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10583763-DS-14 | 10,583,763 | 25,125,082 | DS | 14 | 2137-07-31 00:00:00 | 2137-07-31 20:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea x 2 days
lower leg swelling x 3 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with COPD, HFpEF (TTE
___, EF>65%, dry weight: 135lbs), mild-moderate AR,
mild-moderate TR, thoracic + abd aortic aneurysm with h/o Type A
thoracic dissection s/p repair (___), Crohn's disease s/p
colostomy + subsequent reversal ___, not on any medications),
Bell's palsy w/ R facial droop, HTN, and hypothyroidism who is
being admitted from ___ clinic on ___ for worsening dyspnea.
The pt was recently hospitalized from ___ for concomitant
COPD and CHF exacerbation. For her COPD exacerbation, she
received a 5-day course of prednisone/AZT with plans to f/u with
Pulm as outpatient, although never did. Regarding her acute
HFpEF
exacerbation, on admission her BNP was ~11,000 (baseline 3000)
with mild interstitial edema on CXR. At the time of discharge,
she had 1+ edema above the ankles and demanded to be discharged
home despite recommendation for further diuresis (d/c weight:
142.8lbs, above dry weight: 135lbs). Her home Lasix was
increased
to 40mg bid prior to discharge. She did not keep her f/u PCP apt
after leaving the hospital.
However since discharge, the pt said she felt better than
before,
but never returned to baseline. Over the next several weeks she
complained of progressive shortness of breath with exertion.
Also
w/ increasing ___ edema. Orthopnea at baseline without PND.
Otherwise she also continued to have chronic cough productive of
small amounts of white sputum. No fevers, chills, chest pain,
n/v
or abdominal pain. Says that her scale at home is broken, so
could not comment on possible weight gain. Notably, the pt does
admit to occasionally missing doses of Lasix bc of the
inconvenience of frequent urination.
She presented to clinic on ___ after calling the clinic with
complaints of the above symptoms. Her weight there was recorded
143lbs, 8lbs above presumed dry weight. She was seen by Dr.
___ at referred her to the ED due to concern for concurrent
CHF/COPD exacerbation.
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:
===========================
VITALS: T 97.7, BP 118/71, HR 89, RR 20, O2 93% on RA
GENERAL: Alert and interactive, eating dinner, NAD
HEENT: NCAT. Sclera anicteric and without injection.
NECK: Supple, JVD 13cm, +HJR
CARDIAC: RRR, no m/r/g
LUNGS: Decreased breath sounds, diffuse wheezes and rhonchi
ABDOMEN: Soft, non tender, non distended BS+
EXTREMITIES: 2+ ___ edema to knees bilaterally
SKIN: Warm and well perfused
NEUROLOGIC: CN2-12 grossly intact, AOx3
DISCHARGE PHYSICAL EXAM:
==========================
VITALS: ___ 1140 Temp: 97.5 PO BP: 120/70 HR: 78 RR: 18 O2
sat: 93% O2 delivery: Ra
GENERAL: Alert and interactive, sitting in bed in NAD
HEENT: NCAT. Sclera anicteric and without injection.
CARDIAC: RRR, no m/r/g
LUNGS: Wheezes audible without stethoscope. Air movement poor,
with diffuse wheezes in all lung fields and delayed expiration
ABDOMEN: Soft, non tender, non distended BS+
EXTREMITIES: 2+ ___ edema to thighs, L>R
SKIN: Warm and well perfused; mild venous stasis changes at
ankles; poor toenail hygeine
NEUROLOGIC: Mild right upper and lower facial droop (chronic);
otherwise CN2-12 grossly intact, AAOx3
Pertinent Results:
ADMISSION LABS:
===================
___ 12:05PM BLOOD WBC-8.6 RBC-4.68 Hgb-12.0 Hct-39.3 MCV-84
MCH-25.6* MCHC-30.5* RDW-16.5* RDWSD-50.9* Plt ___
___ 12:05PM BLOOD Neuts-77.6* Lymphs-13.1* Monos-4.9*
Eos-3.4 Baso-0.7 Im ___ AbsNeut-6.70* AbsLymp-1.13*
AbsMono-0.42 AbsEos-0.29 AbsBaso-0.06
___ 12:05PM BLOOD Glucose-143* UreaN-36* Creat-1.7* Na-145
K-4.6 Cl-103 HCO3-24 AnGap-18
___ 12:05PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-7739*
___ 12:05PM BLOOD cTropnT-0.02*
___ 04:50PM BLOOD cTropnT-0.01
___ 07:00AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1
___ 07:00AM BLOOD TSH-6.5*
___ 12:25PM BLOOD ___ pO2-34* pCO2-51* pH-7.33*
calTCO2-28 Base XS-0
DISCHARGE LABS:
==================
___ 07:54AM BLOOD WBC-11.4* RBC-4.66 Hgb-11.9 Hct-38.4
MCV-82 MCH-25.5* MCHC-31.0* RDW-16.7* RDWSD-49.3* Plt ___
___ 07:54AM BLOOD Glucose-102* UreaN-66* Creat-2.0* Na-142
K-4.2 Cl-97 HCO3-27 AnGap-18
___ 07:54AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3
Brief Hospital Course:
PATIENT SUMMARY:
Ms. ___ is a ___ year old female with COPD, HFpEF (TTE
___, EF>65%, dry weight: 135lbs), mild-moderate AR,
mild-moderate TR, thoracic + abd aortic aneurysm with h/o Type A
thoracic dissection s/p repair (___), Crohn's disease s/p
colostomy + subsequent reversal ___, not on any medications),
Bell's palsy w/ R facial droop, HTN, and hypothyroidism who was
admitted ___ from ___ clinic for dyspnea x 2 days and ___ edema
2 weeks.
ACUTE ISSUES:
=============
# Acute on chronic HF exacerbation
She presented with reported dyspnea, lower extremity edema,
and ~4 lbs weight gain (dry weight 135lbs), along with BNP
elevated above baseline consistent w/ acute on chronic HFpEF.
Last TTE on ___ notable for EF>65%, mild-mod AR, mild-mod TR.
The likely etiology of her acute HFpEF is medication
non-adherence, as she reports missing doses of her evening Lasix
(40mg bid), worsened by patient not attending PCP appointment
after past discharge as she was unaware of having one. Patient
was diuresed during hospital stay with Torsemide PO 60mg BID on
___ and was net negative 1.4L. She was extensively
counseled on medical recommendation to stay in hospital for
further medical optimization. Patient understood the risks of
leaving the hospital and was able to articulate them fully
including risk of clinical deterioration and death. She also
understood our concern that she would be home alone. She is
getting in touch with her sister-in-law and her niece to call
and check on her. She also said she would get in touch with her
neighbors who would check on her. She verified that she would
return to the hospital if her breathing becomes any more
compromised or she fails to improve. She is aware of her
upcoming outpatient appointment with her pcp on ___. She
should have repeated TTE in the outpatient setting.
# COPD Exacerbation
Pt w/ long hx of COPD, prior admissions for exacerbations, most
recently ___. She received IV AZT 500mg x1 + IV methylpred
125mg x1 in ED on ___. She was flu negative, and her CXR was
grossly clear. Patient does not complain of overwhelming cough,
at this time, although exam significant for poor air movement
and diffuse wheezes. Her ambulatory sat decreased to 89-92%. It
improved to 97% on RA upon resting. She was discharged with a 5
day course of AZT (last dose ___. She was also discharged on
a prolonged tapered prednisone dose of 2 days of 30mg, 2 days of
20mg and 2 days of 10mg. She was also given duonebs every 4
hours and prn albuterol. Her home Anoro Ellipta and Budesonide
0.25 mg/2 mL inhalation BID was held iso systemic
steroids/frequent nebs (NB: pt admits that she is not always
compliant with budesonide at home). She should restart these
medications after Duonebs and Prednisone finishes.
# CKD
Cr 1.7 at admission, up to 2.0 prior to discharge. Kidney
function appears close to previous new baseline around 1.7-2.0.
# Thrombocytopenia:
Plt 141 at presentation. Not significantly lower than baseline
and improved prior to discharge to 169. Likely secondary to
inflammation iso COPD exacerbation and HFpEF exacerbation.
CHRONIC ISSUES:
===============
# HTN - Patient continued on home Coreg 12.5mg BID and
amlodipine 5mg daily.
# Hypothyroidism - TSH 6.3 on admission. Patient continued on
home Synthroid 75mcg daily.
# HLD
- Patient prescribed Rosuvastatin 5mg QPM, however, she reports
that
she no longer takes this medication at home. It was not
restarted upon admission.
# Thoracic, Abdominal aortic aneurysm
In ___, pt had a Type A thoracic dissection s/p repair with
graft placed. ___ CXR notable for: Severe upper mediastinal
widening due to generalized aortic ectasia and arterial
enlargement, which has not progressed. Appears stable.
- Continued on home ASA 81mg QD
# Crohn's disease s/p colectomy requiring colostomy + subsequent
reversal (___). Not on any home medications.
CORE MEASURES
=============
#CODE: Full, confirmed
#CONTACT: ___ (sister-in-law) ___
ALTERNATIVE CONTACT: ___niece) ___
TRANSITIONAL ISSUES:
=======================
[] Discharge weight: 139.7
[] Discharge Creatinine: 2.0
[] Patient discharged on a 1 week course of Torsemide 60mg PO
Daily, after which she should follow up with Dr. ___
dosage adjustments if not able to follow up with PCP at that
time, should switch back to home dose of Lasix 40mg BID
[] Patient with HFpEF, not currently on ___, not initiated
during this hospitalization given ___. Consider starting as
outpatient pending normalization of kidney function.
[] Likely needs TTE repeated as outpatient given hx of aortic
disease as well as presentations for dyspnea.
[] Needs PFTs as outpatient (non seen in ___ records) for
monitoring of COPD.
[] Patient counseled to follow prednisone taper as prescribed.
[] Please work with patient to fill out HCP paperwork
>30 minutes spent on discharge activites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 0.25 mg/2 mL inhalation BID
2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Furosemide 40 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
6. amLODIPine 5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
9. Rosuvastatin Calcium 5 mg PO QPM
10. Carvedilol 12.5 mg PO BID
11. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*1
Tablet Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
nebulizer inhaled Every 4 horus Disp #*1 Ampule Refills:*0
3. PredniSONE 10 mg PO DAILY Duration: 3 Doses
RX *prednisone 10 mg 4 tablet(s) by mouth Daily Disp #*16 Tablet
Refills:*0
4. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth Daily Disp #*21 Tablet
Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. amLODIPine 5 mg PO DAILY
8. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
9. Aspirin 81 mg PO DAILY
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
11. Budesonide 0.25 mg/2 mL inhalation BID
Start once finish the prednisone
12. CARVedilol 12.5 mg PO BID
13. Levothyroxine Sodium 75 mcg PO DAILY
14. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until you finish the torsemide.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
----------
Chronic pulmonary obstructive disease exacerbation
Diastolic Heart Failure exacerbation
Secondary:
----------
Tobacco dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had difficulty breathing and some lower leg swelling.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with diuretics to help remove fluid that was
caused by a heart failure exacerbation.
- You were treated with Prednisone and azithromycin, as well as
inhaled medications for your COPD exacerbation.
- We strongly encouraged you to stay for ongoing monitoring, but
you were very adamant that you wanted to go home. You promised
us you would return to the hospital if your breathing got any
worse.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please stop the budesonide until you finish the prednisone.
- Please stop the Lasix until you finish the Torsemide.
- Please stop the ___ and ___ 1 week of Duonebs and then
continue the ___.
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Follow up with Dr. ___ on ___ for further
adjustments to your medications.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10583763-DS-17 | 10,583,763 | 20,583,635 | DS | 17 | 2137-11-11 00:00:00 | 2137-11-11 19:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ woman with history of COPD, tobacco
use, HFreF, who presents with respiratory distress. Patient
states for the past 2 or 3 days she has been having increasing
shortness of breath, wheeze, and cough. She denies fevers, chest
pain. She has had some increasing lower extremity edema, denies
increasing orthopnea. States she has been taking all her
medications at home as prescribed. No abdominal pain, vomiting,
diarrhea, dysuria, hematuria. Patient called EMS, who found her
in respiratory distress, speaking ___ words at a time, and
administered nebulizer treatments with some improvement.
Of note, patient was admitted ___ for COPD exacerbation,
discharged on pred taper. She met with Palliative Care for
advanced care planning, and mentioned she did not want to be
intubated but is agreeable to re-hospitalization. Also admitted
___ with COPD and CHF exacerbation, ___
with COPD exacerbations. PCP initiated ___
___, but patient reports she has been inconsistently
taking
meds at home d/t confusion. She has ongoing tobacco use ___
cigarettes daily, has not tried nicotine patches she's been
prescribed, declined buproprion.
- In the ED, initial vitals were: HR 69 BP 112/63 RR 18 97%
on RA
- Exam was notable for: appears uncomfortable, increased work
of
breathing, prolonged expiratory phase, diffuse wheezing on
auscultation
Cardiovascular: Regular rate and rhythm. Normal S1 and S2. 2+
symmetric peripheral edema. Warm and dry
- Labs were notable for:
___ 05:40PM BLOOD WBC: 7.1 RBC: 4.06 Hgb: 10.5* Hct: 34.7
MCV: 86 MCH: 25.9* MCHC: 30.3* RDW: 16.8* RDWSD: 52.3* Plt Ct:
172
___ 05:40PM BLOOD Glucose: 129* UreaN: 34* Creat: 1.6* Na:
141 K: 4.4 Cl: 105 HCO3: 26 AnGap: 10
___ 05:40PM BLOOD CK-MB: 10 MB Indx: 4.3 proBNP: 6027*
VBG 7.27 / ___
- Studies were notable for:
CXR widened aorta, mildly nlarged heart.
- The patient was given:
In EMS: Albuterol (Proventil/Ventolin) 2.5 mg, Duonebs
In ED: Magnesium Sulfate, MethylPREDNISolone Sodium Succ 80 mg,
Ipratropium-Albuterol Neb x 2, Azithromycin 500
On arrival to the floor, pt reports she is feeling much better
since getting nebs. She hopes to only be here ___ days. She's
not
sure if she would want intubation or not if it came to that
because she doesnt want to be uncomfortable, but does feel she
would get better. Doesnt think her lung disease is necessarily
severe.
