective of pulmonary edema. The
airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality. A right internal jugular central venous catheter
extends to the cavoatrial junction.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: Bilateral renal hypodensities are too small to
characterize apart from a 5.4 x 7.4 cm cyst arising from the
right mid to lower pole. There is no evidence of suspicious
focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. There is a 2.4 cm
well-circumscribed ovoid structure in the low right pelvis
adjacent to small bowel loops, sigmoid colon and to the bladder
and is of unclear etiology. There is diverticulosis of the
sigmoid colon without evidence of diverticulitis. The appendix
is not visualized. A surgical clip adjacent to the cecum may
reflect finding secondary to prior appendectomy. There is no
free intraperitoneal fluid or free air.
PELVIS: A small amount of air within an otherwise unremarkable
bladder is likely reflective of recent instrumentation. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No large
ovarian lesion.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal
atherosclerotic disease is noted.
BONES AND SOFT TISSUES: There is a transversely oriented lies
fracture through the sternum. Additionally, there are mildly
displaced fractures of the right ___ right anterior ribs as
well as the left ___ left anterior ribs. DISH and multilevel
degenerative changes are seen in the thoracic spine. The
abdominal and pelvic wall is within normal limits. A partially
visualized VP shunt catheter courses along the anterior
subcutaneous tissues and terminates deep to the right abdominal
wall.
IMPRESSION: No evidence of hemorrhage within the chest, abdomen
or pelvis. Mild pulmonary edema, small bilateral pleural
effusions and dependent lower lobe atelectasis. Multiple mildly
displaced anterior rib fractures bilaterally as well as a
nondisplaced sternal fracture.
CXR ___
Cardiac, mediastinal and hilar contours appear stable. There
persistent opacities at each lung base, not significantly
changed. These are likely to be explained by atelectasis. Mild
interstitial process suggests mild pulmonary edema, but
decreased. Small persistent pleural effusions are likely. No
pneumothorax.
IMPRESSION: Decrease in pulmonary edema; otherwise unchanged.
Echocardiogram ___
The left atrial volume index is moderately increased. The right
atrium is mildly enlarged. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. The visually
estimated left ventricular ejection fraction is >=60%. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. Mildly dilated
right ventricular cavity with normal free wall motion. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal.
The aortic valve leaflets (3) appear structurally normal. There
is no aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is trivial mitral regurgitation.
There is diastolic mitral regurgitation due to atrial
fibrillation with ventricular bradycardia. The tricuspid valve
leaflets appear structurally normal. There is moderate [2+]
tricuspid regurgitation. There is SEVERE pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Right ventricular cavity dilation. Moderate tricuspid
regurgitation. Sever e pulmonary artery systolic hypertension.
This constellation of findings suggests a chronic or acute on
chronic pulmonary condition (primary pulmonary HTN, pulmonary
embolism, etc.).
CXR ___
Right internal jugular line tip is at the level of mid SVC.
Heart size and mediastinum are enlarged. Left retrocardiac
consolidation and right basal consolidations have not
substantially changed in the interim. There is mild vascular
congestion but no overt pulmonary edema. Small amount of
bilateral pleural effusion is noted. No pneumothorax.
CXR ___
New left pectoral generator sends pacer lead to the right atrium
and pacemaker defibrillator lead to the right ventricle.
Indwelling right neck line ends in the SVC. There is residual
right lower lobe atelectasis, and small pleural effusions, right
greater than left. There is no pneumothorax. Mild cardiomegaly
is unchanged.
IMPRESSION: New left pectoral atrioventricular pacer
defibrillator. No complications. Persistent small pleural
effusions.
Echocardiogram ___
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. Overall
left ventricular systolic function is normal. The visually
estimated left ventricular ejection fraction is 55-60%. Global
longitudinal strain is depressed (-1 1.2 %; normal less than
-20%). Regional variation could not be assess due to limited
image quality in 3 Chamber view. Regional variation could not be
assess due to limited image quality in 3 Chamber view. Mildly
dilated right ventricular cavity with normal free wall motion.
Tricuspid annular plane systolic excursion (TAPSE) is normal.
The mitral valve leaflets are mildly thickened with no mitral
valve prolapse. There is trivial mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
mild to moderate [___] tricuspid regurgitation. There is mild
pulmonary artery systolic hypertension.
IMPRESSION: Patient had difficulties to cooperate due to dyspnea
that is why a full echocardiographic examination was not
performed (aortic valve not visualized). 1) Normal LV systolic
function by LVEF (largely determined by radial LV contractile
function). Global longitudinal strain mild to moderately
depressed however. 2) RV mildly dilated with normal RV systolic
function in setting of mild to moderate tricuspid regurgitation
and mild pulmonary systolic arterial hypertension. Image quality
of the TR jet is acceptable. Compared with the prior TTE (images
reviewed) of ___, the findings are similar. However,
pulmonary systolic arterial pressure has decreased.
Brief Hospital Course:
Ms. ___ is a ___ with h/o hypertension, hyperlipidemia,
type 2 diabetes mellitus, atrial fibrillation with ? prior TIA,
CAD S/P DES to RCA ___ who presented to ___
and collapsed with a VF arrest. She was defibrillated once with
200 Joules, epinephrine 1 mg was administered, and ROSC was
obtained within ___ minutes. During the code, she was also
intubated. After the arrest, she was following commands and
tracking with her eyes, so TTM was deferred. She was transferred
to BID for medical management and coronary angiography.
ACUTE MEDICAL ISSUES
# Ventricular Fibrillation Cardiac Arrest, Torsades de Pointes,
Bradycardia: Patient was triaged at ___ after being
found in parking lot/lobby in VF arrest. As above, she was
resuscitated and transferred to ___ for coronary angiography.
Due to history of fall, CT head was obtained which showed no
acute intracranial process. Coronary angiography showed right
coronary artery with mild diffuse disease throughout and patent
mid RPL stent but no acute lesion on which to intervene. Of
note, in further discussions with her insurance case manager
through ___ and from records obtained from ___
___ and ___, it appears Ms. ___ has
had as many as 17 left heart catheterizations with angiography
this year for chest pain. She was transferred to the general
cardiology service where she was monitored on telemetry and
found to be bradycardic to the ___ with prolonged QTc >550 msec
on EKG. Transthoracic echocardiography from the earlier portion
of her admission was significant for RV dilation with severe
pulmonary artery pressures, mild symmetric left ventricular
hypertrophy and LVEF >60%. It was felt her VF was driven by
severe right heart failure due to left heart failure and she was
diuresed (as below). We held beta-blockade in the setting of
severe bradycardia, which was further managed with bolus
atropine IV. She had a high PVC burden on telemetry that was
managed with gentle diuresis and electrolyte repletion. The
patient had one episode of torsade de pointes that was captured
on telemetry but was asymptomatic. She had a dual chamber ICD
placed on ___ and subsequently was v-paced in the ___ with
decreased PVC burden. She will require follow up with cardiology
within one week of discharge.
# Atrial Flutter with ventricular rates in the 40-50s: The
patient was found to be in atrial flutter on transfer to the
floor with ventricular rates in the ___. Her atrial flutter
was thought to be secondary to her severe RV dilation. She has a
history of atrial fibrillation/atrial flutter per chart review
and was not previously on anticoagulation. She was initially put
on a heparin drip which was discontinued prior to ICD placement
and three days later initiated on apixaban. She spontaneously
converted to sinus rhythm as she was diuresed, suggesting her
arrhythmia was likely secondary to severe RV dilation in the
setting of heart failure. Her CHADS2VASC is 4. She should remain
on lifelong anticoagulation to minimize her risk of stroke.
# Acute on Chronic Anemia, Iron deficiency anemia: The patient
was admitted with a Hgb of 9.4 which dropped to a nadir of 5.9
after being transferred to the floor. Her haptoglobin was normal
and RDW within normal limits, leading us to believe she was not
hemolyzing. She was transfused with 2 units of pRBCs and imaged
with CT Torso with contrast which showed no active
extravasation. It was thought that her drop in Hgb was likely
dilutional in the setting of resuscitation and subsequent
___ hydration. Iron studies revealed low serum
iron, normal ferritin and decreased TIBC suggesting iron
deficiency anemia compounded by anemia of chronic disease. She
received 4 days of IV iron. Her Hgb on discharge was 7.9.
# Sternum and Rib Fractures: The patient had a transversely
oriented Lies fracture through the sternum and mildly displaced
fractures of the right ___ right anterior ribs as well as the
left ___ left anterior ribs. She was treated with scheduled
acetaminophen 1000 mg Q6H and Oxycodone ___ mg Q4H PRN and
discharged on this pain regimen.
# Hypomagnesemia: Ms. ___ was admitted with a serum Mg of
0.8. Per records from ___ ___ where she was
evaluated in late ___, her Mg on discharge was 0.5. EP
evaluated the patient and felt that hypomagnesemia in and of
itself was likely not the etiology of her VF, but in the setting
of severe RV strain or substrate may have contributed to her
arrhythmia. She was aggressively repleted with IV Mg during
diuresis and prior to ICD placement. He was subsequently started
on Mg sulfate 1200 mg BID prior to discharge. Her hypomagnesemia
in the setting of non-gap acidosis was thought to be likely due
to renal losses as she had no bowel movements during her first
week of admission. Spot urine lytes prior to diuresis showed Mg
in the urine, but 24-hour Mg was not obtained. She reportedly
had been evaluated by a nephrologist at ___ and
perhaps told/or started on amiloride. She should follow up as an
outpatient with her previous nephrologist for further evaluation
of her hypomagnesemia. Her Mg on discharge was 2.6.
# Heart Failure with Preserved Ejection Fraction/Diastolic HF:
Ms. ___ was gently diuresed with furosemide 40-80 mg IV
daily prior to ICD placement. Given TTE (as above), she was
subsequently started on a furosemide drip at 10 mg/hour for 24
hours for diastolic heart failure. She was transitioned to PO
torsemide and titrated to a maintenance dose of 80 mg every
other day. He weight on admission was 96.66 kg and on discharge
was 93.4 kg. She was net negative -675 cc prior to discharge.
Her Cr was 1.3 on discharge.
# Pulmonary Hypertension: Patient had an elevated PA Systolic
Pressure of 74 on TTE from ___. She had a repeat TTE on ___
with PASP of 31 mm Hg above RA pressure. Her pulmonary
hypertension was thought to be likely WHO Group II from left
heart disease given response from diuresis. A right heart
catheterization was deferred due to recent ICD placement. She
would benefit from additional evaluation including RHC and V/Q
scan for CTEP as an outpatient.
# Hematuria: Patient had unexplained hematuria with small to
moderate amount of blood and ___ RBCs per HPF. This resolved
without further workup. Her hematuria was thought to be
secondary to trauma from VF and resuscitation. She may benefit
from further workup of this issue with a urologist.
# Leukocytosis: Patient had unexplained leukocytosis with signs
or symptoms of systemic infection. Urine and blood cultures were
negative and her white count trended to within normal limits.
CHRONIC MEDICAL ISSUES
# CAD: Patient was continued on ASA 81 daily, atorvastatin 80mg.
Clopidogrel 75 mg daily was discontinued as her last DES was
placed in ___ per patient's history, chart review and
discussion with her case manager at ___
___.
# ? Gastroparesis; Malnutrition: Patient described 1 month of
severe nausea and vomiting with limited PO food and water
intake, early satiety. She had no episodes of nausea or vomiting
during hospitalization. Unclear whether this represents
gastroparesis, given her relatively well controlled diabetes
(A1c 7.0 in ___. She should follow up with GI as outpatient
for further evaluation if this issue persists.
# Type 2 diabetes mellitus: Held home metformin during
hospitalization, and kept on sliding scale insulin.
# Hyperlipidemia: Atorvastatin 80 mg as above
# Hypothyroidism: Continued home levothyroxine 75 mcg
# Anxiety/depression: Sertraline was held due to long QTc and
restarted after ICD placement.
# GERD: Omeprazole was held due to long QTc and ranitidine was
started.
# COPD: CPAP and Ipratropium nebulizers were used PRN.
# VP Shunt: Patient has VP shunt and was last evaluated by a
neurologist more than ___ years ago, per patient. Due to concern
for rising white count and altered mental status, neurosurgery
evaluated her and felt that it was unlikely that her VP shut was
blocked or infected. She should have further follow up with an
outpatient neurologist for further evaluation of the shunt.
TRANSITIONAL
[ ] Continue to down-titrate her oxycodone as outpatient. She
had required q4h dosing while in the hospital.
[ ] Patient will need additional PCP follow up regarding her
acute on chronic anemia
[ ] Patient will need follow-up in 1 week at ___
and future follow up with her cardiologist at ___
[ ] Patient may follow up with a gastroenterologist for further
evaluation of her nausea, vomiting and early satiety
[ ] Patient should follow up with nephrologist for further
evaluation of her hypomagnesemia
[ ] Patient should follow up with a urologist regarding her
hematuria.
[ ] Patient will need additional followup regarding elevated
PSAP and concern for pulmonary hypertension.
[ ] Patient has a VP shunt and should be further evaluated by a
neurologist given last follow-up was at least ___ years prior.
[ ] Patient has a 2.4 cm well-circumscribed ovoid structure in
the low right pelvis adjacent to small bowel loops, sigmoid
colon and to the bladder and is of unclear etiology. Per
radiology may be calcified epiploic appendages or dropped gall
stone.
NEW MEDICINES: apixiban, torsemide, magnesium oxide, oxycodone,
ranitidine, sertraline
STOPPED MEDICINES: spironolactone, citalopram, Plavix,
pantoprazole
Discharge weight: 93.4 kg (205.9 pounds)
Discharge Cr: 1.3
Discharge diuretic: torsemide 80 mg po every other day
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Pantoprazole 40 mg PO Q12H
10. Potassium Chloride 10 mEq PO BID
11. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Apixaban 5 mg PO BID
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Magnesium Oxide 1200 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
9. Ranitidine 150 mg PO BID
10. Sertraline 100 mg PO DAILY
11. Torsemide 80 mg PO EVERY OTHER DAY
Last dose received ___. Aspirin 81 mg PO DAILY
13. Atorvastatin 80 mg PO QPM
14. Carvedilol 25 mg PO BID
15. Ferrous Sulfate 325 mg PO DAILY
16. Losartan Potassium 50 mg PO DAILY
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Potassium Chloride 10 mEq PO BID
Hold for K >
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Ventricular Fibrillation
# Cardiac Arrest
# Sternal and rib fractures
# Hypomagnesemia
# Symptomatic Bradycardia
# Prolonged corrected QT interval
# Torsade de pointes
# Coronary artery disease with prior patent prior stent
# Atrial flutter
# Acute on chronic Heart Failure with Preserved Ejection
Fraction/Diastolic Heart Failure
# Pulmonary Hypertension
# Iron Deficiency Anemia requiring transfusion
# Anemia of chronic disease
# Leukocytosis
# Hematuria
# Hyperlipidemia
# Type 2 diabetes mellitus with possible gastroparesis
# Presence of a ventriculo-peritoneal shunt
# Anxiety
# Depression
# Gastroesophageal reflux disease
# Chronic obstructive pulmonary 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 ___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because your heart stopped beating.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We restarted your heart with chest compressions, drugs and
electrical shocks.
- You were found to have an unsafe heart rhythm that put your
higher risk of sudden death.
- We surgically implanted a cardiac defibrillator. This helps
your heart beat at a normal rate and will protect you if your
heart stops beating. You may feel a shock, or discharge, if your
heart stops. If you feel this you should immediately seek
medical care.
- We replenished your electrolytes because you have low
potassium and low magnesium. You should make sure to follow up
with your kidney doctor, ___.
- We replenished your iron because you were anemic. You should
be sure to follow up with your primary care doctor for further
evaluation of your anemia.
- We checked you heart function with an echocardiogram. You were
found to have increased pulmonary pressure. Its important for
you to follow up with a cardiologist to monitor your heart
function.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please make sure to follow up with your primary cardiologist,
or heart doctor, ___.
- Please make sure to follow up with your nephrologist, or
kidney doctor, at ___.
- Please make sure to follow up at the ___ Cardiac Device
Clinic within 1 week of discharge.
- Please make sure to take all your medications as prescribed.
- You were found to have fluid on your lungs. This was felt to
be due to a condition called heart failure, where your heart
does not pump hard enough and fluid backs up into your lungs.
You were given a diuretic medication through the IV to help get
the fluid out. You improved considerably and were ready to leave
the hospital.
- Your weight at discharge is 93.4 kg (205.9 pounds). Please
weigh yourself today at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10580442-DS-4 | 10,580,442 | 29,946,670 | DS | 4 | 2189-11-12 00:00:00 | 2189-12-16 23:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vaginal bleeding
Major Surgical or Invasive Procedure:
___ IVC filter placement
History of Present Illness:
Primary Oncologist: ___
Primary Care Physician: ___ ___
CC: ___
HPI:
___ woman with no significant past medical history, no
significant regular primary care who was recently diagnosed with
metastatic cholangiocarcinoma and now presents with vaginal
bleeding.
In terms of the patients recent history, she first presented in
___ when she was diagnosed with Lyme disease. During that
visit she was found to have jaundice, referred for CT, which
identified a gallbladder mass. ERCP on ___
identified a gallbladder stricture, and brushings were positive
for adenocarcinoma. CT torso on ___ showed a liver
mass centered at the gallbladder measuring 7.8 x 6 0 x 6.6 cm
occupying segment V of the liver with associated periportal and
mediastinal lymphadenopathy, also with bilateral lung nodules.
Her ___ on ___ measured
___ U/ml. Chest CT also identified pulmonary embolism for she
was started on Lovenox and bridged to warfarin.
More recently, ___ woke up this morning and when using the
bathroom noticed bright red blood in the toilet bowl. She
presented to ___ for presumed GIB. While at ___
pelvic exam demonstrated dried blood in vault with blood most
likely coming from the os. US showed possible mass, transferred
to ___ for OB/GYN eval. Patient otherwise has been feeling
well at home aside from fatigue and poor PO intake. She reports
one episode of bleeding this morning but otherwise denies
ongoing vaginal bleeding and denies current bleed.
In the ED, initial VS: 98.6 102 128/74 15 95%. Hct of 33 stable
and actually higher than baseline. OB/GYN was consulted who
indicated she is stable for outpt workup, ok to anticoagulate as
necessary for PE. Vitals on transfer: 121 104/66 28 96% RA.
Patient denies nausea, vomiting, diarrhea at home though is
hving some nausea on admission to floor. Denies lightheadedness,
dizziness, syncope or pre-syncope. She denies abdominal painm
chest pain, dypnea though does admit to tachypnea. No orthopnea,
P___, ___
___ of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ when she was diagnosed with Lyme disease. During
that visit she was found to have jaundice
- ___ CT identified a gallbladder mass.
- ___ ERCP on identified a gallbladder stricture,
and brushings were positive for adenocarcinoma.
- ___ CT torso showed a liver mass centered at the
gallbladder measuring 7.8 x 6 0 x 6.6 cm occupying segment V of
the liver with associated periportal and mediastinal
lymphadenopathy, also with bilateral lung nodules. Her ___
___ U/ml.
- ___ first Onocology visit: considering combination
chemotherapy with gemcitabine/cisplatin administered per ABC-02
regimen
PAST MEDICAL HISTORY:
- Recent diagnosis of metastatic adenocarcinoma (chlangio vs
gallbladder primary)
- Recent diagnosis of Lyme Disease
PAST SURGICAL HISTORY:
- None
Social History:
___
Family History:
The patient's father died of tobacco associated lung cancer
diagnosed at ___ years. Her mother is alive at ___ years with
dementia. Two older sisters died as an infant. She has three
children. Her son has NASH liver disease. Her daughter has
hypertension and hypercholesterolemia. Several family members
also suffer from depression and bipolar disorder.
Physical Exam:
Physical Examination:
GEN: Alert, oriented to name, place and situation. no acute
signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: No lower leg edema
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
___ 04:30PM BLOOD WBC-10.6 RBC-3.70* Hgb-11.3* Hct-33.3*
MCV-90 MCH-30.4 MCHC-33.8 RDW-15.0 Plt ___
___ 05:50AM BLOOD WBC-10.1 RBC-3.36* Hgb-10.2* Hct-31.4*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.6 Plt ___
___ 05:50AM BLOOD ___ PTT-35.0 ___
___ 05:50AM BLOOD Glucose-90 UreaN-7 Creat-0.5 Na-140 K-3.4
Cl-103 HCO3-28 AnGap-12
___ 06:50AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
___ PUS ___: The uterus has markedly irregular
anterior texture. The endometrium is thickened and centrally
within the endometrium, there is a 2-cm mass which has a width
of 7 mm. In the right adnexa, there is an 8-cm, large structure
containing both solid and cystic anterior markedly deranged
appearance and which likely represents an ovarian mass. On the
left side in the adnexa, there is a 2 x 1-cm, mostly solid
structure, which possibly could represent the left ovary but as
there is no vascularity present but for the central portion of
this structure, it is not a typical appearance for an ovary but
rather an enlarged lymph node. There is also slight free fluid
present in the left pelvis.
IMPRESSION: 2-CM LARGE MASS WITHIN THE ENDOMETRIUM AND 8-CM
LARGE MASS IN THE RIGHT ADNEXA, PROBABLY REPRESENTING AN OVARIAN
MASS. ALSO, 2-CM STRUCTURE ON THE LEFT SIDE, PROBABLY
REPRESENTING AN ENLARGED LYMPH NODE.
Echo ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated with
moderate global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The tricuspid valve leaflets fail to
fully coapt. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: The right ventricle is moderately dilated with free
wall hypokinesis and relative sparing of the RV apex
___ sign). There is pressure/volume overload. The
tricuspid leaflets do not coapt due to RV dilation with
consequent moderate to severe tricuspid regurgitation. Moderate
elevation of pulmonary artery systolic pressure. The left
ventricle is somewhat compressed by the RV. Its function is
normal.
CTA ___
FINDINGS: There is a saddle pulmonary embolism with filling
defects in the
right main pulmonary artery and filling all segmental branches
of the right
lung. There are filling defects in the left pulmonary artery
and filling all
except one of the left lower lobe subsegmental branches.
Thrombus is seen in
the lingular segment and the left upper lobe segmental branches.
There is
evidence of right heart strain with bowing of the
interventricular septum and
reflux of contrast into the hepatic veins. There is no
pericardial effusion.
The ascending aorta is dilated measuring 2.8 cm, unchanged.
There is no mediastinal, hilar, or axillary lymphadenopathy.
There are no
focal consolidations and no pleural effusion or pneumothorax.
The cysts at
the liver dome and the left hepatic lobe are unchanged. A
hypodense lesion in
the liver dome, 401B:23, is vague and measures approximately 8
mm and appears
new compared to prior study and may represent new evidence of
metastasis.
The airways are patent to the subsegmental level. The esophagus
is normal.
IMPRESSION:
1. Saddle pulmonary embolism with evidence of right heart
strain. Pulmonary
emboli involve virtually all lung segments bilaterally.
3. Hepatic cysts are unchanged. A vague hypodensity in the
liver dome is new
from ___, and may represent new metastasis.
Lower extremity doppler US ___
FINDINGS:
On the right side the common femoral, femoral and popliteal
veins are patent
with normal anechoic compressible vessel lumen. There is
occlusive thrombus
seen within the right calf veins below the popliteal
trifurcation.
On the left there is occlusive thrombus seen extending from the
popliteal vein
inferiorly. The common femoral and femoral veins are patent
with normal
anechoic compressible vessel lumen.
IMPRESSION:
1. Left popliteal vein DVT.
2. Right calf vein DVT.
Brief Hospital Course:
The patient was admitted for vaginal bleeding, which stabilized.
An urgent gyn f/u appointment was scheduled to evaluate her
adnexal mass. Early the first morning of her stay she was found
to be hypotensive with elevated HR and RR. She received IV
fluids with some improvement, but several hours later was again
very dyspneic with minimal activity. She reported this was a
significant change from the previous night and was sent for stat
chest CTA. This showed a large saddle pulmonary embolism. She
was therapeutic on warfarin for several weeks prior for
incidentally discovered PEs. She was switched to heparin drip.
Echocardiogram showed some signs of right heart strain but no
indication for intervention. Lower extremity dopplers showed
DVTs in both legs. Given that further embolism could be
potentially fatal, IVC filter was urgently placed. She remained
stable and the following day was switched to ___ for
anticoagulation. She was weaned off of oxygen. The rest of her
hospital stay was unremarkable and she was discharged home in
good condition on ___. She will follow up with her oncologist
to begin treatment for her cholangiocarcinoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Glucosamine (glucosamine sulfate) 500 mg Oral daily PRN joint
pain
3. Warfarin 1 mg PO DAILY16
4. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
5. Ondansetron 8 mg PO Q8H:PRN nausea, vomiting
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea, vomiting
3. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting
4. Glucosamine (glucosamine sulfate) 500 mg Oral daily PRN joint
pain
5. Enoxaparin Sodium 60 mg SC Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
vaginal bleeding from uterine mass
pulmonary embolus
tachycardia
SECONDARY:
cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to vaginal bleeding and new
ovarian/uterine masses. While you were here you had shortness
of breath and fast heart rate, and you were found to have a
large pulmonary embolus (blood clot in the lungs). You were
known to have a PE in the recent past, and since this new large
clot happened while you were on Warfarin you have been changed
to a lifelong injectable blood thinner called Lovenox (or
Enoxaparin). In addition, you received an IVC filter (inferior
vena cava filter in the vein that goes to the heart/lungs, to
try and prevent more clots from getting to the lungs).
While you were here, your oxygen level and heart rate were
monitored; now you are not requiring any oxygen and your heart
rate is fine. You are safe to be discharged home with plans to
follow up with Gynecology-Oncology and Medical Oncology
(appointments listed below).
We made the following changes to your medications:
-STOP Warfarin
-START Lovenox (Enoxaparin)
You have been on Lovenox injections in the past, when your
Warfarin was started. The dose at that time was 70mg; you still
have some of those syringes at home so please use those and
inject 60mg twice a day. You are not being given a prescription
for the Lovenox right now because it would be very expensive
according to your insurance. On ___ please call Oncology
___ and ask to speak with ___ (Case Manager)
so that your insurance company can be contacted about the need
for lifelong Lovenox.
Followup Instructions:
___
|
10580722-DS-3 | 10,580,722 | 28,895,529 | DS | 3 | 2188-02-07 00:00:00 | 2188-04-21 17:13:00 |
Name: ___ 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:
___: Ultrasound-guided percutaneous cholecystostomy
History of Present Illness:
___ year old M ___ speaking only presents with RUQ
pain. It started around 8 pm yesterday, overnight got
progressively worse and prompted him to come to ED at 2 pm.
___ speaking interpreter was requested to obtain the
medical history. He states that he has been having intermittent
RUQ abdominal pain since ___ when he presented to
hospital in ___ and was diagnosed with acute
cholecystitis
requiring hospital admission and antibiotics. He was discharged
and re presented again in ___ of this year with similar
complains. At that point he was taken to operating room for open
cholecystectomy which per patient's report was aborted because
"his gallbladder was attached to his colon". He had a drain in
place after the procedure and it is unclear whether it was JP
drain or perc chole but per patient's report it had been
draining
bile and was taken out in 2 days after the procedure. He has
been
doing well until a month ago when he moved to US and started to
have intermittent postprandial RUQ pain which he was able to
control with PO Aspirin.
He states that besides of pain he does not have any other
complaints, was able to tolerate diet without nausea or
vomiting,
denies fever or chills, last non bloody BM yesterday.
Past Medical History:
PMH: "kidney problem"
PSH: aborted open cholecystectomy, b/l hernia repair
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Exam:
Vitals: T 98.1, HR 66, BP 164/77, RR 16, sat 100%/RA
GEN: A&Ox3, appears comfortable
HEENT: No scleral icterus, mucus membranes moist
CV: Regular
PULM: Clear to auscultation b/l, No labored breathing
ABD: Well healed R subcostal incision, Soft, nondistended, mild
TTP at RUQ, no rebound, -___ sign, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 04:37AM BLOOD WBC-5.7 RBC-4.35* Hgb-12.2* Hct-37.0*
MCV-85 MCH-28.0 MCHC-33.0 RDW-13.2 RDWSD-41.1 Plt ___
___ 05:20AM BLOOD WBC-4.9 RBC-4.38* Hgb-12.3* Hct-37.6*
MCV-86 MCH-28.1 MCHC-32.7 RDW-13.4 RDWSD-41.5 Plt ___
___ 10:33AM BLOOD WBC-7.0 RBC-4.44* Hgb-12.6* Hct-38.4*
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.6 RDWSD-41.8 Plt ___
___ 04:37AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-139
K-4.6 Cl-100 HCO3-31 AnGap-13
___ 05:20AM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-139 K-4.0
Cl-101 HCO3-26 AnGap-16
___ 10:33AM BLOOD Glucose-181* UreaN-15 Creat-0.8 Na-138
K-4.1 Cl-98 HCO3-28 AnGap-16
___ 04:37AM BLOOD ALT-20 AST-21 AlkPhos-52 TotBili-0.6
___ 05:20AM BLOOD ALT-22 AST-22 AlkPhos-54 TotBili-0.7
___ 10:33AM BLOOD ALT-20 AST-20 AlkPhos-56 TotBili-0.4
___ 04:37AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0
___ 05:20AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
Gallbladder US:
Large stone impacted in the neck of the gallbladder without
specific evidence to suggest acute cholecystitis.
CT A/P:
1. A 2.1 cm gallstone is again seen impacted in the gallbladder
neck. Compared to the same-day ultrasound, there appears to be
new mild
gallbladder wall edema suggestive of acute calculous
cholecystitis in the
correct clinical setting. If imaging confirmation is desired,
HIDA scan or MRI with hepatobiliary agent could be considered.
2. A hypoattenuating lesions segment VI is too small to
completely characterize, but statistically likely a cyst or
biliary
hamatoma. 3. Lipoma deep to the right gluteus maximus
musculature.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal ultra-sound showed a large stone impacted in the neck
of the gallbladder without specific evidence to suggest acute
cholecystitis. Abdominal/pelvic CT revealed new mild gallbladder
wall edema suggestive of acute calculous cholecystitis. The
patient underwent ultrasound-guided placement of ___
pigtail catheter into the gallbladder, which went well without
complication. The patient was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
..
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute calculous cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain. Imaging revealed
a large stone impacted in your gallbladder neck. You were taken
to Interventional Radiology and had a drain placed into your
gallbladder to drain the bile. Your pain is improved and you are
tolerating regular food. You are now ready to be discharged home
to continue your recovery. You will be sent home with the drain
in place and should follow up in the Surgery clinic to discuss
having your gallbladder removed in the future. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10580722-DS-4 | 10,580,722 | 26,312,753 | DS | 4 | 2188-06-26 00:00:00 | 2188-06-26 19:26:00 |
Name: ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
___: open cholecystectomy
History of Present Illness:
Mr. ___ is a ___ male
___, presenting with RUQ abdominal pain in
the context of a complex history of cholecystitis as below.
In brief, he first began having intermittent RUQ pain in ___ when he presented to a hospital in ___, was
diagnosed
with cholecystitis, treated with antibiotics. He re-presented
there in ___, at which time he was taken to the operating room
for an open cholecystectomy which was aborted due to
"gallbladder
attached to his colon". He moved to the ___ in ___, and was
admitted to the ___ service in ___ with persistent symptoms and
imaging suggestive of chronic cholecystitis and stone impacted
in
the cystic duct/gallbladder neck. He had placement of a
percutaneous cholecystostomy drain on ___, and as noted in
Dr. ___ notes (most recently seen ___, was
planned for an interval cholecystectomy 6 months thereafter
(likely in late ___, not yet scheduled).
Translation provided by sister at bedside. Today, he presents
with unprovoked RUQ pain which began 12 hours prior to
consultation. Patient confirms he felt this to be similar to
prior episodes, and more within the RUQ of the abdomen rather
than externally at the drain insertion site. This pain was
persistent and progressive, worsened with deep breathing. He was
tolerating POs prior to onset of pain, has not attempted POs
thereafter. Passing flatus, and had a normal BM yesterday. Perc
chole drain is in place and continues to drain clear bile. He
reports no nausea/vomiting, no CP/SOB, and no chills/night
sweats, but is noted to have a low-grade fever in the ED. He was
given zosyn prior to surgical consultation.
Past Medical History:
PMH: "kidney problem"
PSH: aborted open cholecystectomy, b/l hernia repair
Social History:
___
Family History:
noncontributory
Physical Exam:
At admission:
Vitals: 100.4 90 146/82 21 99%RA
GEN: A&O, NAD, cooperative and interactive
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, non-distended, mildly tender to palpation in RUQ
(*although note that he received 4mg morphine within past hour),
no rebound or guarding, perc chole drain in place with c/d/I
insertion site and clear bile in drainage bag, well-healed old
surgical scar
Ext: No ___ edema, ___ warm and well perfused
At discharge:
VS: 98.4, 71, 130/69, 18, 97%ra
Gen: A&Ox3, NAD
CV: HRR
Pulm: LS CTAB
Abd: Soft, mildly TTP incisionally. No rebound or guarding. RUQ
transverse incision CDI with staples OTA, no induration,
erythema or drainage
Ext: No edema
Pertinent Results:
10.6 > 40.7 < 207
136 | 97 | 16 < 156
4.9 | 26 | 0.9
ALT 19 AST 28 AP 73 Tb 0.4 Lip 58
Lactate 2.1
___ 10.2 PTT 28.1 INR 0.9
Trop <0.01
UA negative
Imaging:
RUQ U/S ___ -
1. Cholelithiasis. Evaluation of the gallbladder is otherwise
slightly limited due to the presence of a percutaneous drain.
2. A 0.8 cm hyperdense lesion in the liver likely represents
hemangioma.
CT abdomen/pelvis ___ -
1. A percutaneous cholecystostomy tube appears coiled in the
gallbladder. Gallstones remain at the gallbladder neck.
2. Apparent thickening of the bladder wall may be secondary to
underdistention, however infection cannot be excluded, recommend
correlation with urinalysis.
3. New small right pleural effusion and bibasilar atelectasis.
Brief Hospital Course:
Mr. ___ was presented to the ___ ED on ___ with right
upper quadrant abdominal pain. Imaging showed gallstones at the
gallbladder neck and chronic cholecystitis. He was given IV
Zosyn in the ED and admitted to the Acute Care Surgery service
for IV hydration and plans for surgery. He was taken to the
Operating Room on ___ where he underwent an uncomplicated
open cholecystectomy. A JP drain to bulb suction was left behind
in the right upper quadrant. For full details of the procedure,
please see the separately dictated Operative Report. He was
returned to the PACU in stable condition, and after satisfactory
recovery from anesthesia, was transferred to the surgical floor.
He was started on a clear liquid diet post-operatively and his
diet was advanced as tolerated. His pain was initially managed
with a PCA, and he was eventually transitioned to oral pain
medications with good effect. His foley catheter was removed on
POD1, and he had no issues voiding spontaneously. JP drain
output remained serosanguinous and drain was removed prior to
discharge.
At the time of discharge on POD2, 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
chronic cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ and
underwent open cholecystectomy. You are recovering well and are
now ready for discharge. Please follow the instructions below to
continue your recovery:
You were admitted to the hospital with chronic cholecystitis.
You were taken to the operating room and had your gallbladder
removed. You tolerated the procedure well and are now being
discharged home to continue your recovery with the following
instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Staples will be removed at your follow up appointment.
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed.
o Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10580887-DS-15 | 10,580,887 | 28,304,647 | DS | 15 | 2124-10-17 00:00:00 | 2124-10-17 19:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain, diarrhea, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ is an ___ with a history of C diff one year ago
who presents with worsening abdominal pain and diarrhea after
being seen in the ED on ___ and found to have C diff.
She presented to the ED on ___ with 6 days of profuse watery
diarrhea. She was found to have C diff and was discharged on PO
metronidazole. Since discharge from the ED she has been adherent
with metronidazole but had worsening diarrhea, abdominal pain,
and decreased PO intake. Today she had decrease in BMs (only
one) and increased abdominal pain, prompting presentation. She
has had no fevers, vomiting, or bloody diarrhea. She has not had
any recent antibiotics.
Her episode of C diff one year ago occurred in the setting of
nearly 20 days of clindamycin for tonsillitis. She developed
severe bloody diarrhea and initially failed Flagyl with
prolonged course of Flagyl subsequently initiated with
resolution of symptoms.
In the ED, initial VS were: 8 98.0 82 103/70 16 100% RA
Labs showed:
WBC 6.5 Hgb 13 Plts 314
Na 141
K 4.1
BUN 4 / Cr 0.7
ALT: 8 AP: 50 Tbili: 0.6 Alb: 4.3
AST: 14
Lip: 28
Lactate: 0.9
___: 12.9 PTT: 34.6 INR: 1.2
Imaging showed:
___ CT A/P with contrast: No acute findings to explain the
patient's abdominal pain or diarrhea. Trace free fluid in the
pelvis is likely physiologic.
Patient received:
___ 21:24 IV Ondansetron 4 mg
___ 21:24 IV Morphine Sulfate 2 mg
___ 22:00 IVF NS 1000 mL
___ 23:10 IV MetroNIDAZOLE (500 mg ordered)
___ 23:11 IV Morphine Sulfate 2 mg
___ 00:12 IV MetroNIDAZOLE 500 mg
Transfer VS were: ___ 105/67 15 99% RA
On arrival to the floor, patient reports abdominal pain
somewhat improved with morphine in the ED. Feels somewhat
nauseated. Not sure how much she would be able to take PO. Has
also had a cold recently with some congestion and nonproductive
cough but no dyspnea, CP.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Depression
C. diff
Social History:
___
Family History:
NC - no family history of IBD or C. Diff infections.
Physical Exam:
======================
ADMISSION PHYSICAL EXAM
======================
VS: 98.2 103/68 71 16 97 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, anicteric sclera, dry MM
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, BS+, significant tenderness to palpation
in LUQ, LLQ, and RLQ without rebound or guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
======================
DISCHARGE PHYSICAL EXAM
======================
VS: 97.9 PO, 104 / 63, 66, 16, 98% RA
GENERAL: young woman in NAD
HEENT: Anicteric sclera, MMM
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB - no wheezes, rales, rhonchi
ABDOMEN: BS+, nondistended, significant tenderness to palpation
in LLQ, suprapubic, and epigastric regions without rebound or
guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
=================
ADMISSION LABS
=================
___ 08:55PM BLOOD WBC-6.5 RBC-4.61 Hgb-13.0 Hct-40.2 MCV-87
MCH-28.2 MCHC-32.3 RDW-13.2 RDWSD-41.8 Plt ___
___ 08:55PM BLOOD Neuts-55.3 ___ Monos-10.5 Eos-1.4
Baso-0.6 Im ___ AbsNeut-3.59 AbsLymp-2.08 AbsMono-0.68
AbsEos-0.09 AbsBaso-0.04
___ 08:55PM BLOOD Plt ___
___ 08:55PM BLOOD ___ PTT-34.6 ___
___ 08:55PM BLOOD Glucose-94 UreaN-4* Creat-0.7 Na-141
K-4.1 Cl-102 HCO3-26 AnGap-13
___ 08:55PM BLOOD ALT-8 AST-14 AlkPhos-50 TotBili-0.6
___ 08:55PM BLOOD Lipase-28
___ 08:55PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.3 Mg-1.9
___ 08:55PM BLOOD HCG-<5
___ 08:58PM BLOOD Lactate-0.9
=================
IMAGING/STUDIES
=================
___ CT ABD/PELVIS W/O CONTRAST IMPRESSION: No acute
findings to explain the patient's abdominal pain or diarrhea.