Past Medical History:
PMH:
COPD
HTN, dCHF
Hypothyroidism
Bell's palsy
CKD
CHF, diastolic, with prior EF 65%, now 40%
Crohn's disease, quiescent
Surgical history
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 had colon cancer
Father CAD
Brother CHF, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 96.2 BP 131 / 72 HR 64 RR 20 O2 Sat 98 on 5L
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP<10cm.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diffuse wheezes, poor air movement.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: +Clubbing. 2+ periph edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Moves all 4 with purpose
Discharge Physical Exam
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP<10cm.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diffuse wheezes, poor air movement.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: +Clubbing. 2+ periph edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Moves all 4 with purpose
Pertinent Results:
Admission Labs
___ 05:40PM BLOOD WBC-7.1 RBC-4.06 Hgb-10.5* Hct-34.7
MCV-86 MCH-25.9* MCHC-30.3* RDW-16.8* RDWSD-52.3* Plt ___
___ 05:40PM BLOOD Neuts-64.3 ___ Monos-7.8 Eos-5.1
Baso-0.7 Im ___ AbsNeut-4.53 AbsLymp-1.54 AbsMono-0.55
AbsEos-0.36 AbsBaso-0.05
___ 05:40PM BLOOD Plt ___
___ 05:40PM BLOOD Glucose-129* UreaN-34* Creat-1.6* Na-141
K-4.4 Cl-105 HCO3-26 AnGap-10
___ 05:40PM BLOOD CK(CPK)-235*
___ 05:40PM BLOOD CK-MB-10 MB Indx-4.3 proBNP-6027*
___ 05:40PM BLOOD cTropnT-0.02*
___ 10:00AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.6
___ 05:47PM BLOOD ___ pO2-43* pCO2-60* pH-7.27*
calTCO2-29 Base XS-0 Intubat-NOT INTUBA
___ 05:47PM BLOOD Lactate-1.0
___ 05:47PM BLOOD O2 Sat-69
Imaging
TECHNIQUE: AP view of the chest.
COMPARISON: Chest x-ray from ___. CTA chest from ___.
FINDINGS:
When compared to multiple priors, there has been no change.
Eventration of
the right hemidiaphragm is again noted with likely adjacent
atelectasis. The
lungs are otherwise clear. Enlarged mediastinal contour is
compatible with
known thoracic aortic aneurysm. Median sternotomy wires are
intact. No acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Discharge Labs
___ 06:49AM BLOOD WBC-10.6* RBC-4.46 Hgb-11.4 Hct-37.4
MCV-84 MCH-25.6* MCHC-30.5* RDW-17.2* RDWSD-52.7* Plt ___
___ 06:49AM BLOOD Plt ___
___ 06:49AM BLOOD ___ PTT-31.4 ___
___ 06:49AM BLOOD Glucose-89 UreaN-61* Creat-1.9* Na-139
K-4.8 Cl-99 HCO3-26 AnGap-14
___ 06:49AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.5
Brief Hospital Course:
Ms. ___ is an ___ woman with history of COPD, tobacco
use, HFreF, who presents with ___ days dyspnea, found to have
COPD exacerbation and volume overload.
Transitional Issues:
===========================
[] Lasix 80mg with increase in Cr to 1.9 though weight stable.
Patient discharge with plan for Cr repeat on ___ at ___
[] If Cr improved to baseline, consider starting furosemide 60mg
daily on ___ or ___
[] Last dose of prednisone and azithromycin on ___
[] ___ conversation with change in code status to DNR/DNI, MOLT
signed
ACUTE/ACTIVE ISSUES:
===================
# Acute on chronic HFrEF
Volume overload in the setting of medication non-adherence and
URI. TTE w/
LVEF 40%, mild LVH, PDA distribution systolic dysfunction.
Respiratory status improved with diuresis and empiric treatment
of COPD. Lasix 80mg PO with stability in weight though Cr
increased to 1.9. Patient feels strongly about discharge and
able to have labs drawn in 1 day with plan to follow up with
outpatient PCP. Holding diuretics on day of discharge with
likely plan to resume furosemide 60mg daily in ___ days pending
labs. Emailed PCP re plan.
# COPD exacerbation
Trigger likely URI and incomplete med adherence d/t confusion
with new meds, ongoing cigarette smoking, and CHF exacerbation.
Treated with prednisone and azithromycin for ___nemia
Baseline ___. Suspect related to CKD. No e/o bleed.
# CKD
Cr 1.6 baseline likely 1.5-1.6, has been as high as 2.1
recently. Cr bump on discharge as above.
#Goals of care:
Discussed with patient re code status and confirmed DNR/DNI with
MOLST signed and placed in chart.
# Hypothyroid- cont home levothyroxine 75mg
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. amLODIPine 5 mg PO QPM
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. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
12. Furosemide 40 mg PO EVERY OTHER DAY
13. Furosemide 60 mg PO EVERY OTHER DAY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. amLODIPine 5 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
8. CARVedilol 12.5 mg PO BID
9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Lisinopril 5 mg PO DAILY
12. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
14. HELD- Furosemide 60 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until contacted by PCP
15. HELD- Furosemide 60 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until seen by pcp
16. HELD- Furosemide 60 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until directed by pcp
17.Outpatient Lab Work
BMP
ICD 10 code N17.9
Please fax results to ___ FAX: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
=====================
Acute on chronic heart failure exacerbation
Secondary diagnosis:
========================
COPD Exacerbation
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for shortness of breath
What was done for me while I was in the hospital?
- You got intravenous Lasix to help remove fluid from you lungs
- you were treated for a COPD exacerbation
What should I do when I leave the hospital?
- Please go to Health Care Associated for lab work tomorrow
(___)
- Dr. ___ will call you with results with plan to restart
furosemide depending on your lap results
- Please call Dr. ___ ___ by ___
morning (___) if you have not heard from him to determine
dose of Lasix as you should be restarting Lasix by ___ at
the latest
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10583763-DS-20 | 10,583,763 | 26,382,608 | DS | 20 | 2138-03-08 00:00:00 | 2138-03-11 12:52:00 |
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:
HPI(4): Ms. ___ is an ___ female with COPD, CHF
(diastolic w EF 40%), CKD, hypothyroidism, thoracic type A
aortic
dissection s/p repair, colostomy and reversal for Crohn's, open
cholecystectomy, hysterectomy, with recent admission for CHF
exacerbation presenting with shortness of breath.
Patient reports that he was discharged on ___, and started to
feel increasingly short of breath over the past 2 days. Patient
typically checks daily weights, but has not been checking them
over the past few days. Last time she checked a few days ago,
she
weighed 137 on her home scale, and reports that she was 135 when
she first came home from the hospital last. Endorses increasing
orthopnea, cough (nonproductive), without associated fever,
chills, chest pain, nausea, vomiting. Does endorse some mild
increased lower extremity edema however admits she doesn't
really
look at her legs and it's hard for her to compare to before.
Patient is still completing oral vancomycin course for C.
difficile, 1 dose left, and endorses some decreased use of her
diuretics in the setting of her diarrhea (from 60mg daily of
Lasix to 40mg daily), but states that she has not had
significant
diarrhea over the past few days, having ___ episodes of
semi-formed stools per day. She was putting out good urine to
60mg Lasix dose, less so with 40mg dose.
Of note, she reports that her dyspnea is "stronger" this time
than usual when she has her CHF exacerbations, therefore she
thinks this time it's more COPD rather than CHF. When asked to
clarify further exactly what the difference is in dyspnea
between
the two conditions, she says this is a good question and she'll
have to get back to me about this.
Initial ED vital signs were notable for: T 97.1, HR 93, BP
147/69, RR 22, 99% neb.
Exam notable for:
Decreased breath sounds at the left base, bilateral crackles to
the apices.
JVD present, 2+ pitting edema to the upper shins bilaterally.
Labs were notable for:
- CBC: WBC 10.9 (70%n), hgb 9.7, plt 194
- Lytes:
139 / 100 / 26 AGap=13
-------------- 97
5.0 \ 26 \ 1.4
- trop 0.04
- ___ 21622
- VBG 7.33/54
- Lactate:1.1
Studies performed include: CXR with No definite acute
cardiopulmonary process.
Patient was given:
___ 13:43 IV Furosemide 60 mg
___ 15:28 IV Azithromycin 500 mg IV
___ 15:28 PO PredniSONE 40 mg
Vitals on transfer: T 98.0, HR 84, BP 139/50, RR 22, 95% 2L NC
Upon arrival to the floor, reports history as above. Currently
feeling much better than when she first came to the ED.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypertension
Hypothyroidism
Type A thoracic aortic aneurysm s/p repair
COPD
Crohn's disease
HF with borderline EF (40%)
CKD
Diverticulitis
Social History:
___
Family History:
Mother had colon cancer
Father CAD
Brother CHF, DM
Physical Exam:
EXAM(8)
VITALS: ___ Temp: 97.8 PO BP: 137/74 HR: 84 RR: 20 O2
sat: 94% O2 delivery: 2L
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. External jugular is
distended to mid-neck at 45 degrees (patient short of breath
when
attempted to put at 30 degrees therefore unable to do so), no IJ
distention noted
RESP: Breathing non-labored. Poor air movement bilaterally,
scattered end-expiratory wheezes, no crackles
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. 2+ pitting edema in
bilateral legs
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:
___ 12:10PM BLOOD WBC-10.9* RBC-3.84* Hgb-9.7* Hct-31.1*
MCV-81* MCH-25.3* MCHC-31.2* RDW-16.2* RDWSD-47.0* Plt ___
___ 05:21AM BLOOD WBC-6.7 RBC-4.26 Hgb-10.6* Hct-35.4
MCV-83 MCH-24.9* MCHC-29.9* RDW-16.1* RDWSD-48.7* Plt ___
___ 12:10PM BLOOD Glucose-97 UreaN-26* Creat-1.4* Na-139
K-5.0 Cl-100 HCO3-26 AnGap-13
___ 04:20AM BLOOD Glucose-147* UreaN-36* Creat-1.6* Na-142
K-4.9 Cl-99 HCO3-27 AnGap-16
___ 04:55PM BLOOD Glucose-140* UreaN-51* Creat-1.7* Na-139
K-4.6 Cl-96 HCO3-29 AnGap-14
___ 07:15AM BLOOD ___
___ 04:55PM BLOOD Calcium-8.7 Phos-4.0 Mg-2.2
___ 12:10PM BLOOD TSH-95*
___ 12:10PM BLOOD T3-57* Free T4-0.7*
I personally reviewed the [ECG] and my interpretation is: LVH,
sinus rhythm, no acute ischemic changes, T waves upright except
for in lead aVR, not significantly different than last ECG
___ CXR
FINDINGS: When compared to most recent exam, there has been no
significant interval change. Enlargement of the mediastinal
contour is compatible with known underlying thoracic aortic
aneurysm. The heart is at least mildly enlarged. There is
eventration of the right hemidiaphragm with adjacent opacity,
presumably atelectasis. No pleural effusion. No acute osseous
abnormalities.
IMPRESSION: No definite acute cardiopulmonary process.
Brief Hospital Course:
___ is an ___ female with COPD, CHF (diastolic w
EF
40%), CKD, hypothyroidism, thoracic type A aortic dissection s/p
repair, colostomy and reversal for Crohn's, open
cholecystectomy,
hysterectomy presenting for shortness of breath, due to CHF and
COPD exacerbation.
This is her fifth hospitalization this year for this combination
of syptoms, and she was hospitalized for the same set of
symptoms
seven times last year.
ACUTE/ACTIVE ISSUES:
====================
#Acute on Chronic Systolic HF with borderline EF (40%):
#Acute Hypoxic Respiratory Failure:
#COPD with exacerbation.
She was initially diuresced with IV lasix, and then transitioned
to oral lasix on ___ when her weight was 137 lbs; however, on
___ her weight increased to 143 lbs, and IV diuresis was
continued and she was discharged at a weight of 143.6.
She may benefit from transition to torsemide from lasix, and
this should be discussed at heart failure f/u.
She responded very well to oral steroids, and she was prescribed
a long taper. We tried to obtain pulmonary f/u, but their
office would not schedule f/u due to many missed appointments.
___ MD emailed to see if appointment could be offered.
#C diff colitis:
#Crohn's disease s/p colectomy:
Has finished treatment course of vancomycin.
#Severe Hypothyroidism: Last admission TSH elevated to 96 iso
being noncompliant with her medications. Possible that some mild
myxedema is contributing to her ___ swelling in addition to CHF
- Continue home levothyroxine
- TSH showing slow decline; she may have complance, but not be
absorbing well due to gut edema
#Leukocytosis:
#Eosinophilia: resolved.
#New mild microcytic anemia: Hgb down to 9.7, previously around
___ as of last week. No reports of bleeding. Possibly
dilutionally down if truly intravascularly volume overloaded.
MCV
borderline low. Could be ___ thyroid disease, consider iron
deficiency as well.
-checking iron studies
# Recurrent admissions, some medication non adherence, not
complying with medical advice: Patient repeatedly stated that
she did not need "extra help" at home. OT saw her and felt that
she had good medication recollection, but that her MOCA was 16.
There was a lengthy email chain among inpatient and outpatient
providers; collectively felt that patient would greatly benefit
from enrollment in ___ so that she would
receive more intensive home based services; patient does respond
to diuretics and steroids, and closer management of her OCPD and
CHF would lead to fewer admissions.
CHRONIC/STABLE ISSUES:
======================
#CAD
No coronary angiogram in our records, but patient with new WMA's
on last TTE in ___. Was seen by cards in ___ with plans
for medical optimization.
- Continue home aspirin
#Moderate aortic root dilation: Seen on TTE ___
-outpatient f/u
#CKD
Baseline Cr 1.4-1.8.
- Renally dose medications
- CTM
#Hypertension
- hold home lisinopril
- continue carvedilol as above
#Tobacco use
- Nicotine patch
#Hyperlipidemia
Patient has a history of myalgias associated with atorvastatin
10
mg qday. Patient has had discussions with her PCP about being on
rosuvastatin, but patient does not wish to take a statin.
- Re-visit with patient about initiating statin as outpatient
#Vitamin B12 deficiency
- Continue home vitamin B12
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. CARVedilol 6.25 mg PO BID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Vancomycin Oral Liquid ___ mg PO QID
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
8. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
9. Lisinopril 5 mg PO DAILY
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Cyanocobalamin ___ mcg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
14. Furosemide 60 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 3 Doses
2. PredniSONE 40 mg PO DAILY
4 tablet(s) by mouth qam on ___, 3 tabs ___, 2 tabs
___, 1 tab ___
3. Furosemide 80 mg PO DAILY
Take this dose until you followup with the heart specialist on
___. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Aspirin 81 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. CARVedilol 6.25 mg PO BID
9. Cyanocobalamin ___ mcg PO DAILY
10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
15. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see the cardiologist on ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Shortness of breath due to both COPD and CHF
2. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and were found to
have significant wheezing due to COPD and extra fluid in your
lungs due to your heart failure. You initially lost a lot of
weight due to fluid removal, but you have gained five pounds in
water weight in one day, and you refused to stay for additional
medication to remove fluid from your lungs. We will discharge
you on a higher dose of Lasix, and hope that you get to your
goal weight of 137 lbs. Your weight on discharge is 143.6.