Trace free fluid in the pelvis is likely physiologic.
___ AXR IMPRESSION: Normal bowel gas pattern. No evidence
of toxic megacolon or radiographically apparent cause of
abdominal tenderness.
=================
MICROBIOLOGY
=================
___ 3:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:51 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ 1:51 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___. ___ 10:42AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
=================
DISCHARGE LABS
=================
___ 04:20AM BLOOD WBC-7.2 RBC-4.55 Hgb-13.0 Hct-40.4 MCV-89
MCH-28.6 MCHC-32.2 RDW-13.2 RDWSD-42.8 Plt ___
___ 04:20AM BLOOD Plt ___
___ 04:20AM BLOOD Glucose-75 UreaN-3* Creat-0.6 Na-143
K-4.1 Cl-104 HCO3-27 AnGap-12
___ 04:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.9
Brief Hospital Course:
PATIENT SUMMARY
=================
___ is an ___ with a history of C. diff who presented
with worsening abdominal pain and diarrhea and found to have
recurrent C. diff infection.
ACUTE ISSUES
==============
# Mild C. diff colitis: Originally evaluated by the ED on
___ for abdominal pain and diarrhea, and was found to have
a normal CT Abd/Pelvis and negative stool O&P, however a +C.
Difficile stool assay. She was initiated on Metronidazole,
however represented and was ultimately admitted to Medicine on
___ with worsened abdominal pain and diarrhea. She had a
normal WBC count, lactate, and Creatinine - thus more suggestive
of mild recurrent C. Difficile colitis. She was initially
treated with IV Flagyl and PO Vancomycin, however was ultimately
transitioned to and discharged on solely PO Vancomycin x14 days
(___). She was also discharged with Zofran and Compazine to
help with nausea associated with taking Vancomycin. She is to
follow up with ___ Student Health within the week, and to follow
up with GI as well to discuss further evaluation of recurrent C.
Diff in an otherwise healthy ___ woman. She was tolerating POs
without signs or symptoms of dehydration at the time of
discharge.
CHRONIC ISSUES
===============
# Depression: Continued home sertraline
TRANSITIONAL ISSUES
====================
[ ] Complete PO Vancomycin x14 days ___, to end on
___
[ ] Pt to call ___ to arrange follow up within the
week
[ ] Follow up with GI as scheduled. Will need to have referral
placed by PCP prior to scheduling appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 150 mg PO DAILY
2. MetroNIDAZOLE 500 mg PO TID
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth once
every 8 hours Disp #*30 Tablet Refills:*0
2. Simethicone 40-80 mg PO QID:PRN pain
RX *simethicone 125 mg 1 capsule by mouth every 6 hours Disp
#*30 Capsule Refills:*0
3. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 14 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*56 Capsule Refills:*0
4. Sertraline 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Mild Recurrent C. Difficile Infection
SECONDARY:
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were having belly pain, nausea, and diarrhea - and were
found to have a repeat C. Difficile infection
What did you receive in the hospital?
- We used a different medication, call Vancomycin, to treat
your C. Difficile infection
- We tried Zofran and Compazine to treat your nausea, and these
seemed to help
What should you do once you leave the hospital?
- Continue to take Vancomycin as prescribed
- Follow up with Student Health within 1 week to check on how
your infection is doing
- Follow up with our GI doctors to discuss ___ about your C.
Difficile
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10581045-DS-18 | 10,581,045 | 28,284,392 | DS | 18 | 2183-10-28 00:00:00 | 2183-10-29 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Mevacor
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Operative Dates:
___ abdominal closure
___ Ex-lap, washout, then partial closure
___ ex lap, open abdomen w/abthera
PICC LINE placement: ___
PICC line removed: ___
History of Present Illness:
___ year old male s/p remote left CCY and appendectomy who
presents to the ED on ___ as a transfer from ___
with abdominal pain and concern for GI
bleed. History was limited due to acuity and patient's AMS. Per
EMS, the
patient presented to OSH earlier in the day with abdominal
pain and was about to be discharged today when he had large
volume bloody diarrhea. The patient was also noted to be mildly
hypotensive and tachycardic. CT obtained at OSH showed dilated
loops of bowel but was otherwise unremarkable. OSH labwork was
remarkable for leukocytosis
and a lactate of 5. The patient was administered empiric
antibiotics and started on 1 unit of PRBCs. The patient was
transferred to the ED for further evaluation. Upon arrival,
the patient is somnolent and oriented to person but not
time.
Past Medical History:
CAD s/p stent ___ years ago, not on anticoagulation
rheumatoid arthritis
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
HR: 115 BP: 98/54 Resp: 34 O(2)Sat: 100 Normal
Constitutional: acutely ill-appearing
HEENT: Normocephalic, atraumatic
No ___ tenderness
Chest: tachypneic to 30 with clear bilateral breath sounds
Cardiovascular: tachycardic to 120
Abdominal: diffuse abdominal tenderness,
peritonitic/surgical abdomen. Moans to pain with slightest
touch or moving the bed
Rectal: Maroon guaiac positive
Extr/Back: No cyanosis, clubbing or edema
Skin: mottled, cool
Neuro: somnolent, moved all extremities equally, awakened to
voice
Psych: confused
Physical examination upon discharge: ___:
vital signs: 98.3, hr=91, bp=112/62 rr=20, 93 % room air
GENERAL: NAD
CV: ns1, s2
LUNGS: Diminished BS right side, no wheezes
ABDOMEN: hypoactive BS, soft, non-tender, midline abdominal
suture line clean and dry
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, conversant, speech clear, no
tremors
MUSCULOSKELETAL: muscle st upper ext. +3/+5, lower ext. +3/+5,
limited ___
SKIN: Mepiplex to coccyx for localized area of erythema
Pertinent Results:
___ 04:25AM BLOOD WBC-4.9 RBC-2.97* Hgb-9.3* Hct-29.3*
MCV-99* MCH-31.3 MCHC-31.7* RDW-15.0 RDWSD-53.4* Plt ___
___ 03:54AM BLOOD WBC-5.1 RBC-2.89* Hgb-9.0* Hct-28.9*
MCV-100* MCH-31.1 MCHC-31.1* RDW-15.2 RDWSD-55.6* Plt ___
___ 03:48AM BLOOD WBC-6.7 RBC-2.82* Hgb-8.7* Hct-28.4*
MCV-101* MCH-30.9 MCHC-30.6* RDW-15.1 RDWSD-55.9* Plt ___
___ 10:25PM BLOOD WBC-15.9* RBC-3.82* Hgb-12.1* Hct-39.2*
MCV-103* MCH-31.7 MCHC-30.9* RDW-14.6 RDWSD-54.7* Plt ___
___ 04:25AM BLOOD Plt ___
___ 03:55AM BLOOD ___ PTT-27.7 ___
___ 04:25AM BLOOD Glucose-127* UreaN-25* Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-25 AnGap-10
___ 03:54AM BLOOD Glucose-134* UreaN-24* Creat-0.7 Na-141
K-4.5 Cl-106 HCO3-25 AnGap-10
___ 03:48AM BLOOD Glucose-138* UreaN-23* Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-25 AnGap-9*
___ 06:03AM BLOOD ___
___ 01:35AM BLOOD ___
___ 10:25PM BLOOD Glucose-95 UreaN-36* Creat-2.0* Na-142
K-4.4 Cl-107 HCO3-14* AnGap-21*
___ 03:48AM BLOOD ALT-83* AST-66* AlkPhos-79 TotBili-0.2
___ 06:25AM BLOOD CK(CPK)-504*
___ 09:49PM BLOOD CK(CPK)-879*
___ 03:00PM BLOOD CK(CPK)-1019*
___ 09:51AM BLOOD CK(CPK)-944*
___ 06:25AM BLOOD CK-MB-8 cTropnT-0.11*
___ 05:12PM BLOOD CK-MB-17* MB Indx-1.8 cTropnT-0.08*
___ 04:25AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
___ 05:00PM BLOOD TSH-2.3
___ 07:00PM BLOOD Free T4-1.1
___ 07:00PM BLOOD IgA-141
___ 10:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:17AM BLOOD Lactate-1.2
___ 01:31PM BLOOD freeCa-1.23
___: CXR:'
1. Left lower lobe opacity, which may represent atelectasis,
aspiration
pneumonitis, or developing pneumonia.
2. Trace left pleural effusion.
___: ECHO:
LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity
size. Normal regional systolic function.
The visually estimated left ventricular ejection fraction is
75-80%. Hyper-dynamic ejection fraction. Mid-cavitary gradient.
RIGHT VENTRICLE (RV): Normal free wall motion.
PERICARDIUM: No effusion. Anterior fat pad
EMR
___: CT abd. and pelvis:
1. Mild mucosal enhancement and subcutaneous edema involving the
descending and sigmoid colon, which most likely represents
colitis.
2. Several dilated loops of small bowel with air-fluid levels,
which most
likely represent mild postoperative ileus.
3. No evidence of a drainable fluid collection or free
intraperitoneal air.
___: CXR:
Comparison to ___. The feeding tube was removed.
On today's
radiograph the patient shows mild elevation of the left
hemi-diaphragm at
overall low lung volumes. Mild cardiomegaly persists. There
are signs of
mild pulmonary edema and a newly appeared left basal parenchymal
opacity,
potentially reflecting pneumonia in the appropriate clinical
setting. The
opacities accompanied by a small left pleural effusion. No
pneumothorax.
___: colonic pathology:
Colonic mucosal biopsies, three:
1. Descending:
- Minute fragment of granulation tissue with scant residual
surface epithelium, consistent with ulcer
sampling, and abundant intact colonic mucosa with hyperplastic
changes.
2. Sigmoid:
- Colonic mucosa with extensive ulceration and prominent
granulation tissue formation demonstrating focal
fibrino-purulent exudate.
- Scant intact colonic mucosa with focal features suggestive of
hyperplastic polyp, otherwise
unremarkable.
-CMV immuno-histochemical stain is negative for viral
inclusions, with satisfactory control.
3. Rectum:
- Colonic mucosa with an incidental hyperplastic polyp,
otherwise unremarkable.
___: PICC line:
IMPRESSION:
1. Left PICC line terminates near the cavo-atrial junction,
appropriately
positioned.
2. Bilateral lung volumes remain low (left worse than right),
but improved from prior.
___: CT ___:
1. Evaluation for cervical instability is limited by patient's
head turned
toward the left. The atlanto dens interval is not widened. No
evidence of
acute fracture or traumatic mal-alignment. If there is concern
for cervical spine instability/injury, MR ___ can be
obtained to assess for ligamentous injury.
2. Multilevel degenerative changes as detailed above.
3. Moderate bilateral pleural effusions partially imaged.
RECOMMENDATION(S): If there is concern for cervical spine
instability/injury, MR ___ can be obtained to assess for
ligamentous
injury.
___: Dobhoff:
Dobhoff tube terminating in the stomach. Improvement in left
basilar
opacities.
___: CXR:
IMPRESSION:
1. Increased left basilar opacities, which most likely
represents
subsegmental atelectasis, however aspiration pneumonitis cannot
be excluded.
2. Trace left pleural effusion.
___ 8:05 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
___ 11:19 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
Brief Hospital Course:
___ is an ___ year-old man who presented to the ___ as
a transfer from an outside hospital with abdominal pain and
concern for lower GI bleed. On arrival to the ED the patient was
reportedly confused and provided a limited history. He
reportedly developed severe abdominal pain the evening prior to
presentation. At the OSH, a CT demonstrated dilated loops of
bowel but was otherwise unremarkable. His labs were notable for
a leukocytosis, and elevated lactate. While at the OSH, he
reportedly had a large bloody bowel movement. He subsequently
became mildly hypotensive and developed tachycardia. He was
started on antibiotics, given 1U pRBC and transferred to the
___ ED for further evaluation.
On arrival, the patient was noted to be altered, oriented only
to self and his abdomen was diffusely tender to palpation with
rebound. He continued to be hypotensive, with tachycardia, and
somnolent. He was reported to desaturate to the 80% on room
air, thus, he was intubated for airway protection. He was given
stress dose steroids in the setting of chronic prednisone use
and peripheral vasopressors were started. A CTA of the abdomen &
pelvis was performed with findings concerning for bowel
ischemia. The patient was emergently taken to the operating
room where he underwent an exploratory laparotomy and temporary
abdominal closure. The operative course was stable with a 100cc
blood loss. The patient was extubated after the procedure and
transferred to the intensive care unit for monitoring.
He returned to the OR on ___ and subsequently on ___
for abdominal washout and closure of laparotomy wound. His
post-operative course was complicated by encephalopathy and he
received phenobarbital due to concern for withdrawal. He was
also reported to have elevated troponins thought to be due to
demand ischemia. In order to provide nutrition, a dobhoff
feeding tube was placed which the patient self discontinued.
The patient was called out to the surgical floor ___.
REVIEW OF SYSTEMS:
CV: The patient was initially reported to be hypertensive and
required intravenous anti-hypertensive agents. After tolerating
a regular diet, his home blood pressure agents were resumed.
His blood pressure normalized at 112/62. He was also noted
after transfer from the intensive care unit, to have elevated
troponins. A Cardiology consult was obtained on ___.
Recommendations were made for resuming ASA and atorvastatin. An
ECHO was done which showed no wall abnormality. Out-patient
cardiology follow-up was recommended for additional evaluation
of his CAD.
RESP: Through-out the patient's hospitalization, the patient
maintained adequate oxygenation on room air. His o2 sat has been
93 % on room air.
ABDOMEN: The GI service was consulted for post-operative
diarrhea. A cat scan of the abdomen was done which showed
mucosal enhancement and subcutaneous edema suggestive of
colitis. The patient underwent a colonoscopy which showed
ulcers in the descending colon and diverticuli, findings which
were suggestive of ischemic colitis. The patient underwent
stool, O+P, and c.diff testing which was negative. During his
hospitalization, he had occasional bouts of guaiac positive
stool, but his hematocrit has remained stable. His abdomen has
been soft and non-tender.
GI: The patient was evaluated by the Speech and Swallow service
to assess his ability to swallow. Prior to the insertion of a
dobhoff feeding tube, TPN was initiated. After the patient was
cleared for thick liquids, the TPN was discontinued. The
patient advanced to soft solids and thin liquids. He still
requires 1:1 supervision with his meals and remains on
aspiration precautions. During his hospitalization, his
appetite has been diminished because of his dislike for hospital
food and he was started on cyclic tube feedings. The dobhoff
feeding tube was removed on ___. The patient requires
assistance and supervision with meals.
GU: The patient has been voiding without difficulty, with and
without a condom catheter. BUN= 27, creat of 1.0.
SKIN: Scattered bruising no the arms and legs
MUSCUSKELETAL: The patient was noted to have a rigid neck after
his transfer to the surgical floor and overall hypersensitivity
to touch Several services were consulted including Geriatric,
Neurology, Psychiatry, and Pain service. Muscle relaxants were
utilized which demonstrated a mild relaxation effect. The
patient was started on a trial of dantrolene, which seemed to
relax his muscle. It was discontinued 1 week ago. Blood
cultures and urine cultures were obtained which were negative.
Over the last week, he has had marked improvement in his muscle
rigidity. The patient is now able to ambulate with walker to
chair and his ROM of his neck has improved.
MENTATION: Upon transfer to the surgical floor, the patient
experienced profound delirium. Input was received from the
Gerontology and Psychiatry services. Narcotic pain medicine was
held and environmental factors leading to delirium were
identified. The patient's mental status has returned to
baseline. He is alert and oriented, following commands and
anxious to proceed with the next step in his rehabilitation.
In preparation for discharge, the patient was evaluated by
physical therapy and recommendations were made for discharge to
a rehabilitation facility to further regain his strength and
mobility.
The patient was discharged on ___. His vital signs were stable
and he was afebrile. His dobhoff feeding tube was removed at
the time of discharge. He was voiding without difficulty and
had return of bowel function. Discharge appointments were made
in the acute care clinic and with his cardiologist.
Medications on Admission:
- Lisinopril 20mg daily
- Rosuvastatin 40mg daily
- Prednisone 5mg daily
- diltiazem 240 mg daily
- meloxicam 7.5mg BID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
may wear down to PRN as pain decreases
2. Artificial Tears GEL 1% ___ DROP BOTH EYES Q12H:PRN itchy
eyes
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 100 mg PO QHS
6. Heparin 5000 UNIT SC BID
7. Ramelteon 8 mg PO QHS:PRN sleep
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. amLODIPine 5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Diltiazem 60 mg PO QID
12. Lisinopril 40 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. PredniSONE 5 mg PO DAILY
15. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ischemic colitis
Secondary:
torticollis
altered mental status
elevated troponins
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 the Acute Care Surgery Service on ___
with severe abdominal pain. You had abdominal surgery and found
to have infected fluid around your intestines. You were very
sick and required a ventilator to help you breath and IV
antibiotics. Over time, your infection resolved. You had trouble
meeting your nutritional needs and therefore you were given
nutrition through the IV and then had a tube placed in your nose
to give your stomach tube feeds. You continued to get stronger
and were able to eat. You are now doing better, tolerating a
regular diet, and ready to be discharged to rehab to continue
your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10581221-DS-9 | 10,581,221 | 24,313,676 | DS | 9 | 2114-09-28 00:00:00 | 2114-09-28 12:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"I've been having suicidal ideation"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ male with a history of generalized anxiety
disorder and hypertension who is referred from his provider at
___ after presenting there today with
anxiety and SI with plan to either cut wrists or overdose on
propranolol. Patient reports struggling with anxiety and
depression since middle school. He states that he is trying to
change careers but is dreading the music performance and
practice necessary to complete his bachelors degree before
transitioning to a post-___ pre-med program. He reports
increased anxiety, denies panic attacks, endorses ruminating
about things.
Patient states that last night he lay away for hours with
suicidal thoughts, hoping they would pass. He denies ever acting
on these thoughts, but states they have been there for many
years. Pt reports decreased mood interest in activities he used
to enjoy, like playing video games. He reports his sleep has
always been poor, denies change in appetite, says he has
"virtually no" motivation, "low" energy, endorses feelings of
guilt. He states, "Sometimes, I feel like I'm just doing this
for - I don't want to say for attention - but I feel guilty
about seeking help for this because I'm convinced I can just get
over it." He reports that he has "been combating suicidal
thoughts for a long time."
Per ___, NP at ___, ___ walked into the clinic with
chest pain and anxiety and mentioned that he was considering
ending his life last night, was lying on his bed and didn't want
to move because he was fearful of what he would do to himself.
He told her he had a plan to either use a knife or overdose on
propranolol. About 2 weeks ago, he presented in a similar state
but wasn't speaking specifically about suicidal ideation. He
was distressed after visiting his family over the weekend. His
sister and uncle have addictions problems, which causes a lot of
stress for him. At that time, he was able to be seen by a
counselor and a psychiatrist at that time and was able to
contract for safety. Per ___ has been diagnosed with
generalized anxiety disorder and hypertension. Does use
marijuana regularly, has been successful at stopping it in the
past, but it has been a coping mechanism for him when he is
under stress. Stopping marijuana was what led to his
presentation on ___.
On interview, ___ states that he is not currently feeling
suicidal, but that the feelings come and go, worse at night and
when patient is practicing music or thinking about a
performance. Patient states that originally he just had
performance anxiety, but it has increased to a sense of dread
surrounding all aspects of music. ___ denies feelings of
paranoia, but does state that at times, he feels almost as if
someone is watching him when
he can't fall asleep.
Past Medical History:
Hypertension
Social History:
___
Family History:
Sister and uncle with drug use disorder
Physical Exam:
PHYSICAL EXAMINATION (on admission):
VS: T:98.8 , BP:143/87 , HR:58 , R:16 , O2 sat:97% on RA
General: Overweight male, appears stated age, NAD, wearing
glasses and hospital gown
HEENT: Normocephalic, atraumatic. PERRL, EOMI.
Back: No significant deformity.
Lungs: CTA ___. No crackles, wheezes, or rhonchi.
CV: RRR, no murmurs/rubs/gallops.
Abdomen: +BS, soft, nontender, nondistended. Extremities: No
clubbing, cyanosis, or edema.
Skin: No rashes, abrasions, scars, or lesions.
Neurological:
Cranial Nerves: CNII-XII grossly intact
Motor: Normal bulk and tone bilaterally. No abnormal movements,
no tremor. Strength: full power ___ throughout.
Sensation: Intact to light touch throughout.
Gait: Steady. Normal stance and posture. No truncal ataxia.
Cognition:
Wakefulness/alertness: awake and alert
Attention: intact to interview
Orientation: oriented to person, time, place, situation
Memory: intact to recent and past history
Fund of knowledge: consistent with education
Speech: normal rate, quiet volume, and flat tone
Language: native ___ speaker, no paraphasic errors,
appropriate to conversation
Mental Status:
Appearance: Overweight male, appears stated age, NAD, wearing
glasses and hospital gown, wide-eyed, anxious-appearing
Behavior: cooperative, pleasant, appropriate eye contact, no
psychomotor agitation or retardation
Mood and Affect: "anxious " / mood-congruent, anxious,
suspicious
Thought Process: linear, coherent, goal-oriented. No LOA.
Thought Content: denies SI/HI/AH/VH but does state that he has
had SI in the last day and that sometimes it feels like someone
is watching him while he's laying in bed
Judgment and Insight: guarded/ guarded
DISCHARGE MENTAL STATUS EXAM
Vital Signs:
T 97.9, BP 147/98, HR 84, RR 16, SpO2 99% RA
MSE-
Appearance: adequate grooming and hygiene, appears stated age
Behavior: calm and cooperative, good eye contact, smiles
spontaneously, no notable PMA/PMR
Speech: grossly normal rate/tone/prosody/volume
Mood: 'Good'
Affect: mood linear, logical, future-oriented
Thought Content: no SI/HI, no evidence of delusions
Perceptions: no AVH
Insight/Judgment: good/fair
Cognitive Exam: Alert/Oriented x3, fluent speech in ___
Pertinent Results:
___ 02:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:45AM BLOOD VitB12-542 Folate-13
___ 04:45AM BLOOD TSH-2.7
___ 01:00PM BLOOD Cholest-266*
___ 01:00PM BLOOD Triglyc-184* HDL-48 CHOL/HD-5.5
LDLcalc-181*
Brief Hospital Course:
This is as ___ year old single Caucasian man, previously
diagnosed with depression, anxiety, currently a senior at ___
___, who presented to ___ as a referral from
his outpatient psychiatric provider with worsening depression,
anxiety, chest pain and suicidal ideation with plan to cut his
wrists or overdose on propranolol.
.
Upon interview, patient reports longstanding history of
depression and anxiety beginning in childhood with recent
worsening of symptoms in the setting of academic stressors,
conflict with family. Given subjective symptoms with low mood,
poor sleep, energy, poor concentration, suicidal ideation,
anhedonia, he likely meets criteria for major depressive
disorder without psychotic features. Also likely meets criteria
for generalized anxiety disorder. However, given the chronicity
of his depression with chronic suicidal ideation, I am also
suspicious of underlying cluster B traits with recent
decompensation. I cannot rule out underlying substance use,
given reports of cannabis use perhaps overuse of Ativan,
although tox screen was notably negative.
.
#. Legal/Safety: Patient admitted on a ___, upon
admission signed a CV, which was accepted. Stating he did not
want to be in the hospital, he also signed a 3 day notice on
___ that expired on ___. Given improvement in
depression, adherence with treatment, denial of suicidal
ideation and good behavioral control, I did not believe he met
criteria to file 7&8b at this time.
Of note, Mr. ___ maintained his safety throughout his
psychiatric hospitalization on 15 minute checks and did not
require physical or chemical restraints.
.
#. MDD, recurrent, severe, without psychotic features/GAD
- Patient was compliant in attending some groups and maintained
good behavioral control throughout his admission. He was active
in treatment and demonstrated improved insight, discussing his
perfectionistic tendencies and how this may affect his mood and
anxiety. Patient allowed the treatment team to contact his
parents, who were supportive in his care.
- After discussion of the risks and benefits, we continued
Sertraline 200 mg po qd, which he tolerated well with no
complaints of side effects. Discussed the risks and benefits of
augmenting this SSRI, and patient agreed to a trial of
risperidone which was started at 0.5 mg po qhs and 0.5 mg po bid
prn agitation. He tolerated the risperidone well with
improvement in mood and anxiety with no unwanted side effects
- For anxiety and insomnia, we discussed the risks and benefits
of Valium, which was started at 5 mg po bid. However, patient
required few doses, and given his overuse of the Ativan, this
was tapered off prior to discharge with no worsening of anxiety
or depression
- Given concern for overdose, propranolol was tapered off prior
to discharge. In addition, patient allowed friend to remove
propranolol from the apartment, which was confirmed by the
treatment team.
- By time of discharge, patient was notably consistently denying
thoughts of suicide or self harm and reported improvement in
mood. He was notably linear, goal and future oriented with plan
to return to ___ and follow up with outpateint treaterse.
#. Hypertension: as above
- Patient weaned off propranolol as noted above with BP's that
remained stable throughout his admission
- Recommend continuing to monitor as an outpatient
.
#. High Cholesterol
-Lipid Panel during admission was elevated, no pharmacologic
intervention initiated
-Recommend re-check Lipid Panel as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol 20 mg PO BID
2. Sertraline 200 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Discharge Medications:
1. RisperiDONE 0.5 mg PO QHS
RX *risperidone 0.5 mg 1 tablet(s) by mouth nightly Disp #*15
Tablet Refills:*0
2. RisperiDONE 0.5 mg PO BID:PRN anxiety, agitation
RX *risperidone 0.5 mg 1 tablet(s) by mouth twice per day as
needed Disp #*30 Tablet Refills:*0
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Sertraline 200 mg PO DAILY
RX *sertraline 100 mg 2 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Generalized Anxiety Disorder with depressive symptoms
Discharge Condition:
Vital Signs:
T 97.9, BP 147/98, HR 84, RR 16, SpO2 99% RA
MSE-
Appearance: adequate grooming and hygiene, appears stated age
Behavior: calm and cooperative, good eye contact, smiles
spontaneously, no notable PMA/PMR
Speech: grossly normal rate/tone/prosody/volume
Mood: 'Good'
Affect: mood linear, logical, future-oriented
Thought Content: no SI/HI, no evidence of delusions
Perceptions: no ___
Insight/Judgment: good/fair
Cognitive Exam: Alert/Oriented x3, fluent speech in ___
Discharge Instructions:
You were hospitalized at ___ for suicidal ideation with a plan
in the setting of acute escalating anxiety.
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way, including having suicidal ideation,
planning, or intent, and are unable to immediately reach your
health care providers.
It was a pleasure to have worked with you, and we wish you the
best of health.
Followup Instructions:
___
|
10581256-DS-7 | 10,581,256 | 20,091,895 | DS | 7 | 2178-02-06 00:00:00 | 2178-02-06 22:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
hazelnut
Attending: ___
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old right-handed woman who has a history of
viral cerebellitis (in ___ grade) with no residual neurologic
deficit who presents with dizziness.
She has a viral URI for the past week with cough and "losing her
voice". Over the past ___ days, she developed a holocephalic
pressure-type headache. She denies any positional trigger to
the
headache. She has been spending a lot of time in bed over the
past couple of days.
Today, she went to work. During her work day, she felt that it
is increasingly difficult to work. She "cannot walk straight."
States that her coworker tested pronator drift on her and found
a
"drift in the right arm." States that she feels dizzy but "it's
not vertigo". When asked, she denies a spinning sensation of
herself or the environment but she feels that her head sometimes
drops "like I am on a rollar coaster". She denies any actual
jerking movement of the head or any part of her body.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. Mom states that "it is hard for her to gain weight".
Past Medical History:
Cerebellitis in ___ grade, diagnosed in ___ ___
Endometriosis
Depression
Anxiety
Denies HTN, HLD, DM, irregular HR, h/o clot
Social History:
___
Family History:
Unknown. She is adopted.
Physical Exam:
Physical Exam:
98.0, 102, 134/80, 16, 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA
Cardiac: RRR
Abdomen: soft, NT/ND.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. She has good recall of recent and distant history. The
pt had good knowledge of current events. There was no evidence
of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
Her right arm drifts without pronation. She orbits her right
arm
around the left. No bradykinesia in RAM bilaterally. No
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout.
-DTRs:
2+ and symmetric throughout b/l UE an ___.
-Coordination:
On FNF and HKS, she deviates from the course throughout but the
amplitude of the deviation does not increase when she is
approaching the target. I cannot appreciate any dysmetria.
Mirroring is intact. (When she was walking and swaying, she was
able to reach her arms out to hold on to objects without sign of
ataxia)
When being tested for truncal ataxia, she has a dramatic sway
(in
all direction) but catches herself. Her truncal sway is
distractible (by counting MOYb and colors of the rainbow.)
-Gait: Good initiation. Dramatic sway to all direction without
falling. Narrow-based, normal stride. Lowered herself and
crouched on the ground upon tandem walking. Romberg with sway
and
she takes a step to steady herself.
Discharge Exam
As above except:
MS: Awake, alert cooperative with exam, simple and complex
commands. Able to recite ___ backwards.
CN: 6->4 EOMI, no facial droop, Weber revealed no hearing
deficits.
Motor: ___ in all major muscle groups including delt, bi, tri,
FE/WE, IP, ham, quads, TA
Sensation: proprioception intact
Coordination: FNF intact, no rebound
Gait: narrow based but falled to the left, balance/truncal
ataxia improved with distraction
Pertinent Results:
___ 05:58PM BLOOD WBC-7.1 RBC-5.10 Hgb-15.2 Hct-44.3 MCV-87
MCH-29.8 MCHC-34.3 RDW-12.8 Plt ___
___ 05:58PM BLOOD Neuts-56.3 ___ Monos-5.6 Eos-3.2
Baso-0.5
___ 05:58PM BLOOD Plt ___
___ 05:58PM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-141
K-3.8 Cl-102 HCO3-25 AnGap-18
___ 05:11AM BLOOD Calcium-9.3 Phos-5.2* Mg-2.2
MRI ___
No acute infarct or mass effect or abnormal enhancement. No
evidence of
cerebellitis. The cerebellar tonsils are minimally low lying
right lower than left. Correlate clinically and followup as
needed. No priors.
Other details as above.
Brief Hospital Course:
___ with h/o viral cerebellitis p/w dizziness in the setting of
one week of viral URI. On admission, there were a number of
functional findings on her exam (right arm drift without
pronation with right arm orbiting around the left arm,
distractible truncal sway etc). There was no nuchal rigidity or
fever to necessitate emergent LP. Given her h/o viral
cerebellitis, she was admit to general neurology for MRI. MRI
showed no leptomeningeal enhancement, structural abnormalities
or any other acute findings. It did showed low laying cerebellar
tonsils right lower than left (no intervention indicated). Pt
evaluated the patient and provided her with a walker. They also
recommended outpatient ___. She was scheduled for close follow up
in outpatient neurology clinic and discharged in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fexofenadine 180 mg PO DAILY
2. Sertraline 150 mg PO DAILY
3. ClonazePAM 1 mg PO QHS
Discharge Medications:
1. ClonazePAM 1 mg PO QHS
2. Fexofenadine 180 mg PO DAILY
3. Sertraline 150 mg PO DAILY
4. Outpatient Physical Therapy
Multifactorial Gait Disorder
Evaluate and Treat
5. Rolling Walker
DX: Multifactorial Gait Disorder
Prognosis: Good
Length of need: >13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Vertigo
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 ___ after you had the onset of
difficulty walking, left drift with no pronation, and truncal
ataxia. You had no evidence of an acute infection (no nuchal
rigidity or fever) so LP was deferred. Given you history of
viral cerebellitis, you were admitted to general neurology for
MRI. MRI showed no leptomeningeal enhancement, structural
abnormalities or any other acute findings. It did showed low
laying cerebellar tonsils right lower than left which is a
normal variant (no further treatment required). Physical Therapy
evaluated you and provided you with a walker. They also
recommended outpatient ___ session. Please make sure to
participate in these sessions to avoid unneccessary falles. You
have been scheduled for close follow up in outpatient neurology
clinic. It was a pleasure caring for you during your stay.
Followup Instructions:
___
|
10581271-DS-13 | 10,581,271 | 20,037,205 | DS | 13 | 2122-03-13 00:00:00 | 2122-03-19 08:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Garlic / Milk / Codeine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Pericardial Drain Placement ___
History of Present Illness:
This is a ___ with a PMHx of fibromyalgia and distant vasovagal
syncope s/p pacemaker placement and generator removal who
presents with three weeks of fevers, chills, and dyspnea on
exertion recently diagnosed with a pneumonia now found to have a
pericardial effusion with tamponade physiology.
At the time of admission she is s/p pericardial drain placement
and is sleepy from sedation so this history is obtained from
patient and prior notes/interviews. She reports fevers, chills,
and fatigue 3 weeks ago. This was associated with dizziness and
dyspnea on exertion. She presented to ___
where there was a concern for pneumonia so she was treated with
ciprofloxacin changed to levofloxacin. There, HIV, legionella,
and S. pneumo were negative. Blood cultures were negative. Flu
A/B and throat culture were negative. She since completed the
course of Levofloxacin. She completed this course of antibiotics
but had progressive symptoms where she became dyspneic with
minimal movement, and therefore presented to the ___ ED. She
also reports pleuritic chest pain during that time and shoulder
pain worse than her fibromyalgia pain. She has not traveled
recently. She denies joint swelling or changes in urine
color/quantity. She continues to have low-grade fevers.
In the ED:
Initial vitals were: T 102.0, HR 106, BP 132/91, RR 16, and
SpO2 97% on RA.
Labs: negative troponin, H/H 13.6/42.6, Cr 0.7, lactate 2.5.
Imaging: Bedside echocardiogram showed a mod/large pericardial
effusion. CXR showed enlarged cardiac silhouette and
retrocardiac opacity silhouetting the hemidiaphragm. EKG with
low voltage.
Consults: Cardiology performed bedside echo demonstrating 3cm
effusion with pulsus of 14 and RV diastolic collapse.
Patient was given: Percocet x1 and 1L NS.
She was taken to the cath lab for pericardial drainage. The
procedure was difficult requiring multiple passes subxyphoid.
She subsequently became bradycardic, unresponsive, and PEA
arrested. She had CPR for 30 seconds and received atropine x1
and epinephrine x1. She achieved ROSC and VS were subsequently
normal. She was started on Dopamine and placed on supplemental
O2. The drain was subsequently placed successfully with 600cc SS
fluid sent to the lab and the drain kept to gravity.
On arrival to the ICU, the patient was satting high-80s on NRB
but came up after a few minutes to 97% on NRB. Her BP
downtrended to ___ on dopamine 5. She was mentating well.
She was given 250cc NS bolus and dopamine was increased to 7.5.
She reports chest and shoulder pain that has continued since
arrival to the ED.
REVIEW OF SYSTEMS:
(+) per HPI
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
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.
Past Medical History:
- History of distant syncope likely due to vasovagal etiology,
status post pacemaker implantation several years ago, status
post
negative electrophysiological study in ___, status post
pacemaker generator removal in ___.
- Fibromyalgia
- Depression
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Mother had psychiatric problems "same as me."
Physical Exam:
ADMISSION EXAM:
===============
VS: T ___ HR 110 BP 103/55 on dopamine 5 RR 22 SpO2 98% on NRB
GEN: No acute distress, sleepy but arousable, speaking very
softly
HEENT: NC/AT, PERRL, sclera anicteric, OP clear
NECK: Supple, no JVP elevation, no bruits
CV: RRR, pericardial rub present, no murmurs auscultated
LUNGS: Nonlabored, decreased breath sounds at bases, faint
rales
ABD: Soft, nontender, nondistended, NABS
EXT: Warm, well-perfused, no edema
SKIN: No rash or lesions
NEURO: Sleepy but arousable, slow to answer questions but AOx3,
face symmetric, moves all 4 extremities equally, gait deferred
DISCHARGE EXAM:
===============
VS 98.3 80 ___ 95%/RA
Tele: PVCs
___: NAD, sitting up in bed, A+Ox3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
CV: distant heart sounds with systolic murmur present, RRR
Lungs: Clear bilaterally, NLB
Abdomen: Soft, minimal ___ tenderness
Ext: WWP, no cyanosis or edema
Neuro: Grossly normal
Skin: palpable, non-blanching pupura on BLE and elbows and
abdomen, confluent, pruritic and burning per report with
intermittent numbness
Pertinent Results:
ADMIT LABS
==========
___ 02:34PM BLOOD WBC-17.7*# RBC-4.83 Hgb-13.6 Hct-42.6
MCV-88 MCH-28.2 MCHC-31.9* RDW-13.3 RDWSD-43.0 Plt Ct-UNABLE TO
___ 02:34PM BLOOD Neuts-85.3* Lymphs-9.4* Monos-4.0*
Eos-0.3* Baso-0.4 Im ___ AbsNeut-15.08* AbsLymp-1.67
AbsMono-0.70 AbsEos-0.06 AbsBaso-0.07
___ 06:00PM BLOOD ___ PTT-27.5 ___
___ 02:34PM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-134
K-5.5* Cl-98 HCO3-22 AnGap-20
___ 02:34PM BLOOD ALT-22 AST-38 AlkPhos-119* TotBili-1.3
___ 02:34PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.5 Mg-2.0
DISCHARGE LABS
==============
___ 07:25AM BLOOD WBC-9.6 RBC-3.86* Hgb-10.9* Hct-34.4
MCV-89 MCH-28.2 MCHC-31.7* RDW-13.6 RDWSD-43.7 Plt ___
___ 07:25AM BLOOD Glucose-93 UreaN-12 Creat-0.5 Na-138
K-4.5 Cl-105 HCO3-22 AnGap-16
PERTINENT LABS
==============
___ 02:34PM proBNP-360*
___ 02:34PM cTropnT-<0.01
___ 09:55PM BLOOD CK-MB-9 cTropnT-0.70*
___ 04:10AM BLOOD CK-MB-14* cTropnT-0.46*
___ 04:02AM BLOOD CK-MB-3 cTropnT-0.09*
___ 04:02AM BLOOD ANCA-NEGATIVE B
___ 04:02AM BLOOD RheuFac-16*
___ 04:02AM BLOOD C3-156 C4-34
___ 04:10AM BLOOD TSH-0.59
___ 04:02AM BLOOD Cryoglb-NO CRYOGLO
___ 09:55PM BLOOD ___
___ 03:17PM BLOOD Lactate-2.5*
___ 12:51AM BLOOD Lactate-1.0
MICRO/IMAGING
=============
___ BLOOD CULTURES: negative
___ 02:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ PERICARDIAL FLUID CULTURES: negative
___ LYME SEROLOGY: negative
___ BLOOD CULTURES: negative
___ 04:02AM BLOOD HCV Ab-NEGATIVE
___ 04:02AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
Pericardial Fluid Cytology (___): Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS. Neutrophils, lymphocytes, red
blood cells.