You have a cardiology followup appointment on ___, and they can
adjust your Lasix dose further at that time and determine
whether it is safe to resume your Lisinopril.
It is very important that you weigh yourself regularly and that
you stop smoking, as that is one thing that you control that can
help your COPD. We are discharging you on a slow taper and are
attempting to arrange a pulmonary followup appointment.
Followup Instructions:
___
|
10583763-DS-23 | 10,583,763 | 23,175,746 | DS | 23 | 2138-05-10 00:00:00 | 2138-05-10 20:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ female with medical history
notable for COPD, HFrEF, recent admission for COPD/HFrEF
exacerbation requiring intubation, hypertension, hypothyroidism,
type a thoracic aortic aneurysm status post repair, CKD,
diverticulitis, Crohn's disease who presents to the ED with
dyspnea, found to be hypoxic.
Of note, she was recently discharged on ___. She was admitted
from ___ for hypoxemic respiratory failure likely due to
CHF
exacerbation with component of COPD exacerbation. She required
intubation and aggressive diuresis with IV Lasix. She was
initially DNR/DNI per a MOLST for that admission but reversed
her
code status after failing BiPAP.
For this admission she states that she was feeling dyspneic.
Called EMS who noted that she was hypoxic to the ___, placed on
nonrebreather and brought to ED. She tells me that she was
noncompliant with her diet because she was feeling better and
eating more.
On arrival to the ED, she was triggered for respiratory
distress.
RR 23, other vitals stable. Exam notable for diffuse wheezing.
CXR with some possible RLL vascular congestion vs evolving
consolidation, as well as diffuse interstitial infiltrates.
Received IV methylpred 80mg x1, stacked duonebs x3, azithromycin
500mg and placed on BiPAP. Her respiratory status rapidly
improved and she was transitioned to 2L NC.
On arrival to the floor states her dyspnea is improved. Dry
cough. No chest pain.
Past Medical History:
-Hypertension
-Hypothyroidism
-Type A thoracic aortic aneurysm s/p repair
-COPD
-Crohn's disease
-HFrEF (40%)
-CKD
-Diverticulitis
Social History:
___
Family History:
Mother had colon cancer
Father CAD
Brother CHF, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GEN: NAD appropriate mood and affect
HEENT: NC/AT EOMI no JVP appreciable at 90 degrees
CV:RRR
PULSES: 2+ radial
RESP: Diffusely expiratory wheezes
ABD: soft NTND
EXT:pedal edema bilateraly
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 97.3 BP 114 / 68 HR 75 RR 20 O2 97% RA
GENERAL: Alert, oriented, no acute distress, sitting up in chair
HEENT: Sclerae anicteric, MMM, JVD not appreciated with patient
upright
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur heard best at USB, no rubs/gallops
LUNGS: breathing calmly, diminished lung sounds in posterior,
minor crackles heard in lung bases bilaterally, wheezing
significantly improved
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
EXTREMITIES: Warm, well perfused, 2+ pulses, 2+ pitting edema in
b/l ___ with dark skin in the ___ b/l, no clubbing/cyanosis
SKIN: Warm, dry, no rashes or notable lesions, though ___ has a
dressing covering a wound per patient report
NEURO: AOx3.
Pertinent Results:
ADMISSION LABS
==============
___ 01:56AM BLOOD WBC-6.6 RBC-4.19 Hgb-10.4* Hct-35.5
MCV-85 MCH-24.8* MCHC-29.3* RDW-17.7* RDWSD-54.1* Plt ___
___ 01:56AM BLOOD Neuts-74.0* Lymphs-16.3* Monos-6.9
Eos-1.7 Baso-0.5 Im ___ AbsNeut-4.90 AbsLymp-1.08*
AbsMono-0.46 AbsEos-0.11 AbsBaso-0.03
___ 01:56AM BLOOD Glucose-111* UreaN-42* Creat-1.8* Na-143
K-4.6 Cl-103 HCO3-26 AnGap-14
___ 01:56AM BLOOD Albumin-4.0 Calcium-9.1 Phos-5.2* Mg-2.2
___ 01:56AM BLOOD ALT-14 AST-34 AlkPhos-105 TotBili-0.2
___ 01:56AM BLOOD ___ PTT-34.4 ___
___ 01:56AM BLOOD Lipase-43
___ 01:56AM BLOOD cTropnT-0.04* ___
___ 01:44AM BLOOD ___ pO2-49* pCO2-56* pH-7.37
calTCO2-34* Base XS-4
___ 02:02AM BLOOD Lactate-1.9
PERTINENT RESULTS
=================
___ CXR: Mild pulmonary edema with likely small left pleural
effusion, overall similar to the previous study. Stable enlarged
cardiomediastinal silhouette.
___ Blood culture: growth negative to date (___).
DISCHARGE LABS
==============
___ 07:43AM BLOOD WBC-7.2 RBC-3.73* Hgb-9.4* Hct-31.3*
MCV-84 MCH-25.2* MCHC-30.0* RDW-17.5* RDWSD-53.5* Plt ___
___ 07:43AM BLOOD Glucose-94 UreaN-60* Creat-2.0* Na-145
K-4.7 Cl-98 HCO3-23 AnGap-24*
___ 07:43AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.4
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
Discharge Cr: 2.0
Discharge Wt: 64.1 kg
[ ] Ms. ___ should complete her course of azithromycin and
prednisone (end ___ for COPD exacerbation
[ ] Repeat thyroid function tests as outpatient
[ ] Speech and language consultation noted substantial dysphagia
and risk of aspiration. Consider outpatient work-up of swallow
function
[ ] repeat PFTs.
[ ] Speech and language consultation was concerned for
tracheobronchomalacia as a cause of recurrent admissions with
honking cough and more dyspneic appearance compared to prior.
They suggest work-up by pulmonology with dynamic chest CT
[ ] continue to monitor her weights and uptitrate diuretic as
needed.
BRIEF SUMMARY:
==============
Ms. ___ is an ___ female with medical history notable
for
COPD, HFrEF, recent admission for COPD/HFrEF exacerbation
requiring intubation, who presents to the ED with dyspnea, found
to be hypoxic and admitted with concern for COPD/HFrEF
exacerbation. Her dyspnea is improved without oxygen requirement
s/p albuterol nebs, prednisone, azithromycin, IV Lasix, and
Diuril. She was discharged back on her home torsemide.
ACUTE ISSUES
============
#Dyspnea, hypoxia
#COPD exacerbation
#HFrEF exacerbation
Ms. ___ shortness of breath, found to be satting ___ on RA
at home per EMS, required BiPAP briefly in ED, transitioned to
2L NC after initiation of steroids and stacked duonebs. Of note,
she has had recent hospitalizations (most recent dc'd ___ for
hypoxemic RF, requiring intubation, thought to be combined HFrEF
exacerbation/COPD exacerbation. For this presentation, likely
contributions from both COPD and HFrEF, possibly in setting of
dietary nonadherence. Lung exam, improvement s/p nebs and
solumedrol, and wheezing support COPD; proBNP, CXR, and pitting
edema support HFrEF. Unlikely PNA w/o fever, changes in sputum,
normal WBC. Of note, SLP suggested dx of tracheobronchomalacia
given repeated hospitalizations, lung exam with honking cough,
and dyspneic appearance. We trended daily weights, I/Os, BID
lytes while diuresing with as much as 200 IV Lasix and 500 IV
Diuril. For her HF, we continued home carvedilol 6.25 BID,
Hydral 10 TID, Isosorbide dinitrate 10 TID (fractionated home
imdur). For COPD, she received IV solumedrol in the ED, was
continued on 40 prednisone daily on the floor and azithromycin
(course: ___. We continued home inhalers (swapped
non-formulary symbicort for formulary advair) and weaned O2
supplementation as tolerated. At discharge, she was without an
oxygen requirement or dyspnea, weight 64.1 kg. She has 2 more
days of azithromycin and prednisone to complete, given to her at
discharge.
#Dysphagia
Concern for aspiration by nursing. Seen by ___ who recommended
nectar thick liquid diet with soft solids given high aspiration
risk. Patient threatened to leave AMA over her diet, and instead
accepted risks of aspiration in discussion with SLP to
liberalize her
diet. We thus switched her to a regular diet. She had no
aspiration pneumonitis or pneumonia during this admission.
CHRONIC/STABLE ISSUES
=====================
#CKD
Baseline Cr 1.6-2.0. No ___ on admission. We trended daily,
especially in the setting of diuresis. Discharge Cr 2.0.
#Abnormal thyroid function
Last D/C summary with TI to repeat TFTs. Continued on home
levothyroxine 75 mcg PO.
#Anemia
Unclear etiology. Normal MCV, though on lower end of normal.
Iron
studies previously normal (___). No concern for bleed. Anemia
of chronic disease possible but would expect iron abnormalities.
We trended CBC without significant drops in Hct.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. CARVedilol 6.25 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Torsemide 80 mg PO BID
8. HydrALAZINE 10 mg PO Q8H
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. Cyanocobalamin ___ mcg PO DAILY
12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
13. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 2 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate 90 mcg 2 puff IH every six (6) hours Disp
#*1 Inhaler Refills:*0
5. Aspirin 81 mg PO DAILY
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
7. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Cyanocobalamin ___ mcg PO DAILY
9. HydrALAZINE 10 mg PO Q8H
RX *hydralazine 10 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine [Euthyrox] 75 mcg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
14. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
16. Torsemide 80 mg PO BID
RX *torsemide [Demadex] 20 mg 4 tablet(s) by mouth twice a day
Disp #*240 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Heart failure with reduced ejection fraction exacerbation
Chronic obstructive pulmonary disease exacerbation
SECONDARY DIAGNOSIS
=====================
Dysphasia
Chronic kidney disease
Anemia
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after developing severe shortness of
breath. You were found to have a COPD exacerbation and heart
failure exacerbation.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did an x-ray of your chest, which showed us that you were
likely having a heart failure exacerbation
- We also treated you for your COPD exacerbation with steroids,
azithromycin, and albuterol nebulizer
- We treated you for your heart failure exacerbation by giving
you IV diuretics (IV versions of your water pill). We also
continued your blood pressure medications (Hydralazine,
Isosorbide, carvedilol) from your last hospital discharge
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Go to your scheduled appointments with your primary care
doctor, cardiologist (heart doctor), and pulmonologist (lung
doctor)
- Continue to take all your medicines and keep your
appointments. Finish your prednisone and azithromycin as
directed.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10583763-DS-26 | 10,583,763 | 26,479,081 | DS | 26 | 2138-08-20 00:00:00 | 2138-08-20 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
================
CBC/COAGS
___ 04:30AM BLOOD WBC-8.0 RBC-4.69 Hgb-11.6 Hct-38.8 MCV-83
MCH-24.7* MCHC-29.9* RDW-18.3* RDWSD-53.6* Plt ___
___ 04:30AM BLOOD Neuts-80.3* Lymphs-11.0* Monos-7.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-6.43* AbsLymp-0.88*
AbsMono-0.61 AbsEos-0.00* AbsBaso-0.02
___ 12:44PM BLOOD ___ PTT-48.3* ___
CMP
___ 04:30AM BLOOD Glucose-36* UreaN-48* Creat-1.9* Na-137
K-5.1 Cl-99 HCO3-17* AnGap-21*
___ 04:30AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.4
CARDIAC/VBG/LACTATE
___ 04:30AM BLOOD cTropnT-0.12* ___
___ 12:44PM BLOOD CK-MB-22* cTropnT-0.11*
___ 12:59PM BLOOD ___ pO2-92 pCO2-46* pH-7.29*
calTCO2-23 Base XS--4 Comment-GREEN TOP
___ 07:23AM BLOOD ___ pO2-127* pCO2-41 pH-7.38
calTCO2-25 Base XS-0
___ 04:56AM BLOOD Lactate-2.2*
___ 12:59PM BLOOD Lactate-1.2
Discharge Labs:
===============
CBC:
___ 07:08AM BLOOD WBC-4.5 RBC-3.96 Hgb-9.7* Hct-31.7*
MCV-80* MCH-24.5* MCHC-30.6* RDW-17.9* RDWSD-51.3* Plt ___
Chemistry:
___ 07:08AM BLOOD Glucose-62* UreaN-42* Creat-1.6* Na-138
K-4.0 Cl-95* HCO3-27 AnGap-16
___ 07:08AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.7
SPEP/UPEP/Light Chain:
___ 07:30AM BLOOD PEP-NO SPECIFIC ABNORMALITIES SEEN
DIFFUSE (POLYCLONAL) STAINING EXTENDS FROM THE GAMMA REGION INTO
THE BETA REGION. THIS PATTERN, CALLED 'BETA-GAMMA BRIDGING' IS A
SOFT SIGN OF POLYCLONALLY ELEVATED IGA, OFTEN ASSOCIATED WITH
LIVER DISEASE. THE ALPHA-2 GLOBULIN BAND IS DIMINISHED, THE
USUAL MAIN COMPONENT IS HAPTOGLOBIN
FreeKap-122.9* FreeLam-49.2* Fr K/L-2.50* b2micro-12.8*
___ 10:01AM URINE U-PEP-NO PROTEIN DETECTED
PERTINENT STUDIES
=================
___ Imaging CHEST (PA & LAT)
1. Slight interval improvement in, now mild to moderate,
pulmonary edema.
2. Slight interval decrease in size in bilateral pleural
effusions, now trace.
CT Chest:
1. Limited motion degraded study performed without the
administration of intravenous contrast.
2. Known aneurysmal dilatation of the thoracic aorta and
innominate artery, demonstrating progression from ___, but
overall stable from the more recent studies performed in ___.
Note that the study was not optimized for assessment of acute
coronary syndrome.
3. Stable dilatation of the central pulmonary arterial
vasculature, likely reflecting underlying pulmonary
hypertension.
4. Stable cardiomegaly.
5. Multiple enlarged mediastinal lymph nodes, measuring up to 14
mm in short axis, unchanged from ___. There is likely
additional bilateral hilar lymphadenopathy, not well assessed on
today's non-enhanced scan.
6. Overall deterioration in the appearance of the lung
parenchyma, with progression of multifocal parenchymal
opacities, which now involve a larger surface area in multiple
lobes. In the appropriate clinical context, this is consistent
with an infectious process. No discrete lung mass is identified.
7. Small bilateral pleural effusions, larger on the right,
demonstrating decrease in volume from the study performed in
___.
8. Small volume abdominal ascites.
9. Multifocal lucent bone lesions concerning for malignancy,
multiple myeloma or metastatic disease specifically. The
dominant lucent lesion within the T11 vertebral body with
associated central height loss through the superior endplate of
T11 is stable from the prior study but significantly larger when
compared to the study performed in ___. There is a
lucent lesion along the posterior aspect of the L1 vertebral
body, demonstrating an increase in size from ___, and
new from ___. There are multifocal lucent lesions in
the ribs bilaterally. The small lucent lesion in the right
posterolateral rib 3 was not definitely seen on the prior study.