___ 06:45PM OTHER BODY FLUID WBC-4550* ___ Polys-47*
Lymphs-40* Monos-5* Macro-8*
___ 06:45PM OTHER BODY FLUID TotProt-5.7 Glucose-76
LD(LDH)-523 Amylase-22 Albumin-3.0
___ 02:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE
Negative test result. M. tuberculosis complex
infection unlikely.
Test Result Reference
Range/Units
NIL 0.03 IU/mL
MITOGEN-NIL 0.70 IU/mL
TB-NIL <0.00 IU/mL
___ 04:02
SJOGREN'S ANTIBODY (SS-A) <1.0 NEG <1.0 NEG AI
SJOGREN'S ANTIBODY (SS-B) <1.0 NEG <1.0 NEG AI
___ 04:10
MYCOPLASMA PNEUMONIAE 1.09 H <=0.90
ANTIBODY (IGG)
Reference Range:
<=0.90 Negative
0.91-1.09 Equivocal
>=1.10 Positive
MYCOPLASMA PNEUMONIAE 47 <770 U/mL
ANTIBODY (IGM)
Reference Range:
<770 U/ml Negative
770-950 U/mL Low positive
>950 U/mL Positive
___ 04:10
HISTOPLASMA ANTIBODY (BY CF AND ID)
YEAST PHASE ANTIBODY <1:8 ___
MYCELIAL PHASE ANTIBODY <1:8 <1:8
Interpretive Criteria:
<1:8 - Antibody Not Detected
> or = 1:8 - Antibody Detected
HISTOPLASMA ANTIBODY, ID Negative Negative
___ 04:10
BLASTOMYCOSIS ANTIBODY (BY CF AND ID)
BLASTOMYCES AB CF <1:8 <1:8
Interpretive Criteria:
<1:8 Antibody Not Detected
> or = 1:8 Antibody Detected
BLASTOMYCES AB ID Negative Negative
___ 04:10
B-GLUCAN
Results Reference Ranges
------- ----------------
32 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
TTE ___
The left atrium is normal in size. No spontaneous echo contrast
is seen in the body of the right atrium. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. An eccentric, posteriorly-directed jet of
mild (1+) mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation, secondary to pacemaker lead impingement is seen.
The estimated pulmonary artery systolic pressure is normal. [In
the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
IMPRESSION: Normal global biventricular systolic dysfunction.
Mild mitral
regurgitation. Severe pacemaker lead-related tricuspid
regurgitation
CXR ___
Enlarged cardiac silhouette, potentially due to cardiomegaly
and/or
pericardial effusion. Retrocardiac opacity silhouetting the
hemidiaphragm. This could be due to combination of underlying
effusion and atelectasis, and/or possible infection.
CXR ___
In comparison with the study of ___, there are
substantially lower
lung volumes. Continued enlargement of the cardiac silhouette
with
pericardial drain in place and dense streak of atelectasis in
the left mid
zone. Poor definition of the left hemidiaphragm again is
consistent with
volume loss in the left lower lobe.
Little if any elevation of pulmonary venous pressure.
Dual-channel pacer and leads are unchanged
TTE ___
In comparison with the study of ___, there are
substantially lower
lung volumes. Continued enlargement of the cardiac silhouette
with
pericardial drain in place and dense streak of atelectasis in
the left mid
zone. Poor definition of the left hemidiaphragm again is
consistent with
volume loss in the left lower lobe.
Little if any elevation of pulmonary venous pressure.
Dual-channel pacer and leads are unchanged
CXR ___
Pericardial catheter is been removed. Moderate enlarged of the
cardiac
silhouette is stable. Right lung is clear. The combination of
left lower
lobe atelectasis and left pleural effusion unchanged.
Brief Hospital Course:
___ y/o F with a h/o fibromyalgia, PPM placement for syncope s/p
removal with leads remaining, sacral nerve stimualtor for urge
incontinence, who presented with pericardial effusion and
tamponade, pleural efussions, fever, fatigue and rash.
ACTIVE PROBLEMS
# Pericardial effusion c/b tamponade: Etiology unclear. Rheum,
ID, and Dermatology were consulted. Workup notable for negative
culture data, ___ negative, ANCA negative, Ro/La negative, C4
and C3 normal, Hep C negative, Hep B immune, HIV negative (OSH),
RF 16 (normal ___, TFT's normal, LFT's normal, Beta-glucan
negative, Lyme negative, Flu negative. Workup also notable for
leukocytosis ___, which was eventually downtrending, with
neutrophilia on differential. Initially treated with
antibiotics, which were discontinued given low suspicion for
infectious etiology. Originally was managed in the CCU, with
course complicated by PEA arrest (w/ ROSC) after pericardial
drainage. Pericardial fluid analysis with 4550 cells, 47% polys,
glu 76, Prot 5.6, negative culture. Pericardial drain since
removed, and afterwards a repeat TTE ___ was without any
features of constriction. She was treated with Ibuprofen 800mg
Q8 for ~2 weeks on discharge and Colchicine 0.6mg BID planned
for 3 months along with Omeprazole daily for GI ppx. She will
follow up with her outpatient cardiologist.
# Acute hypoxic resp failure, shortness of breath: SOB improved
throughout hospital stay. Was maintained on NC oxygen as needed.
Ambulatory sats were normal at time of discharge. Severe TR
could be contributing, in addition to the pericardial disease.
She had no peripheral edema, elevated LFTs, or abdominal
swelling to indicate severe RV failure. We recommend outpatient
workup for pulmonary hypertension.
# Tricuspid Regurgitation: Noted on both TTE's this admission,
with a suggestion that her RV pacer lead may be contributing to
her TR. RV pacer leads are ___ years old, and although PPM has
been removed, it was originally placed for arrhythmia/syncope of
unclear etiology. Discussed with outpatient Cardiologist Dr.
___ does not recommend removal of leads. Follow up
with outpatient Cardiology.
# Hypotension: Was on pressors in CCU, requiring dopamine,
which was weaned ___. Also required intermittent 500cc fluid
boluses during CCU course. Improved to SBPs 90-100s on
discharge.
# PEA Arrest: In the setting of pericardial drainage had cardiac
arrest. Had ROSC after 30 sec's CPR, Epi, and Atropine. Lactate
downtrended afterwards from 2.5 to 1.0. Was monitored on
telemetry. No further episodes.
CHRONIC PROBLEMS
# Depression/Anxiety: Continued home Citalopram 10mg daily,
Clonazepam 0.5mg BID PRN
TRANSITIONAL ISSUES
- Colchicine stops in late ___ (3 months)
- Ibuprofen ends ___ (2 weeks)
- Continue high dose omeprazole (40mg) until ___, then can
resume home dose of 20mg
- Needs follow up for severe tricuspid regurgitation and
evaluation for possible pulmonary hypertension
- Pending studies on discharge: Histoplasma, mycoplasma,
blastomycosis
- Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Citalopram 10 mg PO DAILY
3. ClonazePAM 0.5 mg PO BID:PRN anxiety
4. Omeprazole 20 mg PO DAILY
5. terbinafine HCl 250 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Citalopram 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
please take 2 tablets of your home dose of 20mg until ___, then
resume 1 tablet daily
4. Colchicine 0.6 mg PO Q12H
last day ___
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice daily Disp
#*160 Tablet Refills:*0
5. Ibuprofen 600 mg PO Q8H Duration: 9 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth three times daily Disp
#*27 Tablet Refills:*0
6. ClonazePAM 0.5 mg PO BID:PRN anxiety
7. terbinafine HCl 250 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
#Pericardial effusion
#Cardiac tamponade
#Cardiac Arrest, PEA
#Acute hypoxic respiratory failure
#Severe Tricuspid Regurgitation
#Leukocytoclastic vasculitis
Secondary:
#Fibromyalgia
#Anemia, normocytic
#Mixed urinary incontinence s/p sacral nerve stimulator
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___. You were admitted to
our hospital for chest pain and trouble breathing. You were
found to have a "pericardial effusion," which is a fancy term
for fluid around the heart. Because of this, you had the fluid
drained. You were seen by our rheumatologists, infectious
disease doctors, and dermatologists. Unfortunately, we were not
able to determine the cause of this, which is not uncommon.
Usually, this disease does not recur, but occasionally it does.
In order to reduce the risk of fluid returning around the heart,
you will need to be on medications for the next several weeks.
Additionally, the echocardiogram (ultrasound of the heart) that
was done showed that you had abnormal function of one of your
heart valves (the tricuspid valve). You will need to follow up
with Dr. ___ how to further evaluate you in the
future. We are recommending that you get testing for pulmonary
hypertension (high blood pressure in the lungs and on the right
side of the heart) at some point in the future.
Please review the attached medication list and take your
medications as prescribed. Please follow-up with outpatient
doctors as ___.
You need to have the sutures removed from your Left lower back
skin biopsy in 2 weeks (___)
Once again, it was a pleasure, and we wish you the best.
___ Medicine Team
Followup Instructions:
___
|
10581279-DS-12 | 10,581,279 | 21,621,051 | DS | 12 | 2156-10-16 00:00:00 | 2156-10-17 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Nausea, Vomiting
Major Surgical or Invasive Procedure:
Therapeutic and diagnostic paracentesis ___
History of Present Illness:
Mr. ___ is an ___ male with history of
DMII, hypertension, Alzheimer's disease, and ___ disease
who presents for failure to thrive.
The patient was brought in by his family for lethargy,
weakness, poor PO intake for ___s exertional
SOB. He been progressively become more weak, had been using a
walker but over the last several days started having to use a
wheelchair. Has noted abdominal distension for several months.
Decreased PO intake and loss of appetite with associated 10
pound weight loss. Sleeping a lot more as well. Per patient, one
fall last week. Also with two episodes of loose stools over the
past several weeks, now resolved. Also reports weight loss over
the past few weeks. Denies fevers/chills, chest pain, abdominal
pain, nausea/vomiting. Patient seen in urgent care at ___
___ where he was hypotensive (SBP ___ and noted to have a
firm, distended, tender abdomen on exam. He received 300ml NS
with improvement in BP to 140/65.
Vitals at ___ were: 97.7 58 154/64 16 96% RA. Labs were
notable for WBC 5.7, H/H 12.2/39.8, Plt 378, Na 136, K 4.3,
BUN/Cr ___ (baseline Cr 1.1-1.3), LFTs wnl, albumin 2.6,
lactate 1.5, INR 1.2, UA bland. CT abdomen/pelvis showed large
volume ascites with possible soft tissue mass of transverse
colon at the hepatic flexure versus omentum that is collapsed on
bowel due to the ascites. The patient was transferred to ___
for large volume paracentesis and repeat CT scan after
paracentesis to assess for malignancy.
In the ED, initial vital signs were: 97.6 58 140/71 16 95% RA.
The patient was given nothing. Vitals prior to transfer were:
97.7 63 125/72 16 95% RA.
Past Medical History:
- ___ Disease
- Alzheimer' Disease
- Dementia
- Depression
- Peripheral Vascular Disease
- BPH
- DMII
- Hyperlipidemia
- Hypertension
- s/p right shoulder surgery
Social History:
___
Family History:
No FH of malignancy
Physical Exam:
ON ADMISSION
VITALS: Temp 97.5, HR 60, BP 133/60, RR 18, O2 sat 96% RA
GENERAL: Pleasant, fatigued-appearing, in no apparent distress.
HEENT: Bilateral temporal wasting, atraumatic, no conjunctival
pallor or scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Soft, distended, non-tender, diminished bowel sounds,
no organomegaly.
EXTREMITIES: Warm and well-perfused. Bilateral 2+ lower
extremity edema to the knees.
NEUROLOGIC: A&Ox2 (name, ___, CN
II-XII grossly normal, normal sensation with strength ___
throughout.
ON DISCHARGE
VS: T 97.8 BP 120/57 HR 60 RR 19 97 % RA 18
GENERAL: Alert and oriented to person, at times hospital. Was
sleeping in am, later sat upright.
HEENT: Bilateral temporal wasting
NECK: Supple, no LAD, no thyromegaly.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally over anterior
chest.
ABDOMEN: Soft, mildly distended but only tender to very deep
palpation diffusely
EXTREMITIES: Warm and well-perfused. Bilateral 2+ lower
extremity edema to the knees as well as in the hands. slight
knee PROM pain.
NEUROLOGIC: CN II-XII grossly normal, full strength/sensation
exam deferred
Pertinent Results:
ON ADMISSION
===========================
___ 04:25PM BLOOD WBC-6.2 RBC-3.97* Hgb-10.1* Hct-33.2*
MCV-84 MCH-25.4* MCHC-30.4* RDW-16.7* RDWSD-49.4* Plt ___
___ 04:25PM BLOOD Glucose-97 UreaN-28* Creat-1.1 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
___ 04:25PM BLOOD Albumin-2.7* Calcium-9.0 Phos-2.9 Mg-1.9
___ 04:25PM BLOOD ALT-8 AST-15 AlkPhos-88 TotBili-0.2
RADIOLOGY
===============================
___ GUIDED PARACENTESIS
INDICATION: ___ year old man with dementia and failure to thrive
with
distended abdomen with ascites. // Fluid removal.
TECHNIQUE: Ultrasound guided DIAGNOSTIC AND THERAPEUTIC
paracentesis
COMPARISON: CT examination dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated
a large
amount of ascites. A suitable target in the deepest pocket in
the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were
discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned
procedure,
confirming the patient's identity with 3 identifiers, and
reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the
skin was
prepped and draped in the usual sterile fashion. 1% lidocaine
was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket
in the right
lower quadrant and 5 L of serosanguineous fluid was removed. 20
cc of fluid
were sent for diagnostic evaluation to chemistry and
microbiology as
requested. Approximately 800 cc were sent for cytology
examination.
The patient tolerated the procedure well without immediate
complication.
Estimated blood loss was minimal.
Dr. ___ the procedure.
IMPRESSION:
Diagnostic and therapeutic paracentesis as described above.
___, MD electronically signed on ___ ___
11:___BD/PELVIS
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ year old man with new profudn ascites, B/L
pleural effusions,
and Enhancing soft tissue density along the anterior aspect of
the greater
omentum concerning for neoplastic disease. Patient now s/p ___
cc therapeutic
and diagnostic paracentesis. Would like CT torse w contrast to
r/o neoplastic
disease. // r/o neoplastic disease, eval for pleural effusion
vs pulm edema
vs pna in chest
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the abdomen and pelvis following intravenous contrast
administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Total DLP (Body) = 2,061 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest
performed on the same
day for description of the thoracic findings..
ABDOMEN:
PERITONEUM: Large volume ascites in the abdomen and pelvis is
slightly
decreased since ___. Again visualized is a large
heterogeneously
enhancing nodular mass with internal vascularity that extends
from the greater
curvature of the stomach across the transverse colon
inferolaterally into the
ascending colon (06:54 to 74) compatible with a greater omental
mass. There
also peritoneal deposits in the right lateral aspect of the
diaphragm (03:20).
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains
gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: There is a simple cyst in the upper pole the left
kidney measuring
up to 2.7 cm (6:61). There are also subcentimeter hypodensities
in both
kidneys which are too small to characterize. The kidneys are of
normal and
symmetric size with normal nephrogram. There is no
hydronephrosis or
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is diffuse
significant
wall thickening and submucosal edema of the small bowel, most
prominently in
the ileum. Differential includes inflammation or lymphoma.
Ischemia is less
likely given the unchanged appearance since most recent
comparison study 1 day
ago. The colon and rectum are within normal limits. The
appendix is not
visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is a
large amount of pelvic free fluid contiguous with the large
volume abdominal
ascites.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is a pathologic fracture and an expansile lytic
lesion of the
right inferior pubic ramus (6:120). Similarly, there is a lytic
lesion with
avulsion fracture of the left greater trochanter (9b:36) Healing
fractures of
the ___, and ___ left ribs and ___ and ___ right ribs
are noted. An
acute compression fracture of the L2 vertebral body is
visualized.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Large heterogeneously enhancing nodular soft tissue mass
along the anterior
aspect of the greater omentum concerning for malignancy.
2. Large volume ascites in the abdomen and pelvis, despite some
improvement
compared to the study from the day before.
3. Diffuse wall thickening and submucosal edema of the small
bowel, most
prominently in the ileum. The differential includes
inflammation, lymphoma,
and much less likely ischemia.
4. Pathologic fracture and an expansile lytic lesion of the
right inferior
pubic ramus and in the left greater trochanter with avulsion
fracture.
5. Acute L2 compression fracture. Multiple bilateral rib
fractures.
Osteopenia.
6. Cholelithiasis without evidence of cholecystitis.
CT CHEST
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with new ascites and pleural
effusions,
concerning for intraperitoneal malignancy.
TECHNIQUE: Multi-detector helical scanning of the chest was
coordinated with
oral contrast ingestion and intravenous infusion of nonionic,
iodinated
contrast agent, reconstructed as contiguous 5 mm and 1.0 or 1.25
mm thick
axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP
axial images.
Sequential scanning of the abdomen and pelvis will be reported
separately.
Images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.3 s, 31.7 cm; CTDIvol = 16.8 mGy
(Body) DLP = 507.4
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy
(Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy
(Body) DLP =
17.4 mGy-cm.
4) Spiral Acquisition 18.3 s, 70.1 cm; CTDIvol = 14.8 mGy
(Body) DLP =
1,010.7 mGy-cm.
5) Spiral Acquisition 8.2 s, 31.5 cm; CTDIvol = 16.9 mGy
(Body) DLP = 505.5
mGy-cm.
Total DLP (Body) = 2,061 mGy-cm.
** Note: This radiation dose report was copied from CLIP
___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: There no prior chest CT scans for comparison.
FINDINGS:
Supraclavicular and axillary nodes are not enlarged.
Subcutaneous fat is
depleted and soft tissue edema is generalized. Findings below
the diaphragm
will be reported separately.
Atherosclerotic calcification is moderate in head and neck
vessels and
moderate to severe in coronary arteries. Ascending aorta is
dilated in a
fusiform fashion to maximum diameter of 44 mm. Pulmonary
arteries are mildly
enlarged, main 35 mm. These along with cardiac chambers are
best evaluated by
dedicated cardiac imaging. There is no pericardial effusion.
Moderate nonhemorrhagic left and small right pleural effusions
layer
posteriorly. Both are hypodense, -3 to 8 ___, compared to
ascites, ___ ___,
suggesting this is not simple hepatic hydro thorax, more likely
due to total
body fluid overload or hypoproteinemia. Mild thickening of the
right anterior
costal pleura, 8:116, is probably not related to current pleural
effusions,
more likely reflection or a remote pleural insult. No other
pleural surfaces
are thickened and pleura is not hyperemic. Aside from
relaxation atelectasis
in the lung bases, lower lobes are clear. Heterogeneous
opacification in the
right middle lobe could be all atelectasis as well but a very
small region of
pneumonia is not excluded.
Thyroid is unremarkable. Esophagus is moderately distended with
ingested
contrast agent throughout its length. Assessing function and
the integrity of
the lower esophageal sphincter would require a fluoroscopic
contrast swallow
monitored in real time.
Mediastinal lymph nodes are not pathologically enlarged.
There no bone lesions in the chest cage suspicious for
malignancy
IMPRESSION:
No good evidence for intrathoracic malignancy. Bilateral
pleural effusions,
left greater than right are hypodense with respect to ascites,
suggesting
another explanation such as volume overload or hypoproteinemia
also
responsible for anasarca and reflected in severe depletion of
subcutaneous
fat.
Mild dilatation ascending thoracic aorta. Possible pulmonary
arterial
hypertension.
Small pneumonia, right middle lobe, is possible. Larger areas
of bibasilar
consolidation are attributable to relaxation atelectasis, which
could explain
the right middle lobe appearance as well.
MICROBIOLOGY
======================================
___ 3:56 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 10:09 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 10:09 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ON DISCHARGE:
=======================================
___ 06:27AM BLOOD WBC-5.2 RBC-3.35* Hgb-8.5* Hct-27.8*
MCV-83 MCH-25.4* MCHC-30.6* RDW-16.8* RDWSD-49.3* Plt ___
___ 06:27AM BLOOD Glucose-126* UreaN-29* Creat-1.0 Na-132*
K-4.8 Cl-101 HCO3-21* AnGap-15
___ 06:27AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.7
Brief Hospital Course:
Mr. ___ is an ___ male with history of
DMII, hypertension, Alzheimer's disease, and ___ disease
who presents for failure to thrive, with concerning malingant
ascites (cytology pending) and nodular soft tissue in omentum
concering for malignancy
# Failure to Thrive ___ possible malignancy: Patient with
longstanding history of Alzheimer's and ___ with
increased difficulty to care for at home presenting with
increasing weakness and new difficulty ambulating. Exam
significant for distended abdomen with abdominal CT showing
large amount of ascites on ___. Patient had therapeutic
paracentesis (5 L cc) which was concerning (SAAG < 1.1) for
malignancy and not cirrosis/chf/poor nutrition. Repeat CT Chest
and abd/pelvis showed possible mass concerning for malignancy in
omentum. Cytology pending. For now will plan d/c to rehab with
cytology to f/u by PCP and inpatient team to arrange onc F/U to
discuss prognosis if cytology positive, and arrange ___ followup
if cytology negative for omental mass biopsy. ___ team contacted
in house and reviewed images; omental mass will be amenable to
biopsy if cytology ends up being negative. Nutrition also saw
patient in house and supplements were ordered. ___ rehab
will be contacted about pening cytology results, based on
results wil have F/U with GI onc vs ___ for omental biopsy.
# Possible PNA on CT chest: Patient came in afebrile without
cough and without leukocytosis; however CT chest done above for
staging purposes showed consolidations possible concerning for
PNA. Gave empiric coverage for HCAP therapy. 5 days levofloxacin
___. He was afebrile without cough in house.
# Anemia: Hgb downtrended from 10 to 8.8 after para on ___.
This morning is down to 8.5 (from 9.9), although all lines are
down. Blood pressure is also relatively lower than prior
readings but no tachycardia. It was relatively stable and hgb
was 8.5 on d/c.
CHRONIC ISSUES:
# ___ Continued home rivastigmine. Patient is due for
F/U SPECT which he will have next week; he will followup in
movement disorder clinic. He will also have followup with
___ clinic per family request.
# DMII Held home metformin, did Humalog ISS in house.
# Depression Continued home sertraline
# Hyperlipidemia: Continued home atorvastatin
# End stage dementia: Stable. Scheduled for SPECT as outpatient,
and scheduled to followup in movement disorders clinic on ___. Also scheduled to followup with gerontology.
TRANSITIONAL ISSUES
=======================================
-Please have rehab arrange follow up with PCP ___ ___ days,
patient requires an appointment made with heme onc or ___ pending
cytology results. Inpatient team will followup this as well (if
cytology reszutls negative, will arrange for ___ guided biopsy;
if results positive, will arrange for GI onc followup to discuss
prognosis with family).
-Upon d/c at rehab, please arrange for new PCP at
___ per patient's family request. Unable to arrange
in house as patient being d/ced to rehab
-Given longstanding dementia and poor nutritional and functional
status at home, arranged for followup with gerontology on d/c.
-If cytology returns positive, please arrange for follow up GI
heme onc appointment at ___
-If cytology returns negative, please have PCP email
___ to schedule outpatient ___ guided
biopsy of omental mass
-HCP is daughter ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. rivastigmine 4.6 mg/24 hr transdermal Q24H
2. Sertraline 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. MetFORMIN (Glucophage) 250 mg PO BID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. rivastigmine 4.6 mg/24 hr transdermal Q24H
3. Sertraline 25 mg PO DAILY
4. MetFORMIN (Glucophage) 250 mg PO BID
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Heparin 5000 UNIT SC BID
continue while patient with limited mobility
7. Levofloxacin 500 mg PO DAILY Duration: 5 Days
last day of antibiotic should be ___. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Probable malignant ascites
End stage dementia
Failure to Thrive
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
you came to the hospital because you had fluid in your belly and
had nausea and vomiting. At the hospital, it was determined that
the fluid from your belly may be coming from a possible
malignancy in your omentum, a fold of tissue in your abdomen. We
drained fluid from your belly to make you feel better, and ouy
felt better. We sent the fluid for testing. We are sending you
to rehab to help your nutritional status and help regain your
strength, but will contact you for follow up when your results
of the fluid we sent for testing come back.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10581279-DS-13 | 10,581,279 | 23,059,877 | DS | 13 | 2156-10-27 00:00:00 | 2156-10-27 11:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal discomfort, failure to thrive
Major Surgical or Invasive Procedure:
___ ___ guided paracentesis (therapeutic and diagnostic)
___ ___ guided omental biopsy
History of Present Illness:
___ YOM with PMH of DM2, hypertension, mixed dementia (likely
Alzheimer's disease, vascular dementia, Parkinsonims) who
presents for failure to thrive, with concerning malingant
ascites (showing atypical mesothelial proliferation) and nodular
soft tissue in omentum concering for malignancy, now with
worsening ascites admitted for failure to thrive and need for
large volume ascites.
Notably, patient was recently discharged on ___ from ___ at
which time he was found to have omental mass concerning for
malignancy. Patient was also noted on imaging to have likely
pathologic fractures of right inferior pubic rami and left
trochanteric femur fracture. He underwent paracentesis with
cytology results pending at the time of discharge, but have now
returned non-diagnostic, with atypical cells noted.
ROS: 10 point ROS performed and negative except as noted in HPI.
Past Medical History:
Per OMR
- Mixed dementia (likely Alzheimer's, vascular dementia and
Parkinsonism)
- Depression
- Peripheral Vascular Disease
- BPH
- DMII
- Hyperlipidemia
- Hypertension
- internal hemorrhoids
- diverticulosis (last c-scope ___
- s/p right shoulder surgery
Social History:
___
Family History:
Per OMR:
No FH of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: reviewed in bedside chart, afebrile, VSS
PAIN: denies
GEN: NAD, comfortable appearing
HEENT: ncat anicteric MMM
NECK: no JVD
CV: RRR, no m/r/g
RESP: CTA ___, no wheezes/rhonchi
ABD: +bs, soft, no guarding or rebound; + distention, however
not tense, with + fluid wave, non tender
EXTR:no c/c/e
DERM: clean, dry, no rash
NEURO: face symmetric speech fluent, AOx2
PSYCH: calm, cooperative
DISCHARGE PHYSICAL EXAM:
VS: 97.8, AF, 132/57, 64, 18, 97% RA
Pain: zero/10
BS: 100's
Weight 71.7kg (admit weight 75kg on ___, post-para weight ___
Gen: disheveled, NAD, lying in bed, awake
HEENT: anicteric, MMM
CV: RRR, + murmur
Abd: soft, NT, distended, but not tense, +BS
Ext: 1+ edema at ankle
Derm: dry, warm
Neuro: AAOx2 ___, ___, fluent speech
Psych: calm, appropriate
Pertinent Results:
ADMISSION LABS:
====================
___ 05:40PM BLOOD WBC-6.2 RBC-3.23* Hgb-8.2* Hct-26.7*
MCV-83 MCH-25.4* MCHC-30.7* RDW-17.5* RDWSD-52.2* Plt ___
___ 05:40PM BLOOD Neuts-73.4* Lymphs-15.1* Monos-9.0
Eos-1.6 Baso-0.3 Im ___ AbsNeut-4.57 AbsLymp-0.94*
AbsMono-0.56 AbsEos-0.10 AbsBaso-0.02
___ 05:40PM BLOOD ___ PTT-32.7 ___
___ 05:40PM BLOOD Glucose-125* UreaN-30* Creat-1.0 Na-134
K-4.4 Cl-102 HCO3-24 AnGap-12
___ 05:47PM BLOOD Lactate-1.6
___ 07:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
___ 07:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
PERTINENT LABS:
====================
___ 10:00AM BLOOD Ret Aut-1.4 Abs Ret-0.04
___ 07:25AM BLOOD ALT-13 AST-18 AlkPhos-91 TotBili-0.2
___ 07:25AM BLOOD Iron-15* calTIBC-131* Ferritn-963*
TRF-101*
___ 07:50AM BLOOD Hapto-417*
___ 07:10AM BLOOD VitB12-369 Folate-7.5
___ 05:10PM BLOOD TSH-3.9
___ 03:45PM ASCITES TotPro-3.7 Glucose-74 LD(LDH)-862
Albumin-1.7
MICROBIOLOGY:
====================
___ Blood culture x 1: No growth, FINAL
___ Ascites culture: No growth, FINAL
PATHOLOGY:
====================
___ Peritoneal Fluid Cytology
DIAGNOSIS:
Peritoneal fluid:
Atypical epithelioid proliferation.
Note: Atypical epithelioid cells with nuclear pseudo-inclusions
forming occasional rosettes with central eosinophilic globules.
Stains performed retrospectively on case ___ show atypical
cells are positive for keratin cocktail and negative for
inhibin, S100, and MART-1, excluding
melanoma and adrenal cortical carcinoma. A prior cytology
specimen showed staining for calretinin and WT-1 suggesting a
mesothelial origin.
Tissue biopsy is suggested for further characterization of
tissue architecture.
___ Omental Mass Biopsy: PENDING
IMAGING:
====================
___ Ultrasound guided paracentesis
IMPRESSION:
Successful ultrasound-guided diagnostic and therapeutic
paracentesis yielding 5 L of serosanguineous fluid.
DISCHARGE LABS:
====================
___ 07:50AM BLOOD Hct-24.9*
Brief Hospital Course:
___ yo M with advanced dementia (AD/PD), DM2, HTN, recent
diagnosis of ascites, likely malignant, with evidence of omental
thickening on imaging, who presents for repeat paracentesis and
expedited work-up of likely underlying advanced malignancy.
# ascites, likely malignant
# omental mass
# pathologic fracture / lytic lesion of pubic ramus
Overall picture most c/f metastatic malignancy, but with
cytology non-diagnostic twice. However, atypical cells are
seen, and low SAAG (< 1.1), presence of pathologic fractures are
highly concerning for metastatic disease of unknown primary.
Patient had 5L of ascitic fluid removed during hospitalization.
He had presented with wgt of 75kg, and wgt was stable in 70-71
kg during hospitalization. Weight 71.6 kg on day of discharge.
Patient was started on low-dose Lasix of 10mg to help prevent or
slow down fluid re-accumulation. Omental biopsy was performed
with ___ guidance on ___, with results pending. Procedure
with minimal bleeding and had stable HCT's cycled. For his
pathologic fractures, Orthopedics recommends outpatient
follow-up in ___ and can WBAT. He will likely
need future outpatient therapeutic paracentesis for comfort.
Abdominal PleurX was also considered, but cannot be placed at
this time, as per d/w ___, a definitive diagnosis of malignancy
will need to be confirmed and will need discussion with Oncology
prior to placement of PleurX, in the event that Oncology prefers
not to have foreign body in place while undergoing palliative
chemotherapy once goals of care are finalized.
awaiting cytology results. Patient's was seen by Palliative
Care and also pt's daughter met with ___ Care. At this
time, the plan is for patient to remain full code and to pursue
formal Oncology evaluation/recommendations once biopsy results
are available before making further decisions in goals of care.
# Anemia, normocytic
Stable. Iron panel c/w anemia of chronic disease. Retic# c/w
hypoproliferation.
# Dementia (Alzheimer's, Parkinsonism) / # Depression
Stable, although HCP reports a significant decline in the past 6
months. Previously on Namenda, Sinemet.
- continue rivastigmine patch
- continue sertraline
- f/u with Neurology as outpatient
# DM2: Blood sugars in good range. No meds while inpatient.
Continue to monitor BS. No significant insulin requirements.
Can resume metformin on discharge.
# Hyperlipidemia: continue home statin.
# Diet: Diabetic diet
# DVT PPX: HSQ. Was on this medication on admission from rehab.
Being discharged on HSQ but can consider stopping as his
ambulatory status improves. ___ need to hold in the future for
paracentesis.
# CODE STATUS: Full
# CONTACT: ___ (daughter/HCP) ___ (home),
___ (cell)
TRANSITIONAL ISSUES:
1. Omental biopsy from ___ results pending
2. Monitor ascites, if needed, can contact ___ at ___
___ for therapeutic paracentesis. Can also consider
abdominal PleurX catheter if within goals of care.
3. Needs Oncology referral once biopsy results available.
Daughter (HCP) wants evaluation at ___.
4. Ortho-Oncology appointment made for f/u at ___ for
pathologic fracture. For physical activity, patient is
Weight-bearing as tolerated (WBAT)
5. f/u with Neurology clinic as needed
6. Lasix dosing can be further titrated at rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. rivastigmine 4.6 mg/24 hr transdermal Q24H
3. Sertraline 25 mg PO DAILY
4. MetFORMIN (Glucophage) 250 mg PO BID
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Heparin 5000 UNIT SC BID
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 40 mg PO QPM
3. Heparin 5000 UNIT SC BID
4. rivastigmine 4.6 mg/24 hr transdermal Q24H
5. Senna 8.6 mg PO BID:PRN constipation
6. Sertraline 25 mg PO DAILY
7. MetFORMIN (Glucophage) 250 mg PO BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Furosemide 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ascites, presumed malignant
Dementia
Anemia
Inferior pubic rami fracture (right), trochanteric avulsion
fracture (left)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because you had abdominal pain
relating to a re-accumulation of abdominal fluid. You underwent
a paracentesis (a procedure to remove the fluid from your
abdomen) on ___ which helped your symptoms. This fluid was sent
for further work-up examination, but the fluid studies were
non-diagnostic.. You were also started on a diuretic (water
pill) called Lasix to help prevent or slow down reaccumulation
of the fluid. You then underwent a guided biopsy of a mass in
your abdomen called an omental mass, with biopsy results still
pending. You were seen by ___ and they recommended rehab.
Followup Instructions:
___
|
10581510-DS-10 | 10,581,510 | 28,710,380 | DS | 10 | 2190-12-11 00:00:00 | 2190-12-12 13:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
increased seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old right-handed woman with a history of
left
hemibody focal motor seizures since head trauma in ___ presents
with increased seizure frequency. She reports that her seizures
often have a warning sign of pain in the left biceps, followed
be
a short ___ second) shaking of the left arm. Then her left arm
and leg with stiffen and shake for seonds to 1 minute. She is
unable to control it. She maintains full awareness and can speak
throughout the event. After it ends, she feels like her baseline
self and is able to return to her activity. Sometimes after her
warning, she can take deep breaths and hyperextend her left hand
and wrist as sometimes this will prevent the seizure from
coming.
She can often trigger the seizures if someone pulls on her left
arm or if she leans on it. The seizure type has not changed
since
they started in ___ and she does not have any other type of
seizures. She has never had a generalized event. Recently her
seizures were relatively well-controlled in that she would have
___ seizure per day. Typically she will have one 20 minutes
after
awakening, although if she stays in bed for 40 minutes, she can
often avoid it. However since approximately ___, she
started having an increasing number of events. It increased
slowly, going to 2, then 3 a day. For the past couple of weeks
it
is now ___ seizures per day. They are occurring so frequently
that if she is unable to get herself to a safe area to sit or
lie
down, she will fall. She has fallen several times, to the point
that her husband has placed chairs all around the house so that
she can sit if one comes on. She hit her head during one event a
few weeks to months ago, but no other head trauma. She did
fracture her left ankle in ___ for which she wore an aircast
for
a few weeks, but reports this was not seizure related and she
has
had no other major injuries other than scrapes and bruises. She
notes that her pharmacy switched their oxcarbazepine supplier a
few months ago as the color of the pills changed from dark brown
to light brown. Otherwise she denies any changes in her other
medications and she does not miss any doses. She denies any
recent fevers or colds. She reports decreased sleep for the past
2 days but no trouble sleeping previously. She denies any
increases in stress recently.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-left sided focal motor seizures, arm > leg
-right subdural hematoma with contusion, s/p craniectomy for
evacuation on ___ after being hit by a tree vs? assault
-R-occipital stroke thought to be secondary to SDH as above
-Drug-induced hepatitis
-Arthroscopic knee surgery over ___ years ago
-chronic low back pain and sciatica
-left ankle fracture - ___ - required air cast, no surgery
Social History:
___
Family History:
Older brother had a heart murmur operated on at ___
___ when he was ___ years old. No family history of
seizures.
Physical Exam:
Physical Exam:
Vitals: T: 97.2 P: 71 BP: 148/68 RR: 18 SaO2: 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to relate
history without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has symmetric strengh.
-Motor: Normal bulk, tone throughout. No pronator drift. No
adventitious movements. No asterixis. Giveway at bilateral IPs
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ 5 4+ 4 5 5 5 5 5 5
R 5 ___ ___ 4+ 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally. UE RAMs
symmetric.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Difficulty walking in tandem with frequent side steps
and fell towards right.
========================
DISCHARGE EXAMINATION:
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD WBC-5.0 RBC-3.93* Hgb-12.3 Hct-34.5*
MCV-88 MCH-31.2 MCHC-35.6* RDW-13.2 Plt ___
___ 02:30PM BLOOD Neuts-54.3 ___ Monos-5.0 Eos-6.0*
Baso-0.8
___ 02:30PM BLOOD Glucose-126* UreaN-14 Creat-0.5 Na-134
K-4.1 Cl-97 HCO3-24 AnGap-17
___ 02:30PM BLOOD ALT-43* AST-45* AlkPhos-123* TotBili-0.3
___ 02:30PM BLOOD Albumin-4.7
TOX SCREEN:
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
UA:
___ 02:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
CXR ___: No acute cardiopulmonary process.
EEG ___: This is likely a normal continuous EEG monitoring
study. There were 7 pushbutton events primarily for left body
myoclonus with no EEG change on the background. The background
showed low amplitude diffuse beta likely due to medication
effect. No focal slowing or epileptiform discharges were
recorded. No electrographic seizures were seen. There were
occasional sharp features over bilateral frontal and central
region embedded in the arousal pattern. Its significance needs
to be correlated with clinical scenario.
Brief Hospital Course:
___ year-old ___ woman with a history of left hemibody focal motor
seizures subsequent to head trauma in ___ p/w increased seizure
frequency, possibly related to changing supplier of
oxcarbazepine vs. recent weight gain. Patient was admitted for
monitoring. Her initial labs did not show any evidence of
infection or other metabolic derangement that could cause
increase in seizure. She was monitored with video EEG monitoring
which showed myoclonus without EEG correlates. Her Keppra was
increased to 1000/1250 and clonazepam was also increased to
___. Oxcarbazepine was continued at 600 mg BID. She will need
to follow up with Dr. ___ further management. She
was seen by ___ in house given the falls at home and they
recommended physical therapy as outpatient.
Her LFTs were mildly elevated on admission but trended down on
repeat labs. Urine and tox screen were negative. A1C was checked
given ?NIDDM, but it was normal during this hospitalization.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. LeVETiracetam 1000 mg PO BID
2. Oxcarbazepine 600 mg PO BID
3. Clonazepam 1 mg PO TID
4. Baclofen 10 mg PO qHS
5. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BID
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Ibuprofen 400 mg PO Frequency is Unknown
Discharge Medications:
1. Baclofen 10 mg PO QHS
2. Clonazepam 1 mg PO BID
at 8 am and 2pm
3. Clonazepam 2 mg PO QHS
RX *clonazepam 2 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*2
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Ibuprofen 400 mg PO Q8H:PRN pain
6. LeVETiracetam 1000 mg PO DAILY
7. LeVETiracetam 1250 mg PO QPM
RX *levetiracetam 250 mg 1 tablet(s) by mouth in the evening
Disp #*30 Tablet Refills:*2
8. Oxcarbazepine 600 mg PO BID
9. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: seizure disorder secondary to traumatic brain
injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic Status: mild weakness in left side in deltoid, wrist
and finger extensor, as well as slowed finger tapping and rapid
alternating movement, chronic since her ___ R frontal subdural
hematoma and evacuation.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of increased seizures
at home. You were monitored on video EEG. Your Keppra and
clonazepam were increased. You were also seen by physical
therapy and they recommended that you undergo physical therapy
for gait stability.
Followup Instructions:
___
|
10581673-DS-2 | 10,581,673 | 20,082,443 | DS | 2 | 2130-03-18 00:00:00 | 2130-03-18 20:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / penicillin G
Attending: ___
Chief Complaint:
Back pain, numbness and weakness
Major Surgical or Invasive Procedure:
___: L1 laminectomy; T11-L4 fusion
History of Present Illness:
___ yo F on ASA 325mg hx kyphoplasty at L1 4 weeks ago who
presents with numbness and weakness. ___ pt had L5-S1
steroid injection and subsequently felt an abnormal sensation in
her rectum that developed in to numbness in her groin/labia. She
had worsening back and leg pain ___ and ___ into the
anterior thighs and lateral leg into lateral foot, worse on the
right. The numbness in her groin is worse on the left. Yesterday
she was dragging her right leg according to family due to pain.
Today her right leg gave out from weakness. She had foley placed
at OSH bc MRI showed distended bladder. Last urinated at
10:30am, MRI was performed at 22:30. Denies fecal incontinence.
Past Medical History:
- dilated cardiomyopathy
- hypercholesterolemia
- hypertension
- left bundle branch block
- nonrheumatic mitral regurgitation
- chronic idiopathic constipation
- cystocele
- incomplete uterovaginal prolapse
- L1 compression fracture
- major depression
- squamous cell carcinoma
- unspecified osteoarthritis
Social History:
___
Family History:
Father and uncles with coronary artery disease.
No other significant family history.
Physical Exam:
======================
ADMISSION EXAM
======================
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atruamatic
Neck: Supple.
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 4 5 4 5 4 5
L 5 5 5 5 5 4- 5 4 5 4 5
Sensation:
Decareased sensation to light touch in bilat lateral legs, into
lateral foot and bottom of feet and heels right worse than left,
decreased perianal sensation with numbness in the labia left
worse than right.
Rectal tone present
Reflexes: B T Br Pa Ac
Right unable to obtain reflexes
Left unable to obtain reflexes
No clonus
No hoffmans
======================
DISCHARGE EXAM
======================
VS: ___ 0741 Temp: 99.0 PO BP: 117/56 L Lying HR: 83 RR: 18
O2 sat: 96% O2 delivery: Ra
GEN: AOx1, in no acute distress
HEENT: Eyes anicteric, MMM
CV: RRR, II/VI HSM at ___, JVP <8cm
Resp: CTAB
GI: Soft, NTND
GU: No foley
Ext: Nor peripheral edema
Skin: no rash grossly visible
Neuro: A&O to person only, unable to perform days of week
backwards
CN II-XII intact, strength ___ and SILT in bilateral lower
extremities
Psych: normal affect, pleasant
Pertinent Results:
=====================
ADMISSION LABS
=====================
___ 06:00AM BLOOD WBC-6.5 RBC-3.65* Hgb-12.1 Hct-36.3
MCV-100* MCH-33.2* MCHC-33.3 RDW-13.4 RDWSD-47.9* Plt ___
___ 06:00AM BLOOD Neuts-71.0 ___ Monos-7.9 Eos-1.2
Baso-0.3 Im ___ AbsNeut-4.61 AbsLymp-1.25 AbsMono-0.51
AbsEos-0.08 AbsBaso-0.02
___ 06:00AM BLOOD ___ PTT-27.6 ___
___ 06:00AM BLOOD Glucose-93 UreaN-12 Creat-0.6 Na-147
K-3.7 Cl-107 HCO3-28 AnGap-12
___ 02:51AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.8
=====================
PERTINENT RESULTS
=====================
MICROBIOLOGY
=====================
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR*
___ 06:00AM URINE RBC-2 WBC-4 Bacteri-FEW* Yeast-NONE
Epi-<1
===
___ 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 08:00AM URINE RBC-5* WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
===
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM*
___ 04:00PM URINE RBC-1 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-0
====
Urine cultures ___: Finalized without growth
====
Blood cultures ___: No growth to date
=====================
IMAGING
=====================
CT L-spine without contrast (___):
1. Study is limited secondary to diffuse osteopenia.
2. Nondisplaced bilateral proximal T12 rib fractures as
described.
3. Acute compression fracture of L1 with retropulsion of the
posterior fracture fragments resulting in moderate to severe
vertebral canal narrowing.
4. Redemonstration of known L2 vertebral body probable chronic
compression
deformity with superior endplate minimal bony retropulsion and
at mild vertebral canal narrowing.
5. Mild-to-moderate bilateral L5-S1 bony neural foraminal
narrowing.
6. Patient's known multilevel lumbar spondylosis better
demonstrated on recent outside lumbar spine MRI.
7. High-density material within L1 and L2 vertebral bodies as
described,
question history of vertebroplasty.
===
Intraoperative lumbar spine films (___):
Osteopenia and multilevel degenerative changes of the lumbar
spine, with fractures and retropulsion of the L1 and L2
vertebral bodies, and methylmethacrylate from
kyphoplasty/vertebroplasty at L1 and L2, are again
noted, in keeping with findings on the same day CT scan.
Intraoperative radiographs show multiple steps during posterior
spinal fusion procedure, including vertical spinal rod, and
pedicle screws at the
presumptive T11, T12, L2, L3, and L4 levels, on view # 4.
Correlation with real-time findings is requested for further
assessment.
Please see operative note for additional details.
===
CXR (___): There is no focal consolidation. The heart is
mildly enlarged. There is no consolidation. The aorta is
atherosclerotic and tortuous. Postoperative changes are evident
in the spine. There are no large pleural effusions.
IMPRESSION: Mild cardiomegaly. Postoperative changes.
===
TTE (___): The left atrial volume index is mildly increased.
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. There is moderate
to severe global left ventricular hypokinesis (LVEF = 30 %).
Global longitudinal strain is depressed (-12.5%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION:
1) Moderate to severe global LV systolic dysfunction with
significant myocardial regional wall motion abnormalities not
following a specific coronary artery distribution suggestive of
diffuse cardiomyopathic process with regional variation in
myocardial contractility.
2) Grade II LV diastolic dysfunction with elevated LVEDP.
===
Lumbosacral plain films (___): Posterior fusion hardware
between T11 through L4, without evidence of hardware
complication.
===
CXR (___): Heart size is enlarged. Mediastinum is stable.
Lungs are clear.
===
NCHCT (___): No acute intracranial abnormality identified.
Atrophy and probable chronic small vessel disease.
=====================
DISCHARGE LABS
=====================
___ 06:14AM BLOOD WBC-8.7 RBC-3.08* Hgb-10.0* Hct-30.1*
MCV-98 MCH-32.5* MCHC-33.2 RDW-15.1 RDWSD-51.0* Plt ___
___ 06:14AM BLOOD Glucose-86 UreaN-11 Creat-0.5 Na-144
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 06:14AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with history of dilated
cardiomyopathy (LVEF ___, HTN, HLD, nonrheumatic MR, history
of kyphoplasty at L1 4 weeks prior to presentation who presented
with lower extremity numbness and weakness, found to have L1
compression fracture and severe lumbar spinal stenosis with
compression of the thecal sac on MRI s/p urgent decompression
with laminectomy, reduction, and fusion T11-L4 on ___, with
post-operative course complicated by acute on chronic anemia,
hypotension, ___, and toxic-metabolic encephalopathy.
============================
ACUTE ISSUES
============================
# L1 compression fracture:
# Severe lumbar stenosis:
# Cauda equina syndrome: On ___, Ms. ___ presented with
back pain and lower extremity weakness after an outpatient
epidural steroid injection. MRI at an outside hospital showed
severe stenosis; Foley catheter was placed for urinary retention
and the patient was transferred to ___ for further care. She
was initially admitted to the neurosurgical service, and whe was
taken urgently to the OR on ___ with Dr. ___ L1
laminectomy and T11-L4 fusion. Her operative course was
uncomplicated; drain was placed in the OR. Postoperatively, she
was extubated and monitored in PACU before transfer back to the
floor. Post-op x-ray was performed on POD#1. Hemovac remained in
place POD#1 due to high output and she was fit with a TLSO
brace. On POD#3, ___, the Hemovac drain was removed. She
mobilized with ___. The patient's Foley was removed and she was
able to void spontaneously. The patient's pain was treated with
scheduled Tylenol and Tramadol as needed. She should continue to
wear TLSO brace when out of bed. She will need her staples
removed and wound check in ___ days post-operatively, as well
as spine follow up with AP/lateral spinal plain films in 4
weeks.
# Toxic-metabolic encephalopathy: ___ hospital course was
complicated by waxing and waning mental status consistent with
delirium in setting of surgery and acute illness. NCHCT was
obtained without acute intracranial abnormality. The patient's
pain was treated as above. Her gabapentin dose was decreased.
The patient was given Ramelteon to help promote a normal
sleep-wake cycle.
# Acute on chronic anemia: Patient with history of iron
deficiency anemia, found to have worsened anemia on ___ and
transfused 2 units PRBCs with appropriate increase in
hemoglobin. Likely related to procedural blood losses.
Hemoglobin subsequently remained stable and the patient did not
require further transfusions. Hb 10 on day of discharge. Patient
continued on home iron supplement.
# Bacteriuria: Urinalysis from ___ notable for 4 WBC, small
amount of bacteria, trace leukocytes, urine culture negative,
without clear symptoms of urinary tract infection. She was
initially started on ciprofloxacin, but this was stopped on ___
as culture was negative and patient was asymptomatic. The
patient complained of urinary frequency after Foley was removed;
multiple repeat urinalysis and cultures were negative for
infection.
# ___: Cr 1.1 initially from baseline of 0.6. Resolved with
fluids. Cr 0.5 on day of discharge.
# HTN: The patient had an episode of symptomatic orthostatic
hypotension on post-operative day 1, likely secondary to
hypovolemia and anemia. The patient's antihypertensives were
initially held, and she was given intravenous fluids and blood
transfusions as above with resolution of her hypotension. Her
antihypertensives were slowly re-introduced, with stable blood
pressures. Her home carvedilol was resumed, and half her home
dose of valsartan. Please continue to monitor blood pressures
and titrate medications as appropriate.
# Chronic sCHF: LVEF ___. TTE from ___ unchanged from prior.
Cardiology was consulted for assistance with management. Patient
was initially hypovolemic and was given intravenous fluids to
good effect. She was subsequently euvolemic throughout the rest
of her course and did not require further fluids or diuresis.
Her carvedilol and valsartan were resumed as above. Unable to
obtain true discharge weight as patient unable to stand without
TLSO brace.
=============================
CHRONIC/STABLE ISSUES
=============================
# HLD: Continued atorvastatin. Resumed aspirin (81 mg daily
decreased from home 325 mg daily) in discussion with
neurosurgery.
# Depression: Patient no longer taking escitalopram
>30 minutes spent on care/coordination on day of discharge.
=============================
TRANSITIONAL ISSUES
=============================
- Discharge weight: unable to obtain as patient in TLSO brace
- Monitor volume status and consider diuresis if needed (LVEF
25%)
- Patient should wear TLSO brace when out of bed
- Patient will need an appointment for suture/staple removal and
wound check in ___ days postoperatively (surgery on ___.
Please call ___ to make this appointment.
- Patient to follow up with Dr. ___ in 4 weeks, and
will need AP/Lateral X-rays at the time of this appointment.
Please call ___ to make this appointment.
- Discharged on scheduled Tylenol and low-dose tramadol as
needed for pain control. Please continue to assess pain and
adjust regimen as appropriate. Patient has required very little
tramadol while hospitalized.
- Please check blood pressure and adjust antihypertensive
regimen as appropriate. Discharged on half of home valsartan
dose, uptitrate to home dose as appropriate.
- Gabapentin dose decreased from 300 TID to ___ TID due to
confusion; please continue to assess mental status and adjust
dose as appropriate.
- Started on Ramelteon at night for sleep; continue to assess
need for this medication.
- Continued home vitamin D and started on calcium
supplementation for bone health.
- Patient on ASA 325 as an outpatient; restarted on ASA 81 mg
daily given no clear indication for full-dose aspirin
- Communication: ___, daughter, ___
- Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO BID
2. Gabapentin 300 mg PO TID
3. Carvedilol 25 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Ferrous Sulfate 325 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium Carbonate 500 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Miconazole Powder 2% 1 Appl TP TID:PRN rash
5. Ramelteon 8 mg PO QHS
6. Senna 8.6 mg PO BID
7. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Every 8
hours Disp #*5 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
9. Gabapentin 100 mg PO Q8H
10. Valsartan 80 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Carvedilol 25 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
- L1 compression fracture
- Lumbar spinal stenosis
- Cauda Equina Syndrome
SECONDARY:
- Toxic-metabolic encephalopathy
- Orthostatic hypotension
- Acute kidney injury
- Asymptomatic bacteriuria
- Chronic systolic congestive heart failure
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having back pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We found that your spinal canal was narrow and was pressing on
your spinal cord.
- You had urgent surgery to fix this.
- After the surgery, your blood pressures were low. You were
given fluids and blood transfusions, and your blood pressures
became normal.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
Surgery
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
*** You must wear your brace at all times when out of bed. You
may apply your brace sitting at the edge of the bed. You do not
need to sleep with it on.
*** You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication
(Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
It is OK to take a baby aspirin.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
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.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10581673-DS-3 | 10,581,673 | 28,855,775 | DS | 3 | 2130-05-22 00:00:00 | 2130-05-22 12:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
lisinopril / penicillin G
Attending: ___
Chief Complaint:
right hip pain, urine/ bowel incontinece
Major Surgical or Invasive Procedure:
___ T11-L4 fusion revision
History of Present Illness:
This is a ___ year old female who is s/p T11-L4 fusion and
and L1 lami ___ with AP/lateral lumbar spine films at ___
from
___ consistent with status post vertebroplasty at the L1 and
L2 levels. L1 remains significantly collapsed, unchanged. The
appearance of L2 is unchanged. The patient presents today with
her two daughters secondary to her ongoing right hip pain ___
intermittent, right anterior hip and also right posterior flank.
The pain does not radiate. She reports voiding last night and on
her way back to bed "leaking small amounts of urine". She also
reports one episode of bowel incontinence today. Overall, the
patient appears to have significant memory limitations and
daughters try to assist in providing information and jogging the
patients memory throughout the interview. The patients reports
of urinary leaking and bowel incontinence are not confident. She
looks at her daughters and states "did I ? "
Past Medical History:
- dilated cardiomyopathy
- hypercholesterolemia
- hypertension
- left bundle branch block
- nonrheumatic mitral regurgitation
- chronic idiopathic constipation
- cystocele
- incomplete uterovaginal prolapse
- L1 compression fracture
- major depression
- squamous cell carcinoma
- unspecified osteoarthritis
Social History:
___
Family History:
Father and uncles with coronary artery disease.
No other significant family history.
Physical Exam:
___ x 3. PERRLA.
CN II-XII intact.
LS clear
RRR
Abdomen soft, NTND
___ BUE and BLE. No drift.
Incision clean, dry, and intact.
Pertinent Results:
Please refer to OMR for pertinent lab and imaging results
Brief Hospital Course:
Ms. ___ is a ___ F with history of thoracolumbar fusion
who presented to the ED for worsening right hip pain and
possible urinary leaking ___ after voiding. An MRI of her spine
revealed screws from prior fusion encroaching spinal cord. She
went to the OR from the ED and underwent T11-L4 fusion revision.
She was extubated in the OR and transferred to PACU for
recovery.
#Fusion revision
She was fitted for TLSO brace on POD1. Post-op xrays showed
correct hardware placement. Dressing was removed on POD2.
Patient had drainage from distal end of incision so light
dressing was replaced. She will follow up ___ days post op for
staples removal and in 1 months with AP/LAT XRays with Dr.
___.
#Vasovagal episode
On ___, the patient had a vasovagal episode while having a
bowel movement. Carvedilol was stopped. Labs sent. UA/UC*. CXR
negative. EKG and telemetry reviewed by Cardiology, which were
okay. Carvediolol was restarted at 12.5mg BID, with plan to
titrate up to home dose. Her blood pressure continued to
improve. She should restart her valsartan in the next few days.
#R hip pain
Xray of R hip was negative for fracture.
#Heart failure
Prior to MRI findings patient was admitted to the cardiology
service for work-up of presyncope and ventricular tachycardia.
Post-operatively cardiology was consulted for further
management. Her carvedilol was decreased for low BP and HR. She
will follow up with cardiology next week for ___ of Hearts
monitor and she should follow up with her Cardiologist in the
next ___ weeks.
#Nutrition
On admission patient reported weight loss due to hip pain she
has not been able to functionally cook and prepare foods for
herself. Milkshakes were sent daily and her weight was
monitored. Multivitamins with minerals were added per nutrition
recommendation.
Medications on Admission:
Most current list per daughter on ___
___ 80mg BID
Feosol 325mg daily
ASA 81mg daily
atorvastatin 40mg daily
carvedilol 25mg BID
cholecalciferol (vitamin D3) 1000unit daily
gabapentin 200mg TID
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Bisacodyl 10 mg PO/PR DAILY
3. Calcium Carbonate 500 mg PO TID
4. Diazepam 5 mg PO BID:PRN pain
RX *diazepam 5 mg 1 (One) tab by mouth twice a day Disp #*20
Tablet Refills:*0
5. Heparin 5000 UNIT SC BID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) to 1(one) tablet(s) by mouth
every four (4) hours Disp #*40 Tablet Refills:*0
8. Potassium Chloride 40 mEq PO BID Duration: 2 Doses
9. Senna 8.6 mg PO BID
10. Carvedilol 12.5 mg PO BID
11. Gabapentin 300 mg PO Q8H
12. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
13. Atorvastatin 40 mg PO QPM
14. Docusate Sodium 100 mg PO BID
15. Ferrous Sulfate 325 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until ___
18. HELD- Valsartan 80 mg PO BID This medication was held. Do
not restart Valsartan until hypotension is resolved
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mal-positioned hardware
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:
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples. You will need staple
removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your staples.
Please avoid swimming for two weeks after staple removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your brace at all times when out of bed. You may
apply your brace sitting at the edge of the bed. You do not need
to sleep with it on.
You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
- Weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10581759-DS-12 | 10,581,759 | 20,322,153 | DS | 12 | 2127-10-11 00:00:00 | 2127-10-13 23:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ventricular lead malfunction
Major Surgical or Invasive Procedure:
Right ventricular lead revision
History of Present Illness:
Mr. ___ is an ___ with history of cerebrovascular accident,
non-ST elevation myocardial infarction status post percutaneous
coronary intervention to LAD and diagonal in ___, ischemic
cardiomyopathy and inducible ventricular tachycardia status post
ICD placement in ___ and revision in ___, and paroxysmal
atrial fibrillation on warfarin who is admitted for right
ventricular lead failure. He reports that he was in his usual
state of health until ___ days prior to admission, when he
noticed intermittent alarming of his pacemaker. He denies
symptoms of any kind, including fevers/chills, lightheadedness,
chest pain, palpitations, or shortness of breath. He was advised
to proceed to the device clinic, where he was found to have
right ventricular lead malfunction and referred to the ED for
admission. Of note, he underwent right ventricular Fidelis lead
extraction in ___, with implantation of new ___ 4076 ICD
lead at that time, but has not required intervention since.
In the ED, initial vital signs were as follows: 98.1 89 156/94
18 96% RA. Admission labs were notable for potassium of 5.3 (4.6
on repeat) and INR of 2.6 in the setting of warfarin use. CXR
was negative for acute cardiopulmonary process.
On arrival to the floor, he reports feeling entirely comfortable
and is eating dinner happily.
Past Medical History:
Hypertension
Hyperlipidemia
Cerebrovascular accident and non-ST elevation myocardial
infarction status post LAD and diagonal stenting in ___
Ischemic cardiomyopathy
Inducible ventricular tachycardia status post ICD placement in
___ and revision in ___
Paroxysmal atrial fibrillation
Hiatal hernia
Esophageal stricture status post dilatation
Status post resection of basal cell skin cancer
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
General: Well-appearing in no acute distress.
Neck: No JVD.
CV: Regular rate, no murmurs.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender/nondistended.
Ext: WWP, no peripheral edema.
Neuro: Alert, appropriately interactive, moving all 4
extremities spontaneously.
At discharge:
VS: AF/98, 127/72, 89 (70s-90s), 18, 97% RA
General: Well-appearing elderly man in no acute distress.
Neck: No JVD. No carotid bruits.
CV: Irregular rhythm, no murmurs, rubs, or gallops, left chest
dressing c/d/i without surrounding erythema/ecchymosis and
minimal tenderness to palpation, +hematoma at left chest pocket
remains within borders demarcated ___
Lungs: Clear to auscultation bilaterally anteriorly
Abdomen: Soft, nontender/nondistended, +BS
Ext: WWP, no peripheral edema, right groin with faint
erythema/ecchymosis, nontender, no palpable hematoma or audible
bruit
Neuro: Alert, appropriately interactive, moving all 4
extremities spontaneously
Pertinent Results:
On admission:
___ 04:25PM BLOOD WBC-6.6 RBC-4.86# Hgb-12.2* Hct-38.1*
MCV-78*# MCH-25.2* MCHC-32.1 RDW-16.9* Plt ___
___ 04:25PM BLOOD Neuts-69.0 ___ Monos-6.3 Eos-2.2
Baso-0.6
___ 04:25PM BLOOD ___ PTT-40.5* ___
___ 04:25PM BLOOD Glucose-102* UreaN-31* Creat-1.1 Na-140
K-5.3* Cl-101 HCO3-24 AnGap-20
___ 04:30PM BLOOD Lactate-1.3 K-4.6
At discharge:
___ 07:00AM BLOOD WBC-5.3 RBC-4.36* Hgb-11.1* Hct-34.8*
MCV-80* MCH-25.6* MCHC-32.0 RDW-17.3* Plt ___
___ 07:00AM BLOOD ___ PTT-62.7* ___
___ 07:00AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-138
K-4.0 Cl-100 HCO3-28 AnGap-14
___ 07:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
Studies:
EKG (___):
Atrial fibrillation with a mean ventricular rate of 86.
Ventricular premature depolarizations. Borderline left
ventricular hypertrophy by voltage criteria in the limb leads.
Non-specific repolarization abnormalities. Compared to the
previous tracing of ___ there is no diagnostic change.
IntervalsAxes
___
___
CXR (___):
No acute cardiopulmonary process.
EKG (___):
Atrial fibrillation with a rapid ventricular response. Leftward
axis. Left
ventricular hypertrophy by voltage in leads I and aVL with ST-T
wave
abnormalities of strain and/or ischemia. There are three wider
QRS complexes,
ventricular versus supraventricular with aberration. Since the
previous
tracing of ___ the rate is now faster. Wide complex beats
are more
prominent. ST-T wave abnormalities are more prominent. Clinical
correlation
is suggested.
IntervalsAxes
___
___
CXR (___):
As compared to the previous radiograph, there is no substantial
change in the position of the pacemaker leads, as compared to
the previous
image. One lead projects over the lateral aspects of the right
atrium and one over the right ventricle. The size of the
cardiac silhouette as well as its appearance has not changed.
No pulmonary edema. No pneumothorax.
Brief Hospital Course:
Mr. ___ is an ___ with history of cerebrovascular accident,
non-ST elevation myocardial infarction status post percutaneous
coronary intervention to LAD and diagonal in ___, ischemic
cardiomyopathy and inducible ventricular tachycardia status post
ICD placement in ___ and revision in ___, and paroxysmal
atrial fibrillation on warfarin who was admitted for right
ventricular lead failure.
Active Issues:
(1)Right ventricular lead failure: He was found to have likely
right ventricular lead malfunction on the basis of device
interrogation on ___, requiring lead revision. ICD was
deactivated temporarily in anticipation of procedure, with
multiple runs of asymptomatic nonsustained ventricular
tachycardia observed on telemetry. Right ventricular lead was
revised successfully on ___ and ICD reactivated. In the
setting of systemic anticoagulation for atrial fibrillation as
below, he developed a left chest hematoma at the site of his
pacemaker, with improvement over the course of admission. He
received vancomycin for postprocedural infectious prophylaxis
and was discharged on clindamycin to complete a 7 day total
antibiotic course. Follow ups in electrophysiology and device
clinics were arranged.
Inactive Issues:
(1)Chronic systolic heart failure: In the setting of known
chronic systolic heart failure (LVEF of 40-45% in ___, he
remained euvolemic appearing throughout admission. Home regimen,
including lisinopril and aspirin, was continued. Metoprolol
succinate dose was increased from 100mg to 150mg daily for
improved rate control.
(2)Coronary artery disease: As above, home lisinopril and
aspirin were continued, as was atorvastatin. Metoprolol
succinate dose was increased as above.
(3)Atrial fibrillation: He remained rate controlled throughout
admission on equipotent dosing of metoprolol tartrate in place
of home metoprolol succinate, with dose increase as above. In
the setting of CHADS2 score of 6, home warfarin was held
throughout admission in anticipation of right ventricular lead
revision as above with heparin bridging therapy.
Postprocedurally, he remained in house on warfarin with a
heparin bridge until INR became therapeutic. Close monitoring of
his INR by his primary care provider was ensured ___.
(4)Hyperlipidemia: Home atorvastatin was continued throughout
admission.
(5)GERD: Home omeprazole was continued throughout admission.
Transitional Issues:
* Follow ups in electrophysiology and device clinics were
arranged.
* He received vancomycin for postprocedural infectious
prophylaxis and was discharged on clindamycin to complete a 7
day total antibiotic course.
* Close monitoring of his INR by his primary care provider was
ensured ___ next INR is to be checked ___.
* Pending studies: None
* Code status: Full
* Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Lisinopril 80 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Warfarin 2.5 mg PO DAILY16
6. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Lisinopril 80 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Warfarin 2.5 mg PO DAILY16
6. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet extended release 24
hr(s) by mouth Daily Disp #*30 Tablet Refills:*0
7. Clindamycin 600 mg PO Q8H Duration: 4 Days
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth Every 8 hours
Disp #*24 Capsule Refills:*0
8. Outpatient Lab Work
ICD9: ___
Please check INR on ___ and send to Dr. ___ (Phone
___ Fax: ___ for review.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Right ventricular lead malfunction status post repair
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 during your admission
to ___. As you know, you were
admitted after one of the leads of your pacemaker was found not
to be working properly. You underwent a procedure to fix the
lead. A small collection of blood developed at the site, but
remains stable.
Please see the attached sheet for specific medication changes,
including increase in metoprolol dose to improve your heart rate
and a brief course of antibiotics to prevent infection following
your procedure.
Followup Instructions:
___
|
10582192-DS-21 | 10,582,192 | 26,317,316 | DS | 21 | 2196-06-28 00:00:00 | 2196-07-03 12:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Trilafon / Paregoric / Pepto-Bismol / Depakote / Tegretol /
Bromocriptine / Darvocet-N 50 / Clozaril / haloperidol
Attending: ___.
Chief Complaint:
Confusion, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ female with a
past
medical history of paranoid schizophrenia, complex partial
seizures, HTN, HLD, hypothyroidism, MR/TR, OSA, migraines, and
COPD who presents with complaints of dizziness starting this
afternoon. She describes it as more of a lightheaded feeling
than vertigo, exacerbated by going from lying and sitting
positions to standing positions. She denies any associated sxs
to me but is answering in only one word answers, to the ED she
endorsed tachycardia, headache, and unsteady gait with theses
episode although she does have chronically unsteady gait and
uses
a wheelchair to get around. Of note, she presented to the ED on
___ with a similar presentation, at that time a head CT was
performed and was WNL. Pt tells me she hasn't had any recent
med
changes except for increase in fluvoxamine 3 wks ago.
In the ED, initial vitals were: 97.9 81 157/69 16 99% RA. She
was noted to be hallucinating in the ED. Orthostatics were
negative and labs were WNL. Tox screen was negative. CXR was
relatively unremarkable. Her presentation was thought to be due
to med effect. She was seen by psychiatry who made
recommendations for medication changes and was admitted to
medicine for polypharmacy and further w/u of delirium.
On the floor, pt states feels "weird," "loopy" and "a little
confused" however is unable to elaborate and is generally
answering with one word answers. States that her whole body
feels heavy but no specific weakness. Endorses mild chronic
cough however otherwise neg ROS. Denies hallucinations
currently
but did have them in the ED.
Past Medical History:
COMPLEX PARTIAL SEIZURE DISORDER
HEADACHE
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
OBSTRUCTIVE SLEEP APNEA, not using CPAP
MIGRAINES
H/O PPD POSITIVE
COPD
GERD
Social History:
___
Family History:
* Father with suspected bipolar do
* Brother {___} with schizophrenia {deceased}
* Brother {___} with developmental delay
Physical Exam:
99.1 120 / 72 77 20 97 RA
Constitutional: Alert, no acute distress
EYES: Sclera anicteric, EOMI, PERRL, disconjugate gaze
ENMT: MMM, oropharynx clear, normal hearing, normal nares
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM
Respiratory:
Clear to auscultation bilaterally, no wheezes, rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, bilateral non-pitting edema
NEURO: AOX3, answers questions appropriately but odd affect.
SKIN: no rashes or lesions
Pertinent Results:
___ 07:00AM BLOOD WBC-4.7 RBC-4.00 Hgb-11.1* Hct-33.7*
MCV-84 MCH-27.8 MCHC-32.9 RDW-13.0 RDWSD-39.8 Plt ___
___ 07:00AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-144
K-4.2 Cl-104 HCO3-28 AnGap-12
___ 07:00AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.3
___ 04:35PM BLOOD VitB12-454
___ 04:35PM BLOOD TSH-0.68
___ 04:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RPR non reactive
Urine culture negative
___ head ct
No evidence of acute large territory infarct,hemorrhage,edema,or
mass effect.
The ventricles and sulci are normal in size and configuration
for the
patient's age.
No evidence of fracture. Mild hyperostosis frontalis is a
normal variant.
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. No intracranial hemorrhage or evidence of infarct on
noncontrast head CT.
Brief Hospital Course:
Pleasant ___ yo F with hx of paranoid
schizophrenia, complex partial seizures, HTN, HLD,
hypothyroidism, MR/TR, OSA, migraines, and COPD who presents
with
complaints of lightheadedness and confusion starting this
afternoon.
# Confusion/lightheadedness: no clear localizing sxs to suggest
infx cause, tox screen negative, suspect polypharmacy
contributing given pt is on multiple psychiatric and neurologic
medications which may cause confusion and sedation.
Orthostatics
negative in ED.
-f/u urine cx sent in ED although no sxs of UTI.
-will complete w/u with RPR, B12, TSH - all within normal limits
-___ consult
-Appreciate psych recs regarding med management, as follows:
-Continue the following home psychiatric medications:
---Aripiprazole 30 mg PO daily
---Fluvoxamine 150 mg PO qam + qnoon
---Prazosin 3 mg PO qHS
-Continue the following home psychiatric medications, with dose
adjustments:
---Benztropine 1 mg PO QHS -- do not give until ___
---Gabapentin 600 mg PO QID
---Quetiapine fumarate 50 mg q9am, qnoon, q4pm + 200 mg PO qHS
-Hold the following home psychiatric medications:
---Clonidine 0.1 mg PO QID PRN
---Melatonin 1 mg PO qHS
Patient was monitored after these medication changes were made,
(including holding her blood pressure medication) and she had no
recurrent symptoms of dizziness and confusion. She had one
hallucination (she reported disorientation in the middle of the
night, thought that she was at someone's wedding) but this
resolved on its' own. I discussed this with psychiatry staff
who felt that it was reasonable to discharge patient given her
well established support in the community. I discussed this
with the patient who was nervous about this discharge, but
agreed to go home given greater than 48 hours in the hospital.
She was discharged home with the above regimen of medication.
# Hx seizures
-cont home Topamax, lamotrigine, keppra.
# COPD: stable
-cont home albuterol PRN
#HLD: cont home statin
#GERD: cont home famotidine
#HTN: Given normotenson off her her blood pressure medicines
and initial complaints of dizziness, I advised her to hold these
medicines.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine ___ TAB PO ONCE PRN migraine
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough/wheeze
3. ARIPiprazole 30 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Benztropine Mesylate 1 mg PO BID
6. Benztropine Mesylate 0.5 mg PO NOON
7. Restasis 0.05 % ophthalmic (eye) QID
8. CloNIDine 0.1 mg PO QID:PRN ptsd sxs
9. Famotidine 20 mg PO BID
10. Fluvoxamine Maleate 150 mg PO QAM
11. Gabapentin 800 mg PO QID
12. hydrOXYzine pamoate 25 mg oral TID:PRN anxiety
13. lamoTRIgine 500 oral QHS
14. LevETIRAcetam 500 mg PO BID
15. Linzess (linaclotide) 290 mcg oral DAILY
16. Meclizine 25 mg PO TID:PRN vertigo
17. Naproxen 375 mg PO Q8H:PRN Pain - Mild
18. Prazosin 3 mg PO QHS
19. Prochlorperazine 10 mg PO TID nausea
20. QUEtiapine Fumarate 300 mg PO QHS
21. QUEtiapine Fumarate 50 mg PO TID
22. Topiramate (Topamax) 100 mg PO BID
23. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
24. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
25. Cal-Citrate (calcium citrate-vitamin D2) 315/200 oral BID
26. Loratadine 10 mg PO DAILY
27. Multivitamins 1 TAB PO DAILY
28. Senna 17.2 mg PO QHS:PRN constipation
29. Fluvoxamine Maleate 150 mg PO NOON
30. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Benztropine Mesylate 1 mg PO QHS
2. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
3. LamoTRIgine 250 mg PO BID
RX *lamotrigine [Lamictal XR] 250 mg 1 tablet(s) by mouth twice
a day Disp #*30 Tablet Refills:*0
4. QUEtiapine Fumarate 200 mg PO QHS
5. QUEtiapine Fumarate 50 mg PO Q9AM, QNOON, Q4 ___
6. Acetaminophen w/Codeine ___ TAB PO ONCE PRN migraine
Duration: 1 Dose
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough/wheeze
9. ARIPiprazole 30 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Cal-Citrate (calcium citrate-vitamin D2) 315/200 oral BID
12. Famotidine 20 mg PO BID
13. Fluvoxamine Maleate 150 mg PO QAM
14. Fluvoxamine Maleate 150 mg PO NOON
15. LevETIRAcetam 500 mg PO BID
16. Levothyroxine Sodium 75 mcg PO DAILY
17. Linzess (linaclotide) 290 mcg oral DAILY
18. Loratadine 10 mg PO DAILY
19. Meclizine 25 mg PO TID:PRN vertigo
20. Multivitamins 1 TAB PO DAILY
21. Naproxen 375 mg PO Q8H:PRN Pain - Mild
22. Prazosin 3 mg PO QHS
23. Prochlorperazine 10 mg PO TID nausea
24. Restasis 0.05 % ophthalmic (eye) QID
25. Senna 17.2 mg PO QHS:PRN constipation
26. Topiramate (Topamax) 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Lightheadedness, confusion - resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for confusion and
lightheadedness and these improved with some minor adjustments
of your medications. I have faxed prescriptions for Seroquel 200
mg, gabapentin 600 mg and lamotragine 250 mg to the ___ on ___ in ___. Please stop taking your blood
pressure medication triamterene/hctz.
Followup Instructions:
___
|
10582192-DS-23 | 10,582,192 | 24,921,425 | DS | 23 | 2196-09-18 00:00:00 | 2196-09-18 17:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Trilafon / Paregoric / Pepto-Bismol / Depakote / Tegretol /
Bromocriptine / Darvocet-N 50 / Clozaril / haloperidol
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of paranoid
schizophrenia (vs. schizoaffective disorder, bipolar type),
borderline personality disorder, complex partial seizure
disorder
(vs. PNES), neurocognitive disorder NOS, hypothyroidism, and
vertigo, who presented from her adult daycare with concern for
altered mental status and generalized weakness. She denied
headache, pain, or focal weakness or numbness. She reported that
she felt "disoriented" and "dropped her drink" today. She denied
cough or dysuria. The staff at her daycare felt that she was not
at her baseline mental status and referred her to the ED. Of
note, she has had two prior ED evaluations this month for
tremors
and was discharged home.
In the ED, her initial VS were T 97.2F P 78 BP 130/64 RR 18 O2
100%RA. Exam notable for repetitive questioning, AOx2 person and
place, but not time, easily distractible, otherwise neuro
intact,
able to walk with assist. Labs showed: UA with few bacteria,
small leukocytes, 1 epi and 2 WBCs, WBC 7.1, Hb 11.3, PLT 248.
LFTs WNL
Chem 7 showed a bicarb of 21, otherwise unremarkable. Trop x 2
negative. Lactate 1.5. Blood cultures pending
CXR showed: Bibasilar atelectasis. CT HEAD showed no acute
intracranial process
On arrival to the floor, she denied confusion, but reported that
she has been dropping her breakfast and lunch for the past day.
She also reports numbness in both of her arms for the past
several days as well. She denied back pain, fevers, chills,
chest
pain, shortness of breath, abdominal pain, nausea, or vomiting.
She did demonstrate some tangential thoughts and repetitive
questions. She was oriented to person and place. We did attempt
to call her daycare for further collateral, however were
unsuccessful.
Past Medical History:
- paranoid schizophrenia (vs. schizoaffective disorder, bipolar
type)
- complex partial seizure disorder vs. PNES
- bipolar personality disorder
- neurocognitive disorder, unspecified
- HTN
- HLD
- hypothyroidism
- MR/TR
- OSA (not on CPAP)
- migraines
- COPD
- cervicalgia/cervical spondylosis
- vertigo
- osteoarthritis
- obesity
- GERD
Social History:
Patient was born and raised in ___ and ___
respectively.
- Currently living in ___ by herself at "___"
___. She states that she is not working, but has worked in
___ jobs last in ___, now on disability (SSI/SSDI).
Reports graduating high school and in regular education classes.