No new pathologic fractures identified on today's study.
Video Swallow Exam: (Speech and swallow interpretation)
ORAL PHASE:
Lip Closure - complete
Tongue Control During Bolus Hold - mostly complete though
intermittent loss to FOM
Bolus Preparation/Mastication - slow, prolonged, with poor
rotary chew, chewing anteriorly
Bolus Transport - slowed w/ pt reporting need for liquid to
assist with transport of cracker; timely once initiation w/
liquid
Oral Residue (clears?)- trace tongue and palate residue
PHARYNGEAL PHASE:
Initiation of Pharyngeal Swallow - delayed w/ trigger varying
from the valleculae for puree/solids to posterior laryngeal
surface to pyriform sinuses for liquids
Soft Palate (SP) Elevation - complete
Laryngeal Elevation - partial - mild-moderately reduced
Anterior Hyoid Excursion - partial - mild-moderately reduced
Epiglottic Movement - partial inversion
Laryngeal Vestibular Closure - incomplete with narrow to wide
column of contrast at height of swallow
Pharyngeal Stripping Wave - present though diminished
Pharyngoesophageal Segment Opening - posterior prominence
present though did not result in obstruction of bolus flow;
osteophytes also present in area of PES and along spine
Tongue Base (TB) Retraction - trace to narrow column of contrast
between TB and PPW
Pharyngeal Residue (clear?) - trace to mild diffuse residue for
liquids; puree and solid trials too limited to assess residue
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
___ female ___ HFrEF, COPD, CKD presenting with dyspnea
and cough in the setting of not taking diuretics for two weeks,
per MD recommendation. Due to concern for her presentation not
being completely consistent with HF exacerbation, she underwent
chest CT which showed evidence of chronic aspiration. She had a
video oropharyngeal swallow study which showed moderate
oropharyngeal dysphagia and evidence of aspiration. It was
recommended that she consider diet modification to reduce her
risk of aspiration, but she declined and acknowledged the risks
associated with that plan. However, she was willing to accept a
risk-reduction strategy of coughing and swallowing a second time
after each bite.
Additionally, on admission, she was found to have evidence of
left lower extremity cellulitis for which she was treated with
Keflex/doxycycline for 10 days.
TRANSITIONAL ISSUES
====================
[] She had a video swallow study that showed moderate
oropharyngeal dysphagia with aspiration. She was recommended to
make diet changes with thickened liquids, but declined and
accepted the risks. She may benefit from reevaluation of this
issue over time with recommendation of thickened liquids if she
becomes amenable.
[] As a risk-reduction strategy, she agrees to do a
swallow-cough-swallow technique with each bite (mobilizes
residual material from the valleculae that would otherwise
trickle down into the trachea). Please encourage her to
SWALLOW-COUGH-SWALLOW with each bite.
[] Please monitor volume status and titrate diuretics prn.
Discharged on 40mg torsemide qd iso low PO intake. If her PO
intake increases, she may benefit from increasing her diuretic
dose.
[] Her home isordil/hydralazine were held during her admission
due to soft BPs. If BP is consistently above 110 systolic, would
suggest restarting these for benefit in HFrEF.
[] Lytic lesions: CT torso with known lytic lesions concerning
for myeloma or mets. SPEP/UPEP showed no monoclonal bands, so
these remain on unknown etiology. She declined further workup,
citing her limited goals of care.
[] Left paratracheal soft tissue mass: Left thyroid enlargement
versus lymphadenopathy. Please repeat TSH/T4 and thyroid U/S if
within her GOC.
[ ] Discharge weight- 109.79 lbs
[ ] Discharge Cr- 1.6
ACUTE ISSUES:
=============
# Acute on chronic systolic heart failure
Patient admitted for dyspnea in the setting of not taking home
torsemide over past two weeks. She received diuresis to a point
of apparent euvolemia. She is discharged on torsemide 40 mg
daily. This is lower than her former torsemide dose, but her PO
intake is very poor currently and she became lightheaded when he
tried a higher dose. She was continued on home carvedilol
6.25mg BID. Due to soft BPs, her home isordil/hydralazine were
held.
# Oropharyngeal dysphagia
# Chronic aspiration
Chest CT showed severe damage from chronic aspiration. Video
swallow exam showed moderate oropharyngeal dysphagia with
aspiration. We suspect that recurrent aspiration pneumonitis has
been the cause of her frequent hospitalizations.
It was recommended that she consider diet modification to reduce
her risk of aspiration, but she declined and acknowledged the
risks associated with that plan.
As a risk-reduction strategy, she agrees to do a
swallow-cough-swallow technique with each bite (mobilizes
residual material from the valleculae that would otherwise
trickle down into the trachea). Please encourage her to
SWALLOW-COUGH-SWALLOW with each bite.
# LLE cellulitis
On admission exam, LLE notable for erythema, tenderness, and
warmth with several areas of skin breakdown and irregular
border. Pt reported leg redness/swelling for 1 month although
pain increased in past few days. MRSA risk factors include
recent hospitalization 2 weeks ago so patient was treated with
10 days of cephalexin and doxycycline.
# Tobacco use
She was given nicotine patch while inpatient, which was
continued as an outpatient.
CHRONIC ISSUES:
===============
# CKD
Baseline Cr 1.5-1.7. She remained at her baseline throughout
this admission. Discharge Cr was 1.6.
# Hypothyroidism
Continued home levothyroxine 88mcg QD
=============
#CODE: DNR/DNI (per MOLST)
#HCP: ___ (sister-in-law) ___. Note that the
patient makes her own decisions at baseline.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Torsemide 100 mg PO QAM
2. Torsemide 80 mg PO QPM
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. HydrALAZINE 10 mg PO Q8H
7. Aspirin 81 mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
9. CARVedilol 6.25 mg PO BID
10. Cyanocobalamin ___ mcg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
15. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
Discharge Medications:
1. Torsemide 40 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Aspirin 81 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. CARVedilol 6.25 mg PO BID
7. Cyanocobalamin ___ mcg PO DAILY
8. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
13. HELD- HydrALAZINE 10 mg PO Q8H This medication was held. Do
not restart HydrALAZINE until seen by your primary care
provider.
14. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until seen by your primary care
provider.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Heart failure with reduced ejection fraction (LVEF = 30%)
Acute on chronic aspiration
SECONDARY DIAGNOSIS:
Oropharyngeal dysphagia
Type A thoracic aortic aneurysm post repair
Coronary artery disease
Chronic kidney disease
Stage IV COPD
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of difficulty breathing.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We gave you medications to help get rid of some of the extra
fluid in your body that was making your breathing more
difficult.
- You also had a scan of your chest that showed evidence of
aspiration- when food or liquids end up in your lungs when you
swallow. You had a swallow study that confirmed this.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- We continue to recommend that you consider switching to
thickened liquid to help reduce your risk of getting further
material in your lungs.
- Be sure to take all your medications and attend all of your
appointments listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10583763-DS-5 | 10,583,763 | 24,320,098 | DS | 5 | 2130-10-04 00:00:00 | 2130-10-04 11:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Replacement of ascending and hemiarch aorta with a 30-mm
Gelweave Dacron graft. ___
History of Present Illness:
Mrs. ___ reports several days of abdominal bloating, increased
gas and developed abdominal pain, back pain and vomiting. She
went to an outside hospital thinking she had a flair of her
Crohn's disease. A CTA was done which showed a Type A aortic
disection. She was transferred to ___ for surgical repair of
her dissection.
Past Medical History:
hypertension
hypothyroid
Crohn's disease
Bell's palsey-R facial droop
s/p colostomy and reversal for Crohn's
s/p open cholecystectomy
s/p C-Section
s/p hysterectomy
Social History:
___
Family History:
unable to obtain due to emergent nature of dissection
Physical Exam:
Pulse:122 Resp:18 O2 sat:96%
B/P Right:109/68 on esmolol and nipride Left:
Skin: Dry [x] intact [x]
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade _unable to assess
Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [x] Edema [] _none____
Varicosities: None [x]
Neuro: Grossly intact-except R facial droop []
Pulses:
Femoral Right:2+ Left:2+
DP Right:Tr Left:Tr
___ Right:Tr Left:Tr
Radial Right: 2+ Left:2+
Pertinent Results:
___ ___ MRN: ___ TEE (Complete) Done
___ at 5:45:19 AM FINAL
Referring Physician ___
___ Status: Inpatient DOB: ___
Age (years): ___ F Hgt (in): 62
BP (mm Hg): / Wgt (lb): 143
HR (bpm): BSA (m2): 1.66 m2
Indication: Emergent aortic dissection
ICD-9 Codes: 441.00, 441.2
___ Information
Date/Time: ___ at 05:45 ___ MD: ___,
MD
___ Type: TEE (Complete) Sonographer: ___, MD
Doppler: Full Doppler and color Doppler ___ Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: ___-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: *4.2 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the ___ or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
global LV hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Mildly dilated aortic arch. Mildly dilated descending aorta.
Complex (>4mm) atheroma in the descending horacic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
___ VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Small to moderate pericardial effusion. Stranding
is visualized within the pericardial space c/w organization. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: The ___ was under general anesthesia
throughout the procedure. No TEE related complications. The
___ appears to be in sinus rhythm. Results were personally
reviewed with the MD caring for the ___. See Conclusions for
post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is dilated. 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 is present. A left-to-right
shunt across the interatrial septum is seen at rest. An
echodense mass 0.5 cm x 0.5 cm is seen outside the left atrial
appendage floating the pericardial effusion (suggestive of
strands?). No mass seenn in the left atrial appendage. This was
confirmed before sync cardioversion for the afib after
induction.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild global left ventricular hypokinesis
(LVEF = 40 %). Overall left ventricular systolic function is
mildly depressed (LVEF= 40 %). LV function seem to be ___
after initial stabilization of hemjodynamics.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The descending thoracic aorta is mildly dilated. There
are complex (>4mm) atheroma in the descending thoracic aorta.
An echodense mobile density is seen in the ascending aorta from
the ST junction at the Right coronary cusp going across and
extending into the distal ascending aorta with hematoma
suggestive of aortic dissection. In the visualized portion of
aortic arch and descending thoracic aorta, this dissection is
not seen.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is a small to moderate sized pericardial effusion.
Stranding is visualized within the pericardial space c/w
organization. There are no echocardiographic signs of tamponade.
POST-BYPASS:
Normal RV systolic function.
LVEF 45% (Mild global LV systolic dysfunction).
Intact thoracic aorta with the intact graft visualized.
Minimal MR and AI.
___ 04:35AM BLOOD WBC-9.3 RBC-4.30 Hgb-10.7* Hct-32.9*
MCV-77* MCH-24.8* MCHC-32.4 RDW-18.0* Plt ___
___ 04:35AM BLOOD Na-137 K-4.6 Cl-99
___ 04:32AM BLOOD Glucose-86 UreaN-24* Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-32 AnGap-9
___ 02:15AM BLOOD WBC-12.4* RBC-4.51 Hgb-10.9* Hct-32.6*
MCV-72* MCH-24.1* MCHC-33.3 RDW-14.9 Plt ___
___ 02:15AM BLOOD Glucose-133* UreaN-27* Creat-1.1 Na-130*
K-4.5 Cl-97 HCO3-22 AnGap-16
___ 02:15AM BLOOD ALT-11 AST-12 CK(CPK)-85 AlkPhos-113*
Amylase-29 TotBili-0.3
Brief Hospital Course:
On ___ Ms. ___ was brought emergently to the Operating Room
and underwent repair of her Type A aortic dissection. This
procedure was performed by Dr. ___. Please see the operative
note for details. She tolerated the procedure well, weaned from
bypass on Neo Synephrine and Propofol and was transferred in
critical but stable condition to the surgical intensive care
unit. She was given Amiodarone for post-operative atrial
fibrillation, which quickly resolved.
By post-operative day one she was extubated and tolerated
beta-blockade. Her chest tubes were removed. On the following
day she was transferred to the surgical step down floor.
Amiodarone was discontinued secondary to her history of thyroid
dysfunction and she remained in a sinus rhythm. Her epicardial
wires were removed on POD 3. Mesalamine was resumed and no ASA.
Physical Therapy worked with her and she was diuresed towards
her preoperative weight.
She was transferred to ___ in ___ on ___ for
further recovery prior to returning home.
Medications on Admission:
colace 100mg daily
levothyroxine 50mcg daily
lisinopril 10mg daily
mesalamine 800mg three times a day
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 6
days: until at pre-op weight.
11. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 7 days: please
check K+ .
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Type A Aortic Dissection
emergency repair of Type A dissection
hypertension
Crohn's disease
hypothyroidism
Bell's Palsy
s/p colon resection for Crohn's
s/p cholecystectomy
s/p hysterectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10583763-DS-6 | 10,583,763 | 27,404,620 | DS | 6 | 2134-11-18 00:00:00 | 2134-11-22 21:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF with h/o thoracic as well as aortic abdominal aneurysm,
thoracic aortic dissection ___ s/p repair, hypothyroidism,
Crohn's disease s/p resection ___ with temporary colostomy
currently on no medications, systolic CHF, who p/w sudden onset
nausea, dry heaving, and diarrhea x 1 day
Ms. ___ reports that she was in her USOH until ___ morning
(___). She had 1 episode of loose stools in the morning after
eating a muffin and her usual morning coffee. She then had a
busy day, doing housework and watching some TV. She was sitting
down to watching the 6pm news when she suddenly developed severe
nausea and had 1 episode of diarrhea. She reports intense
sweating during the episode. The diarrhea was mostly watery and
did not have any blood. She denies any abdominal pain or chest
pain during this episode. She denies any vomiting or fevers
during the day. She then called ___ given how poorly she felt
and was brought to the ED.
She states that before ___, her Crohn's flares presented
similarly. She also notes that her aortic dissection previously,
also presented similarly. On ___, she bought some chicken
wings from ___ and at them cold on ___ night. Otherwise,
she does not note anything unusual in her diet. She denies any
sick contacts.
ROS: 10-point ROS negative except as noted above in HPI
Past Medical History:
Systolic CHF (dx ___, EF 35-40%, mild LVH, mod AR, mod TR)
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
s/p colostomy and reversal for Crohn's
s/p open cholecystectomy
s/p C-Section
s/p hysterectomy
Social History:
___
Family History:
Mother passed at ___ in her sleep. She had colon cancer s/p
resection and had a heart condition. Father passed away at age
___, he had diabetes and heart disease. Brother recently passed
away 2 weeks ago at age ___, he had CHF, DM, and aneurysms.
Physical Exam:
ADMISSION EXAM:
VITALS - 97.4, 155/72, 66, 20, 100% RA
GENERAL - pleasant, well-appearing, sitting up in bed and eating
crackers, in NAD
HEENT - NC/AT, no conjunctival pallor or scleral icterus,
PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP is flat at 90 degrees
CARDIAC - RRR, normal S1/S2, soft II/VI systolic murmur heard
throughout precordium
PULMONARY - CTAB, without wheezes or rhonchi
ABDOMEN - multiple well healed scars, normal BS, soft, NT, ND,
no HSM
EXTREMITIES - warm, well-perfused, no cyanosis, 1+ pitting edema
of the left ankle
SKIN - no rashes evident
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE EXAM:
GENERAL - pleasant, well-appearing, sitting edge of bed and
eating in NAD
HEENT - NC/AT, no conjunctival pallor or scleral icterus,
PERRLA, EOMI, OP clear
NECK - supple, no LAD, JVP is flat at 45 degrees
CARDIAC - RRR, normal S1/S2, soft II/VI systolic murmur
PULMONARY - CTAB, without wheezes or rhonchi
ABDOMEN - multiple well healed scars, normal BS, soft, NT, ND,
no HSM
EXTREMITIES - warm, well-perfused, no cyanosis, 1+ pitting edema
of the left ankle up to ___ of calf
SKIN - no rashes evident
NEUROLOGIC - A&Ox3, moving all 4 limbs without focal deficits
Pertinent Results:
ADMISSION LABS
___ 08:02PM BLOOD WBC-8.0 RBC-4.05 Hgb-10.3* Hct-33.5*
MCV-83 MCH-25.4* MCHC-30.7* RDW-15.9* RDWSD-48.2* Plt ___
___ 08:02PM BLOOD Glucose-97 UreaN-30* Creat-1.8* Na-140
K-4.3 Cl-103 HCO3-24 AnGap-17
___ 07:40AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1
___ 08:02PM BLOOD CRP-5.8*
___ 23:14
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 9 < OR = 30 mm/h
DISCHARGE LABS
___ 07:40AM BLOOD WBC-7.7 RBC-4.15 Hgb-10.5* Hct-34.1
MCV-82 MCH-25.3* MCHC-30.8* RDW-15.9* RDWSD-47.7* Plt ___
___ 12:55PM BLOOD Glucose-117* UreaN-29* Creat-1.4* Na-139
K-4.1 Cl-106 HCO3-21* AnGap-16
___ Left Leg Ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Ms. ___ is an ___ yo woman with h/o CHF (last EF 35-40% ___,
hypothyroidism, and history of AAA and Crohn's who presents with
sudden onset nausea and diarrhea, resolved on admission,
admitted with concern for ___.
# Gastroenteritis: Patient's sudden onset nausea and watery
non-bloody diarrhea were likely due to infectious
gastroenteritis vs food borne illness. No sick contacts. Less
likely are Crohn's flare and ischemic colitis given no fever,
rapid resolution of symptoms and ESR / CRP WNL. Patient has not
any IBD flares since her colonic resection in ___. Patient did
not have any nausea, vomiting or diarrhea during
hospitalization. Tolerating POs well on discharge with no
recurrence of symptoms during hospital course.
# ___ on CKD: Patient admitted with creatinine of 1.8. Prior
records show 1.2 at ___ in ___. Also in ___ she
was diagnosed with CHF and started on diuretics. PCP records
show ___ 1.8 in ___ and 2.08 in ___. In ___ her PCP
decreased both her lisniopril and Lasix doses. On admission Cr
was 1.8, decreased to 1.4 after 2L of IVF and holding home
diuretics. Likely she has some component of pre-renal given
response to fluid and history of diarrhea and poor PO intake x
1day. Her home Lasix was restarted given EF 35% and her
lisinopril was decreased to 10mg daily.
CHRONIC ISSUES
# Abdominal and Thoracic Aneurysm: Patient has known thoracic
aortic aneurysm involving the ascending and descending aorta,
with last measurements at the apex of the arch of 6.2 cm. The
proximal decending aorta measured 5 cm, and 4.3 cm in the mid
descending aorta. She underwent replacement of ascending and
hemiarch aorta with a 30-mm Gel weave Dacron graft for Type A
aortic dissection in ___. She apparently discussed surgical
options with Dr. ___ at one point(per ___ note, pt
declined surgical intervention), however during this admission
she reports she would be amenable to surgical intervention if
recommended and does not remember she had a discussion about
surgical intervention previously. She reports that surgery was
not offered as an option. Follow up was scheduled as outpatient
with Vascular Surgery. Counseled patient on tobacco cessation.
After discussion, patient agreed to nicotine replacement therapy
with gum. She was provided with a prescription on discharge.
# HTN: Home Lasix and lisnopril held due to ___. Furosemide
restarted prior to DC and lisinopril dose was reduced to 10 mg
daily. Continued home amlodipine throughout hospitalization.
#Hypothyroidism: continued home levothyroxine
TRANSITIONAL ISSUES:
-Lisinopril decreased to 10 mg daily from BID. Cr on D/C 1.4.
-Follow up with vascular surgery to discuss surgical
intervention on aneurysm.
-Recommend that patient quit smoking
# CONTACT: sister ___ ___
# CODE: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Lisinopril 10 mg PO BID
3. Carvedilol 12.5 mg PO BID
4. Amlodipine 5 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Furosemide 40 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking craving
RX *nicotine (polacrilex) 2 mg use when you have smoking craving
Q2H Disp #*360 Gum Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastroenteritis
___ on CKD
Secondary:
Thoracic and abdominal aortic aneurysm
Crohn's Disease
Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ on ___ after having a few
episodes of nausea and diarrhea. It appears your diarrhea was
most likely from a virus or bacteria. After reviewing your labs
and examining you, it does not seem likely that it was caused by
Chrons flare or your aneurysm. You had some kidney injury on
admission. We gave you fluids and held your water pill and your
kidneys improved. We recommend decreasing your lisinopril to
10mg once a day until you see Dr. ___. Please attend all of
your follow up appointments and take all of your medications as
prescribed. We are working to arrange for you to follow up with
vascular surgery to discuss surgical options for your aneurysm.
We recommend that you stop smoking (or smoke as little as
possible). It was a pleasure taking part in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10583763-DS-9 | 10,583,763 | 21,825,147 | DS | 9 | 2136-05-29 00:00:00 | 2136-05-29 18:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pmhx COPD, CHF, HTN who presents for dyspnea.
She was having worsening sputum production and SOB. She was seen
at ___ on ___ for dyspnea, treated for COPD exacerbation,
discharged to home on levaquin, prednisone. She was not able to
fill the prescription. She woke at 4:00 AM with dyspnea, called
EMS morning of ___ for transport as she felt her breathing had
worsened. She also had a cough productive of whitish sputum. She
arrived to ___ on a nebulized combivent per EMS.
She was given steroids in the ED as well as a breathing
treatment. Reports that her breathing is improved.
She was admitted to medicine for COPD exacerbation. On
examination on the floor, she reports that her breathing is
better.
Past Medical History:
PAST MEDICAL HISTORY:
Systolic CHF (dx ___, EF 35-40%, mild LVH, mod AR, mod TR)
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
PAST SURGICAL HISTORY:
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 had a heart condition
Father: Died at age ___, he had diabetes and heart disease
Brother: Died at age ___, he had CHF, DM, and aneurysms
Physical Exam:
ADMISSION PHYSICAL:
VITALS: 98.1 133 / 77R Lying 88 20 98 2L
GENERAL: Alert, oriented, no acute distress, conversant,
breathing comfortably
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Diminished air movement, no crackles appreciated
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, 2+ pitting edema to
mid-calf
NEURO: Face grossly symmetric. Moving all limbs with purpose
against gravity. Pupils equal and reactive, no dysarthria.
DISCHARGE PHYSICAL:
VITALS: T 98.5 BP 100-140/60-70 HR 85 RR ___ O2 98% RA
GENERAL: Alert, oriented, no acute distress, conversant,
breathing comfortably
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Diminished air movement, no crackles appreciated,
ambulating with less SOB compared to ___
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, 2+ pitting edema to
mid-calf
NEURO: Face grossly symmetric. Moving all limbs with purpose
against gravity. Pupils equal and reactive, no dysarthria.
Pertinent Results:
ADMISSION LABS:
___ 10:12PM BLOOD WBC-9.7 RBC-4.68 Hgb-11.7 Hct-38.3 MCV-82
MCH-25.0* MCHC-30.5* RDW-17.0* RDWSD-49.7* Plt ___
___ 10:12PM BLOOD Neuts-75.6* Lymphs-14.0* Monos-5.3
Eos-4.2 Baso-0.5 Im ___ AbsNeut-7.34* AbsLymp-1.36
AbsMono-0.52 AbsEos-0.41 AbsBaso-0.05
___ 10:12PM BLOOD Glucose-100 UreaN-30* Creat-1.4* Na-139
K-6.7* Cl-101 HCO3-24 AnGap-14
___ 10:00AM BLOOD proBNP-2400*
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-10.8* RBC-4.49 Hgb-11.3 Hct-36.7
MCV-82 MCH-25.2* MCHC-30.8* RDW-17.0* RDWSD-50.2* Plt ___
___ 05:50AM BLOOD Glucose-103* UreaN-42* Creat-1.6* Na-145
K-4.3 Cl-103 HCO3-27 AnGap-15
IMAGING:
CXR ___:
1. Bibasilar opacities likely represent atelectasis.
2. Hyperinflated lungs are compatible with known COPD.
3. Superior mediastinal widening is similar to prior studies,
compatible with
known aortic aneurysm, better seen on the CTA chest from ___.
Brief Hospital Course:
___ with pmhx COPD, CHF, HTN who presented for dyspnea ___ COPD
exacerbation. During this hospitalization, she was ruled out for
pneumonia and CHF exacerbation, and her COPD was managed with
azithromycin, steroids, and duonebs. A more detailed hospital
course by problem is outlined below.
#COPD: She had just recently been discharged from ___ for a
COPD exacerbation but was unable to fill her o/p meds afterwards
(levaquin and prednisone). She re-presented with dysnpea. On
admission, there was low concern for pneumonia given the absence
of leukocytosis and fever, and the absence of focal
consolidations on CXR. The patient's BNP of 2400 was lower than
previous (4000 on ___, making a CHF exacerbation less
likely. We therefore treated Ms. ___ for a COPD exacerbation w/
azithromycin, prednisone, and duonebs. She was discharged with
azithromycin and prednisone.
#Congestive Heart Failure: Pt's BNP on admission was 2400, which
is lower than 4000 on ___. Her last echo in ___ showed an
EF of 40%. We therefore continued pt's home Lasix, while holding
her carvedilol in the setting of a COPD exacerbation.
#Hypertension: Continued home amlodipine.
#Hypothyroid: Continued home synthroid.
#Tobacco use: Provided a nicotine patch.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Azithromycin 500 mg PO Q24H Duration: 3 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
2. Furosemide 40 mg PO EVERY OTHER DAY
3. Furosemide 20 mg PO EVERY OTHER DAY
4. Nicotine Patch 7 mg TD DAILY
RX *nicotine 7 mg/24 hour 1 patch Daily Disp #*28 Patch
Refills:*0
5. PredniSONE 40 mg PO DAILY Duration: 3 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*6 Tablet
Refills:*0
6. umeclidinium 62.5 mcg/actuation inhalation QAM COPD
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
8. amLODIPine 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Carvedilol 12.5 mg PO BID
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___.
Why did you come to the hospital?
You were admitted to our hospital for being short of breath,
coughing, and producing sputum, a result of a COPD exacerbation.
What did we do for you?
- We obtained blood tests to evaluate whether or not you were
infected; between the blood test results and a chest x-ray, we
determined that your symptoms were not due to infection or an
exacerbation of your heart failure, but rather due to a COPD
exacerbation
- We treated you with steroids, antibiotics, and breathing
(nebulizer) treatments
- We monitored you to observe symptom improvement, and
discharged you from the hospital
What do you need to do?
- Take your medications as prescribed. Hold off carvedilol for 3
days until you complete your azithromycin and prednisone
treatments, then you can re-start carvedilol.
- Follow up with your primary care physician
___ was ___ pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10583892-DS-3 | 10,583,892 | 27,282,067 | DS | 3 | 2135-09-01 00:00:00 | 2135-09-02 16:35:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Biaxin / lisinopril / amlodipine / codeine / Fosamax / Pepcid /
pravastatin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left cerebellar stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is an ___ yo woman with PMH significant for HTN, HLD
and
recent stroke (___) who presents as a transfer from ___
___
with an MRI showing a left cerebellar infarct. The patient
reports that at some point on ___ she noticed an "fuzzy
feeling" in the back of her head. The patient went to sleep
___ night feeling well. early th morning she woke up to
get
some water and felt very unsteady on her feel. like she was
being
pulled to the left. she was about to get herself some mild and
something soft to eat (she just had a root canal done on
___.
She got her self back to her room and fell asleep. Later that
morning when she got up she continued to feel unsteady. She
spoke
to her daughter who felt this was likley related to the root
canal and poor po intake. On ___ the daughter came to pick
the
patient up for a doctors ___ for the
"dizziness") and found her constantly "listing" to the left. Her
PCP sent her to the ___ who acquired a CT, MRI and MRA.
The MRI showed scattered acute ischemic infarcts in the inferior
left cerebellum - prompting her transfer to ___.
The patient prior stroke in ___ consisted of right hand and
face numbness. It is not clear if an etiology was identified.
On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia, drop
attacks, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, paresthesias. No bowel
or bladder incontinence or retention.
On general ROS: 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:
PMH:
HTN
HLD
stroke ___
hx vertigo
cataracts
macular degeneration
Social History:
___
Family History:
FHx:
NC
Physical Exam:
Admission Exam:
T: 97.7 HR: 86 BP: 170/80 RR: 16 Sat: 97% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress
HEENT: Sclera are non-injected. Mucous membranes are moist.
CV: RRR
Lungs: CTA
Abdomen: NT
Extremities: No Edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and time. Able
to relate history without difficulty. Language is fluent and
appropriate with intact comprehension, reading, repetition and
naming of both high and low frequency objects. subtle
dysprosody.
There were no paraphasic errors. Speech was not dysarthric. Able
to follow both midline and appendicular commands. No neglect,
left/right confusion or finger agnosia.
Cranial Nerves:
I: not tested
II: visual fields full to confrontation,
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric with activation; symmetric speed and
excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. Mild L pronation
without drift. rebound L>R
Strength:
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
Reflexes:
___ Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes are down going bilaterally.
Sensory: normal and symmetric perception of pinprick, vibration
and temperature.
Coordination: Finger to nose without dysmetria bilaterally -
slower on left. No intention tremor. RAM with less consistent
cadence on the left. trouble with mirroring on the left.