Attended ___ years of college. Reports a history of past
physical abuse from parents and her ex-husband, though she
identifies her ex-husband as a source of support currently. She
divorced in ___ and does not have any children. She grew up
with parents, 3 brothers (one lives in ___, one deceased),
and 1 sister (lives in ___.
- Goes to day-program at ___ in ___
- She has ___ who comes to her house to help her with her
medications (once per week).
- She is religious, attends church regularly (is ___)
and cites God as a main protective factor.
- Alcohol: denies, last time was ___
- Tobacco: denies
- Other illicit substances and IVDU: denies
Family History:
* Father with suspected bipolar do
* Brother {___} with schizophrenia {deceased}
* Brother {___} with developmental delay
Physical Exam:
ADMISSION:
VS: T 99.1F BP 147/70 mmHg P 70 RR 18 O2 97% RA
General: Comfortable, playing with toy football.
HEENT: Dysconjugate gaze. PERRL. Anicteric sclerae.
Neck: Supple.
CV: RRR, no MRGs; Normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended.
Ext: Warm and well-perfused. No edema.
Neuro: A&Ox2. CNs II-XII intact with exception of L gaze
deviation. ___ strength in grip, biceps, triceps, deltoids, hip
flexion, dorsiflexion, plantar flexion. Endorses diminished
sensation ("a bit") over bilateral arms, legs, and abdomen.
DISCHARE:
General: Comfortable, well appearing.
HEENT: PERRL. Anicteric sclerae.
CV: RRR, no MRGs; Normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended.
Ext: Warm and well-perfused. No edema.
Neuro: AOx3
Pertinent Results:
ADMISSION:
___ 05:15PM BLOOD WBC-7.1 RBC-4.14 Hgb-11.3 Hct-35.6 MCV-86
MCH-27.3 MCHC-31.7* RDW-14.8 RDWSD-46.6* Plt ___
___ 05:15PM BLOOD Neuts-72.6* Lymphs-16.2* Monos-8.6
Eos-1.7 Baso-0.6 Im ___ AbsNeut-5.16 AbsLymp-1.15*
AbsMono-0.61 AbsEos-0.12 AbsBaso-0.04
___ 05:15PM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-140
K-5.3* Cl-107 HCO3-21* AnGap-12
___ 05:15PM BLOOD ALT-15 AST-26 AlkPhos-118* TotBili-0.2
___ 05:15PM BLOOD cTropnT-<0.01
___ 11:02PM BLOOD cTropnT-<0.01
___ 07:12AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
___ 05:15PM BLOOD Albumin-4.2
___:12AM BLOOD TSH-2.7
___ 07:45AM BLOOD Lithium-0.3*
___ 06:06AM BLOOD Lithium-0.6
___ 07:12AM BLOOD Lithium-1.0
___ 05:50PM BLOOD Lactate-1.5 K-4.9
DISCHARGE:
___ 07:45AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-147
K-4.2 Cl-111* HCO3-26 AnGap-10
___ 07:45AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1
___ 07:45AM BLOOD Lithium-0.3*
IMAGING:
CT HEAD ___. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. No acute osseous abnormality.
CXR ___
Bibasilar atelectasis.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with paranoid schizophrenia (vs.
schizoaffective disorder, bipolar type), borderline personality
disorder, complex partial seizure disorder (vs. PNES),
neurocognitive disorder NOS, who presented from her day program
with concern for altered mental status and generalized weakness.
# REPORTED ENCEPHALOPATHY
# PARANOID SCHIZOPHRENIA
# COMPLEX PARTIAL SEIZURE DISORDER (VS. PNES)
# NEUROCOGNITIVE DISORDER, NOS
# BORDERLINE PERSONALITY DISORDER
The patient presented with sleepiness at her day program. This
was unfamiliar behavior to staff. The patient requested to go to
___. After arrival to the
hospital, the patient quickly returned to baseline mental
status. Psychiatry was consulted due to suspicion of medication
effect. The following medication changes were made: Decreased
fluvoxamine to 100 BID, held quetiapine 50 TID but continued
bedtime dose, discontinued lithium, discontinued prazosin.
Loratadine, meclizine, naproxen, and prochlorperazine were also
held. Patient was discharged at baseline mental status for
follow-up with psychiatry and neurology.
# COPD. Continued albuterol inhaler PRN.
# GERD. Continued famotidine 20 mg BID.
# HYPOTHYROIDISM. Continued levothyroxine 75 mcg daily.
# VERTIGO. Held home meclizine.
TRANSITIONAL ISSUES:
- Decreased fluvoxamine to 100 BID, held quetiapine 50 TID but
continued bedtime dose, discontinued lithium, discontinued
prazosin. Loratadine, meclizine, naproxen, and prochlorperazine
were also held.
- Patient was discharged at baseline mental status for follow-up
with psychiatry and neurology.
- Follow-up with neurology for consideration of decreasing
Lamictal or Keppra.
- Pending blood cultures should be followed up in clinic.
#CODE: Full (presumed)
#CONTACT: brother, ___, ___, Case manager,
___, ___
>30 minutes spent coordinating discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Milk of Magnesia 30 mL PO Q6H:PRN constipation
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Famotidine 20 mg PO BID
4. LevETIRAcetam 500 mg PO BID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Prazosin 3 mg PO QHS
7. QUEtiapine Fumarate 50 mg PO TID
8. Topiramate (Topamax) 100 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Senna 17.2 mg PO QHS:PRN constipation
11. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
12. QUEtiapine Fumarate 200 mg PO QHS
13. ARIPiprazole 30 mg PO DAILY
14. LamoTRIgine 250 mg PO BID
15. Fluvoxamine Maleate 150 mg PO BID
16. Linzess (linaclotide) 290 mcg oral DAILY
17. Gabapentin 600 mg PO TID
18. Atorvastatin 20 mg PO QPM
19. Loratadine 10 mg PO DAILY
20. Prochlorperazine 10 mg PO Q8H:PRN nausea
21. Naproxen 375 mg PO Q8H:PRN Pain - Moderate
22. Restasis 0.05 % ophthalmic (eye) QID
23. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral DAILY
24. Meclizine 25 mg PO Q8H:PRN dizziness
Discharge Medications:
1. Fluvoxamine Maleate 100 mg PO BID
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. ARIPiprazole 30 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral DAILY
7. Famotidine 20 mg PO BID
8. Gabapentin 600 mg PO TID
9. LamoTRIgine 250 mg PO BID
10. LevETIRAcetam 500 mg PO BID
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Linzess (linaclotide) 290 mcg oral DAILY
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. Multivitamins 1 TAB PO DAILY
15. QUEtiapine Fumarate 200 mg PO QHS
16. Restasis 0.05 % ophthalmic (eye) QID
17. Senna 17.2 mg PO QHS:PRN constipation
18. Topiramate (Topamax) 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# ENCEPHALOPATHY
# PARANOID SCHIZOPHRENIA
# COMPLEX PARTIAL SEIZURE DISORDER (VS. PNES)
# NEUROCOGNITIVE DISORDER, NOS
# BORDERLINE PERSONALITY DISORDER
# COPD
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 ___
sleepiness.
While you were here:
-We changed some of your medications
-You started to feel better before leaving hospital
When you go home:
-Please continue all medications as directed
-Please follow-up with the below doctors
-___ also follow-up with your psychiatrist
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10582264-DS-7 | 10,582,264 | 26,429,947 | DS | 7 | 2186-05-23 00:00:00 | 2186-05-24 13:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
___: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
3 generalized seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with history of global developmental
delay resulting in intellectual disability and prior staring
episodes as a child who presents after 3 GTCs while at school.
The history is provided by the mother, who was told the history
by a school official.
He attends a school called ___ and was eating lunch, when
his arms became stiff and he started to shake after falling
down. He went to the ED, CT Head was negative. He returned to
school, had another seizure lasting 45 seconds, was sent back to
the ED, where he had a third seizure. Each seizure was self
resolved. He received Keppra 500 mg, Ativan 1 mg at OSH. ___
___ was unable to do EEG, so transferred him to ___.
He has never had
GTCs before.
He had 2 seizures at age ___, characterized by a few seconds of
staring. He had an EEG that showed abnormal activity in the
frontal lobe (unknown which side) and an MRI that was reportedly
normal. He was on depakote for a short amount of time
(approximately weeks).
No recent illness. Mom speaks to him on the phone daily and said
he has sounded like himself. He ran out of Zyrtec last week,
which he takes year-round for seasonal allergies.
At baseline, he is at a ___ grade level for reading and math. He
is able to walk and run. He bathes himself, dresses himself, and
feeds himself. He was going to start driving lessons this
___.
Past Medical History:
1. Intellectual disability after global developmental delay,
MRI as a child age ___ normal
2. Episodes of staring at age ___, on an AED for weeks and then
discontinued
3. ADHD in the past
4. Tics in the past
Social History:
___
Family History:
- Grand-Aunt's granddaughter: Second cousin with epilepsy
Physical Exam:
Admission Physical Exam:
T= 98.1F, BP= 129/61, HR= 90, RR= 14, SaO2= 99% on RA
General: sleepy, uncooperative, NAD.
HEENT: forehead bruise and skin abrasions, MMM, oropharynx
clear
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: patient was sleepy and difficult to arouse. He
did not answer questions about his name, where he is, or which
family member came with him to the emergency room.
-Cranial Nerves:
I: Olfaction not tested.
II: Unable to test because patient would not open eyes and
forcefully closed eyes when examiner attempted to open them.
III, IV, VI: Unable to assess.
V: Unable to assess
VII: No facial droop, facial musculature symmetric
VIII: Hearing grossly intact.
IX, X: Unable to assess.
XI: able to move head side to side.
XII: Unable to assess.
-Motor: Normal bulk throughout. No adventitious movements, such
as tremor, noted. Moves all extremities symmetrically and
antigravity.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: Able to feel mildly noxious stimulus in all four
extremities.
-Coordination/Gait: unable to test.
========================================
Discharge Physical Exam:
General: NAD
HEENT: Forehead bruise and skin abrasions, MMM, oropharynx
clear
Neck: Supple
Pulmonary: CTA bilaterally
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: warm and well perfused with no edema
Neurologic:
-Mental Status: Awake, alert and oriented. Able to answer
questions appropriately. Sentence structure is simple. Usually
answers "yes" or "no" but can form sentences up to 7 words.
Often looks to his mother for clarification. Slight abnormal
prosody in speech.
-Cranial Nerves:
II: Vision appears adequate. Able to read at distances. Denies
blurry vision.
III, IV, VI: EOMI. No nystagmus.
V: Intact bilaterally.
VII: Face symmetric at rest and with activation.
VIII: Hearing grossly intact.
IX, X: Intact.
XI: Intact.
XII: Intact.
-Motor: Normal bulk throughout. No adventitious movements, such
as tremor, noted. Moves all extremities symmetrically and
antigravity.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
-Sensory: Intact bilaterally to light touch.
-Coordination/Gait: No dysmetria. No pronator drift. Gait
steady in standard gait.
Pertinent Results:
___ 05:07AM BLOOD WBC-4.9 RBC-4.85 Hgb-14.0 Hct-41.4 MCV-85
MCH-28.9 MCHC-33.9 RDW-13.0 Plt ___
___ 03:15AM BLOOD Neuts-68.2 ___ Monos-7.5 Eos-1.8
Baso-0.5
___ 05:07AM BLOOD Plt ___
___ 05:07AM BLOOD Glucose-97 UreaN-11 Creat-0.9 Na-143
K-3.7 Cl-105 HCO3-27 AnGap-15
___ 05:07AM BLOOD ALT-18 AST-17 AlkPhos-82 Amylase-51
___ 05:07AM BLOOD Lipase-39
___ 05:07AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.0
___ 03:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MRI: Normal MRI of the brain using seizure protocol.
EEG: Most of the record showed a normal posterior waking
background, but there were some brief bursts of generalized
epileptiform activity correlated with myoclonus, all suggesting
a generalized epilepsy pattern. There were no electrographic
seizures.
Brief Hospital Course:
Mr. ___ is a ___ yo male with a history of developmental
delay and resultant intellectual disability of unknown etiology
and prior staring spells as a child who presented after 3
generalized tonic seizures at his school. Mother reports that
he had staring episodes when he was ___ years old but no longer
has them. Additionally, he had "tics" in the past after he
started Tenex for ADHD, but the "tics" have improved since he
started his current school ___ years ago.
After admission, he was connected to continous video EEG which
captured an episode where Mr. ___ reporting that he felt
his vision was blurry and then started having head nods that
were consistent with myoclonic jerks on EEG. His EEG also
showed bitemporal lobe slowing. During this time, he was awake
and responsive. He did not have a clinical generalized seizure
during the hospital stay. He did not have any electrographic
seizures captured on the EEG.
He was initially started on Keppra since he was loaded with
Keppra at ___. He was continued on Keppra 750mg
BID on the first day of hospitalization but was then weaned to
Keppra 500mg and it was then discontinued. He was started on
Depakote on the second day of admission with no negative side
effects. He will be discharged on Depakote 750mg BID. He will
follow up with Neurology Clinic with Dr. ___. Seizure
precautions was extensively discussed with Mr. ___ and his
mother and they voiced understanding.
Medications on Admission:
1. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Divalproex (DELayed Release) 750 mg PO BID
RX *valproic acid [Depakene] 250 mg 3 capsule(s) by mouth twice
a day Disp #*90 Capsule Refills:*4
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
- Generalized tonic clonic seizures
- Myoclonic jerks
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
Neurology ___ due to 3 generalized tonic clonic seizures.
You had an EEG during your hospital stay which showed that you
had myoclonic jerks which are movements that look like tics that
is consistent with having seizures. You also had a MRI of your
brain which was normal.
You have been started on Depakote, which is a antiseizure
medication. Since you had a seizure, you cannot drive for at
least the next 6 months. Also, please do not be near sharp
objects or fire which can be dangerous if you lose consciousness
and fall onto it. Also, do not swim, bath or be near water
without other people around.
You will follow up with a Neurologist outpatient. Please also
follow up with a primary care doctor in ___ in
approximately 1 month to have your blood checked for a CBC and
liver function tests since you are on Depakote.
It was a pleasure taking care of you in the hospital.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10582415-DS-14 | 10,582,415 | 28,717,822 | DS | 14 | 2155-04-18 00:00:00 | 2155-04-18 09:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ FOR CONSULTATION: Atraumatic ___
HISTORY OF THE PRESENTING ILLNESS:
==================================
___ is a ___ year old woman with hypertension and CHF
in the setting of severe aortic stenosis who presents as a
transfer from ___ for further management of atraumatic ___
with IVH.
History is obtained from the medical record and the patient's
niece, ___. The patient is unable to provide any
meaningful history other than that her symptoms began on
___.
___ states that she has been out of town in ___ and
only
returned home to visit her aunt, ___, yesterday afternoon.
She notes that her aunt was "not right" at the time. The patient
had reportedly told her niece that she developed sudden onset
"shooting pains into the front of her head and into her neck"
while washing her face on the ___ afternoon. She
subsequently complained of a stiff neck and fatigue.
___ advised that she go to the hospital for further evaluation
but ___ declined. ___ helped put her aunt into bed and
planned to check on her the next day.
In the afternoon of ___, ___ visited ___ and ___ her
to
"more off" than she had been the day before. She was sleeping in
the library throughout the day, lethargic, and noted that her
"speech was off" but not slurred. ___, who is a retired ___,
took her blood pressure which was 220/110. She ultimately called
EMS and the patient was brought to ___ for further
evaluation.
In the ___, vitals signs were notable for: HR 57,
Respiratory Rate: 18, Blood-pressure: 175/74. Oxygen Saturation:
98% room air. She was "alert" with "no diplopia in any gaze."
She
was noted to be "generally slow to respond" though had normal
upper and lower extremity strength.
CT head showed bifrontal subarachnoid hemorrhage with IVE.
Patient was transferred to ___ for neurosurgical evaluation.
At baseline, the patient drives her own car, goes to the
___
independently, and walks with a cane or walker. She lives in an
independent living facility and does "not take very good care of
her health" according to ___.
___ states that ___ has been consistently a DNAR/DNI. She
was offered TAVR in the past for severe aortic stenosis but
declined.
Patient currently denies pain but is unable to participate in
full ROS otherwise.
Past Medical History:
PAST MEDICAL HISTORY:
=====================
Severe aortic stenosis
Congestive heart failure, improved with Lasix over past 6 months
Hypertension
Social History:
___
Family History:
No neurologic family history
Physical Exam:
Admission Physical Examination
Vitals: HR 62, BP 171/68, RR 28, SA 96% RA
General: Somnolent, leaning on left side in bed with lights off
wearing eye glasses
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Mild neck stiffness, no carotid bruits appreciated.
Pulmonary: CTAB, normal work of breathing
Cardiac: ___ SEM noted over LUSB, RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: Trace ___ edema.
Skin: No rashes or lesions noted.
Neurologic Exam:
-Mental Status: Eyes mostly closed, mumbling incoherently
throughout the interview and exam - particularly when asked why
she is in the hospital. Speaks very coherently when asked about
historical details such as her birthday. Able to read without
difficulty. Able to repeat. She is perseverative and
inattentive.
Multiple paraphasic errors. Able to intermittently follow 1 but
not 2-step commands. She states that she is at ___"
when asked her currently location. She is able to ___
___
from list of 3 options. Able to spell WORLD forwards but not
backwards.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 5 4+ 5 5 ___ 5 5 5
-Sensory: Withdraws to noxious in all 4.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was extensor bilaterally with tonically
up-going
left toe
-Coordination: No dysmetria with FNF though limited by MS.
-___: Deferred.
Discharge physical examination
Awake, alert, conversational, appears comfortable
Pertinent Results:
CTA ___xamination is limited due to significant beam hardening
artifact. Within
these limits, there is increased high density lining the sulci
of the
bilateral frontal lobes consistent with subarachnoid hemorrhage.
In addition
there is a layering ventricular blood mildly increased from
prior. The
ventricles and sulci are significant large consistent with
cerebral atrophy,
unchanged from prior. High density focus along the inner table
of the left
frontal bone (series 3, image 17) likely represents a vessel.
1.2 x 1.6 cm
calcified dural-based lesion likely represents a meningioma.
Significant periventricular and subcortical white matter
hypodensities
consistent with small vessel ischemic changes. No evidence of
new
intracranial hemorrhage or large territory infarct. There is no
evidence of
skull fracture.
CT of the head:
The vessels of the circle what is are patent without evidence of
large vessel
occlusion or intracranial aneurysm. Dural sinuses are patent.
Extensive
calcification of the bilateral intracranial carotid arteries.
CTA of the neck:
There is extensive calcifications of the aortic arch. The
bilateral common
carotid and vertebral arteries are patent without evidence of
high-grade
stenosis. There is moderate stenosis due to atherosclerotic
calcifications at
the carotid bifurcation. Lung apices demonstrate mild
centrilobular
emphysematous changes.
___ 08:40AM ALT(SGPT)-10 AST(SGOT)-19 CK(CPK)-61 ALK
PHOS-43 TOT BILI-0.6
___ 08:40AM %HbA1c-5.4 eAG-108
___ 08:40AM WBC-10.1* RBC-4.15 HGB-12.5 HCT-37.7 MCV-91
MCH-30.1 MCHC-33.2 RDW-13.8 RDWSD-46.5*
___ 09:00PM GLUCOSE-119* UREA N-17 CREAT-0.7 SODIUM-136
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-27 ANION GAP-14
___ 09:00PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.0
___ 09:00PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.0
___ 09:00PM NEUTS-77.3* LYMPHS-12.2* MONOS-9.7 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-6.23* AbsLymp-0.98* AbsMono-0.78
AbsEos-0.01* AbsBaso-0.02
___ 09:00PM PLT COUNT-276
___ 08:43PM URINE HOURS-RANDOM
___ 08:43PM URINE UHOLD-HOLD
___ 08:43PM URINE COLOR-Straw APPEAR-HAZY* SP ___
___ 08:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-20*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.5
LEUK-LG*
___ 08:43PM URINE RBC-5* WBC-175* BACTERIA-FEW* YEAST-NONE
EPI-1 TRANS EPI-4
___ 08:43PM URINE HYALINE-2*
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history notable
for hypertension, severe aortic stenosis, and CHF who presented
to
the hospital with a subarachnoid hemorrhage with biventricular
extension. She was seen by Neurosurgery who felt that it was
likely hypertensive in nature & that no intervention was
warranted. CTA, however, raised the possibility of an AComm
aneurysm. The options for invasive diagnostic and therapeutic
interventions were discussed with Ms. ___, her family, and
the medical team, the decision was made to pursue hospice care.
She was discharged to inpatient hospice in hemodynamically
stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN cough
3. Furosemide 10 mg PO DAILY
4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
5. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN wheezing
6. LevoxyL (levothyroxine) 25 mcg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever
2. Haloperidol 0.5-2 mg IV Q4H:PRN nausea/vomiting
3. Hyoscyamine 0.125-0.25 mg SL Q4H:PRN excess secretions
4. LORazepam 0.5-2 mg PO Q2H:PRN anxiety
5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q1H:PRN moderate-severe pain or respiratory distress
6. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN delirium
7. Scopolamine Patch 1 PTCH TD Q72H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of confusion resulting
from an acute subarachnoid hemorrhage, likely from a ruptured
aneurysm. While you were hospitalized, invasive diagnostic and
therapeutic interventions were offered, however, after
discussions between you, your family, and your medical team, it
was clear that these interventions were not within your goals of
care, and comfort directed treatment was pursued. You were
discharged to inpatient hospice.
It was a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10582595-DS-14 | 10,582,595 | 20,690,213 | DS | 14 | 2110-02-17 00:00:00 | 2110-02-17 16:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex / Benadryl
Attending: ___
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Open reduction internal fixation, left anterior column
posterior hemi-transverse acetabular fracture.
2. Open reduction position of left bimalleolar ankle
fracture.
3. Left chest thoracostomy tube
History of Present Illness:
___ with history of a-fib on coumadin and previous CVA w/o
deficits presents to ___ as transfer from OSH s/p fall with
multiple fractures. She was reportedly found down at her home
after fall from ___ feet from interior balcony in her home when
she was last seen normal. Patient states she remembers the
entire episode and falling to the floor, with no LOC. At OSH had
neg CT head, cxr showing rib fracture, and hct down 10pts from
three weeks ago. She was given 1 unit of PRBC's and Vitamin K to
reverse anticoagulation prior to transport. There was report of
impacted hip fracture as well as left ankle fracture. She was
transferred to ___ for further management.
Past Medical History:
- Atrial fibrillation on coumadin
- HTN
- Osteoarthritis
- Glaucoma
- RIGHT total hip replacement
- Hysterectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
(On presentation to ER)
Temp: 97.0 HR: 142 BP: 148/92 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Opens eyes to commands
HEENT: Ecchymosis on right cheek, Pupils equal, round and
reactive to light, Extraocular muscles intact, no proptosis
c-collar placed on arival, no tenderness
Chest: Clear to auscultation; no chest wall crepitus or ttp
Cardiovascular: irregular, tachy
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Left ankle swelling/injury without deformity,
equal radial pulses, dopplerable DP and ___ pulses
bilaterally
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation (alert and oriented though slightly
slow to open eyes and follow commands)
Pertinent Results:
___ 05:00PM GLUCOSE-149* UREA N-29* CREAT-0.8 SODIUM-133
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13
___ 05:00PM WBC-12.1* RBC-3.75* HGB-10.4* HCT-31.1*
MCV-83 MCH-27.8 MCHC-33.6 RDW-14.1
___ 05:00PM ___ PTT-36.3 ___
IMAGING:
Xray Left Ankle ___: Acute fractures involving the medial
malleolus, distal fibula (Weber B) with syndesmotic disruption
and widened medial mortise.
Xray Pelvis ___: Multiple pelvic fractures detailed above
including right superior and inferior pubic ramus fractures,
left acetabular fracture with protrusio defect and left inferior
pubic ramus fractures.
CT C-spine ___: No acute fracture
CT Chest w/contrast ___: Multiple pulmonary nodules,
nondisplaced posteriorlateral ___ and 9th rib fx
CT Abd/Pelvis ___: Hepatic cyst, L psoas hematoma 8.7 by 4.6 by
11.7cm, intermuscular hematomas of the pelvic girdle w/o active
extravasation
CT head w/o contrast (___): negative for ischemia or hemorrhage
Brief Hospital Course:
Her Emergency Department course as follows:
On arrival to ___ ED she had a GCS 15 with dopperable pulses
in both lower extremities. She underwent CT imaging - CT c-spine
was negative but cervical collar was left in place initially due
to potential of orthopedic injuries being a distracting factor;
the collar was eventually removed. CT scan of the chest, abdomen
and pelvis confirming rib fractures on left ___ non-displaced
and complex pelvic fracture without evidence of active
extravasation. It should also be noted that there were 4-mm
pulmonary nodules in the left lower lobe and lingula for which
follow up with a repeat chest CT in one year is being
recommended. Hematocrits in ED remained stable. Her CK and
lactate were initially elevated which was concerning for
rhabdomyolysis but her creatinine remained stable; she was given
fluid resuscitation. She was noted to be in atrial fibrillation
with HR up to 120's and was given Diltiazem and started on a
drip. No other hemodynamic instability was noted. Two Units of
FFP were given to reverse her INR in the ED. Orthopedic
consultation was obtained.
ICU course as follows:
She was admitted to the Acute Care Surgery team and transferred
to the Trauma ICU for close monitoring and stabilization prior
to orthopedic repair of her injuries. She was taken to the
operating room on ___ for open reduction internal fixation,
left anterior column posterior hemi-transverse acetabular
fracture and open reduction position of left bimalleolar ankle
fracture. There were no intraoperative complications.
Postoperatively she had significant pain control issues
prompting Acute Pain Service consultation.
Her hematocrit dropped from admission value of 31.1 to 21.2 on
___ and she was transfused with 4 units PRBC's for anemia due to
acute blood loss which was felt likely due to her pelvic
fracture. She also received 3 units of FFP to correct her
Coumadin-induced coagulopathy.
She was also started on Zosyn for treatment of a recent
complicated UTI that had failed Bactrim therapy as outpatient.
On POD#2 she was transferred to a surgical floor, however after
only a short time she was found to be minimally responsive and
was transferred back to the ICU for further workup. By the time
of arrival back to the ICU her mental status began to show some
improvement as she was waking up more. A CT scan of the head was
done and revealed no acute processes; her change in mental
status was felt likely due narcotic medication.
A chest x ray obtained on POD#3 was concerning for left pleural
effusion and an ultrasound supported this. A chest tube was
placed with drainage of ~400cc serosanguinous fluid. She was
started on a Ketamine drip and clonidine patch for pain control.
The following day POD#4 her chest xray was markedly improved and
the chest tube was removed with concomitant improvement in pain.
The Ketamine was weaned off and pain control accomplished with
clonidine patch, gabapentin, and oxycodone for breakthrough. By
POD#4 she underwent a swallow evaluation and her diet was
upgraded to mechanical soft and thin liquids.
Her floor course as follows:
She was transferred from the ICU to the floor for ongoing care.
She underwent left lower extremity ultrasound to assess for DVT
given swelling but no evidence of clot was found. She did
however have a significant cellulitis near her left ankle
surgical site and was recommended for Vancomycin IV. A formal
Infectious Disease consult was obtained who recommended
continuation of the Vancomycin through ___. A PICC line was
placed. She will need her ESR and CRP checked on ___ Vanco
levels will also need to be followed and dosing adjusted
accordingly. Next Vanco trough to be done ___.
Her INR was noted to be elevated and her home dose of 6.5 mg
Coumadin was held on ___ for an INR 3.2. Her INR will need to
be followed closely and when restarting it is being recommended
that she be given at least half of her usual home dose.
Physical and Occupational evaluations were obtained and she is
being recommended for acute level rehab after her hospital stay.
Medications on Admission:
- coumadin 6.5 mg daily
- metoprolol 50 mg BID
- diltiazem 120 mg daily
- digoxin 0.125 mg daily
- lisinopril 5 mg daily
- xalantan eye gtt
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: One (1) Dose
Injection four times a day as needed for per sliding scale.
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
3. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
over left chest region rib fx site ___.
12. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every ___.
13. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: New
dose being recommneded - home dose previously 6.5 mg but stopped
d/t elevated INR. .
14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) GM
Intravenous Q 24H (Every 24 Hours) for 7 days.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Ultram 50 mg Tablet Sig: 0.5 Tablet PO four times a day as
needed for pain.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p Fall
Injuries:
1. Left anterior column posterior hemi-transverse acetabular
fracture
2. Left bimalleolar fracture
3. Rib fractures on left ___ (non-displaced)
4. Moderate left pleural effusion
5. Wound cellulitis left ankle
6. ___ cyst left popliteal fossa
7. Acute blood loss anemia
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 to the hospital following a fall where you
sustained multiple injuires including rib fractures and
fractures of your pelvic/hip, fibula (lower leg) and ankle
bones. You required surgery to fix the broken bones and now
being recommended for a rehabilitation facility to help
strengthen you.
During your hospital stay you also developed an infection on the
leg where your fractures are located. Intravenous antibiotics
were recommended and a special intravenous catheter line called
a PICC was placed into your veins to deliver the medications.
Your blood thinning medication called Coumadin required some
adjustments while you were in the hospital based on your INR
blood levels. You are being discharged to rehab on a lower dose
than you were on at home. The rehab facility will be able to
monitor your blood levels closely and will adjust the dose
accordingly.
Followup Instructions:
___
|
10582697-DS-12 | 10,582,697 | 29,745,452 | DS | 12 | 2117-03-15 00:00:00 | 2117-03-15 12:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Brain Mass
Major Surgical or Invasive Procedure:
___ right temporal craniotomy for tumor resection
History of Present Illness:
Mr. ___ is a ___ year-old male with hx of DM, Hyperlipidemia,
Depression presented to OSH for evaluation complaining of
headaches over the past few months. Patient and family also
report over the last month patient has c/o nausea and vomiting
and ataxia resulting in falls. Patient himself minimizes his
symptoms and only presented to the ED today the urgent request
of his wife and daughter. At ___ patient underwent a
___ which reveals a large right sided brain mass with 4mm of
MLS. Patient was loaded with keppra and transferred to ___ for
further managment. Upon examination patient reports intermittent
headaches, nausea/vomiting, feeling uncoordinating. He denies
blurry vision, double vision, numbness, tingling or weakness.
Past Medical History:
Hypertension
Hyperlipidemia
NIDDM
Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:97.7 BP: 138/76 HR:69 R 14 O2Sats 97% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3 mm EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception bilaterally.
Toes downgoing bilaterally
Coordination: Dysmetric LUE on finger-nose-finger, rapid
alternating movements and heel to shin intact
PHYSICAL EXAM ON DISCHARGE:
Neurologically intact.
Incision closed with staples, clean/dry/intact without
surrounding erythema or discharge.
Pertinent Results:
***MR HEAD W & W/O CONTRAST Study Date of ___ 9:02 AM
Peripherally enhancing mass centered in the right temporal lobe
with
significant vasogenic edema as detailed above, most concerning
for a primary glial neoplasm, less likely metastatic disease.
Given central restricted diffusion, abscess is not excluded
although considered less likely given solid nodular enhancement
of this lesion.
***ECG ___ 8:08:54 AM
Sinus rhythm. Slight A-V conduction delay. Otherwise, within
normal limits. No previous tracing available for comparison.
***CHEST XRAY (PRE-OP PA & LAT) Study Date of ___ 10:54
AM
The cardiomediastinal silhouette is within normal limits. The
pulmonary
vasculature is normal. There is streaky linear atelectasis at
the left lung base. No focal consolidation, pleural effusion, or
pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
***CT CHEST W/CONTRAST Study Date of ___ 5:07 ___
IMPRESSION:
1. Nonspecific pulmonary nodules, suggest followup CT in 6
months.
2. Otherwise normal CT chest.
***CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:07
___
IMPRESSION:
1. No evidence of metastatic disease within the abdomen or
pelvis.
2. Cholelithiasis without evidence of acute cholecystitis.
3. There is a 1 cm simple hepatic cyst within segment 7
4. Please refer to separate CT chest for additional details.
***MR HEAD W/ CONTRAST (PRE-OP) Study Date of ___ 4:16 AM
IMPRESSION:
1. Stable heterogeneously and peripherally enhancing 3.6 cm
right temporal lobe mass with surrounding edema.
2. Stable leftward midline shift and mild right uncal
herniation.
***CT HEAD W/O CONTRAST (POST-OP) Study Date of ___ 4:44
___
IMPRESSION:
1. Postoperative changes related to patient's interval right
parietotemporal brain tumor resection.
2. Stable degree of uncal herniation and 2 mm leftward midline
shift.
3. Grossly stable right temporal and parietal edema.
4. New small nonspecific right mastoid fluid.
***MR HEAD W & W/O CONTRAST (POST-OP) Study Date of ___
10:13 AM
IMPRESSION:
1. Curvilinear enhancement along the anterior and medial
aspects of the right temporal surgical bed, with associated slow
diffusion. This could represent residual tumor versus
intra-operative contusion. Recommend close follow up.
2. Persistent extensive vasogenic edema in the right cerebral
hemisphere with stable mild leftward shift of supratentorial
midline structures. However, right uncal herniation and mass
effect on the midbrain have improved.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ after CT Head
demonstrated a large right-sided brain mass with surrounding
cerebral edema and 4mm midline shift. He was monitored overnight
in the ICU without significant events. He was started on Keppra
and Decadron. His neurologic exam remained stable. MRI was
obtained to further assess the lesion. He was transferred to the
inpatient floor with surgery planned for ___.
On ___, the patient was neurologically stable. A CT torso was
ordered which showed small pulmonary nodules, but no evidence of
malignancy.
On ___, the patient remained neurologically stable and
underwent routine pre-operative planning for surgery.
On ___, Mr. ___ was taken to the operating room for a right
temporal craniotomy for tumor resection. The surgery was
uncomplicated. He was taken to the PACU post operatively where
he was monitored. His post operative NCHCT showed expected post
operative changes. He was agitated post-operatively and his
blood pressure was difficult to control. A narcardipine drip was
started.
On ___, the patient remained neurologically stable. He was
started on lisinopril 5mg daily, and his blood pressure control
improved. The patient was transferred to the floor.
Post-operative MRI was completed and showed some enhancement in
the anteromedial surgical bed, likely residual tumor versus
intraoperative contusion, along with persistent vasogenic edema
in the right cerebral hemisphere.
On ___, the patient remained neurologically stable. He was
evaluated by physical therapy and occupational therapy, who
cleared him for discharge home without services. His dressing
was removed and his incision was noted to be clean/dry/intact
without erythema or discharge. At the time of discharge, the
patient was tolerating regular diet, voiding and moving his
bowels independently, and ambulating without difficulty. A
thorough discussion was had with the patient and his family
regarding post-discharge instructions and appropriate follow-up.
The patient expressed readiness for discharge.
Medications on Admission:
1. Venlafaxine XR 75 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. GlipiZIDE 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. GlipiZIDE 2.5 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Simvastatin 20 mg PO QPM
4. Venlafaxine XR 75 mg PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
6. LeVETiracetam 1000 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Dexamethasone taper
Discharge Disposition:
Home
Discharge Diagnosis:
Brain tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Surgery
You underwent surgery to remove a tumor from your brain.
Frozen preliminary was: glioblastoma
Please keep your incision dry until your staples are removed.
You may shower at this time but keep your incision dry.
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 have been discharged on a Decadron (dexamethsone) taper.
Please take this medication as follows:
-4mg every 6 hours x 8 doses (2 days); then,
-4mg every 12 hours x 4 doses (2 days); then,
-2mg every 6 hours x 8 doses (2 days); then,
-2mg every 12 hours x 4 doses (2 days); then,
-2mg once daily until follow-up appointment
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
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.
Followup Instructions:
___
|
10582697-DS-16 | 10,582,697 | 25,234,873 | DS | 16 | 2119-12-13 00:00:00 | 2119-12-13 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of T2DM, HTN, HLD, Depression, Glioblastoma (s/p C8 of
Bevacizumabm, Randomized to VB-111 Plus Bevacizumab Arm in ___
___, who presented to ED from clinic with failure to
thrive
As per review of Dr ___ note from today, patient
noted to have extremely poor functional status since returning
home from rehab earlier this month for which he is unable to
care
for himself and is now dependent on others. MRI was performed to
assess for progression, which it reportedly has not per Dr
___, but formal radiology read has not yet been completed.
Accordingly, Dr ___ that his overall decline was likely
___ delayed radiation induced encephalopathy and noted that he
would need to come off the protocol treatment for glioblastoma,
ruled out for infectious causes of encephalopathy, before
pursuing placement in rehab facility.
As per discussion with the patient, he is unsure of why he is in
the hospital or being admitted. He noted that he remembers
seeing
Dr ___ doesn't recall their conversation. He noted that he
remembers being at home beforehand but can not speak of his
functional state or daily events. He was able to answer yes and
no questions however, and stated that he had no fever, chills,
headache, sore throat, cough, SOB, chest pain, nausea, vomiting,
diarrhea, abdominal pain, rash but did endorse burning with
urination. He wondered whether or not he had a repeat UTI.
In the ED, initial vitals: 96.6 75 120/83 16 97% RA. WBC 12.3,
Hgb 14, plt 138, CHEM wnl except for BUN of 44, LFTs wnl. VBG
7.41/44. CXR revealed: no acute cardiopulmonary process
Patient was not given any medications and was admitted to
oncology for further care.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___:
"Treatment History:
(1) ___ Headache started
(2) ___ Nausea and vomiting started
(3) ___ Left leg weakness with gait instability
(4) ___ Fall
(5) ___ Head CT showed a mass in the right temporal lobe of
the brain
(6) ___ MRI brain with gadolinium showed a mass in the
right
temporal lobe of the brain
(7) ___ DFCI ___ screen consent presented
(8) ___ DFCI ___ screen consent signed
(9) ___ Resection of right temporal tumor by Dr. ___: glioblastoma with IDH1 mutation negative
(10) ___ DFCI ___ main consent presented
(11) ___ DFCI ___ screen consent signed
(12) ___ Leukaphoresis
(13) ___ Radiation and concomitant daily temozolomide
started and completed it on ___ to 6000 cGy (200 cGy x 30
fractions),
(14) ___ Stopped dexamethasone,
(15) ___ Head MRI with gadolinium showed stable disease,
(16) ___ DFCI ___ DCVax randomized immunization #1,
(17) ___ DFCI ___ DCVax randomized immunization #2,
(18) ___ DFCI ___ DCVax randomized immunization #3,
(19) ___ to ___ Cycle 1 adjuvant temozolomide at 150
mg/m2/day x 5 days (but only received the 180 mg capsules),
(20) ___ Head MRI with gadolinium showed stable disease
(21) ___ ___ ___ DCVax randomized immunization #4,
(22) ___ to ___ C2 adjuvant temozolomide at 125
mg/m2/day x 5 days,
(23) ___ to ___ C3 adjuvant temozolomide at 125
mg/m2/day x 5 days,
(24) ___ Head MRI with gadolinium showed partial response,
(25) ___ DFCI ___ DCVax randomized immunization #5,
(26) ___ to ___ C4 adjuvant temozolomide at 125
mg/m2/day x 5 days,
(27) ___ to ___ C5 adjuvant temozolomide at 125
mg/m2/day x 5 days,
(28) ___ to ___ C6 adjuvant temozolomide at 125
mg/m2/day x 5 days,
(29) ___ DFCI ___ DCVax randomized immunization #6,
(30) ___ Head MRI with gadolinium showed partial response,
(31) ___ Head MRI with gadolinium showed partial response,
(32) ___ DFCI ___ DCVax randomized immunization #7,
(33) ___ Head MRI with gadolinium showed continued partial
response,
(34) gadolinium-enhanced head MRI on ___ showed definite
disease progression,
(35) Portacath placement on ___,
(36) end-of-study for DCVax DFCI ___ on ___ ,
(37) signed consent on ___ for VB-111 with or without
bevacizumab per DFCI protocol ___,
(38) screening visit on ___ for DFCI protocol ___,
(39) gadolinium-enhanced head MRI on ___ showed unchanged
progressive disease when compared to the previous one on
___,
(40) signed consent on ___ for ___ ___ protocol
comparing VB-111 plus bevacizumab versus bevacizumab alone,
(41) randomized to receive C1D1 VB-111 and bevacizumab on
___ in DFCI protocol ___,
(42) admission to ___ ICU from ___ to ___ for
cytokine release syndrome,
(43) stopped dexamethasone on ___,
(44) received on ___ C1D14 bevacizumab (randomized to
VB-111
plus bevacizumab arm) per DFCI protocol ___,
(44) colonoscopy on ___ that did not show polyp or bleed,
(45) received on ___ C1D28 bevacizumab (randomized to
VB-111
plus bevacizumab arm) per DFCI protocol ___,
(46) received on ___ C1D42 bevacizumab (randomized to
VB-111
plus bevacizumab arm) per DFCI protocol ___,
(47) gadolinium-enhanced head MRI performed on ___ showed
decreased enhancement by 56% in size,
(48) received C2D1 VB-111 and bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(49) received C2D15 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in DFCI protocol ___,
(50) received C2D29 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in DFCI protocol ___,
(51) gadolinium-enhanced head MRI performed on ___ showed
continued partial response,
(52) received C2D43 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in DFCI protocol ___,
(53) received C3D1 VB-111 and bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(53) received C3D15 bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in ___ protocol ___,
(54) received C3D29 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in DFCI protocol ___,
(55) received C3D43 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in DFCI protocol ___,
(56) gadolinium-enhanced head MRI performed on ___ showed
continued partial response,
(57) received C4D1 VB-111 and bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(58) received C4D14 bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(59) received C4D31 bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(60) received C4D43 bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(61) received C5D1 VB-111 and bevacizumab (randomized to VB-111
plus bevacizumab arm) on ___ in DFCI protocol ___,
(62) admission to OMED Service from ___ to ___,
(63) received C5D15 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in DFCI protocol ___,
(64) received C5D29 Bevacizumab (Randomized to VB-111 Plus
Bevacizumab Arm in DFCI ___ on ___,
(65) received C5D43 Bevacizumab (Randomized to VB-111 Plus
Bevacizumab Arm in ___ ___ on ___,
(___) received C6D1 VB-111 and Bevacizumab (Randomized to VB-111
Plus Bevacizumab Arm in DFCI ___ on ___,
(67) received C6D15 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in ___ protocol ___,
(68) received C6D29 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in ___ protocol ___,
(___) received C6D43 bevacizumab (randomized to VB-111 plus
bevacizumab arm) on ___ in ___ protocol ___,
(70) received C7D1 VB-111 and Bevacizumab (Randomized to VB-111
Plus Bevacizumab Arm in DFCI ___ on ___,
(71) received C7D15 Bevacizumab (Randomized to VB-111
Plus Bevacizumab Arm in DFCI ___ on ___,
(72) received C7D29 Bevacizumab (Randomized to VB-111
Plus Bevacizumab Arm in DFCI ___ on ___,
(73) received C7D43 Bevacizumab (Randomized to VB-111
Plus Bevacizumab Arm in ___ ___ on ___,
(74) lumbar puncture on ___ showed an opening pressure of
21
cm of H2O, 0 WBC, 0 RBC, 118 protein, 60 glucose, 24 LDH and no
oligoclonal bands but the procedure did not improve his gait,
(75) surveillance gadolinium-enhanced head MRI on ___
showed
continued partial response,
(76) received C8D1 VB-111 and Bevacizumab (Randomized to VB-111
Plus Bevacizumab Arm in DFCI ___ on ___,
(___) received C8D15 Bevacizumab (Randomized to VB-111 Plus
Bevacizumab Arm in DFCI ___ on ___,
(78) evaluation at ___ in ___, ___ on ___
for
encephalopathy,
(79) transfer and admission to ___ Service at ___ on ___
for urinary tract infection,
(80) received C8D29 Bevacizumab (Randomized to VB-111 Plus
Bevacizumab Arm in ___ ___, and
(81) discharged on ___ to ___
___ and returned home on ___
PAST MEDICAL HISTORY:
T2DM
HTN
HLD
Depression
Ruptured Tendon s/p repair
GBM, as above
Social History:
___
Family History:
Both of his parents are deceased. His father had diabetes but
dies from heart disease. His mother had thyroid cancer. He had
2 sisters; one had juvenile diabetes and the other had type I
diabetes and heart disease. He has a brother who is alive but
has type II diabetes. He has 3 children, 2 sons and 1 daughter,
all of which are healthy.
Physical Exam:
ON ADMISSION
=============
Vitals: ___ 0119 Temp: 97.3 Axillary BP: 113/70 HR: 72 RR:
18 O2 sat: 97% O2 delivery: RA
GENERAL: sitting in bed, appears comfortable, smiling, NAD
EYES: PERRLA, EOMI, anicteric
HEENT: OP clear, MMM
NECK: supple
LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no increased
WOB
CV: RRR no m/r/g, normal S1/S2, normal distal perfusion
ABD: Soft, NT, ND, normoactive BS
GENITOURINARY: no foley
EXT: warm, dry, normal muscle bulk, no deformity
SKIN: warm, dry, no rash
NEURO: AOx2 (name, president ___, hospital, but not date and
could not state why he is here), able to answer simple questions
regarding symptoms but could not discuss recent events at home,
strength ___ in extremities, CNII-XII intact without deficits
ACCESS: port in right chest with dressing c/d/i
ON DISCHARGE
=============
97.9 138/79 84 16 96%RA
General: Well-appearing gentleman. Pleasantly confused. In no
distress or discomfort.
Pertinent Results:
___ 01:30PM BLOOD WBC-12.3*# RBC-4.12*# Hgb-14.0# Hct-42.2#
MCV-102* MCH-34.0* MCHC-33.2 RDW-17.2* RDWSD-65.7* Plt ___
___ 04:59AM BLOOD WBC-8.8 RBC-3.60* Hgb-12.2* Hct-35.9*
MCV-100* MCH-33.9* MCHC-34.0 RDW-16.8* RDWSD-61.2* Plt ___
___ 01:30PM BLOOD ___ PTT-27.5 ___
___ 01:30PM BLOOD Glucose-222* UreaN-44* Creat-0.9 Na-139
K-4.4 Cl-100
___ 04:59AM BLOOD Glucose-164* UreaN-42* Creat-0.7 Na-136
K-4.3 Cl-100 HCO3-25 AnGap-11
___ 01:30PM BLOOD TotProt-6.9 Albumin-4.1 Globuln-2.8
Calcium-9.0 Phos-4.2
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with glioblastoma s/p
resection, XRT and multiple lines of treatment who presented
with inability to ambulate and confusion. Found to be due to
irreversible and progressive radiation induced encephalopathy
leading to transition to hospice.
#Radiation induced encephalopathy: Pleasantly confused without
agitation.
Medications for fatigue, tremor and mood were continued.
#Gioblastoma: With some signs of progression on most recent MRI.
LevETIRAcetam 500 mg PO Q8H was continued to prevent discomfort
of seizures.
#Constipation: Patient had not had a bowel movement in days.
Started on docusate, PEG and qod bisacodyl.
TRANSITIONAL ISSUES:
====================
#Change in code status: Patient is now DNR/DNI, MOLST form in
chart
#Change in goal of care: Patient's care focus has transitioned
to comfort. ___ be re-admitted for comfort only.
#Transport: Patient is unable to ambulate or transfer due to
progressive/irreversible encephalopathy. Transport by ambulance
is medically necessary.
45 minutes were spent formulating and coordinating this
patient's complex discharge plan
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO BID
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. Losartan Potassium 50 mg PO BID
4. MethylPHENIDATE (Ritalin) 10 mg PO QAM
5. MethylPHENIDATE (Ritalin) 5 mg PO QPM
6. Multivitamins 1 TAB PO DAILY
7. Ranitidine 150 mg PO BID:PRN GERD
8. Senna 8.6 mg PO DAILY:PRN constiaption
9. Simvastatin 10 mg PO QPM
10. Venlafaxine XR 150 mg PO DAILY
11. Acetaminophen 500 mg PO Q4H:PRN Pain - Mild
12. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
hiccups
13. Dexamethasone 4 mg PO WITH TREATMENT
___. MetFORMIN (Glucophage) 500 mg PO BID
15. LevETIRAcetam 500 mg PO Q8H
16. Phosphorus 250 mg PO BID
Discharge Medications:
1. Bisacodyl 10 mg PO EVERY OTHER DAY
2. Polyethylene Glycol 17 g PO DAILY
3. Docusate Sodium 100 mg PO BID Constipation
4. Ranitidine 150 mg PO BID GERD
5. Acetaminophen 500 mg PO Q4H:PRN Pain - Mild
6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
hiccups
7. Carbidopa-Levodopa (___) 2 TAB PO BID
8. LevETIRAcetam 500 mg PO Q8H
9. MethylPHENIDATE (Ritalin) 10 mg PO QAM
10. MethylPHENIDATE (Ritalin) 5 mg PO QPM
11. Phosphorus 250 mg PO BID
12. Senna 8.6 mg PO DAILY:PRN constiaption
13. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Radiation Induced Encephalopathy
Glioblastoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with confusion and inability
to move independently.
We found that this is unfortunately caused by brain damage due
to your radiation treatments. This is unfortunately not
reversible and will only worsen over time. There are no
treatments for this and you are no longer a candidate for cancer
treatments.
We discussed this in depth with you, your wife and son a
Followup Instructions:
___
|
10582978-DS-21 | 10,582,978 | 21,421,548 | DS | 21 | 2163-04-05 00:00:00 | 2163-04-06 11:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia, hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ YO AA female with CKD stage 5 likely due to diabetic
nephropathy and hypertensive nephrosclerosis who presented from
her outpatient ___ clinic due to anemia, hyperkalemia,
and worsening kidney function.
The patient sees Dr. ___ at ___. She was lost to
follow up since ___ but re-established care on ___. At her
appointment she was found to have mild uremic symptoms (lack of
appetite, weight loss, nausea, fatigue), worsening creatinine
(5.93 ___ and anemia (7.2 ___. At that visit her
lisinopril was stopped due to concern for hemodynamic/ vascular
component to her worsening renal function. She was also started
on iron supplementation BID. She visited the clinic again on
___, and labs revealed creatinine of 6.76, BUN 97, K 6.0, HCO3
of 12, and hemoglobin of 6.4. The patient was called and
instructed to go to ED for blood transfusion and possible HD
initiation. The patient does not have HD access.
In the ED, initial vitals: 98.3 58 200/53 18 100% RA
Labs were significant for H/H 5.8/6.6, K 6.6-> 5.1, creatinine
6.6, bicarb 11, and positive UA. She was guaiac negative in the
ED.
CXR showed mild hilar congestion and atelectasis versus
pneumonia at the left lung base.
She was given:
IVF 1000 mL NS
IV Insulin Regular 10 units
IV Dextrose 50% 12.5 gm
IV Calcium Gluconate 1 g
PO Sodium Polystyrene Sulfonate 30 gm
IVF 150 mEq Sodium Bicarbonate/ 1000 mL D5W at 75 mL/hr
PO Metoprolol Tartrate 25 mg
PO/NG HydrALAzine 50 mg
IVF 150 mEq Sodium Bicarbonate/ 1000 mL D5W at 75 mL/hr
PO/NG Hydrochlorothiazide 25 mg
IVF 150 mEq Sodium Bicarbonate/ 1000 mL D5W at 75 mL/hr
PO/NG HydrALAzine 50 mg
IVF 150 mEq Sodium Bicarbonate/ 1000 mL D5W at 75 mL/hr
2 units PRBCs
Vitals prior to transfer: 98.3 49 192/62 16 100% RA.
On the floor, the patient says she is feeling better, more
energized, after the blood. She denies headache, blurry vision,
chest pain, shortness of breath, nausea/vomiting, abdominal
pain, abnormal stools, dysuria. Reports normal urine output. She
says she is still processing the need for dialysis and wants to
talk about the decision with her family.
Past Medical History:
HTN
DM2 with retinopathy
Hypercholesterolemia
CVA with residual right foot weakness
CAD s/p NSTEMI ___
Bradycardia
Gastritis/duodenitis
Anemia
Social History:
___
Family History:
Sister with breast cancer, mother with brain hemorrhage, HTN,
DM. No family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4 189/74 52 18 100% RA
GEN: Alert, lying in bed, no acute distress.
HEENT: MMM, no oropharyngeal erythema/edema
NECK: Supple without LAD
PULM: bibasilar crackles, no wheezing or rhonchi
COR: ___ SEM at ___, slow rate, no rubs or gallops
ABD: Soft, NT ND, normal BS
EXTREM: Warm, no edema
NEURO: CN II-XII intact, ___ strength throughout
DISCHARGE PHYSICAL EXAM:
VS: 98.6 165/51 56 18 99% RA
GEN: Alert, lying in bed, no acute distress.
HEENT: MMM, no oropharyngeal erythema/edema
NECK: Supple without LAD
PULM: CTAB
COR: ___ SEM at ___, slow rate, no rubs or gallops
ABD: Soft, NT ND, normal BS
EXTREM: Warm, no edema
NEURO: CN II-XII intact, ___ strength throughout
Pertinent Results:
ADMISSION LABS:
___ 08:15PM BLOOD WBC-8.6 RBC-2.44* Hgb-6.1* Hct-19.0*
MCV-78* MCH-25.0* MCHC-32.1 RDW-14.2 RDWSD-40.0 Plt ___
___ 08:15PM BLOOD Neuts-56 Bands-0 ___ Monos-6 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-4.82 AbsLymp-3.10
AbsMono-0.52 AbsEos-0.17 AbsBaso-0.00*
___ 08:15PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Target-1+ Burr-1+ Tear
Dr-1+ How-Jol-1+ Bite-1+
___ 08:15PM BLOOD ___ PTT-23.1* ___
___ 08:15PM BLOOD Glucose-118* UreaN-109* Creat-6.6* Na-137
K-6.4* Cl-111* HCO3-11* AnGap-21*
___ 06:16AM BLOOD ALT-9 AST-13 AlkPhos-52 TotBili-0.4
___ 01:50AM BLOOD Calcium-9.1 Phos-6.6* Mg-2.0
___ 06:16AM BLOOD calTIBC-235* Ferritn-165* TRF-181*
DISCHARGE LABS:
___ 06:18AM BLOOD WBC-6.3 RBC-2.73* Hgb-7.2* Hct-21.3*
MCV-78* MCH-26.4 MCHC-33.8 RDW-15.1 RDWSD-42.2 Plt ___
___ 06:18AM BLOOD Glucose-135* UreaN-93* Creat-6.1* Na-136
K-3.9 Cl-104 HCO3-18* AnGap-18
___ 06:18AM BLOOD Calcium-8.0* Phos-5.5* Mg-1.6
IMAGES:
EKG ___: Sinus rhythm. Non-specific ST segment changes. No
previous tracing available
for comparison.
CXR ___: Mild hilar congestion. Atelectasis versus
pneumonia at the left lung base.
MICRO: Urine culture contaminated
Brief Hospital Course:
___ YO AA female with CKD stage 5 likely due to diabetic
nephropathy and hypertensive nephrosclerosis presented from her
outpatient ___ clinic due to anemia, hyperkalemia, and
worsening kidney function.
# CKD stage 5: Patient's kidney disease has progressively
worsened over the past few years. She has symptoms of uremia:
weight loss, decreased appetite, decrased energy, and nausea.
She also had electrolyte disturbances on admission (acidosis,
hyperkalemia). She was encouraged to start dialysis this
admission, but she declined, saying she needed to time to make a
decision. She will likely need initiation of dialysis within the
next few weeks. She will follow up with her outpatient
nephrologist next week.
# Hyperkalemia: Her potassium was 6.4 on admission, due to
worsening kidney function. She was initially given kayexalate,
bicarb, insulin/dextrose, and calcium gluconate with improvement
in her potassium levels. She was also educated on a low
potassium diet. Her K was 3.9 at discharge.
# Metabolic acidosis: Her bicarbonate was 11 on admission, due
to worsening renal function. She initially was given IV bicarb
with improvement in her acidosis. She was discharged on oral
bicarb supplements.
# Microcytic anemia: Patient with chronic anemia, slightly
worsened at presentation from level in ___ (hemoglobin then
was 7.2). Most likely due to underproduction from her kidney
disease. She was given 3 units of blood with improvement in her
blood counts.
# HTN: Patient with SBP in 200s in the ED. Her lisinopril was
stopped last week by her nephrologist. Her home regimen of
metoprolol, furosemide, and hydrazine was continued. She was
started on amlodipine for further blood pressure control.
# Hyperlipidemia: Continued crestor.
# Diabetes: Diet-controlled with HgB A1C 6.2%. No active issues.
# Bradycardia: Patient with a several year hx of bradycardia.
Her heart rate was in the ___ in house. Her metoprolol XL
was decreased to 12.5mg daily.
# CAD: Patient with hx of NSTEMI in ___ with stress test
showing anterior wall ischemia. Patient refused heart
catheterization at that time. She was continued on her beta
blocker, statin, aspirin.
# Hx of CVA: Continued aspirin.
TRANSITIONAL ISSUES:
- Started amlodipine for elevated blood pressures
- Decreased metoprolol given bradycardia to ___
- Started sodium bicarbonate for metabolic acidosis
- Should have CBC and electrolytes checked at next visit
- Further discussion about starting dialysis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Furosemide 20 mg PO BID
4. Rosuvastatin Calcium 10 mg PO QPM
5. Ferrous Sulfate 325 mg PO BID
6. sevelamer CARBONATE 800 mg PO WITH LUNCH AND DINNER
7. Ranitidine 150 mg PO BID
8. HydrALAzine 50 mg PO Q6H
9. Loratadine 10 mg PO DAILY:PRN allergies
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. Furosemide 20 mg PO BID
3. HydrALAzine 50 mg PO Q6H
4. Ranitidine 150 mg PO BID
5. Rosuvastatin Calcium 10 mg PO QPM
6. sevelamer CARBONATE 800 mg PO WITH LUNCH AND DINNER
7. Vitamin D ___ UNIT PO DAILY
8. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg one tablet(s) PO daily Disp #*30 Tablet
Refills:*0
9. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Renal Caps] 1 mg one
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
10. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg one tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
11. Aspirin 81 mg PO DAILY
12. Loratadine 10 mg PO DAILY:PRN allergies
13. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
CKD stage 5
Hyperkalemia
Anemia
Metabolic acidosis
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. You were
admitted due to anemia and electrolyte abnormalities, both due
to worsening of your kidney function. You were given 3 units of
blood with improvement in your blood counts. You were also given
medications and fluids to fix your electrolytes. You will need
to start dialysis soon for your poor kidney function. Please
follow up with your nephrologist and PCP after discharge.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10582978-DS-23 | 10,582,978 | 20,715,816 | DS | 23 | 2165-02-20 00:00:00 | 2165-02-20 19:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Clotted AV graft
Major Surgical or Invasive Procedure:
AV Fistulogram with TPA and mechanical thrombectomy
History of Present Illness:
Ms. ___ is a ___ woman with a history of ESRD on HD who
presented from ___ clinic with a clotted AV graft. Per
ED referral report, patient presented to HD (___, ___
on ___, and HD nurse was unable to get any blood flow in the
needle.
Patient had a RUE AVG placed in ___. Graft was
complicated by bleeding issues last ___. She had
fistulagram on ___ of this year due to bleeding from graft
site after accessing.
Past Medical History:
Past Medical History: HTN, DM2 c/b retinopathy, HLD, CVA with
residual right foot weakness, CAD s/p NSTEMI ___, Bradycardia,
Gastritis/duodenitis, Anemia, afib
Past Surgical History:
- RUE loop AV graft creation (___)
- Hip fracture repair
Social History:
___
Family History:
Diabetes. Denies FHx of CV disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.7 | BP 153/87 | HR 71 | RR 18 | 98% RA
GENERAL: NAD. Pleasantly interactive.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva.
Right subconjunctival vs. subchoroidal hemorrhage. MMM.
Edentulous.
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2 with ___ crescendo-decrescendo systolic
murmur.
LUNGS: CTAB but breath sounds more prominent on right than
left. No wheezes, rales, rhonchi. Breathing comfortably without
use of accessory muscles.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: RUE AV graft without thrill or bruit. WWP. No
cyanosis, clubbing, or edema.
NEURO: A&Ox3, moving all 4 extremities with purpose. CN ___
intact.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSCIAL:
VS: 98.7, 153/87, 71, 18, 98% on room air
GENERAL: NAD, mildly tired, interactive
HEENT: AT/NC, right eye shut and injected conjunctiva upon
opening, sclerae anicteric, EOMI, no JVD, no LAD, no tracheal
deviation, neck supple
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: Regular rate and rhythm, S1 and S2 normal, no murmurs
gallops or rubs appreciated
ABDOMEN: +BS, soft without abnormal contours, nondistended,
nontender, no organomegaly appreciated
EXTREMITIES: AV graft appreciated on the right arm, no edema,
pulses present
NEURO: AAO×3, no motor sensory deficits elicited
Pertinent Results:
ADMISSION LABS:
___ 04:47PM GLUCOSE-111* UREA N-39* CREAT-4.4*#
SODIUM-143 POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-25 ANION GAP-25*
___ 04:47PM estGFR-Using this
___ 04:47PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.9
___ 04:47PM WBC-9.0 RBC-3.15* HGB-9.2* HCT-28.6* MCV-91
MCH-29.2 MCHC-32.2 RDW-16.7* RDWSD-53.7*
___ 04:47PM NEUTS-61.3 ___ MONOS-11.0 EOS-2.0
BASOS-0.4 IM ___ AbsNeut-5.50 AbsLymp-2.24 AbsMono-0.99*
AbsEos-0.18 AbsBaso-0.04
___ 04:47PM PLT COUNT-310
___ 04:47PM ___ PTT-24.1* ___
DISCHARGE LABS:
___ 04:55AM BLOOD WBC-7.8 RBC-3.13* Hgb-9.3* Hct-28.6*
MCV-91 MCH-29.7 MCHC-32.5 RDW-16.9* RDWSD-56.0* Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-124* UreaN-52* Creat-5.4* Na-141
K-3.7 Cl-99 HCO3-25 AnGap-17*
___ 04:55AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8
___ 04:55AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
IMAGING:
___ AV Fistulogram:
FINDINGS:
1. Complete thrombosis of the right upper extremity AV graft to
the level of
the outflow vein, just distal the previously placed venous
anastomotic stent
where a previously seen high grade stenosis was seen.
2. Outflow vein stenosis with improvement following covered
stent placement
and angioplasty to 9 mm.
3. Satisfactory appearance of the arterial anastomosis. No
central venous
stenosis.
IMPRESSION:
Satisfactory restoration of flow following chemical and
mechanical
thrombolysis with a good angiographic and clinical result.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of ESRD on HD who
presented from ___ clinic with a clotted AV graft. Per
ED referral report, patient presented to HD (___, ___
on ___, and HD nurse was unable to get any blood flow in the
needle. She thus presents to us for an ___ AV graftogram
and
thrombectomy.
ACUTE ISSUES:
# AV GRAFT MALFUNCTION:
Likely clotted given no flow after cannulation at HD on ___. No
thrill or bruit on exam. Evaluated by ___ and transplant surgery
in the ED; ___ decided to take for graftogram and possible
thrombectomy
on ___. ___ determined existence of a complete thrombosis of the
right upper extremity AV graft to the level of the outflow vein,
just distal the previously placed venous anastomotic stent where
a previously seen high grade stenosis was seen. TPA and
mechanical thrombectomy were performed. The outflow vein
stenosis demonstrated improvement following covered stent
placement and angioplasty to 9 mm. There was satisfactory
appearance of the arterial anastomosis, with no central venous
stenosis. She subsequently underwent dialysis on ___, where
her AV graft was accessed with a blood flow of 350 and
reasonable arterial and venous pressures. Her potassium was 3.7.
Thus, she underwent stable treatment without complications. She
should continue further serial sessions at her primary center
(___).
# ESRD ON HD:
On ___ HD on ___ in ___. Followed
by Dr. ___ as outpatient. Still makes some urine.
Per renal, she was offered catchup HD on ___ to also ensure
functionality of her graft procedure. Her chemistry daily was
trended daily. She was continued on her home sevelemer,
nephrocaps, and lisinopril
# PAML:
Admission attempts to reach son (who knows medications) were
unsuccessful. We were able to reach him and he reported he would
bring a medication list, however, has since not. OMR History tab
and Atrius records used to make list.
CHRONIC ISSUES:
# pAF:
EKG on admission appeared regular, but without clearly organized
atrial activity. On metoprolol rate control but no
anticoagulation, despite very high CHADS2-VASC score with
previous CVA. Please note controversy on whether anticoagulation
is beneficial for AF patients on hemodialysis (cf. ___
AHA/ACC/HRS guideline for the management of patients with atrial
fibrillation: a report of the ___ College of
___ Heart Association Task Force on practice
guidelines and the Heart Rhythm Society. Circulation,
___. Epub ___ "Management of
thromboembolic risk in patients with atrial fibrillation and
chronic kidney disease," ___
- Continue home metoprolol XL 50 mg daily
- Consider ongoing discussion regarding anticoagulation as
transitional issue
# Hypertension:
- Continue home lisinopril 10 mg and amlodipine 5 mg daily
- Continue home metoprolol
# CAD:
# HPL:
- Continue home rosuvastatin 10mg daily
- Continue home metorprolol
- Resume daily ASA 81 mg following procedure
# Subchoroidal hemorrhage:
# Glaucoma (presumed):
# Cataracts:
- Continued home eyedrops as ordered per Atrius records
# Diabetes mellitus:
Per home med list, no on insulin or other antihyperglycemics.
- Gentle Humalog insulin sliding scale, uptitrate as needed
# Gastritis:
- Continue home omeprazole
- Consider weaning and discontinuing PPI as transitional issue
if
symptoms resolved
# Anemia:
Chronic per OMR. Likely related to advanced CKD.
- Continue to monitor
TRANSITIONAL ISSUES:
[] continue further HD sessions at ___ as appropriate
per prior schedule
============================
I have seen and examined the patient, reviewed the findings and
plan of care as documented by Dr. ___ on
___ and agree, except for any additional comments below.
#RUE AV graft thrombosis
#Atrial fibrillation
#ESRD on HD
#DM2 with retinopathy
#HTN
#history of CVA with residual right foot weakness
#HLD
#CAD s/p NSTEMI ___
#history of gastritis
#Anemia
Greater than 30 minutes were spent in discharge planning and
coordination.
___, MD
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Rosuvastatin Calcium 10 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Nephrocaps 1 CAP PO DAILY
8. Gabapentin 100 mg PO TID
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
12. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE DAILY
13. AcetaZOLamide 125 mg PO 3X/WEEK (___)
Discharge Medications:
1. AcetaZOLamide 125 mg PO 3X/WEEK (___)
2. amLODIPine 5 mg PO DAILY
3. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
6. Gabapentin 100 mg PO TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
8. Lisinopril 10 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
AV GRAFT MALFUNCTION
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 in the hospital?
- You were admitted to work-up your blocked dialysis fistula
What was done while I was in the hospital?
- Pictures were taken that showed your fistula had a blood
clot, which was then removed with the interventional radiology
team
- You were observed and started on dialysis in the hospital to
ensure your graft functions properly
What should I do when I go home?
- It is very important that you continue your dialysis
sessions with your previous providers
- ___ go to your scheduled appointment with your primary
doctor
- If you have further issues with your fistula or are having
arm swelling or excessive numbness or tingling, please tell your
primary doctor or go to the emergency room
Best wishes,
Your ___ team
Followup Instructions:
___
|
10583059-DS-14 | 10,583,059 | 28,847,167 | DS | 14 | 2145-07-29 00:00:00 | 2145-07-29 20:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male,___ ith history of
psuedomyxoma peritnoeii, diverticulitis, mesenteric cysts, s/p
laparoscopy, appendecomy, and recurrent vomiting spells, who is
presneting with two weeks of persistent non-bloody emesis and
abdominal pain. Patient is currently TPN dependent for nutrition
(started ___, after found to be malnuourised and severe
weight loss > 30 lbs, and 1 day prior to admission, his PICC
fell out. Patient currently denies any fevers, chills, dysuria,
chest pains, or shortness of breath. Further, patient has been
unable to take any of his home medications due to persistent
emesis.
In the ED, initial vitals were: 97.4 86 104/62 16 98%. Patient
had a CT abdomen/pelvis which showed no evidence of bowel
obstruction, no acute intrabdominal process, stable mildly
complex free fluid within the pelvis, unchanged from prior.
Patient received 1L NS, 10mg morphine IV, 10mg metocolopramide,
8mg zofran, and 1mg lorazepam and admitted to medicine. Patient
also was consented for ___ line placement as well, and ___
team will be seeing patient in the morning.
On the floor patient reports that his symptoms have been
occurring for nearly two weeks, however he sought treatment once
his PICC fell out. He reports that his symptoms have improved
tremendously after receiving IV medications in the ED.
Past Medical History:
PAST HISTORY:
Weight loss of 30 pounds from 150 to 118.
Diverticulitis
Mesenteric cyst
pseudomyxoma peritoneii
Recurrent vomiting spells
ETOH in past
PRIOR SURGERY:
Colonoscopy, ___, ___, TI/random biopsies negative.
Colonoscopy, ___, TI, ileal ulcer
Endoscopy, ___, negative stomach/SB.
Social History:
___
Family History:
Negative for Crohn's or colon cancer.
Physical Exam:
==============
ADMISSION EXAM
===============
Vitals: 98 96/58 80 18 100RA
General: Alert, oriented, lying in bed in left lateral
decubitus position
HEENT: Sclera anicteric, Mucous membranes dry, 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, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, laparoscopy scar
present at umbilicus.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: AOx3
==============
DISCHARGE EXAM
===============
Vitals: 98.1 99.5 70-80s 95-107/46-56 17 100% on RA
General: Thin appearing middle-aged man, alert, oriented,
appears comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, nontender, +bowel sounds,
laparoscopy scars, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PICC line L arm without erythema or tenderness
Site of old PICC R arm without pus, erythema.
Neuro: A&OX3, CN2-12 intact, no focal deficits
Pertinent Results:
=================
ADMISSION LABS
=================
___ 11:30AM BLOOD WBC-16.5* RBC-3.92* Hgb-12.5* Hct-37.7*
MCV-96 MCH-32.0 MCHC-33.3 RDW-13.8 Plt ___
___ 11:30AM BLOOD Neuts-93.2* Lymphs-4.3* Monos-2.0 Eos-0.3
Baso-0.2
___ 11:30AM BLOOD Glucose-107* UreaN-19 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-26 AnGap-13
___ 11:30AM BLOOD ALT-71* AST-63* AlkPhos-80 TotBili-0.7
___ 11:30AM BLOOD Lipase-26
___ 11:30AM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.7 Mg-2.1
___ 11:49AM BLOOD Lactate-1.1
==========
MICRO
==========
Blood cultures ___: NGTD
Blood cultures ___ (drawn off old PICC):
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
TOBRAMYCIN------------ S
Blood cultures ___: NGTD
Blood cultures ___: NGTD
===========
IMAGING
===========
CT ABD/PELVIS ___: ABDOMEN:
The liver is homogeneous in enhancement. No focal lesion
identified.No
intrahepatic or extrahepatic biliary dilatation. The gallbladder
is normal without calcified gallstones. The portal vein, SMV,
and splenic vein are patent.
The spleen is normal. The pancreas enhances homogenously and is
without focal lesions, peripancreatic fat stranding, or focal
fluid collection. The adrenal glands are unremarkable.
The kidneys display symmetric nephrograms and excretion of
contrast. A 6.8 x 6.7 cm (02:17) cyst is seen within the upper
pole of the right kidney. An additional 0.9 x 1.2 cm (02:31)
(previously 1 x 0.8 cm) hypodensity is seen within the
interpolar region of the left kidney and is too small to
characterize. No additional focal renal lesions. No
hydronephrosis or hydroureter identified. No renal or proximal
ureter calculi.
The distal esophagus is normal without hiatal hernia. The
stomach is grossly unremarkable in appearance. No bowel wall
edema, no associated fat stranding, no evidence of small bowel
obstruction. The appendix is not visualized with suture material
along the cecum consistent with previous appendectomy. The large
bowel is otherwise normal in caliber without wall thickening,
fat stranding, or focal mass lesion.
The abdominal aorta is normal in caliber without aneurysmal
dilatation. The celiac axis, SMA, and ___ are patent . Small
amount of atherosclerotic calcification noted. The iliac
arteries are normal in course and caliber.
No retroperitoneal or mesenteric lymph node enlargement by CT
size criteria. No free abdominal fluid, abdominal wall hernia,
or pneumoperitoneum.
PELVIS: The bladder is well distended and normal. No pelvic
side-wall or
inguinal lymph node enlargement by CT size criteria. Stable
mildly complex free fluid within the pelvis, unchanged from ___. The prostate and seminal vesicles are unremarkable.
IMPRESSION:
1. No acute intra-abdominal process.
2. No evidence of small bowel obstruction.
3. Stable mildly complex free fluid within the pelvis, similar
to that seen
on the prior study from ___.
CXR ___
IMPRESSION:
Left PICC line has been repositioned, ends in the low SVC. Lungs
clear. Normal cardiomediastinal and hilar silhouettes and
pleural surfaces.
================
DISCHARGE LABS
================
___ 05:04AM BLOOD WBC-8.4 RBC-3.91* Hgb-12.0* Hct-37.2*
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.9 Plt ___
___ 05:04AM BLOOD Glucose-125* UreaN-16 Creat-0.6 Na-137
K-3.8 Cl-102 HCO3-27 AnGap-12
___ 05:04AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of
diverticulitis, psuedomyxoma peritoneii and mesenteric cysts s/p
laparoscopy and appendecomy, and recurrent vomiting spells, who
is presenting with two weeks of persistent NBNB emesis,
abdominal pain, and chills, after his PICC came out ___ inches.
CT abdomen/pelvis did not show evidence of obstruction or acute
intraabdominal pathology. Labs showed leukocytosis, mild
transaminitis, and hypokalemia, which improved with repletion.
He was treated supportively with IVF, antiemetics, analgesics,
and electrolyte repletion. Blood cultures drawn ___ off of
pt's old ___ line grew GNRs. Even prior to starting
antibiotics, Mr. ___ reported feeling better, was
afebrile, hemodynamically stable, walking around the unit, and
his leukocytosis downtrended. Once his blood cultures turned
positive, he was started on Cipro/Flagyl, narrowed to Cipro once
sensitivities returned showing a pan-sensitive organism.
Organism was not identified at time of discharge. He will
continue on cipro for total 14 day course (last day ___
ACUTE ISSUES:
#GNR bacteremia: Pt had shaking chills prior to admit and
leukocytosis to 16 initially. Blood cultures drawn ___ off of
old PICC grew GNRs. Possible sources include GI (less likely
gallbladder given normal AP/Tbili, normal appearance of GB on CT
abd/pelvis, and absence of cholelithiasis in prior abdomenal US
report). Line infection is possible, though GNRs are less common
than GPCs. UA neg. Pt was afebrile and hemodynamically stable
throughout his hospitalization. Repeat cultures drawn off the
new PICC and peripherally had no growth. His leukocytosis was
downtrending, symptoms improved, and he was able to ambulate
around the unit even prior to initiation of antibiotics. He was
initially started on cipro/flagyl which was narrowed to flagyl.
His cultures speciated to a pansensitive organism (not yet ID-ed
by time of discharge, but ID's as Eneterobacter species at time
of signing of this document). Given his very well clinical
appearance, he was discharged on 2 week course of ciprofloxacin
with instruction to return if fever or chills recurred.
#Recurrent Vomiting: Pt has long history of nausea/vomiting. It
was intially thought that his nasuea/vomiting may be attributed
in the past to traction of the small bowel ___ to the mesenteric
cyst, and therefore removal of this portion with the appendix
may offer some relief, which he sustained for about 4 weeks
post-operatively. His worsening nausea/vomiting may have been
due to his underlying bacteremia, or the bacteremia may have
arisen from a GI source. Imaging did not show obstruction. He
was treated symptomatically with antiemetics, fluids, and
electrolyte repletion. His symptoms improved, he did not have
further vomiting after the day of admission, he was able to
tolerate PO, and electrolytes were stable.
#Transaminitis: Pt initially had mild transaminitis, of
uncertain etiology, possibly due to his underlying illness. His
alk phos and Tbili were normal, and CT imaging showed a normal
gallbladder, making this a less likely source of his bacteremia.
CHRONIC/RESOLVED ISSUES:
# Malnutrition: Patient has been using a PICC line with TPN to
reach goal weight. TPN was continued during his hospitalization.
#Psuedomyxoma Pertioneii with mesenteric cyst: This is felt to
be benign by pathology, however is currently being evalauted by
Dr. ___ at ___ regarding intraperitoneal
chemotherapy with heat therapy. Plan for surgery in
approximately 1 mo.
#Anxiety: Continued sertraline while inpatient. On discharge,
started on hydroxyzine that had been prescribed at recent GI
visit.
TRANSITIONAL ISSUES:
-pt to continue on ciprofloxacin 500mg q12h for a total 14 day
course. Last day ___
-follow-up blood cultures for final speciation and sensitivities
-pt to f/u with GI, PCP
-___ will go home on hydroxyzine, zofran started at recent GI
visit
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Nortriptyline 50 mg PO HS
3. Pantoprazole 40 mg PO Q24H
4. Sertraline 50 mg PO DAILY
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. DiCYCLOmine 20 mg PO DAILY:PRN IBS
7. Naproxen 250 mg PO Q8H:PRN pain
8. HYDROcodone-acetaminophen 7.5-300 mg oral TID:PRN pain
9. HydrOXYzine 25 mg PO Q6H:PRN nausea/anxiety
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Zofran ODT (ondansetron) 8 mg oral q8h:PRN nausea
Discharge Medications:
1. DiCYCLOmine 20 mg PO DAILY:PRN IBS
2. Docusate Sodium 100 mg PO BID
3. Nortriptyline 50 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Sertraline 50 mg PO DAILY
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
8. Zofran ODT (ondansetron) 8 mg oral q8h:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. HydrOXYzine 25 mg PO Q6H:PRN nausea/anxiety
RX *hydroxyzine HCl 25 mg 1 tablet by mouth q6h:prn Disp #*60
Tablet Refills:*0
11. HYDROcodone-acetaminophen 7.5-300 mg oral TID:PRN pain
12. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve hours
Disp #*26 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
nausea, vomiting
GNR bacteremia
SECONDARY DIAGNOSIS:
pseudomyxoma peritoneii
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure taking care of you during your
hospitalization at ___. You
were hospitalized because of nausea, vomiting, and the need to
replace your PICC. You were treated with fluids, pain medicines,
medications to treat nausea, and your electrolytes were
repleted. Your PICC was replaced.