Gait: Not tested
---------------
Pertinent Results:
___ 09:10AM BLOOD WBC-6.3 RBC-3.80* Hgb-12.6 Hct-37.5
MCV-99* MCH-33.2* MCHC-33.6 RDW-12.4 RDWSD-45.1 Plt ___
___ 11:00PM BLOOD WBC-12.0* RBC-3.84* Hgb-12.5 Hct-38.8
MCV-101* MCH-32.6* MCHC-32.2 RDW-12.3 RDWSD-45.5 Plt ___
___ 11:00PM BLOOD Neuts-64.9 ___ Monos-9.8 Eos-1.7
Baso-0.7 Im ___ AbsNeut-7.80* AbsLymp-2.70 AbsMono-1.18*
AbsEos-0.20 AbsBaso-0.09*
___ 09:10AM BLOOD Plt ___
___ 11:00PM BLOOD Plt ___
___ 11:00PM BLOOD ___ PTT-30.2 ___
___ 09:10AM BLOOD Glucose-113* UreaN-24* Creat-1.1 Na-137
K-4.3 Cl-99 HCO3-26 AnGap-16
___ 11:00PM BLOOD Glucose-110* UreaN-19 Creat-0.9 Na-140
K-4.0 Cl-104 HCO3-21* AnGap-19
___ 09:10AM BLOOD ALT-17 AST-26 AlkPhos-86 TotBili-0.4
___ 09:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:10AM BLOOD Albumin-3.7 Calcium-9.9 Phos-3.8 Mg-1.8
Cholest-127
___ 11:00PM BLOOD Calcium-10.2 Phos-3.2 Mg-1.7
___ 09:10AM BLOOD Triglyc-107 HDL-49 CHOL/HD-2.6 LDLcalc-57
___ 09:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:36PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:36PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 09:36PM URINE RBC-16* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
IMAGING:
CT HEAD WITHOUT CONTRAST:
Focal area of hypodensity in the left cerebellar hemisphere on
image 4:6 in
keeping with an acute infarct.
Focal hypodensity in the left thalamus in keeping with a
subacute/chronic
infarct.
Scattered hypodensities in the periventricular, subcortical and
deep white
matter, nonspecific, likely since secondary to small vessel
ischemic changes.
Intracranial atherosclerotic calcification.
CTA HEAD/NECK:
1. Acute infarct in the left cerebellar hemisphere.
2. Focal stenosis of right M1 segment of middle cerebral artery
with bilateral
internal carotid cavernous and supraclinoid ICA atherosclerosis.
Narrowing
and irregularity of multiple anterior and posterior circulation
arteries due
to atherosclerotic disease.
3. Approximately 50% stenosis of the left internal carotid
artery at its
origin.
4. High-grade stenosis near the origin of left vertebral artery.
5. Atherosclerosis of the aortic arch with an ulcerated soft
plaque.
TTE (___): Symmetric LVH with normal global and regional
biventricular systolic function. Mild pulmonary hypertension.
Chest CT (___):
1. Innumerable, small nodules which may be infectious,
inflammatory, or
neoplastic. Short term follow-up is recommended to document
stability or
resolution.
2. Severe atherosclerosis.
Brief Hospital Course:
___ woman with PMH significant for HTN, HLD and recent stroke
(___) who presents as a transfer from ___ with an MRI
showing a left cerebellar infarct. This is the second stroke
that the patient has had in 3 months without a clear cause
identified. These strokes appear embolic, likely artery to
artery without history of atrial fibrillation. Her CTA is
notable for diffuse intra- and extracranial atherosclerosis,
also w/ high-grade left vert stenosis, R M1 focal stenosis and
50% L ICA stenosis, in addition to an ulcerated aortic arch
plaque. Echo was w/ normal EF but LVH and mild pulmonary
hypertension. Given absence of LV thrombus,patient was stopped
on home ASA 81mg and started on Clopidogrel 75mg to be continued
at least until next clinic visit with Stroke Specialists.
Overall the patients symptoms are mild with some rebound,
trouble with fine motor and mirroring on the left.
- Lipids LDL 57/A1C 6.2
- Tele during admission without atrial fibrillation
- There was some concern about prior bright red blood per
rectum, but after speaking w/ PCP was thought to be due to
hemorrhoids and w/o any significant GI bleed in the past.
- Started on Clopidogrel 75mg daily for recurrent stroke in
setting of daily aspirin
- Stopped home ASA 81mg daily
- Continue home atorvastatin 40mg daily
Pulm:
-CXR w/ 1.1cm mass
-Chest CT showing innumerable small nodules without focal mass
per prelim read
-ESR 9/CRP 3.3
CV:
-Held antihypertensives for first 24h after stroke to allow for
autoregulation
-Restarted amlodipine at low dose, 2.5mg daily in setting of
hypertension prior to discharge
-Goal home SBP 120-150 given degree of atherosclerosis w/
associated stenosis
ID: Bactiuria
- s/p 3d of Ceftriaxone for UA suggestive of UTI, though
asymptomatic
TRANSITIONAL ISSUES:
-Stroke: Requires Stroke Neurology follow-up for L cerebellar
infarct and continuation of Clopidogrel monotherapy
-HTN: Please allow for goal SBPs 120-150, slightly elevated to
preserve cerebrovascular perfusion given atherostenosis, may
increase to home amlodipine 7.5mg and losartan 100mg as long as
BPs remain within goal.
-Chest nodules: Requires follow-up with PCP regarding repeat
___ CT in the coming months for follow-up for innumerable
chest nodules to see if resolved ___ self-limited
inflammatory/infectious process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Potassium Chloride 10 mEq PO DAILY
4. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
5. Amlodipine 7.5 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Restasis 1 app Other BID
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
Reduced from home dose, can uptitrate as BP tolerates but GOAL
120-150 systolic
2. Restasis 1 app Other BID
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
8. Potassium Chloride 10 mEq PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Cerebellar Infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Exam: left ataxia arm>leg, with a few saccadic intrusions but no
nystagmus. Gait listing to left. Full strength
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficultly with
balance resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. We would like to add back your blood pressure goals
to maintain a goal of 120-150 as outpatient. We transitioned
you from aspirin to Plavix to help prevent strokes in the
future.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10583939-DS-21 | 10,583,939 | 25,370,733 | DS | 21 | 2114-08-01 00:00:00 | 2114-08-01 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L proximal humerus fracture
Major Surgical or Invasive Procedure:
ORIF left proximal humerus
History of Present Illness:
___ transferred from ___ for a
left humerus fracture and a left pelvic fracture s/p mechanical
fall. Earlier today, patient was walking in her house when she
tripped over a rug, impacting her left shoulder then her left
hip
onto a hard tile floor. She felt immediate L shoulder and hip
pain, and has been unable to walk since the injury. There was no
LOC but patient describes recalling her glasses falling off and
having a persistent bruise along her left cheek. Denies torso
pain, neck pain, or back pain.
Patient BIB EMS to ___ where initial workup including
CTH/C-spine, L shoulder plain films, pelvis and L hip films
demonstrated a proximal L humerus fracture and dislocation, and
a
superior / inferior pubic ramus fracture, superior fracture
minimally displaced. Partial reduction achieved under procedural
sedation and patient placed in sling / swath for transfer.
On arrival to BI ED pt describes persistent pain, worse with
movement, in her anterior pelvis, lower back, and left shoulder.
Past Medical History:
Htn
HLD
anxiety
hypothyroidism
Social History:
___
Family History:
noncontributory
Physical Exam:
Exam on Discharge
AVSS
NAD, A&Ox3
CV: rrr
Pulm: lungs ctab
RUE Incision well approximated. Fires EPL/FPL/FDP/FDS/EDC/DIO.
SITLT radial/median/ulnar. 1+ radial pulse, wwp distally. Arm in
sling and swathe.
Pertinent Results:
___ 06:55AM BLOOD WBC-6.1 RBC-2.86*# Hgb-7.7*# Hct-24.4*#
MCV-85 MCH-26.9 MCHC-31.6* RDW-14.4 RDWSD-44.7 Plt ___
___ 10:15PM BLOOD Neuts-89.1* Lymphs-5.6* Monos-4.4*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.23* AbsLymp-0.58*
AbsMono-0.46 AbsEos-0.01* AbsBaso-0.02
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-91 UreaN-14 Creat-1.2* Na-138
K-3.9 Cl-105 HCO3-25 AnGap-12
___ 06:55AM BLOOD Calcium-8.6 Phos-2.0*# Mg-2.2
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L proximal humerus fracture-dislocation and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF left proximal humerus, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the LUE extremity, and will be discharged on Aspirin
325mg qday for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
lisinopril 5mg daily
atorvastatin 10mg QHS
citalopram 20mg daily
levothyroxine 88mcg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 10 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. DiphenhydrAMINE 12.5-25 mg PO/IV Q6H:PRN Insomnia/Pruritis
5. Docusate Sodium 100 mg PO BID
6. Aspirin 325 mg PO DAILY Duration: 4 Weeks
7. Levothyroxine Sodium 88 mcg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
please wean his medication as your pain improves
9. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left proximal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB LUE; pendulums at shoulder
- ___ remove from sling for elbow, wrist, finger ROM
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- 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:
___
|
10584187-DS-13 | 10,584,187 | 22,173,847 | DS | 13 | 2206-08-13 00:00:00 | 2206-08-14 13:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naprosyn / morphine / allopurinol
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man w/ recent hemithorax and MSSA empyema, recurrent
PNAs since that incident, who presents for evaluation of
hypoxemia and cough. One week ago, at his nursing facility, he
was diagnosed with pneumonia and started on levofloxacin. He is
not normally on oxygen, but required 2 L of oxygen during this
past week at nursing home. His oxygen saturation was noted to be
in the ___ on 2 L by nasal cannula, and EMS was called to
transport him to the hospital for further evaluation. The
patient is reportedly nonverbal since ___ where he
suffered from a fall and a resulting SDH, SAH, and hemithorax
resulting in a prolonged hospitalization. During that admission
he was diagnosed w/ a right-sided MSSA empyema after hemothorax
for which he received chest tube drainage, lytic therapy, as
well as metronidazole and nafcillin. Since that time, he has had
multiple hospital admissions for SOB and tachycardia, each time
diagnosed w/ a PNA and subsequently discharged back to the
nursing home.
ED Course:
Initial vitals: 97.4 128 124/73 34 93% 5L NC. Spiked temp to
101.8. Remained tachycardic and persistent O2 requirement in ED.
Exam notable for -Elderly, chronically ill-appearing, mild
respiratory distress. Pupils equal and reactive. Cardiac exam
tachycardic and regular, without audible murmurs. Lungs with
diffuse rhonchorous breath sounds, particularly at the bilateral
bases, with relatively good air entry and no
wheezes/rales/rhonchi. Abdomen is soft. Lower extremity is
normal perfused without edema.
Labs remarkable for WBC 13.1, BUN 47, Cr 1.3 (normal baseline),
lactate 2.3. VBG 7.48/37. UA bland.
Imaging notable for CXR Low lung volumes. Patchy opacities in
the lung bases could reflect atelectasis, with infection or
aspiration not excluded. Mild pulmonary vascular engorgement.
On arrival to the MICU, pt coughing and dyspneic but w/ good
sats on 4L NC. Unresponsive and does not follow commands. Does
withdraw from painful stimuli. Daughters are at bedside.
Past Medical History:
- recent fall in ___ c/b multiple fractures, SDH, SAH and
right hemothorax recently admitted for right-sided MSSA empyema
(s/p chest tube, lytic therapy, s/p flagyl, s/p nafcillin end
date ___
Hypertension
Hyperlipidemia
Glaucoma
Gout
BPH
Urolithiasis (congenital double ureters on right)
s/p prior pulmonary TB as child
appendectomy
tonsillectomy
T2DM
GERD
Social History:
___
Family History:
no history of kidney disease, autoimmune diseases, or disorders
affecting skin/joints.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Reviewed in metavision
GENERAL: does not answer questions or follow commands,
diaphoretic, tachypneic. withdraws to painful stimuli
HEENT: PERRL, MMM, atraumatic
NECK: supple, JVP not elevated, no LAD
LUNGS: diffuse rhonchi, intermittent wheezes, mildly labored
breathing
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or lesions noted
NEURO: PERRL, withdraws to painful stimuli, otherwise unable to
complete exam given patient's lack of cooperation
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
___ 04:56PM GLUCOSE-182* UREA N-47* CREAT-1.3* SODIUM-143
POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 04:56PM WBC-13.1* RBC-3.82* HGB-11.0* HCT-35.3*
MCV-92 MCH-28.8 MCHC-31.2* RDW-14.5 RDWSD-49.1*
___ 04:56PM NEUTS-82.5* LYMPHS-4.6* MONOS-8.8 EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-10.81* AbsLymp-0.60*
AbsMono-1.15* AbsEos-0.12 AbsBaso-0.05
___ 04:56PM PLT COUNT-266
___ 04:56PM ___ PTT-24.8* ___
___ 05:04PM LACTATE-2.3* K+-4.7
___ 05:04PM ___ PO2-85 PCO2-37 PH-7.48* TOTAL CO2-28
BASE XS-3 COMMENTS-GREEN TOP
___ 05:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:22PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:50PM GLUCOSE-200* LACTATE-1.9
MICRO
___ 4:26 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
IMAGING
Chest AP radiography ___
IMPRESSION:
Low lung volumes. Patchy opacities in the lung bases could
reflect
atelectasis, with infection or aspiration not excluded. Mild
pulmonary
vascular engorgement.
Chest CT without contrast ___
IMPRESSION:
Extensive, worse bilateral consolidations and secretions within
the trachea
and bronchi consistent with aspiration pneumonia.
Improved pleural effusions with now trace fluid remaining on the
left.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is increasing
opacification in the left perihilar and infrahilar region,
concerning for aspiration as
suggested in the recent CT scan. Otherwise, little change.
___ CXR
Lungs are low volume with stable interstitial prominence.
Cardiomediastinal silhouette is stable. There is a small right
pleural effusion. No pneumothorax is seen.
Brief Hospital Course:
========
SUMMARY
========
Dr. ___ is a ___ man with recent hemithorax and
MSSA empyema, recurrent pneumonias who presented ___ for
evaluation of hypoxemia and cough, admitted to ICU for hypoxemic
respiratory failure thought to be secondary to aspiration
pneumonia. He was stabilized and sent to the general medicine
floor, where he was treated for aspiration pneumonia and
recurrent aspirations. Patient improved and after several goals
of care discussions with patient's daughters it was decided the
patient would be discharged to hospice.
ACTIVE ISSUES
=============
#Aspiration pneumonia: Patient presented with hypoxemic
respiratory failure secondary to aspiration pneumonia that was
confirmed on CT and chest x-rays. He was started on empiric
antibiotic treatment with vancomycin, cefepime, and Flagyl. Was
narrowed to cefepime monotherapy given low suspicion for
anaerobic or MRSA pneumonia. Patient completed a 7 day course of
cefepime, with improvement of his respiratory status. Hospital
course was complicated by recurrent aspirations requiring
treatment with NACnebs and deep suctioning. Patient also
received chest physical therapy (however, was limited by
inability of patient to follow commands) and respiratory therapy
for deep suctioning and bronchial hygiene. On ___, patient
aspirated tube feeds and required vigorous deep suctioning with
eventual improvement in respiratory status. 2 feeds were stopped
for a short time but were eventually restarted and titrated up
to goal with good tolerance. Patient eventually improved and
eventually able to be weaned off NAC nebs and deep suctioning.
After several goals of care discussions (see below) it was
decided that it would be in the patient's best interest to be
discharged to hospice where further treatment can be focused on
comfort. For symptomatic treatment, patient was started on
oxycodone as needed for air hunger and glycopyrrolate to reduce
secretions.
#Sinus tachycardia: This was thought to be due to sepsis
initially, however, did not resolve with resolution of
pneumonia. Likely due to hypovolemia from unaccounted insensible
losses. Patient was given several boluses of IV fluid and
tachycardia improved.
#Goals of care discussions: Upon admission, patient was DNR/DNI
but okay for NPPV and for defibrillation but not chest
compressions per the family. Given difficult hospital course
complicated by recurrent aspiration events and severe aspiration
pneumonia, we engaged patients daughters, ___ and ___, and
goals of care discussions. During those discussions, we
expressed our concern that the patient could no longer reliably
handle secretions and would continue to have aspiration events
and develop aspiration pneumonias. We explained that eventually
the patient would not recover from 1 of these events and will
pass away. There were some differing opinions on goals of care
between patient's children. We consulted palliative care who
were extremely helpful in facilitating these discussions between
patient's children. Despite the differing opinions of patient's
children, his healthcare proxy, ___, made it clear that her
father has been suffering in his current state and efforts
moving forward should be focused on making him comfortable
rather than continuing to aggressively treat his aspirations. We
also involved the patient's primary care physician ___ in
the goals of care discussion. Of note, the patient made known
before his stroke in ___ that he did not want extraordinary
measures done were he to be in this situation. Therefore, after
discussion with our legal team here at ___ his healthcare
proxy was invoked. ___ decided that placement into hospice
care would be the best next step for the patient. Patient was
discharged to ___ with plan to continue current
care and to transition to comfort care and NOT rehospitalize if
patient were to decompensate at the facility.
#Troponinemia: His troponin was mildly elevated at 0.03, which
we thought was due to demand. We did not continue to trend, and
there were no concerning EKG changes.
CHRONIC ISSUES
==============
#Nutrition: After aspiration event tube feeds were eventually
restarted and uptitrated to goal rate of 75 cc/h. patient
appears to be tolerating at current rate well. However, if
patient appears uncomfortable could consider decreasing goal
rate by 25% or switching to bolus feeds every 2 to every 4 hour
for patient comfort.
#GERD: Continued famotidine
#Hypertension: Held anti-hypertensives given soft blood
pressures here. Given new focus on patient comfort would not
restart
#BPH: Continued home tamsulosin as urinary retention would be
uncomfortable.
#Glaucoma: Continued home eyedrops
CORE MEASURES
=============
Contact: ___ (Daughter)
Phone number: ___
Cell phone: ___
Code Status: DNR/DNI
TRANSITIONAL ISSUES
===================
[ ] GOALS OF CARE: Patient is confirmed DNR/DNI with his health
care proxy this admission. Patient will be discharged to hospice
care with plan to transition to comfort measures only if patient
decompensates further and should NOT be transferred to hospital.
[ ] Nutrition: If patient appears uncomfortable on current TF
could consider decreasing goal rate by 25% or switching to bolus
feeds every 2 to every 4 hour for patient comfort.
[ ] Air Hunger: For symptomatic treatment, patient was started
on low dose oxycodone 2.5mg q6hrs PRN for air hunger
[ ] Secretion management: Patient was requiring once to twice
daily deep suctioning inpatient but have been avoiding unless
absolutely needed as uncomfortable for patient. Started on IV
glycopyrrolate for secretion management. Would avoid starting
scopolamine in this patient as crosses the blood-brain barrier
and could worsen mental status
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Bisacodyl 10 mg PO QHS:PRN Constipation - First Line
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Famotidine 20 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Multivitamins W/minerals 15 mL PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Tamsulosin 0.4 mg PO QHS
11. Docusate Sodium 100 mg PO BID
12. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 1260/1000
mg oral DAILY
13. Benzonatate 200 mg PO TID:PRN cough
14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
15. Ascorbic Acid ___ mg PO BID
16. GuaiFENesin ___ mL PO Q6H
17. Sodium Chloride Nasal ___ SPRY NU BID
18. Acetylcysteine 20% ___ mL NEB Q4H
Discharge Medications:
1. Glycopyrrolate 0.2 mg IV Q8H:PRN secretions
2. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
3. OxycoDONE Liquid 2.5 mg PO Q6H:PRN Pain/Air Hunger
RX *oxycodone 5 mg/5 mL 2.5 mL by mouth every six hours as
needed Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Ascorbic Acid ___ mg PO BID
8. Benzonatate 200 mg PO TID:PRN cough
9. Bisacodyl 10 mg PO QHS:PRN Constipation - First Line
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
11. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 1260/1000
mg oral DAILY
12. Docusate Sodium 100 mg PO BID
13. Famotidine 20 mg PO DAILY
14. GuaiFENesin ___ mL PO Q6H
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of
breath
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
17. Multivitamins W/minerals 15 mL PO DAILY
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. Sodium Chloride Nasal ___ SPRY NU BID
20. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Aspiration pneumonia
SECONDARY DIAGNOSES
===================
Hypoxemic respiratory failure
Sepsis
Gastroesophageal reflux disease
Hypertension
Glaucoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure taking care of you.
WHY WAS I ADMITTED?
You were admitted to the hospital because you had something
called an aspiration pneumonia, which is a pneumonia that
results from fluid, food, or secretions going down the wrong way
into your lungs. This resulted in your oxygen level greatly
decreasing.
WHAT WAS DONE WHILE I WAS HERE?
You were admitted to the ICU to help stabilize your breathing.
You were given antibiotics to treat your pneumonia. You were
transferred to the regular medicine floor once you were feeling
better. We also suctioned secretions out of your mouth and
airway to help prevent further aspirations.
WHAT DO I NEED TO DO ONCE I LEAVE THE HOSPITAL?
You will be discharged to a ___ facility, where you will
have staff care for you ___. You will be given medications to
help make you more comfortable.
We wish you well,
Your ___ Care Team
Followup Instructions:
___
|
10584187-DS-8 | 10,584,187 | 26,442,027 | DS | 8 | 2201-01-19 00:00:00 | 2201-01-21 23:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Naprosyn / morphine
Attending: ___.
Chief Complaint:
abnormal lab values
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of HTN and remote history of pulmonary Tb, who was
sent to the ED today by his PCP, ___ an elevated
creatinine of 3.7 and ESR of 95. The patient himself complains
of productive cough of scant non-bloody sputum for the past
three weeks. Also endorses decreased energy level and poor
appetite. Of note, during the entire 3 week illness, he did not
notice any change in the color, amount or frequency of
urination. He also denies fever/chills, night sweats, sore
throat, shortness of breath, nausea/vomiting, diarrhea, myalgia,
joint pain, or rashes.
He was initially seen by Dr. ___ on ___ and was found to
have temp of ___ with rales on lung exam. He was prescribed
Ciprofloxacin x7day, albuterol inhaler, and codeine cough syrup
for likely pneumonia. He represented to Dr. ___ on ___ as
his symptoms began to worsen again (initially the above meds
provided some relief). Yesterday, a CXR showed no acute
intrapulmonary process. Yesterday, he also started erythromycin
and his regular home benazapril was discontinued. Labwork was
obtained, the results of which initiated this current admission.
In the ED, his initial vitials were 97.8 66 113/49 21 98% RA. He
received 2L NS. Labs were remarkable for K of 5.2, BUN 94, Cr
3.4. CXR showed prelim hyperexpanded lungs, clear with no
consolidation. No cardiopulmonary process, no PNA. He received
2L NS and one nebulized albuterol treatment.
On arrival to the floor, patient continues to experience
persistent cough. His initial vitial signs were: 97.5 100/47 71
20 96RA.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Hypertension
Hyperlipidemia
Glaucoma
Gout
BPH
Urolithiasis (congenital double ureters on right)
s/p prior pulmonary TB as child
appendectomy
tonsillectomy
Social History:
___
Family History:
no history of kidney disease, autoimmune diseases, or disorders
affecting skin/joints.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.8 66 113/49 21 98% RA
GEN: Sitting in bed, coughing frequently, Alert, oriented, no
acute distress
HEENT: EOMI, sclera anicteric, MMM, OP clear and
non-erythematous
NECK: supple, no JVD, no LAD
PULM: No use of accessory muscles of respiration. Limited
aeration at bases. LLL fine dry crackles. No wheezing.
CV: RRR normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: no rashes or skin lesions
DISCHARGE PHYSICAL EXAM:
VS 97 99/52 66 20 95RA
I/O: 3350/1125
GEN: Sitting in bed, coughing frequently, Alert, oriented, no
acute distress
HEENT: EOMI, sclera anicteric, MMM, OP clear and
non-erythematous
NECK: supple, no JVD, no LAD
PULM: No use of accessory muscles of respiration. Limited
aeration at bases. No crackles No wheezing.
CV: RRR normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: no rashes or skin lesions
Pertinent Results:
ADMISSION LABS
___ 02:35PM BLOOD WBC-7.6 RBC-4.31* Hgb-13.7* Hct-41.3
MCV-96 MCH-31.7 MCHC-33.1 RDW-12.7 Plt ___
___ 02:35PM BLOOD Neuts-86.6* Lymphs-6.7* Monos-6.0 Eos-0.5
Baso-0.1
___ 02:35PM BLOOD UreaN-102* Creat-3.7*# Na-143 K-5.1
Cl-107 HCO3-24 AnGap-17
___ 02:35PM BLOOD ALT-29 AST-34 CK(CPK)-181 AlkPhos-49
___ 02:35PM BLOOD Calcium-9.0
___ 02:35PM BLOOD CRP-20.0*
___ 11:44AM BLOOD ___
___ 11:44AM BLOOD C3-115 C4-53*
___ 11:44AM BLOOD HCV Ab-NEGATIVE
ASO Screen (Final ___: < 200 IU/ml PERFORMED BY LATEX
AGGLUTINATION.
___ 11:44AM BLOOD ANTI-GBM-PND
___ 02:35PM URINE Color-Straw Appear-Clear Sp ___
___ 02:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 11:15AM URINE Hours-RANDOM UreaN-909 Creat-120
TotProt-6 Uric Ac-34.4 Prot/Cr-0.1
___ 11:15AM URINE Osmolal-505
DISCHARGE LABS
___ 07:00AM BLOOD Glucose-101* UreaN-51* Creat-2.3* Na-146*
K-4.4 Cl-111* HCO___ AnGap-17
IMAGING:
CXR: ___: final read: No consolidation or pneumonia.
GU US: ___:
1. No evidence of hydronephrosis or renal stones.
2. Simple right renal cyst.
3. Elevated post-void residual volume of 204 cc.
4. Enlarged prostate.
Brief Hospital Course:
___ with PMH HTN admitted with acute renal failure in the
setting of an upper respiratory illness.
Active Issues
#) Acute renal failure: He presented with prerenal acute renal
failure in the setting of concomitant poor po intake and
ACE/diuretic use. His creatinine was markedly elevated at 3.7
(baseline Cr was 1.4-1.7). FeUrea was consistent with prerenal
cause. Urine sediment bland by microscopy, no evidence of GN or
ATN. He was treated with IVF resuscitation and responded
appropriately with Cr to 2.6 at discharge. Furthermore his
diuretics were held (ACE, HCTZ, Atenolol) during the admission.
In full work-up, following tests were negative (C3/C4, ___,
hepC, ASO). GU ultrasound was without hydronephrosis (only
showed large prostate).
#) Cough/URI: His persistent cough and URI were concerning for
atypical pneumonia. CXR without infiltrate. He continued
taking Erythromycin that was started prior to admission. Also
received nebs and antitussives with some improvement of his
cough prior to discharge.
Chronic Issues
#)HTN: His antihypertensives (HCTZ, benazepril, atenolol) were
held as he was 1) prerenal ARF and 2) soft SBPs ___. Upon
discharge, he was given specific instructions only to restart
Atenolol 25mg daily ___ his previous dose) and to hold both the
ACE and HCTZ until he sees Dr. ___ in clinic.
#) Hyperlipidemia: stable, continued pravastatin
#) Glaucoma: stable, continued eye drops
Transitional Issues:
-Pending labs: anti-GBM
-Code Status: full code, discussed with patient and daughter
-Pt seen and evaluated by ___ who did not feel further ___ was
necessary.
-HTN: his BPs off antihypertensives were actually quite well
controlled. Would consider scaling back on his
anti-hypertensive regimen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. benazepril *NF* 20 mg Oral daily
hold for sbp <100
2. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN cough
3. Erythromycin 500 mg PO TID
4. Atenolol 50 mg PO DAILY
hold for sbp<100 or hr <60
5. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp<100
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Albuterol Inhaler 3 PUFF IH Q6H:PRN SOB
8. Pravastatin 40 mg PO DAILY
9. Ranitidine 75 mg PO DAILY
Discharge Medications:
1. Erythromycin 500 mg PO TID
2. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN cough
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Pravastatin 40 mg PO DAILY
5. Ranitidine 75 mg PO DAILY
6. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure taking care of you while you were admitted to
___. You were admitted with acute renal failure. This was
caused by dehydration with concurrent use of anti-hypertensive
medication. Your kidney function has greatly improved with IV
fluid resuscitation.
It is very important for you to continue to drink lots of fluids
at home (greater than 8 glasses) for the next week or so until
your blood is checked again. Your medications have also been
changed until you see Dr. ___ this week. These changes
are detailed on the next page. In brief, you will stop taking
your benazepril and hydrochlorothiazide. You will continue
taking atenolol, but you will only take Atenolol 25mg daily.
Additionally, you can continue to take Erythromycin as
prescribed until ___. Please call Dr. ___ office on
___ to schedule a follow-up appointment.
Followup Instructions:
___
|
10584187-DS-9 | 10,584,187 | 20,489,414 | DS | 9 | 2206-03-31 00:00:00 | 2206-03-31 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Naprosyn / morphine / allopurinol
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
GASTROSTOMY PERCUTANEOUS ENDOSCOPIC (PEG) ___
History of Present Illness:
___ hx DM, HTN s/p fall from flight of stairs p/w LUE pain, ?LOC
w/ L. SDH/SAH, b/l IVH, L. scapular fx, b/l rib fx, T3/7
vertebral body fx
Past Medical History:
Hypertension
Hyperlipidemia
Glaucoma
Gout
BPH
Urolithiasis (congenital double ureters on right)
s/p prior pulmonary TB as child
appendectomy
tonsillectomy
Social History:
___
Family History:
no history of kidney disease, autoimmune diseases, or disorders
affecting skin/joints.