You were found to have a blood stream infection and were treated
with Ciprofloxacin. You should keep taking this medication for a
total of 14 days. The last day is ___. Please avoid taking
any naproxen or over the counter NSAIDS (such as
ibuprofen/advil) as these can make you feel more nauseous.
Please follow-up with your outpatient providers.
We wish you all the best.
-Your ___ Team
Followup Instructions:
___
|
10583059-DS-15 | 10,583,059 | 20,442,595 | DS | 15 | 2146-04-03 00:00:00 | 2146-04-16 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to Thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of pseudomyxoma peritonei-multicytic peritoneal
mesothelioma who presented for follow-up with GI found to have
severe malnutrition prompting referral for admission.
Patient has a complex history of pseudomyxoma
peritonei-multicystic peritoneal mesothelioma with resection of
2 feet of small bowel last year for tumor, noted to have
multiple periotoneal implants and recurrent difficulty with
malnutrition over the last ___ years. Patient has previously
required TPN to maintain his weight due to abdominal pain,
nausea and vomiting in the past. He was maintained for some time
on TPN then underwnet omentectomy with intraperitoneal
chemotherapy in ___. At some point, TPN was stopped
(possibly after this procedure). Since that time, patient has
lost at least 30 lbs and on most recent labs was found to be
hyponatremic. He was prescribed mirtazapine by his GI doctor
here 2 weeks ago however did not start taking it until ___.
Today, he reports that he has not been able to keep on weight
for years other than when he is on TPN. He hasn't eaten a normal
meal in years and "can't eat a lot". Notes poor appetite for
some time, early satiety, bothered by chocolate, caffeine and
lots of otehr foods. Ongoing abdominal pain that is not always
associated with food, notes a cramping pain, sharp at times,
improves with hot water and showers. Has occasional nonbloody
vomiting and nausea. No longer having diarrhea and goes to
bathroom once daily with formed stools. He notes significant
fatigue and weakness. Intermittent headaches.
In the ED, initial vitals were: 98.7 95 ___ 100% RA
- Labs were significant for WBC 11.8K with normal diff, normal
H/H, Sodium 126, cl 88, BUN 42, Cr 1.0, albumin 4.5, bili 1.1.
- The patient was given 1mg IV lorazepam and 1L NS.
Vitals prior to transfer were: 98.4 92 ___ 98% RA
Upon arrival to the floor, 98.1 106/71 70 20 99%RA. He reports
that he is frustrated by the current situation but feels
currently ok aside from fatigue and significant weakness.
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:
PAST HISTORY:
Weight loss of 30 pounds from 150 to 118.
Diverticulitis
Mesenteric cyst
pseudomyxoma peritoneii
Recurrent vomiting spells
ETOH in past
PRIOR SURGERY:
Colonoscopy, ___, ___, TI/random biopsies negative.
Colonoscopy, ___, TI, ileal ulcer
Endoscopy, ___, negative stomach/SB.
Social History:
___
Family History:
Negative for Crohn's or colon cancer.
Physical Exam:
==================
EXAM ON ADMISSION
==================
Vitals: 98.1 106/71 70 20 99%RA.
General: Alert, oriented, mildly anxious, odd affect, cachectic
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: Thin, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, chest sunken in
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Thin, well healed midline scar, soft, nontender,
non-distended, normoactive bowel sounds
Ext: Warm, well perfused, 2+ DP pulses, no edema
Neuro: CNII-XII intact, A&Ox3, Gait stable
==================
EXAM ON DISCHARGE
==================
PHYSICAL EXAM:
Vitals: T: 98.2 ___ 100%RA ___ 83
Weight ___: 47
Weight ___: 45.8
Weight ___: 46.5
Weight ___: 45.6
Weight ___: 43.7
General: Alert, oriented, no acute distress, malnourished,
cachectic
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: Thin, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, chest sunken in
Abdomen: soft, mildly tender to palpation in epigastric area
midline but
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
======================
___ 08:15PM BLOOD WBC-11.8* RBC-5.02 Hgb-14.7 Hct-42.2
MCV-84# MCH-29.3 MCHC-34.8 RDW-14.7 RDWSD-44.9 Plt ___
___ 08:15PM BLOOD Neuts-62.8 ___ Monos-12.3
Eos-0.3* Baso-0.3 Im ___ AbsNeut-7.38* AbsLymp-2.79
AbsMono-1.45* AbsEos-0.03* AbsBaso-0.03
___ 06:27AM BLOOD ___ PTT-32.9 ___
___:20AM BLOOD UreaN-81* Na-129* K-4.0 Cl-82* HCO3-27
AnGap-24*
___ 09:20AM BLOOD ALT-41* AST-30
___ 09:20AM BLOOD Calcium-9.2 Phos-5.3*#
___ 08:15PM BLOOD Albumin-4.5
DISCHARGE LABS:
======================
___ 06:32AM BLOOD WBC-11.8* RBC-3.91* Hgb-11.5* Hct-34.4*
MCV-88 MCH-29.4 MCHC-33.4 RDW-16.4* RDWSD-52.6* Plt ___
___ 06:32AM BLOOD Glucose-104* UreaN-18 Creat-0.5 Na-137
K-4.6 Cl-105 HCO3-23 AnGap-14
___ 06:32AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8
PERTINENT LABS:
======================
___ 05:16AM BLOOD Free T4-1.4
___ 08:15PM BLOOD TSH-0.26*
___ 05:07AM BLOOD Triglyc-96 HDL-44 CHOL/HD-2.9 LDLcalc-66
STUDIES:
======================
CT ABDOMEN AND PELVIS W/ CONTRAST ___:
IMPRESSION:
1. No acute intra-abdominal abnormality to explain the patient's
leukocytosis.
2. Slight increase of free fluid in the pelvis.
3. The spleen is not visualized, presumably due to surgical
removal. Recommend correlation with the patient's history.
MICROBIOLOGY:
======================
___ 10:41 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Brief Hospital Course:
Mr. ___ is a ___ with history of pseudomyxoma peritoneii
with mesenteric cyst s/p resection with persistent peritoneal
implants and no masses or obstruction on prior abdominal imaging
presenting with persistent failure to thrive and cachexia.
================
ACUTE ISSUES
================
# Malnutrition secondary to pseudomyxoma peritonei-multicystic
peritoneal mesothelioma:
Patient presented with months to years of poor PO intake and
malnutrition intermittently needing TPN with progressive weight
loss since ___ from 137lb to 94lbs (pt report). On
admission, the patient was evaluated by the nutrition team. TPN
was initiated on ___ following the administration of
thiamine. The patient was monitored overnight on tele, and had
no events. Electrolytes were monitored for refeeding syndrome.
He initially required a small amount of Phos supplementation,
and his electrolytes were normal for several days prior to
discharge. On ___, the patient reported increased pain, and his
WBC increased from 13.5 to 19.6. A CT abd w/ contrast was done
to evaluate for an acute process, and none was identified. The
pain improved with tramadol, and the leukocytosis improved. The
patient was discharge with a plan to continue TPN at home.
# Hyponatremia: On admission, found to be 126. Slowly improved
throughout the hospitalization, and was normal on discharge.
Likely hypovolemic hyponatremia in the setting of chronically
poor PO intake.
================
CHRONIC ISSUES
================
# Chronic abdominal pain: Largely remained at baseline per
patient. Was treated with tylenol, tramadol.
# Anxiety/depression: The patient was continued on his home
sertraline, mirtazapine, clonazepam. He has an appointment to
follow up with psychiatry as an outpatient, and is motivated to
do so.
================
TRANSITIONAL ISSUES
================
[ ] ___ labs will be arranged through his home TPN company (___
___, ___ and should be faxed to his PCP, ___.
___ at ___, and his GI specialist, Dr. ___
at ___.
[ ] PCP should ___ to ensure patient has seen his psychiatrist
and confirm that he has made an appointment with a nutritionist
for ongoing management
[ ] Outpatient GI to follow up stool cultures, though BMs
returned to normal and leukocytosis was downtrending without
intervention prior to discharge
[ ] if he would like assessment by BI psychiatry, please contact
Dr. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO BID
2. Colestid (colestipol) ___ mg oral QHS
3. B-50 Complex (vitamin B complex) unknown unknown oral DAILY
4. DiCYCLOmine 20 mg PO BID:PRN abdominal cramping
5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
7. Mirtazapine 7.5 mg PO QHS
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Sertraline 50 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO BID:PRN pain
11. Naproxen 220 mg PO Q12H:PRN pain
Discharge Medications:
1. ClonazePAM 0.5 mg PO BID
2. Colestid (colestipol) ___ mg oral QHS
3. DiCYCLOmine 20 mg PO BID:PRN abdominal cramping
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
5. Mirtazapine 7.5 mg PO QHS
6. Naproxen 220 mg PO Q12H:PRN pain
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Sertraline 50 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO BID:PRN pain
10. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
11. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
12. B-50 Complex (vitamin B complex) 0 unknown ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
- pseudomyxoma peritoneii with mesenteric cyst
- Malnutrition
Secondary Diagnoses:
- hyponatremia
- anxiety
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 being a part of your care team at ___
___. You were admitted to the hospital
because of your weight loss, and we were concerned that you were
not getting enough nutrition. We started you on TPN, and you
gained some weight. We also did a CT scan of your abdomen
because of the pain you were having, which did not show any
changes from past scans that suggested something new was going
on. We have set up a service that will help you continue TPN at
home. They will also set up any additional blood work you will
need.
You should follow up with your primary care doctor ___ Dr.
___ on ___ at 10 am. Appointments with
them are detailed below. We also provided you information to
follow up with our nutrition department, which we think will be
very important for managing you TPN.
We wish you the best of luck with your recovery.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10583237-DS-10 | 10,583,237 | 27,960,885 | DS | 10 | 2162-11-28 00:00:00 | 2162-11-28 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Face Swelling
Major Surgical or Invasive Procedure:
I and D of mouth abscess
History of Present Illness:
This is a ___ yo F with PMH of DM1, Myasthenia ___, and
hypothyroidism who presents 8 days after wisdom tooth removal
with progressive face swelling and mouth pain. The patient had
all 4 wisdom teeth removed on ___. She developed normal
post-operative swelling after the procedure, but then noticed
progressive swelling and worsening pain as the week progressed.
She called her dentist who prescribed Penicillin and oxycodone.
The patient took these, however, her symptoms continued
prompting an emergency room visit at ___. At
___, the patient was given unasyn and pain control. Her Cr
was elevated to 1.5, so a CT scan of the maxilla was deferred
and she was transfered to ___ for further workup.
At ___, the patient had a repeat Cr of 0.5. She was given
another dose of Unasyn and oxycodone. She was evaluated by oral
surgery who recommended OR debridement.
On speaking with the patient, she denies any fevers. She does
say that pus was expressed from her incisions. She has had no
dysphagia, odynophagia, loss of vision, headache, neck pain,
chest pain, or trouble breathing. She describes the pain most
severely ___ the left mandible.
Vitals are stable.
Past Medical History:
DM1
Myasthenia ___
Hypothyroidism
Depression
Social History:
___
Family History:
Thyroid disease
Physical Exam:
VS: 98.3, 124/81, 90, 20, 100% RA
General: NAD, AOX3, appropriate
HEENT: gross edema of bilateral face with periorbital swelling,
normal vision, no facial cellulitis, mouth exam limited by poor
mouth opening, TTP along bilateral mandible, mild reactive
lymphadenopathy, no neck stiffness, tenderness, no sinus
tenderness
CV: RRR, no murmurs
Lungs: CTAB
Abdomen: soft, NT, ND
Ext: no edema
Neuro: Nonfocal
DISCHARGE EXAM:
VSS
Facial swelling improved, mild oozing/bleeding from I/D site
Pertinent Results:
___ 06:48AM BLOOD WBC-4.1 RBC-3.39* Hgb-9.9* Hct-31.8*
MCV-94 MCH-29.3 MCHC-31.3 RDW-13.7 Plt ___
___ 05:30AM BLOOD Neuts-71.3* ___ Monos-3.4 Eos-1.4
Baso-0.9
___ 06:48AM BLOOD Glucose-79 UreaN-4* Creat-0.7 Na-134
K-3.3 Cl-103 HCO3-27 AnGap-7*
___ 06:48AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.7
___ 05:30AM BLOOD HCG-<5
___ 05:52AM BLOOD Lactate-3.0*
BCx: NGTD x 2
___ 8:26 pm SWAB Site: MANDIBLE LEFT MANDIBLE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS AND ___
SHORT
CHAINS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
CT face/neck:
IMPRESSION: Findings concerning for abscess just lateral to the
body of the mandible, on the left. Bilateral facial swelling.
No osteomyelitis.
NOTE ADDED ___ ATTENDING REVIEW: Though there is no finding to
specifically suggest an odontogenic source of the
inflammatory/infectious process centered ___ the left buccal
space, there is an abnormal appearance to the socket of the
mandibular right ___ molar ___ #32), raising the possibility
that there has also been a recent complicated extraction of the
left ___ molar ___ #17) as the etiology of the process, above.
This should be closely correlated with more detailed clinical
history and dental examination.
Also noted are a small amount of fluid layering ___ the left
sphenoid air cell, which does not appear related to the above,
as well as several prominent lymph nodes ___ the submandibular
region and anterior and posterior cervical triangles,
bilaterally, which may be reactive.
Brief Hospital Course:
This is a ___ yo F who presents 9 days after dental surgery with
face swelling, pain, and expression of pus found to have a left
buccal abscess
1. Buccal Abscess: CT without deep infection, however fluid
collection around left mandible confirmed an abscess. Pt went to
OR on ___ for buccal debridement with successful evacuation of
pus. The patient will be treated with 10 days of Augmentin and
14 days of Chlorhexidine rinse. She was given naproxen and
percocet for pain control. She has follow-up scheduled with the
___ dental clinic. The oral surgeon will follow-up her abscess
cultures.
2. DM1: Continued lantus and SSI based on patient's carb
counting regimen.
3. Myasthenia: Continued pyridostigmine
4. Hypothyroid: Continued levothyroxine
5. Anemia: Mild. Unclear baseline. Mild oozing from surgical
site.
# CODE STATUS: Full
# CONTACT: ___ (sister) ___
TRANSITIONAL ISSUES:
- Abscess cultures are pending
- Dental follow-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Pyridostigmine Bromide 60 mg PO Q6H
Discharge Medications:
1. Glargine 6 Units Breakfast
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Pyridostigmine Bromide 60 mg PO Q6H
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Last Day ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Twice A Day Disp #*18 Tablet Refills:*0
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Last day ___
RX *chlorhexidine gluconate 0.12 % Rinse with 15 mL, then spit
Twice A Day Disp #*2 Bottle Refills:*0
6. Naproxen 500 mg PO Q12H:PRN pain
RX *naproxen 500 mg 1 tablet(s) by mouth Twice a Day Disp #*30
Tablet Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Every 6 hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abscess
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 an abscess after your
wisdom teeth removal. This required drainage of the abscess and
you will need to continue antibiotics for a total of 10 days.
Also, you will need to rinse with Chlorhexadine twice a day for
14 days. We have given you medications to help with swelling and
discomfort.
Please see follow-up as scheduled below.
Followup Instructions:
___
|
10583349-DS-18 | 10,583,349 | 26,442,616 | DS | 18 | 2187-05-12 00:00:00 | 2187-05-14 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx HTN, HLD, COPD, DM2, PVD, CAD s/p STEMI ___ ___
DES to RCA p/w presenting with 5d of progressively worsening non
productive cough, SOB, weakness and chills. She also endorses
interscapular pain and L flank pain, which she states are
chronic for her. She denies chest or abd pain and denies
orthopnea, pedal edema, or recent hosptial admissions. She has
had PNAs in the past, which she states feel similar to her
current presentation, though this is worse. States this does not
feel like prior presentations with MI.
.
In the ED, initial vitals were:
T 96 HR 125 BP 112/86 O2 Sat 85% RA
She triggered for hypoxia. CXR in the ED showed bibasilar linear
atelectasis, no focal consolidation and no pulmonary edema. Labs
were notable for WBC 12.8 (82.5% PMNs), Na 131, Cl 89, AG 24,
trop <0.01, BNP 189, Lacate 2.3 and venous pH 7.34. She was
admitted to cardiology for r/o MI.
.
On arrival to the floor, VS were:
T 98 BP 131/65 HR 110 RR 20 O2 Sat 96% RA
She denied CP/SOB/N/V, lightheadedness or palpitations.
.
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, hemoptysis, black stools
or red stools. She denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Past Medical History:
PRIOR CARDIAC HISTORY:
- CAD
- ___: AMI s/p PIC of RCA & LCX
- ___: ISR of LCX s/p stenting
- ___: PTCA/stending of RPLB with 2.5 x 18 mm Cypher DES &
jailing of small caliber lower pole branch
- ___: STE IMI, cath showed LAD ___ mid-vessel stenosis,
LCX with total flush occusion, mid-RCA diffusely diseased with
80% ISR & possible thrombus suggestive of late ISR. Focal 50%
lesion noted at distal RCA bifurc. RPLV stent from ___ patent.
S/p thrombectomy & PCI to mid-RCA using Promus DES
.
OTHER PAST MEDICAL HISTORY:
- PAD
- ___: R CFA thrombectomy & repair after cardiac ___
- HTN
- HLD
- DM with peripheral neuropathy
- COPD
- Urinary incontinence s/p bladder surgery
- Hysterectomy
- GERD
- Arthritis
- Throat polyp's s/p surgery
- Bilateral cataract surgery
- Tonsillectomy
- Appendectomy
Social History:
___
Family History:
- Son: Died from MI at ___
- 2 Daughters: "slight heart ___
- Mother: Died of heart attach in her ___
Physical Exam:
Admission Exam:
VS: T 98 BP 131/65 HR 110 RR 20 O2 Sat 96% RA
GENERAL- NAD, appropriate
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP 5cm above the RA at 45 degrees.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- Diffuse wheezing, worst at the bases, diminished BS at
the L base, inspiratory rhonchi, no rales. No increaed WOB.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- WWP, no c/c/e.
NEURO: A/Ox3, CN II-XII intact, non focal
.
Discharge Exam:
Vitals; 98.9 128/35 69 18 94%on 2L Wt: 69.9 <- 69.8
GENERAL- No acute distress. Well nourished. Laying in bed. NC in
and on 2L
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
MMM
NECK- Supple. JVP ~5-7cm
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- Diffuse wheezing, worst at the bases. Crackles over R.
mid lung field still prsent, but improving. Decreased breath
sounds diffusely.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- WWP, no c/c/e.
NEURO: A/Ox3, CN II-XII intact, non focal
Pertinent Results:
Admission Labs:
___ 12:15PM BLOOD WBC-12.8*# RBC-4.76 Hgb-14.0 Hct-43.8
MCV-92 MCH-29.4 MCHC-32.0 RDW-13.4 Plt ___
___ 12:15PM BLOOD ___ PTT-30.1 ___
___ 12:15PM BLOOD Glucose-290* UreaN-16 Creat-1.0 Na-131*
K-5.4* Cl-89* HCO3-23 AnGap-24*
___ 09:37PM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
___ 12:34PM BLOOD ___ pO2-38* pCO2-50* pH-7.34*
calTCO2-28 Base XS-0 Comment-GREEN TOP
.
Discharge Labs:
___ 07:48AM BLOOD WBC-7.3 RBC-4.02* Hgb-11.7* Hct-37.4
MCV-93 MCH-29.2 MCHC-31.4 RDW-13.1 Plt ___
___ 07:48AM BLOOD Glucose-226* UreaN-13 Creat-0.6 Na-139
K-4.4 Cl-97 HCO3-34* AnGap-12
___ 07:48AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8
.
Pertinent Labs:
___ 12:15PM BLOOD proBNP-189
___ 12:15PM BLOOD cTropnT-<0.01
___ 09:37PM BLOOD CK-MB-3 cTropnT-<0.01
___ 01:36PM BLOOD ___ pO2-77* pCO2-59* pH-7.32*
calTCO2-32* Base XS-1
___ 12:34PM BLOOD Lactate-2.3* K-4.2
___ 01:36PM BLOOD Lactate-1.8
.
Studies:
___ EKG: Baseline artifact. Sinus tachycardia. Non-specific
ST segment changes. Compared to the previous tracing of ___
the heart rate is increased. Other findings are probably
similar.
Rate PR QRS QT/QTc P QRS T
115 162 72 310/406 56 36 73
.
___ CXR (portable): No radiographic evidence for acute
cardiopulmonary process.
.
___ CXR (AP/Lat): There is mild cardiomegaly. Right middle
lobe peripheral opacities are likely infectious in etiology
given the clinical symptoms. Right mid lung opacities are also
from infectious process. The right middle lobe scarring is
again noted.
Brief Hospital Course:
___ with PMHx HTN, HLD, DM2, PVD, CAD s/p STEMI ___ ___ DES to
RCA p/w presented with 5d of progressively worsening non
productive cough, SOB, weakness and chills. Treated with IV
ceftriaxone and azithromycin in ED for CAP and transferred to
cardiology service for further management. Symptoms resolved
with antibiotic and steroid adminstration and thought to
represent COPD exacerbation vs. CAP. discharged home to complete
8 day abx course on home O2.
.
# PNA/COPD exacerbation: Differential includes PNA vs COPD
exacerbation. Ruled out for CHF and ACS with negative BNP and
enzymes. Low Wells score, and not believed to represent PE.
Initially thought to be COPD exacerbation, with increased cough,
sputum production, and O2 need with negative CXR in ED. Treated
with PO azithromycin and IV ceftriaxone while on floor. ___
blood cultures (+) for GPC in clusters, so vanc started. This
was discontinued after speciated to coag negative staph, and no
growth in other cultures. Repeat CXR on floor after IV fluid
administration was suspicious for R. middle lobe PNA. Pt cough
was resolving while in-house, however, she still required O2 as
ambulatory sats <88%. She was discharged home on supplemental
oxygen and levofloxacin to complete an 8 day course of abx for
CAP. Also given 40mg prednisone taper for 1 week, as COPD
exacerbation not entirely ruled out. Plan to follow up with
outpatient cardiologist, Dr. ___ discharge.
.
# Lactic Acidosis: Pt with positive AG, elevated lactate and
relatively normal pH. Likely related to infection, hypoxia.
Normalized following administratio of IV fluids and abx.
.
# CAD: continued home ASA, Plavix, Metoprolol, Crestor
.
#COPD: continued on home symbicort and tiotropium
.
# HTN: continued home Metoprolol
.
# DM: Kept on sliing scale in house and d/c'ed on home insulin
.
Transitional Issues:
#f/u repeat blood cultures
Medications on Admission:
Rosuvastatin Calcium 20 mg PO DAILY
Ranitidine 150 mg PO HS
Amitriptyline 50 mg PO HS
Clopidogrel 75 mg PO DAILY
Glargine 18 Units Breakfast
Metoprolol Succinate XL 50 mg PO DAILY
Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation BID
Onglyza *NF* (saxagliptin) 5 mg Oral daily
Tiotropium Bromide 1 CAP IH DAILY
GlipiZIDE XL 10 mg PO DAILY
Aspirin 325 mg PO DAILY
Discharge Medications:
1. Rosuvastatin Calcium 20 mg PO DAILY
2. Ranitidine 150 mg PO HS
3. PredniSONE 10 mg PO DAILY Duration: 5 Days
Day 1: 4 pills
Day 2: 3 pills
Day 3: 2 pills
Day 4: 1 pill
Day 5: 0.5 pill
Tapered dose - DOWN
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*11 Tablet
Refills:*0
4. Amitriptyline 50 mg PO HS
5. Clopidogrel 75 mg PO DAILY
6. Glargine 18 Units Breakfast
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
Inhalation BID
9. Onglyza *NF* (saxagliptin) 5 mg Oral daily
10. Tiotropium Bromide 1 CAP IH DAILY
11. GlipiZIDE XL 10 mg PO DAILY
12. Aspirin 325 mg PO DAILY
13. Levofloxacin 750 mg PO Q24H Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
community acquired pneumonia and COPD exacerbation
Secondary diagnosis:
Inuslin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___. You were admitted for
worsening shortness of breath, weakness, and chills. We were
initially concerned that your symptoms may have been due to a
heart problem. After looking at your heart rhythm (EKG) and
checking your blood for markers of heart damage (troponins), we
determined that your heart was not causing symptoms.
Your cough worsened during your stay, and after rechecking a
chest x-ray it appears that you have a pneumonia, which may
cause a temporary worsening of your emphysema. You received
medications for both of these conditions. Please continue the
antibiotics for 3 more days (through ___ and steroids for
4 days (through ___.
Physical therapy has recommended home oxygen therapy for you.
Please continue to use this until told not to.
The following medication changes were made:
START levaquin 750mg daily for 3 days (___)
START prednisone taper: 30mg on ___
20mg on ___
10mg on ___
5mg on ___
then STOP
Followup Instructions:
___
|
10583349-DS-19 | 10,583,349 | 26,384,556 | DS | 19 | 2190-08-11 00:00:00 | 2190-08-11 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Traumatic SAH s/p fall with headstrike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ yo F on aspirin and Plavix. Patient was
bending over to pick up a can today when she tripped off the
last
step falling forward and striking her head. She was brought to
OSH ED by EMS. There ___ revealed scattered traumatic SAH. She
was transferred to ___ for neurosurgical evaluation. Upon eval
she reports a headache and generally feeling sore. She denies
visual changes, new numbness/ weakness/tingling.
Past Medical History:
PRIOR CARDIAC HISTORY:
- CAD
- ___: AMI s/p PIC of RCA & LCX
- ___: ISR of LCX s/p stenting
- ___: PTCA/stending of RPLB with 2.5 x 18 mm Cypher DES &
jailing of small caliber lower pole branch
- ___: STE IMI, cath showed LAD ___ mid-vessel stenosis,
LCX with total flush occusion, mid-RCA diffusely diseased with
80% ISR & possible thrombus suggestive of late ISR. Focal 50%
lesion noted at distal RCA bifurc. RPLV stent from ___ patent.
S/p thrombectomy & PCI to mid-RCA using Promus DES
.
OTHER PAST MEDICAL HISTORY:
- PAD
- ___: R CFA thrombectomy & repair after cardiac ___
- HTN
- HLD
- DM with peripheral neuropathy
- COPD
- Urinary incontinence s/p bladder surgery
- Hysterectomy
- GERD
- Arthritis
- Throat polyp's s/p surgery
- Bilateral cataract surgery
- Tonsillectomy
- Appendectomy
Social History:
___
Family History:
- Son: Died from MI at ___
- 2 Daughters: "slight heart ___
- Mother: Died of heart attach in her ___
Physical Exam:
UPON ADMISSION:
PHYSICAL EXAM:
VS: T 98.1 HR 68 BP 167/76 RR 10
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL. 4cm x4cm subgaleal hematoma above L eye,
ecchymosis L eye.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Pertinent Results:
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. Stable subarachnoid hemorrhage.
2. Essentially stable moderate left frontal subgaleal hematoma
and extensive left supraorbital/ periorbital superficial
hematoma, without evidence for intraorbital extension or
fracture.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. Unchanged bilateral subarachnoid hemorrhage without evidence
of new
hemorrhage.
2. No evidence of hydrocephalus.
Brief Hospital Course:
On ___, the patient was transferred to ___ from an OSH and
was admitted to the ICU. Her repeat NCHCT was stable.
On ___, the patient remained neurologically stable, and was
therefore transferred to the floor with telemetry monitoring due
to her cardiac history.
On ___, the patient was neurologically and hemodynamically
without acute events. She was evaluated by physical therapy who
are recommending OT evaluation and repeat ___ visit.
On ___ Patient was neurologically stable. She was re-evaluated
by ___ who felt now that the patient would benefit from rehab. A
NCHCT was repeated and revealed interval improvement in SAH.
On ___ the patient had orthostatic hypotension and was given
and NS IV fluid bolus for probably dehydration. Orthostatics
improved after fluid bolus. She remains neurologically intact on
exam. She was discharged to rehab in stable condition with
instructions for follow up. All questions were answered at time
of discharge
Medications on Admission:
Proventil, singulair, advair, amitriptyline, plavix, aspirin,
metoprolol, zetia, crestor, metformin, lanuts/levemir
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Amitriptyline 50 mg PO QHS
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Ezetimibe 10 mg PO DAILY
6. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. LeVETiracetam 500 mg PO BID
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 50 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Ranitidine 150 mg PO DAILY
12. Rosuvastatin Calcium 10 mg PO QPM
13. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Activity
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.
Medications
You may resume taking your home Aspirin and Plavix on ___.
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.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10583349-DS-20 | 10,583,349 | 24,535,550 | DS | 20 | 2193-06-12 00:00:00 | 2193-06-29 14:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old female on aspirin who presents
to ___ on ___ with R orbital floor, nasal bone,
and maxillary sinus fractures following a mechanical fall.
The patient was at home when she ran out to help her dog. She
normally ambulates with walker but didn't have it at the time.
She fell onto her face on grass. The patient does remember
hitting ground, and did not have any LOC. Initial evaluation at
an OSH demonstrated right sided blowout orbital fx without signs
of entraptment, + R parietal IPH, and R rib fx which prompted
transfer to ___.
Patient denies diplopia. She is edentulous. Her only complaint
is
R sided facial pain.
Past Medical History:
PMH:
Problems (Last Verified ___ by ___:
CORONARY ARTERY DISEASE
DIABETES MELLITUS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
TRAUMATIC SAH
BACK PAIN
PSH:
Surgical History (Last Verified - None on file):
No Surgical History currently on file.
Social History:
___
Family History:
- Son: Died from MI at ___
- 2 Daughters: "slight heart attacks"
- Mother: Died of heart attach in her ___
Physical Exam:
Admission Physical Exam:
Gen: NAD, A&Ox3, lying on stretcher.
HEENT: C collar in place; Bilateral periorbital edema and
ecchymosis R>L; R temporal hematoma is present lateral to
lateral
eye, that is soft without tenderness; PERRL; EOMI except slight
inability to downward gaze on the R. Visual acuity intact. No
nasal septal hematoma. No rhinorrhea. Tongue midline. Dentition
absent, no dentures in place. Sensation grossly intact and
symmetric in V1, 2, 3 distributions. VII function grossly intact
and symmetric. (+) tenderness to palpation along inferior
orbital
rim, superior orbital ridge, and along dorsal of nose. No bony
step-offs. Midface otherwise stable. (+) small superficial
abrasion along nasal dorsum
CV: RRR
R: Breathing comfortably on NC. No wheezing.
Discharge Physical Exam:
V T 98.7 BP 135/60 HR 79 RR 18 O2sat 91% on RA
General: Pleasant, lying in bed, asleep initially but awakens
easily
HEENT: EOMI, V1-V3 intact, hearing equal b/l to finger rub,
notable bruising to right side of face, tongue tacky. hypophonic
voice
CV: RRR, no m/r/g appreciated
Pulm: CTAB, no w/r/r
Abd: Active BS, NT, ND
Skin: bruising around right eye extending below mandible on
right
Psych: anxious, follows conversation and responds appropriately
Neuro: sensation intact to light touch L3-S1 compared to
shoulders, decreased proprioception to great toes b/l.
MSK: ___ to PF, DF, EF, WE, EE, grip b/l.
Pertinent Results:
IMAGING:
___: CXR:
No definite acute intrathoracic process.
Subtle apparent irregularity at the left glenoid is of
indeterminate age.
Correlate with site of pain and consider dedicated left shoulder
radiographs if clinically indicated.
___: Right Hand x-ray:
Multilevel degenerative changes, most severe at the first
carpometacarpal
joint where there is severe osteoarthritis. No acute fracture
seen.
Likely 4 mm subchondral cyst at the proximal medial lunate.
___: Right shoulder x-ray:
No acute fractures or dislocations are seen. There are mild
degenerative
changes of the AC and glenohumeral joint. Humeral head is
high-riding,
consistent rotator cuff pathology.Visualized right lung is
grossly clear.
___: Second Opinion CT Head:
No evidence of fracture or traumatic subluxation. Degenerative
changes.
Small anterior ossicle at C4-5 C5-6 and C7-T1 levels appear
degenerative in nature.
___: CT Chest:
1. Acute fractures of the anterior right ___, and 6th ribs.
Old healing fractures of the lateral right ___, and
9th ribs. No pneumothorax.
2. An 8 mm pulmonary nodule in the right lower lobe has
increased in size from ___ated ___.
Further evaluation is recommended with PET-CT.
RECOMMENDATION(S): PET-CT for further evaluation of the 8 mm
pulmonary nodule in the right lower lobe.
LABS:
___ 06:20PM GLUCOSE-95 LACTATE-0.9 CREAT-0.7 NA+-143
K+-3.8 CL--105 TCO2-27
___ 06:05PM UREA N-16
___ 06:05PM LIPASE-15
___ 06:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 06:05PM WBC-10.4* RBC-3.99 HGB-11.3 HCT-37.4 MCV-94
MCH-28.3 MCHC-30.2* RDW-13.6 RDWSD-45.6
___ 06:05PM NEUTS-81.5* LYMPHS-11.2* MONOS-5.0 EOS-1.1
BASOS-0.5 IM ___ AbsNeut-8.46* AbsLymp-1.16* AbsMono-0.52
AbsEos-0.11 AbsBaso-0.05
___ 06:05PM PLT COUNT-220
___ 06:05PM ___ PTT-26.6 ___
Brief Hospital Course:
___ yo F with history of DM, CAD, and multiple falls presenting
after a mechanical fall with a traumatic SAH, facial fractures
and right sided rib fractures. Neurosurgery was consulted and
recommended holding aspirin for 7 days and follow-up in the
Cognitive Neurology clinic. Plastic Surgery was consulted and
recommended non-operative management while inpatient, sinus
precautions for 1 week, bacitracin to abrasions and outpatient
follow-up. The patient also had an ophthalmology exam, which was
negative for entrapment or globe injury. The patient was
hemodynamically stable and neurologically intact. She was
evaluated by ___ and OT, who recommended rehab once medically
stable. The patient continued to have malaise and a sore throat,
flu swab was sent which was negative.
During this hospitalization, the patient was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. Aspirin was on hold.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. There was an incidental finding on her chest
CT of an enlarging pulmonary nodule for which an outpatient PET
scan was recommended, which was communicated with the patient.
Medications on Admission:
amitryptaline 25mg qhs
ezitimibe 10mg D
Januvia 100mg D
lamotrigine 100mg bid
rosuvastatin 10mg qhs
tramadol 50 bid
tramadol 50 D:prn
albuterol inhaler prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. Ibuprofen 400 mg PO Q8H
5. Januvia (SITagliptin) 100 mg oral DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
7. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
8. Zetia (ezetimibe) 10 mg oral DAILY
9. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
10. Amitriptyline 25 mg PO QHS
11. LamoTRIgine 100 mg PO BID
12. Lidocaine 5% Patch ___ PTCH TD QAM
13. Rosuvastatin Calcium 10 mg PO QPM
14. Senna 17.2 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute fractures of the anterior right ___, and 6th ribs
Right orbital floor fracture, nasal bone fractures
Maxillary sinus fractures
Right parietal SAH
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 ___ after a mechanical fall. You were
found to have facial fractures, bleeding in your brain, and rib
fractures. You were seen by the Neurosurgery team and they
recommended holding your aspirin for one week and following up
in the Concussion Clinic. The Plastic Surgery team was consulted
for the facial fractures. They recommend non-operative
management, sinus precautions, and outpatient follow-up.
Plastic Surgery recommendations:
Bacitracin twice a day and as needed to abrasions
Can rinse with water, pat dry, re-apply ointment.
Recommend sinus precautions x 1 week- elevate head on several
pillows, no smoking, no nose blowing, open mouth sneezing, no
drinking through straws.
Right orbital floor fracture may be operative on an elective
basis,
if patient develops worsening diplopia and/or discomfort.
Follow up in Plastic Surgery Clinic in 7 days for suture
removal.
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:
___
|
10583351-DS-5 | 10,583,351 | 26,908,503 | DS | 5 | 2170-11-14 00:00:00 | 2170-11-14 12:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea and presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male now POD ___ s/p
___ ___ Ease)CABG ___, who was d/c
to
___ rehab on POD 6. Postop course c/b delirium, brief
isolated PAFib, and he was started on Wellbutrin for tobacco
dependence. He was recently discharged home from rehab with
Augmentin for postop PNA. Yesterday his Lasix was increased to
40mg for BLE edema. Immediately after taking a dose, while
standing, he felt acute dyspnea "couldn't get a full breath" and
presycopal "head was foggy" but no accompanying palpitations,
N/V, or diaphoresis. Wife called ___ and symptoms resolved with
sitting. In the ER, CXR showed improved pleural effusions,
bedside TTE reportedly showed no significant pericardial
effusion/WMA/valve dysfunction. He reports second episode of
same symptoms while walking to BR in ER, but these spontaneously
resolved. He was admitted to CDAC d/t lack of ___ 8 bed
availability. Overnight he had no further episodes. Tele
showed
SB-SR ___ deg AVB (HR ___ w/SBP 90-100s) and HR/BP/labwork
appear at baseline from POD 6 levels prior to rehab discharge.
Formal TTE report is pending.
Past Medical History:
Severe aortic stenosis
Hypertension
Borderline hyperlipidemia
Prediabetes
Lyme disease
COPD
CRI
Transitional cell bladder cancer s/p TURBT ___, s/p BCG
treatment ___- under Dr. ___
Sleep apnea (witnessed by wife) - has not had a sleep study
"Spot on right kidney" per patient report
Past Surgical History:s/p tiss AVR, CABGX2 ___ as above
s/p carpal tunnel surgery
s/p anal fistula surgery
s/p hip replacement bilaterally
Social History:
___
Family History:
Mother died at ___ of cancer.
Father died at ___ from an MI.
Physical Exam:
___ 8 Admit PE
Temp: 97.9 (Tm 98.1), BP: 94/55 (90-114/54-70), HR: 57 (57-82),
RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: Ra
Height:71.5 in Weight:100.7 kgs (preop), 98.7kg today
I/O 24h 1050/800
General:WDWN, NAD [x]
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] Upper dentures at home
Neck: Supple [x] Full ROM [x]
Chest: Faint exp wheeze R upper, decreased lower L ___, R base,
otherwise clear w/o rhonchi/rales [x]
Heart: RRR [x] Irregular [] Murmur [x] grade __II/VI SEM best
at apex, no radiation
Sternum: stable, healing well, no erythema, drainage, warmth [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+, BLE
LLE EVH site: ecchymosis upper medial thigh, but incisions are
healing well, no erythema, drainage, warmth [x}
Neuro: Grossly intact [x]
Pulses:
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: no Left:no
Discharge PE:
************
T:98.1, 101 / 58, HR:67,RR:18, O2SAT= 97% ra
I/O:SMN:___ 24H: ___
General:A&O x3, NAD
Chest: Faint exp wheeze R upper, decreased lower L ___, R base,
Heart: RRR [x] Irregular [] Murmur [x] grade __II/VI SEM best
Sternum: stable, healing well, no erythema, drainage, warmth [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+, BLE
LLE EVH site: ecchymosis upper medial thigh, but incisions are
healing well, no erythema, drainage, warmth [x}
Neuro: Grossly intact [x]
Pertinent Results:
Labs:
___ 04:14AM BLOOD WBC-5.4 RBC-2.66* Hgb-8.5* Hct-27.0*
MCV-102* MCH-32.0 MCHC-31.5* RDW-16.8* RDWSD-62.3* Plt ___
___ 04:14AM BLOOD Glucose-95 UreaN-23* Creat-1.7* Na-137
K-5.4* Cl-102 HCO3-21* AnGap-14
___ 04:14AM BLOOD Mg-1.9
___ 06:00AM BLOOD WBC: 6.6 Hct: 26.5*
___ 09:25PM BLOOD WBC: 10.3* RBC: 2.84* Hgb: 9.0* Hct:
29.2*
MCV: 103* MCH: 31.7 MCHC: 30.8* RDW: 16.8* RDWSD: 62.7* Plt Ct:
312
___ 09:25PM BLOOD ___: 13.2* PTT: 26.8 ___: 1.2*
___ 06:00AM BLOOD Glucose: 91 UreaN: 23* Creat: 1.9* Na:
140
K: 4.5 Cl: 103 HCO3: 25 AnGap: 12
___ 01:40AM BLOOD K: 5.0
___ 09:25PM BLOOD Glucose: 102* UreaN: 25* Creat: 2.0* Na:
140 K: 5.9* Cl: 103 HCO3: 20* AnGap: 17
___ 01:40AM BLOOD proBNP: 2219*
___ 09:25PM BLOOD cTropnT: 0.12*
___ 06:00AM BLOOD Mg: 1.8
___ 01:40AM BLOOD Albumin: 3.4*
___ 09:37PM BLOOD Lactate: 2.8*
___ 12:15AM URINE Color: Straw Appear: Clear Sp ___: 1.012
___ 12:15AM URINE Blood: NEG Nitrite: NEG Protein: NEG
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5
Leuks:
NEG
___ URINE CULTURE (Pending):
___ BLOOD CULTURE (Pending):
=
=
=
=
=
=
=
=
================================================================
STUDIES:
CXR ___. Mild prominence of the interstitium with overall
improved fluid status compared to ___.
2. Persistent small left pleural effusion and interval
resolution
of right pleural effusion.
EKG: ___, SR ___ deg, 61bpm, PR 206, qrs 79, QTc 503.
Transthoracic Echocardiogram ___: Findings
This study was compared to the prior study of ___.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Symmetric LVH.
Normal LV cavity size. Suboptimal technical quality, a focal LV
wall motion abnormality cannot be fully excluded. Overall normal
LVEF (>55%).
RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size.
Moderate global RV free wall hypokinesis.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. No MS.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS. Normal
PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal with moderate global free wall
hypokinesis. A bioprosthetic aortic valve prosthesis is present.
The transaortic gradient is normal for this prosthesis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
bioprosthetic aortic valve now in place.
Brief Hospital Course:
___ year old man s/p ___ ___
___, who was readmitted for
dyspnea and presyncope evaluation after recent discharge home
from rehab. He remained hemodynamically stable in sinus rhythm
and his CXR, TTE, and lab results were unremarkable. His lasix
was discontinued for persistent SBP 90-100s, which was also his
baseline prior to initial rehab discharge. His Imdur 30mg daily
was decreased to Isordil 5mg TID. Also, given his resting heart
rate in ___, his lopressor was decreased to 6.25mg BID. He was
started on Augmentin while at rehab for suspected LLL pneumonia,
and he will complete a 10 day course on ___. Of note, his
preop creatinine was 1.5, new baseline at rehab discharge was 2,
and with lasix holiday he has improved down to 1.7. For his
persistent lower extremity edema, ___ stockings will be added
along with low dose Lasix on discharge. He continues on his
Buproprion for smoking cessation, which has been decreased to
daily dosing and should eventually be discontinued per his
primary care physician follow up.
By the time of discharge on POD #18 he was ambulating without
assistance, wounds are healing well, and pain was controlled
with oral non narcotic analgesics. He was discharged to home
with ___ services in good condition with appropriate follow up
instructions.
Medications on Admission:
1. Bisacodyl 10 mg PR QHS:PRN constipation
2. BuPROPion (Sustained Release) 150 mg PO BID smoking cessation
3. Isosorbide Mononitrate 30 mg PO QD
4. Pantoprazole 40 mg PO Q24H
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Potassium Chloride 20 mEq PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
9. Metoprolol Tartrate 25 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Naproxen 250 mg PO Q12H:PRN Pain - Mild
13. Vitamin D ___ UNIT PO DAILY
14. calcium citrate 1 mg oral DAILY
15. Amoxicillin-Clavulanic Acid ___ mg PO BID LLL PNA
16. Docusate Sodium 100 mg PO DAILY:PRN constipation
17. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheeze
RX *albuterol sulfate [Proventil HFA] 90 mcg ___ puffs IH q4h
prn Disp #*1 Inhaler Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Isosorbide Dinitrate 5 mg PO TID
RX *isosorbide dinitrate 5 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
4. Potassium Chloride 20 mEq PO DAILY
Hold for K >
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H LLL PNA
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth q 12 h Disp #*4 Tablet Refills:*0
7. BuPROPion (Sustained Release) 150 mg PO QD smoking cessation
RX *bupropion HCl 150 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*1
8. Metoprolol Tartrate 6.25 mg PO BID
RX *metoprolol tartrate 25 mg 0.25 tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*1
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
10. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth Q ___ Disp #*30
Tablet Refills:*1
11. calcium citrate 1 mg oral DAILY
12. Docusate Sodium 100 mg PO DAILY:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID prn Disp
#*60 Tablet Refills:*1
13. Naproxen 250 mg PO Q12H:PRN Pain - Mild
14. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
15. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth Q HS Disp #*30
Capsule Refills:*1
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Pre-Syncope and Dyspnea
Secondary:
Suspected LLL pneumonia
Coronary artery disease s/p Coronary artery bypass graft x 2
(skeletonized left internal mammary artery to obtuse marginal
artery and a long saphenous vein to posterior descending artery)
___
Aortic stenosis s/p Aortic valve replacement (25 ___
___ Ease tissue valve) ___
Hypertension
Borderline hyperlipidemia
Prediabetes
Lyme disease
COPD
CRI
Transitional cell bladder cancer s/p TURBT ___, s/p BCG
treatment ___- under Dr. ___
Sleep apnea (witnessed by wife) - has not had a sleep study
"Spot on right kidney" per patient report
s/p carpal tunnel surgery
s/p anal fistula surgery
s/p hip replacement bilaterally
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
Edema: 1+ BLE
Discharge Instructions:
You were admitted to ___ for evaluation of your pre-syncopal
(near passing out) symptoms. Testing revealed unremarkable labs
and heart ultrasound (transthoracic echocardiogram), and
improving Chest Xray.
The following changes have been made to your home medication
regimen:
****-?Lasix dosing*****
-Metoprolol dosing was decreased
-Isosorbide mononitrate was changed to Isosorbide dinitrate and
overall nitrate dose was decreased
** ___ stockings on QAM and off QPM for leg swelling **
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10583673-DS-14 | 10,583,673 | 26,257,843 | DS | 14 | 2172-07-06 00:00:00 | 2172-07-07 09:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ Right stereotactic ___ biopsy
History of Present Illness:
___ yo M who presents from assisted living as staff noticed
patient to be disheveled and not himself over past 2 weeks. Pt
describes reason for ED visit for intermittent lightheadedness,
loss of appetite and mild nausea. Denies HA, numbness, weakness
tingling, vision changes. He denies PMH and denies medications
and reports he has not seen a doctor in ___ years.
Past Medical History:
PMHx: hx appendectomy
Social History:
___
Family History:
Family Hx: unknown
Physical Exam:
Upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: mild dysmetria on finger-nose-finger bilaterally
Handedness: Right
Upon discharge:
AAO x 3, PERRL, EOMs intact. No pronator drift.
Sensation and strength full throughout.
Right scalp incision CDI. Closed with staples.
Pertinent Results:
___ CXR
No acute cardiopulmonary process.
___ CT head
Large area of vasogenic edema in the right parietal and temporal
lobes
possibly involving the frontal lobe, resulting in mass effect on
the right lateral ventricle and 4-5 mm shift of midline
structures. These findings are suspicious for an underlying mass
___ MRI head
1. Enhancing right temporoparietal mass with internal
hemorrhage, vasogenic edema, and mass effect on adjacent sulci
and right lateral ventricle with small satellite lesions.
Findings most likely represent GBM although lymphoma or
metastatic disease are less likely considerations.
___ CT chest
1. No convincing evidence of intrathoracic malignancy. Tiny
bilateral
pulmonary nodules are highly unlikely to be related to the
patient's ___ mass, although could be followed up in 3 to 6
months with a chest CT, if desired.
2. Ascending thoracic aortic aneurysm, measuring up to 4.7 cm in
caliber.
___ CT abdomen & pelvis
1. No evidence of intra-abdominal or pelvic malignancy.
2. Moderate intrahepatic biliary duct dilatation with marked
dilation of the common duct. Punctate obstructing stone in the
distal common duct at the level of the ampulla.
3. Chololithiasis, without CT evidence of acute cholecystitis.
4. Mild prostatic enlargement.
5. Sub-centimeter left renal hypodensities, too small to
characterize,
statistically simple cysts.
___ CT head
No change in known mass or mass effect involving the right
parietal, temporal and frontal lobes compared to ___.
___ ___ MRI with contrast
Irregularly enhancing right parietal temporal lesion is again
identified for surgical planning.
___ CT head w/ contrast for stereotaxis
Stereotactic frame is in place about the patient's head. No
change in the known right parietal mass with significant
surrounding vasogenic edema and 3 mm leftward shift of midline
structures.
___ non contrast head CT
Trace hydrocephalus but no evidence of hemorrhage at the biopsy
bed. Unchanged appearance of mass with surrounding edema and
associated mass effect.
___ CT HEAD W/O CONTRAST:
1. No evidence of worsening edema, hemorrhage, or mass effect
to account for patient's change in symptoms.
2. Known right parietotemporal mass with surrounding edema is
better assessed on prior MRI.
___ 06:15AM BLOOD WBC-11.8* RBC-4.69 Hgb-14.7 Hct-41.9
MCV-89 MCH-31.3 MCHC-35.1* RDW-13.8 Plt ___
___ 03:30AM BLOOD WBC-12.6* RBC-4.54* Hgb-13.9* Hct-39.4*
MCV-87 MCH-30.5 MCHC-35.2* RDW-14.3 Plt ___
___ 04:55AM BLOOD WBC-15.3* RBC-4.73 Hgb-14.8 Hct-41.8
MCV-88 MCH-31.2 MCHC-35.3* RDW-13.8 Plt ___
___ 05:10AM BLOOD WBC-17.2*# RBC-4.73 Hgb-14.6 Hct-42.7
MCV-90 MCH-30.8 MCHC-34.1 RDW-14.1 Plt ___
___ 05:40AM BLOOD WBC-6.8 RBC-4.78 Hgb-15.1 Hct-42.7 MCV-89
MCH-31.5 MCHC-35.2* RDW-13.6 Plt ___
___ 01:45PM BLOOD WBC-8.8 RBC-4.77 Hgb-14.6 Hct-43.0 MCV-90
MCH-30.7 MCHC-34.1 RDW-14.2 Plt ___
___ 01:45PM BLOOD Neuts-69.7 ___ Monos-4.8 Eos-1.0
Baso-0.7
___ 06:15AM BLOOD ___ PTT-27.0 ___
___ 06:15AM BLOOD Glucose-113* UreaN-21* Creat-1.1 Na-141
K-5.1 Cl-105 HCO3-30 AnGap-11
___ 06:11PM BLOOD Glucose-119* UreaN-24* Creat-1.1 Na-138
K-4.0 Cl-104 HCO3-26 AnGap-12
___ 03:30AM BLOOD Glucose-135* UreaN-30* Creat-1.2 Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
___ 04:55AM BLOOD Glucose-135* UreaN-27* Creat-1.2 Na-137
K-4.3 Cl-99 HCO3-28 AnGap-14
___ 09:25PM BLOOD Glucose-161* UreaN-31* Creat-1.2 Na-137
K-4.3 Cl-101 HCO3-27 AnGap-13
___ 05:10AM BLOOD Glucose-116* UreaN-27* Creat-1.2 Na-140
K-4.3 Cl-101 HCO3-27 AnGap-16
___ 05:40AM BLOOD Glucose-133* UreaN-24* Creat-1.2 Na-142
K-4.7 Cl-101 HCO3-27 AnGap-19
___ 01:45PM BLOOD Glucose-85 UreaN-21* Creat-1.3* Na-142
K-4.0 Cl-103 HCO3-26 AnGap-17
___ 05:10AM BLOOD ALT-21 AST-26 AlkPhos-97 Amylase-48
TotBili-0.6
___ 08:50PM BLOOD ALT-19 AST-26 LD(LDH)-154 AlkPhos-98
Amylase-46 TotBili-0.6
___ 01:45PM BLOOD ALT-25 AST-30 LD(LDH)-175 AlkPhos-109
TotBili-0.9
___ 06:11PM BLOOD Calcium-8.5 Phos-4.4 Mg-2.1
___ 03:30AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2
___ 04:55AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2
___ 05:10AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.1
___ 05:40AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
___ 01:45PM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.2 Mg-1.8
___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Patient was admitted to the neurosurgery service with a newly
found ___ mass. CT of the head showed right parietal and
temporal vasogenic edema with midline shift. An MRI was then
obtained which showed enhancing right temporoparietal mass.
On ___ he was started on pepcid and an insulin sliding scale.
Imaging workup revealed a dilated bile duct so an ERCP was
ordered.
On ___ his LFTs were within normal limits and a GI consult was
called in addition to social work and ___. The ERCP team felt
that if there will be no intervention for ___ lesion, there
would be no indication for ERCP and stated that should the
patient and family decide to pursue further treatment of the
___ lesions they would perform the ERCP.
On ___ the patient was stable and deciding amongst his options
for his further care. Patient elected to have a ___ biopsy.
On ___ Patient underwent pre-operative workup and was consent
for surgery.
On ___ Patient was neurologically stable. OR case was bumped
until tomorrow.
On ___, the patient underwent stereotactic ___ biopsy. He
tolerated the procedure well. Post op CT was fine. He was
transferred to step down unit for further recovery. He had some
episodes of asymptomatic bradycardia to the ___'s.
On ___, the patient was relatively stable neurologically with
the exception of a worsening left pronator drift.
Neuro-oncology was consulted with recommendations for
bevacizumab to control his neurologic symptoms. Mr. ___
___ follow-up with Dr. ___ Neuro-Onc care with the likely
plan to undergo radiation in conjunction with daily temozolomide
vs. radiation alone if taking temozolomide cannot be performed.
Mr. ___ was evaluated by Physical Therapy who recommend
rehab upon discharge. Mr. ___ should continue levetiracetam
and dexamethasone until his follow-up appointment in the ___
Tumor Clinic with Dr. ___. Mr. ___ remains neurologically
intact with full strength for all extremities. His most recent
___ from ___ remains unchanged and stable.
Dr. ___ will coordinate further care in regards to his
likelihood of glioblastoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. Heparin 5000 UNIT SC TID
5. LeVETiracetam 1000 mg PO BID
6. Senna 17.2 mg PO HS
7. Dexamethasone 4 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right sided ___ mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You underwent surgery to biopsy a ___ lesion from your
___.
You were seen by Dr. ___ Neuro-oncology, who will
coordinate your ongoing treatment.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
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.
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.
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:
___
|
10583681-DS-5 | 10,583,681 | 24,465,993 | DS | 5 | 2124-11-10 00:00:00 | 2124-11-10 18:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rib Pain
Major Surgical or Invasive Procedure:
Bronchoscopy with Biopsy ___
History of Present Illness:
___ hx HTN, COPD, ___ who was referred to the ED with
complaints of chest pain, dyspnea and cough.
Patient originally presented to his PCP ___ with complaints
of worsening back pain ___. He has a hx of LBP from trauma but
none recently that would explain his acute change. His back pain
was associated with tingling radiating down the legs to his
knees. He also had c/o right shoulder pain waking him up at
night. He was found to have a positive straight leg test on the
left and decreased ROM in the shoulder. X-rays of the shoulder &
back were unremarkable. ___ was ordered and he was started on
etodolac and methocarbamol. He continued to have pain, so was
started on oxycodone. He represented to his PCP ___ with
continued back pain and new b/l ___ edema thought to be ___ CHF.
A L-spine MRI and CT was ordered and patient was started on
furosemide. Patient obtained CT on day of admission as
outpatient, noted to have multiple rib lesions/deformities as
well as a spiculated LUL nodule with hilar adenopathy concerning
for multiple myeloma vs multifocal metastatic disease. Patient
was contacted by PCP and was feeling worse so was referred to
the ED by his PCP for pain management and expediated workup.
In the ED, initial vitals: T98.8 P85 BP151/88 RR18 O2 sat 98%
RA. Patient continued to endorse feeling dyspneic w/mild cough,
left chest wall pain. Labs were notable for Hgb 13.6, Cr 0.8,
lactate 1.0. Patient was given dilaudid and admitted to medicine
for further evaluation.
On arrival to the floor, patient sitting comfortably but
uncofrtable with ambulation. Afebrile 97.7; 151/77; HR88; RR 18
93% RA. Patient complains of "sciatica" which has grown
progressively worse over past 2 months. Notes radiating tingling
pain mainly down R leg. No asscoiated weakness. Has some mild
low back pain. Chronic for ___ years but acutely worsened in
last 2 months. Also with significant sharp pain in L upper rib
and at base of R rib cage. Keeps patient awake at night. Ongoing
for 2 months. Has slept poorly for ~2 months.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No palpitations. No
nausea or vomiting. No diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena.
Past Medical History:
Hypertension
COPD
Diastolic CHF
Social History:
___
Family History:
Father deceased at ___ from cancer. Mother died with ___
at ___. Multiple brothers and sisters living in ___, oldest
is ___. All healthy. No known Cancer.
Physical Exam:
ADMISSION PE:
Vitals: 97.7; 151/77; HR88; RR 18 93% RA, significant rib/back
pain
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear (upper dentures),
EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild barrel chested. Purse-lipped breathing but no
asscessory muscle use for breathing, diffuse inspiratory wheezes
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 cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, ambulates with discomfort
DISCHARGE PE:
Vitals: 98.2; 138/75; HR85; RR 18 94% RA, back pain, rib pain,
tolerable
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear (upper dentures),
EOMI
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild barrel chested. Purse-lipped breathing but no
asscessory muscle use for breathing, mild exp wheeze diffusely
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no edema
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, ambulates with discomfort
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-7.4 RBC-4.20* Hgb-13.6* Hct-39.5*
MCV-94 MCH-32.4* MCHC-34.3 RDW-13.2 Plt ___
___ 03:30PM BLOOD Neuts-66.4 ___ Monos-7.3 Eos-2.7
Baso-0.2
___ 09:19AM BLOOD UreaN-18 Creat-0.9 Na-134 K-4.1 Cl-95*
HCO3-27 AnGap-16
___ 03:30PM BLOOD Albumin-4.2
___ 03:35PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-8.4 RBC-3.94* Hgb-12.5* Hct-37.6*
MCV-95 MCH-31.8 MCHC-33.3 RDW-13.3 Plt ___
___ 05:30AM BLOOD Glucose-103* UreaN-14 Creat-0.7 Na-134
K-4.1 Cl-98 HCO3-28 AnGap-12
___ 05:30AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
MICRO: None
STUDIES/IMAGING:
ENDOBRONCHIAL ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE
ASPIRATION, LEFT
INTERLOBAR MASS:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
A few clusters of tumor cells are present on cell block
preparation and are positive on immunostain
for TTF-1.
Brief Hospital Course:
___ hx HTN, COPD, ___ who was referred to the ED with
complaints of chest pain, dyspnea and cough after completing
outpatient CT notable for LUL lesions and lytic bone lesions
concerning for metastatic disease.
# Chest pain/cough: felt to be ___ recently discovered lung
lesions, hilar adenopathy as well as rib lesions/deformities
noted on CT. Concern for metastatic cancer with lung primary.
Patient seen by interventional pulmonology. Underwent
bronchoscopy with biopsies. Results pending at time of
discharge. Controlled pain with PO dilauded this admission,
however patient often appeared hesitant to admit to pain and had
a low narcotic requirement. Discharged with 5mg Oxycodone
q4H:PRN, however he should continue to work on adequate pain
control with his PCP. Patient will also need to follow up with
the interventional pulmonology for final biopsy results as well
as to determine what type of oncologist he should see.
#Insomnia - patient reports poor sleep over the past several
months. Started on trazodone PRN for sleep this admission which
patient reports was helpful.
CHRONIC ISSUES:
#COPD - continued home tiotropium, albuterol,
fluticasone/salmeterol
#dCHF - continued home carvedilol 3.125 BID
#HTN - on carvedilol alone as above
TRANSITIONAL ISSUES:
- Pain control (reports he has enough oxycodone to last until
his next PCP ___ - can further coordinate with PCP ___
___ appt. Advised patient to take stool softeners while taking
narcotics
- ___ after discharge to help with pain management
- F/U with IP to discuss results of biopsy. Results returned
after discharge, included above.
- Oncology follow up pending results of biopsy
- Consider palliative care follow up if needed to aid with pain
management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob, wheezing
3. Tiotropium Bromide 1 CAP IH DAILY
4. Carvedilol 3.125 mg PO BID
5. etodolac 400 mg oral BID:PRN pain
6. Furosemide 20 mg PO DAILY:PRN swelling
7. Methocarbamol 250-500 mg PO BID:PRN muscle spasm
8. OxycoDONE (Immediate Release) 5 mg PO BID:PRN severe pain
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob, wheezing
2. Carvedilol 3.125 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*0
7. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth qHS:PRN
Disp #*30 Tablet Refills:*0
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR<12
9. Nicotine Patch 14 mg TD DAILY
Remove patch at night.
RX *nicotine 14 mg/24 hour 1 patch daily once a day Disp #*14
Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Lung Mass with Rib lesions
Secondary Diagnosis:
-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 during your hospitalization.
You were admitted for pain and an expeditited work up for masses
noted in your lung and ribs on CT. You underwent a bronchoscopy
with biopsy. We controlled your pain with oral medications. You
will need to follow up with the interventional pulmonologists
next week to discuss the biopsy results. You will also follow up
with your primary care doctor on ___ to discuss further pain
control. Please make sure that you are taking stool softeners
when you are taking pain medications.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10583763-DS-12 | 10,583,763 | 28,363,699 | DS | 12 | 2137-03-16 00:00:00 | 2137-03-16 20:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
worsening thickened sputum production, dyspnea on exertion,
wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with COPD, active tobacco use, history of
systolic HF with recovered EF on most recent echo, HTN, CKD
(baseline 1.4-1.8), Crohn's disease (not on therapy),
hypothyroidism, and history of thoracic aortic aneurysm s/p
repair, presenting with dyspnea.
She describes worsening wheezing and shortness of breath over
the
last week, as well as worsening thickened sputum production; she
became worried this morning when her nebulizer did not improved
her symptoms. She had been seen in ED for the same symptoms
___,
sent home with steroids/azithro. She did not fully improve after
the course, and after completion ___ her wheezing and dyspnea
started to worsen. She denies fevers, cough, sick contacts. She
denies chest pain or pressure, lower extremity edema, PND,
orthopnea (sleeps chronically on 3+ pillows because she does not
"like laying flat.")She measures her weight at home and it has
been stable. Adherent to Lasix.
Of note, she has only been using her ventolin inhaler. She has
been prescribed budesonide, Incruse but became confused after
getting new nebulizer equipment at home whether she should start
these medications. She manages her medication, she did pick up
these inhalers.
She has had three COPD exacerbations in the last two months, and
approximately one per month since ___. She is still smoking
tobacco about 0.5 pack per day.
In the ED, initial VS were: 97.6 89 127/66 20 100% 6l
Exam notable for: Diffuse expiratory wheezes. No rales or
rhonchi.
Labs showed: trop neg, BUN/Cr ___, glu 139 otherwise BMP wnl
Imaging showed: CXR Hyperinflated lungs with no focal
consolidation, pulmonary edema or pleural effusion.
EKG: Sinus at 87. Left axis deviation. QTC 484 otherwise normal
intervals. ST depression in V6 consistent with prior. No ST
elevation
Consults: none
Patient received: albuterol neb x3, ipratropium neb x3,
methylpred 125mg IV
Transfer VS were: 98.6 84 ___ 98% RA
On arrival to the floor, patient reports improvement in her
dyspnea.
Past Medical History:
CHF (dx ___, EF 35-40%, mild LVH, mod AR, mod TR; TTE ___
with EF 65% Mild-mod AR, Mild-mod)
Hypertension
Hypothyroid
Crohn's disease, not on any maintenance medications
Diverticulosis
Bell's palsy-R facial droop
Thoracic Type A aortic dissection s/p repair
Thoracic and abdominal aortic aneurysm
Colostomy and reversal for Crohn's
Open cholecystectomy
C-Section
Hysterectomy
Social History:
___
Family History:
Mother: Died at age ___ in her sleep. She had colon cancer s/p
resection and heart disease
Father: Died at age ___, DM and heart disease
Brother: Died at age ___, he had CHF, DM, and aneurysms
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 PO 149 / 88 L Sitting 82 30 94 Ra
GENERAL: appears state age, in no acute respiratory distress,
sitting in bed, speaking in full sentences
HEENT: AT/NC, MMM
CV: RRR, distant heart sounds
PULM: Diffuse expiratory wheezing posteriorly, decreased air
entry. no rales
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema to lower extremities, no cyanosis,
clubbing.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, motor function and sensation grossly
intact/symmetric, R facial droop, R ptosis (chronic)
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: Temp 98 BP 150/83 HR 99 RR 16 RA 93%
GENERAL: appears state age, in no acute respiratory distress,
sitting in bed, speaking in full sentences
HEENT: AT/NC, MMM
CV: RRR, distant heart sounds
PULM: Diffuse expiratory wheezing posteriorly, no increased work
of breathin no rales
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: trace edema to lower extremities, no cyanosis,
clubbing.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, motor function and sensation grossly
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
================
___ 05:50PM BLOOD WBC-10.5* RBC-4.89 Hgb-13.0 Hct-40.4
MCV-83 MCH-26.6 MCHC-32.2 RDW-17.2* RDWSD-50.8* Plt ___
___ 05:50PM BLOOD Neuts-69.7 Lymphs-17.2* Monos-8.5 Eos-3.3
Baso-0.5 Im ___ AbsNeut-7.30* AbsLymp-1.80 AbsMono-0.89*
AbsEos-0.34 AbsBaso-0.05
___ 05:50PM BLOOD Plt ___
___ 09:51PM BLOOD Glucose-139* UreaN-29* Creat-1.5* Na-145
K-4.1 Cl-104 HCO3-26 AnGap-15
___ 09:51PM BLOOD Calcium-9.5 Phos-3.3 Mg-2.2
___ 05:57PM BLOOD ___ pO2-37* pCO2-44 pH-7.40
calTCO2-28 Base XS-1
PERTINENT INTERVAL AND DISCHARGE LABS
====================================
___ 06:45AM BLOOD WBC-8.1 RBC-4.68 Hgb-12.2 Hct-38.5 MCV-82
MCH-26.1 MCHC-31.7* RDW-16.9* RDWSD-50.0* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-123* UreaN-31* Creat-1.5* Na-142
K-4.6 Cl-103 HCO3-24 AnGap-15
___ 06:45AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
IMAGING
=============
CXR from ___:
IMPRESSION:
1. Hyperinflated lungs with no focal consolidation, pulmonary
edema or pleural
effusion.
2. Re-demonstrated dilatation of the thoracic aorta.
Brief Hospital Course:
___ year old female with COPD, active tobacco use, history of
systolic HF with recovered EF on most recent echo, HTN, CKD
(baseline 1.4-1.8), Crohn's disease (not on therapy),
hypothyroidism, and history of thoracic aortic aneurysm s/p
repair, presenting with dyspnea, increased sputum production
c/w
ACTIVE ISSUES
-------------
#COPD exacerbation
#Tobacco use
Increased dyspnea and sputum production in the setting of
negative chest x-ray and cardiac workup and lack of other
systemic signs or symptoms consistent with COPD exacerbation.
Exacerbation possibly in the setting of noncompliance with home
COPD medication (patient has not been taking prescribed LAMA and
budesonide). She was started on 5 day course of p.o. prednisone
and azithromycin with prompt clinical improvement within 24
hours. Able to ambulate prior to discharge with ambulatory O2
sat greater than 92% on room air. Follow-up appointments with
PCP and pulmonologist scheduled. Patient instructed to call PCPs
office if symptoms have not improved by the end of five-day
treatment or to present to the emergency department in case of
new, worsening, or concerning symptoms. Patient has been
counseled on smoking cessation and was prescribed nicotine gum
on discharge.
CHRONIC ISSUES
--------------
#Chronic diastolic heart failure
Stable. Euvolemic on exam. Continued home carvedilol, Lasix.
#CKD
At baseline Cr (1.5-1.7).
#HTN:
Stable. Continued home carvedilol, lisinopril, amlodipine.
#Glaucoma
Stable. Continued home latanaprost and brimonidine drops.
CORE MEASURES:
===============
#CODE: Full (presumed)
#CONTACT: did not provide
CORE
=====
#CODE: Full Code (presumed)
#CONTACT: Mom (___)
Transitional Issues
===================
[]azithromycin ___
[]prednisone 40 mg po qd ___. Consider longer course if
persistent symptoms.
[]ensure compliance with long acting inhaler - LAMA and
budesonide.
[]ensure f/u w/ pulmonology given recurrent exacerbations.
[]Continue smoking cessation counseling with PCP. Prescribed
nicotine gum on discharge.
[]Nicotine replacement gum given to patient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
8. Cyanocobalamin ___ mcg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
11. budesonide 0.25 mg/2 mL inhalation DAILY
12. Rosuvastatin Calcium 5 mg PO QPM
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
Discharge Medications:
- amLODIPine 5 mg PO DAILY
- Aspirin 81 mg PO DAILY
- Carvedilol 12.5 mg PO BID
- Levothyroxine Sodium 75 mcg PO DAILY
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
- Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
- Cyanocobalamin ___ mcg PO DAILY
- Furosemide 40 mg PO DAILY
- Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
- budesonide 0.25 mg/2 mL inhalation DAILY
- Rosuvastatin Calcium 5 mg PO QPM
- Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
- Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
- azithromycin (___)
- prednisone (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-----------------
#COPD exacerbation
SECONDARY DIAGNOSES
-------------------
#Chronic diastolic heart failure
#CKD
#HTN
#Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
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 had shortness of
breath and increased sputum, this was in the setting of an
exacerbation of your COPD. You were given prednisone and an
antibiotic which you should take for 5 days.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Use your Anoro Ellipta and budesonide every day and use your
albuterol as a rescue inhaler.
- Take azithromycin until ___
- Take prednisone until ___ contact PCP if you require an
additional course
- Try your best to stop smoking
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10583763-DS-13 | 10,583,763 | 25,391,614 | DS | 13 | 2137-06-14 00:00:00 | 2137-06-14 21:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with HTN, HLD, hypothyroidism,
COPD, Crohn's disease, CHF, who presented to the ED with
dyspnea. She has had several days of worsening dyspnea, both at
rest and with exertion. She tried to call her PCP to get oral
steroids and azithromycin, which had worked in the past, but had
worsening symptoms prompting her to come to the ED. She reports
being on prednisone and azithromycin a few weeks ago. She has
been having a mild cough with "a lot of mucus." She has also
noticed increased leg swelling bilaterally for 1 week. She
denies recent changes in Lasix dose or missed doses. She denies
chest pain or pressure. She denies fever, nausea, vomiting,
diarrhea. She denies sick contacts or recent travel. She denies
rhinorrhea, nasal congestion, sore throat, myalgias. She tried
Mucinex at home that helped a little. She's been feeling tired.
She was using her albuterol nebs several times per day for the
past few days - she says normally she'd use it ___ times per
day. She does not use the Anoro Ellipta because it makes her
"very nervous and hyper."
In the ED, she was afebrile, pulse initially 83 (up to 118), BP
122/86 (109/64-140/90), RR 20 (___), and O2 saturation of 96%
on room air. She did not require supplemental O2 per ED doctor.
She got duoneb x3, albuterol neb x3, IV Lasix 80mg, Prednisone
60mg, Azithromycin 500mg.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
CHF (dx ___, EF 35-40%, mild LVH, mod AR, mod TR; TTE ___
with EF 65% Mild-mod AR, Mild-mod)
Hypertension
Hypothyroid
Crohn's disease, not on any maintenance medications
Diverticulosis
Bell's palsy-R facial droop
Thoracic Type A aortic dissection s/p repair
Thoracic and abdominal aortic aneurysm
Colostomy and reversal for Crohn's
Open cholecystectomy
C-Section
Hysterectomy
Social History:
___
Family History:
Mother: Died at age ___ in her sleep. She had colon cancer s/p
resection and heart disease
Father: Died at age ___, DM and heart disease
Brother: Died at age ___, he had CHF, DM, and aneurysms
Physical Exam:
VS:
T 97.5 BP 115 / 76HR 82RR2292%RA
GENERAL: alert, sitting in bed comfortably speaking in full
sentences.
EYES: Anicteric, EOMI
ENT: Ears and nose without visible erythema, masses, or trauma.
OP clear. Dentures in place.
CV: RRR, no murmur, no S3, no S4. 2+ radial and pedal pulses
bilaterally.
RESP: No accessory muscle use, coarse breath sounds bilaterally,
somewhat distant. Good air entry bilaterally.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation. No Foley.
MSK: Moves all extremities. 1+ edema to just above ankles.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, EOMI, speech fluent,
moves all limbs
PSYCH: pleasant, appropriate affect, calm, cooperative
Pertinent Results:
ADMISSION LABS:
=============
___ 03:25PM BLOOD WBC-10.3* RBC-4.24 Hgb-11.0* Hct-35.1
MCV-83 MCH-25.9* MCHC-31.3* RDW-16.6* RDWSD-49.4* Plt ___
___ 03:25PM BLOOD Glucose-87 UreaN-37* Creat-1.6* Na-141
K-4.8 Cl-102 HCO3-26 AnGap-13
___ 03:25PM BLOOD ___
DISCHARGE LABS:
=============
___ 05:50AM BLOOD WBC-13.1* RBC-4.07 Hgb-10.4* Hct-33.6*
MCV-83 MCH-25.6* MCHC-31.0* RDW-16.6* RDWSD-49.6* Plt ___
___ 05:50AM BLOOD Glucose-120* UreaN-64* Creat-1.9* Na-141
K-4.4 Cl-98 HCO3-28 AnGap-15
IMAGING/OTHER STUDIES:
===================
CXR ___. Mild pulmonary interstitial edema.
2. Mediastinal prominence reflects known aortic aneurysm,
appears grossly unchanged.
Brief Hospital Course:
___ with COPD (not on oxygen), HFpEF, Crohn's, and HTN, presents
with productive cough, wheezing, ___ edema, and weight gain
consistent with concomitant COPD and CHF exacerbation.
# Dyspnea:
# Acute COPD exacerbation:
# Productive cough:
Patient endorsed several days of increased wheezing, productive
cough, and increased use of her home rescue inhaler. She noted
quick improvement of her symptoms with frequent nebulizers in
addition to a prednisone burst (40mg x 5d, last day ___ and
azithromycin (last day ___. CXR was without focal
consolidation. Outpatient pulmonary follow up arranged.
#Acute on chronic heart failure:
Presented with worsening dyspnea, pitting lower extremity edema,
and weight gain. proBNP elevated at ~11K. She was diuresed with
IV lasix for two days with noticeable improvement in her lower
extremity swelling and overall symptoms. Patient still with 1+
edema to just above ankles on day of discharge but adamantly
wished to be discharged home despite fully understanding the
recommendation for further active diuresis. Patient possessed
capacity to make informed medical decisions. At discharge, her
home lasix was increased back to BID dosing, which had been
effective in the past. Discharge weight of 64.7kg (142.8 lb) is
likely slightly above her true dry weight. Patient will need
close follow up to assess need for further diuretic titration.
CHRONIC/STABLE PROBLEMS:
#HTN: Normotensive throughout stay. Patient mantained on home
Coreg 12.5mg BID and Amlodipine 5mg daily.
#Hypothyroidism: continued home Synthroid 75mcg daily
#HLD: continued home Rosuvastatin 5mg QPM
#History of ascending aortic aneurysm: Repaired in ___, had
thoracic aortic dissection with graft placed. No symptoms to
suggest complication.
#History of Crohn's disease: Prior colectomy in ___ that
temporarily required colostomy. No related issues during this
hospital stay.
TRANSITIONAL ISSUES:
==================
# medication adjustments: Increased Lasix to 40mg BID; on
prednisone 40mg and azithro 250mg until ___.
# Discharge weight (not quite "dry"weight): 64.7kg (142.8 lb)
# please reassess volume and respiratory status at PCP follow up
# Recommend checking BMP at next visit given Lasix adjustment.
# F/u arranged with pulmonology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
5. Carvedilol 12.5 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Rosuvastatin Calcium 5 mg PO QPM
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
11. Budesonide 0.25 mg/2 mL inhalation BID
Discharge Medications:
1. Azithromycin 250 mg PO/NG Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 4 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
3. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. amLODIPine 5 mg PO DAILY
7. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
8. Aspirin 81 mg PO DAILY
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
10. Budesonide 0.25 mg/2 mL inhalation BID
11. Carvedilol 12.5 mg PO BID
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Rosuvastatin Calcium 5 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Acute COPD Exacerbation:
# Acute on Chronic Heart failure exacerbation:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital because you
were having trouble breathing caused by your COPD lung disease
and heart failure. You were given steroids and treated with a
water pill to remove fluid and your symptoms improved.
Please continue all medications as prescribed. It is very
important that you follow up with all scheduled appointments to
monitor your response to the medication adjustments.
We wish you the best!
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. in one day or 5lb in one week.
Followup Instructions:
___
|
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