Physical Exam:
Physical exam on d/c:
Gen: NAD
CV: RRR
Resp: nonlabored breathing on FM
abd: S, nt, nd; PEG in place
Pertinent Results:
___ 05:47AM BLOOD WBC-10.8* RBC-2.87* Hgb-8.4* Hct-27.4*
MCV-96 MCH-29.3 MCHC-30.7* RDW-15.4 RDWSD-53.1* Plt ___
___ 05:10AM BLOOD WBC-14.0* RBC-2.67* Hgb-8.0* Hct-25.3*
MCV-95 MCH-30.0 MCHC-31.6* RDW-15.1 RDWSD-52.2* Plt ___
___ 03:54AM BLOOD WBC-14.1* RBC-2.29* Hgb-6.8* Hct-22.2*
MCV-97 MCH-29.7 MCHC-30.6* RDW-14.7 RDWSD-52.0* Plt ___
___ 05:24AM BLOOD WBC-13.4* RBC-2.40* Hgb-7.0* Hct-23.4*
MCV-98 MCH-29.2 MCHC-29.9* RDW-14.4 RDWSD-51.2* Plt ___
___ 04:08AM BLOOD WBC-11.7* RBC-2.42* Hgb-7.0* Hct-23.8*
MCV-98 MCH-28.9 MCHC-29.4* RDW-14.4 RDWSD-52.1* Plt ___
___ 04:32AM BLOOD WBC-10.2* RBC-2.33* Hgb-6.9* Hct-23.0*
MCV-99* MCH-29.6 MCHC-30.0* RDW-14.6 RDWSD-52.0* Plt ___
___ 04:49AM BLOOD WBC-7.4 RBC-2.30* Hgb-6.8* Hct-22.8*
MCV-99* MCH-29.6 MCHC-29.8* RDW-14.4 RDWSD-52.1* Plt ___
___ 04:35AM BLOOD WBC-8.6 RBC-2.35* Hgb-7.0* Hct-23.0*
MCV-98 MCH-29.8 MCHC-30.4* RDW-14.4 RDWSD-51.3* Plt ___
___ 10:36PM BLOOD Neuts-76.1* Lymphs-7.4* Monos-10.2
Eos-3.7 Baso-0.1 Im ___ AbsNeut-7.67* AbsLymp-0.75*
AbsMono-1.03* AbsEos-0.37 AbsBaso-0.01
___ 05:47AM BLOOD Plt ___
___ 05:10AM BLOOD Plt ___
___ 03:54AM BLOOD Plt ___
___ 05:24AM BLOOD Plt ___
___ 06:22AM BLOOD ___ PTT-28.2 ___
___ 05:47AM BLOOD Glucose-131* UreaN-52* Creat-1.1 Na-142
K-4.2 Cl-102 HCO3-24 AnGap-16
___ 05:10AM BLOOD Glucose-196* UreaN-54* Creat-1.2 Na-141
K-4.3 Cl-101 HCO3-26 AnGap-14
___ 03:54AM BLOOD Glucose-172* UreaN-57* Creat-1.2 Na-142
K-4.2 Cl-103 HCO3-26 AnGap-13
___ 05:24AM BLOOD Glucose-197* UreaN-56* Creat-1.2 Na-145
K-4.0 Cl-105 HCO3-25 AnGap-15
___ 04:08AM BLOOD Glucose-181* UreaN-51* Creat-1.3* Na-146
K-4.1 Cl-108 HCO3-26 AnGap-12
___ 04:32AM BLOOD Glucose-205* UreaN-51* Creat-1.3* Na-147
K-4.3 Cl-109* HCO3-23 AnGap-15
___ 01:44AM BLOOD LD(LDH)-282*
___ 05:08AM BLOOD CK(CPK)-312
___ 12:00AM BLOOD Lipase-20
___ 05:49AM BLOOD cTropnT-0.01
___ 12:00PM BLOOD CK-MB-6 cTropnT-0.02*
___ 05:08AM BLOOD CK-MB-7 cTropnT-0.02*
___ 05:47AM BLOOD Calcium-7.6* Phos-2.7 Mg-2.3
___ 05:10AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.2
___ 12:00AM BLOOD ASA-NEG Ethanol-13* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
___ was admitted to the ICU for close monitoring of
his respiratory status. An epidural was placed, after which he
became hypotensive, briefly requiring pressors. His pleural
effusion remained stable and at the time chest tube placement
was deferred given his stable respiratory status on nasal
cannula. His diet was advanced on HD2 and was transferred to the
floor. While on the floor, his epidural was removed. He was
noted to be aspirating, and failed speech and swallow
evaluation. He also was persistently tachypneic, and a CT chest
was obtained, noting a persistent right sided
effusion/hemothorax; a chest tube was subsequently placed. He
however continued to have respiratory issues and altered mental
status and was transferred back to the ICU on ___. He was
noted to have a UTI and was started on ampicillin. He continued
to have a waxing/waning mental status, and his respiratory
status mildly improved, and was transferred back to the floor
___. He continued to fail speech and swallow - several
attempts at DHT placement were unsuccessful, including an
attempt by GI under mild sedation. His respiratory status
continued to remain unimproved, and was transferred again to the
ICU on ___. A new right chest pigtail was placed with
improvement in his tachypnea. A PICC was placed as well and TPN
initiated. The original chest tube was removed ___, postpull
film showed a small pneumothorax, which resolved by ___. A
PEG was placed ___, and was transferred to the floor ___.
On ___ tube feeds were started. On ___, Na 148, free h2o flush
increased and chest xray showed increased opacity in R
hemithorax. On ___, Na 150, free h2o flush increased, tube feed
residuals to 150, and had respiratory rate 30 with some apnea.
On ___, positive fluid balance 2L, increased Respiratory Rate,
given lasix 10mg IV. On ___, Na 146, Cleared for TLSO (doesn't
need CTLSO per Neurosurgery). On ___, Na 145, failed Speech and
swallow and was made NPO, and NOPCO adjusted his brace. On ___,
WBCs increased to 14. Hct downtrend to 22.2, and he was
transfused 1 unit of blood. CXR was unremarkable. On ___, had
a rehab bed, but WBC 14.0. UA was negative and UCX/BCX pending,
and his PICC line was removed. On ___, Ancef was discontinued,
and he was stable for discharge to rehab.
Medications on Admission:
ATENOLOL 25 mg daily
FEBUXOSTAT 40 mg daily
HYDROCHLOROTHIAZIDE 25 mg daily
HYDROXYZINE 25 mg q8h
Lantus 40 units sq qhs
OXYCODONE-ACETAMINOPHEN ___ q8h
PRAVASTATIN 40 mg daily
ZOLPIDEM 10 mg qhs
Ranitidine 75 mg daily
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Docusate Sodium 100 mg PO BID constipation
4. Famotidine 20 mg PO Q24H
Can take home medication ranitidine; follow up with Primary care
for prescription
5. Senna 8.6 mg PO BID:PRN constipation
6. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth once a day
Disp #*7 Capsule Refills:*0
7. Atenolol 25 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
fall from flight of stairs; left sided subdural
hematoma, scattered subarachnoid hemorrhage, and trace
intraventricular hemorrhage, scapular fracture, rib
fractures,T3/7 vertebral body fractures and underwent
GASTROSTOMY PERCUTANEOUS ENDOSCOPIC (PEG)on ___
Discharge Condition:
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on
___own the stairs, with left sided subdural
hematoma, scattered subarachnoid hemorrhage, and trace
intraventricular hemorrhage, scapular fracture, rib
fractures,T3/7 vertebral body fractures and underwent
GASTROSTOMY PERCUTANEOUS ENDOSCOPIC (PEG)on ___. You are now
ready for discharge to rehab.
Please follow the instructions below to continue your recovery:
* Your injury caused rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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:
___
|
10584297-DS-2 | 10,584,297 | 28,576,262 | DS | 2 | 2124-09-28 00:00:00 | 2124-09-28 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lidocaine /
benzocaine-benzethonium
Attending: ___.
Chief Complaint:
fracture of tibia/fibula
Major Surgical or Invasive Procedure:
Open reduction with internal fixation
History of Present Illness:
___ with h/o AVR due to bicuspid valve on Coumadin, HTN, HLD who
presents as a transfer from ___ due to concern for
NSTEMI.
For the past ___ weeks he has been suffering from what he
describes as cold-like symptoms. These include chest pressure
and difficulty taking a deep breath as well as SOB with laying
flat. He has not had a cough, fever, rigors, pre-syncopal
symptoms, palpitations, nausea, vomiting, diarrhea, abdominal
pain, leg swelling. He ended up being treated with a 5 day burst
of 40 mg prednisone daily with little effect.
On the day of admission he was walking a dog when the leash got
entangled in his legs and he fell down a few steps. he heard a
snap at his ankle. No head strike or loss of consciousness. He
was taken to ___ where he was found to have a distal
tibial fracture, and his pain was managed with dilaudid and
fentanyl. Initial work-up also showed a troponin-I of 0.13 and
EKG with new TWI in the lateral and inferior leads. Given
concern for NSTEMI, he received aspirin and was transferred to
___.
Past Medical History:
- bicuspid aortic valve s/p AVR at age ___ (___)
- "sausage vessel" at birth s/p surgical repair at age ___ (___)
- hypertension
- hyperlipidemia
Social History:
___
Family History:
father with history of bicuspid valve
Physical Exam:
PHYSICAL EXAM on ADMISSION:
Vitals: 97.7 143/71 73 18 99% 2L
General: Alert, oriented, no acute distress but in pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: ___ SEM heard throughout precordium, loud S2, no rub
Lungs: Clear to auscultation bilaterally with decreased air
entry at bilateral bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: LLE wrapped, sensation intact distally and warm, RLE
without edema
Neuro: grossly intact, no focal deficit
PHYSICAL EXAM on DISCHARGE:
Vitals: Tm 100.2 BP 120s-150s/70s P ___ R ___ SatO2
94-98/RA
GENERAL: sitting in bed in NAD. Oriented x3. Mood, affect
appropriate.
NECK: Supple with JVP flat at clavicle.
CARDIAC: RR, normal S1, S2, ___ systolic murmur, no thrills,
lifts. No S3 or S4.
LUNGS: Crackles bilaterally
EXTREMITIES: No edema or cyanosis, cast over left leg
Pertinent Results:
LABS on ADMISSION:
___ 03:00PM BLOOD WBC-14.9* RBC-4.42* Hgb-13.5* Hct-40.7
MCV-92 MCH-30.5 MCHC-33.2 RDW-13.7 RDWSD-46.1 Plt ___
___ 03:00PM BLOOD Neuts-80.2* Lymphs-10.2* Monos-6.9
Eos-1.1 Baso-0.7 Im ___ AbsNeut-11.97* AbsLymp-1.52
AbsMono-1.03* AbsEos-0.16 AbsBaso-0.11*
___ 03:00PM BLOOD ___ PTT-45.8* ___
___ 03:00PM BLOOD Glucose-114* UreaN-21* Creat-0.9 Na-142
K-4.4 Cl-105 HCO3-25 AnGap-16
___ 03:00PM BLOOD proBNP-779*
___ 03:00PM BLOOD cTropnT-0.04*
___ 09:00PM BLOOD cTropnT-0.03*
___ 03:00PM BLOOD Calcium-9.1 Phos-4.4 Mg-2.1
LABS on DISCHARGE:
___ 07:50AM BLOOD WBC-11.2* RBC-3.51* Hgb-10.7* Hct-32.2*
MCV-92 MCH-30.5 MCHC-33.2 RDW-13.3 RDWSD-43.4 Plt ___
___ 07:50AM BLOOD ___ PTT-70.9* ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-177* UreaN-14 Creat-0.7 Na-138
K-3.2* Cl-99 HCO3-30 AnGap-12
___ 06:15AM BLOOD cTropnT-0.04*
___ 07:50AM BLOOD Calcium-8.7 Phos-1.8* Mg-2.1
PERTINENT STUDIES:
- ECG (___):
Sinus rhythm. Left ventricular hypertrophy with secondary
repolarization
abnormalities.
- CXR (___):
Minimal to no pleural effusion. No focal consolidation.
Pulmonary vascular congestion and cardiomegaly.
Large gastric air-fluid level.
- CT lower extremity (___):
There is a comminuted spiral fracture through the distal tibial
diaphysis with a vertical component extending to the articular
surface. The articular surface is disrupted by approximately 4
mm. There is a vertical fracture plane through the posterior
malleolus, this is minimally displaced (400b:60). There is an
oblique fracture through the distal fibula, extending to the
level of the syndesmosis (401b:66). The ankle mortise appears
congruent. No evidence of tendon entrapment in the fracture
fragments. Incidental note is made of an os navicularis (03:11
1). An os peroneum is also noted. No tibiotalar joint effusion
seen. There is preservation of the fat in the sinus tarsi.
Extensive vascular calcifications noted.
- ECHO, TTE (___):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
A bileaflet aortic valve prosthesis is present. The transaortic
gradient is higher than expected for this type of prosthesis.
The opening sound is blunted on the CW images suggesting
impaired leaflet opening. There is more aortic regurgitation
present than is expected due to normal washing jets, but is
difficult to quantify given acoustic/shadowing/turbulence in the
LVOT. The mitral valve leaflets are structurally normal. An
eccentric, posteriorly directed jet of likley Moderate (2+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Moderate to severe symmetric left ventricular
hypetrophy with normal cavity size and hyperdynamic systolic
function. Bileaflet mechanical aortic valve prosthesis with
increased gradients and suggestion of impaired leaflet opening.
Aortic regurgitation present not quantified. Likley moderate
eccentric mitral regurgitation. Aortic valve motion and be
better defined with fluoroscopy +/- TEE and degree of MR and AR
can be better defined with TEE if clinically indicated.
- TEE (___):
No mass/thrombus is seen in the left atrium or left atrial
appendage. There is a small PFO with a left-to-right shunt
across the interatrial septum. Overall left ventricular systolic
function is normal (LVEF>55%). with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. A bileaflet mechanical aortic valve prosthesis
is present. There is severe aortic valve stenosis (valve area
<1.0cm2), there appears to be only motion of one leaflet, the
other leaflet appears immobile.=. Moderate to severe (___)
aortic regurgitation is seen with some evidence of diastolic
flow reversal in the aortic arch.. Moderate (2+) mitral
regurgitation is seen.There is no pericardial effusion. Dr.
___ was notified of the results in person.
- CTA coronary arteries (___):
Limited study. Poor Coronary artery opacification.
Suspected proximal LAD substantial stenosis.
Pulmonary edema, at least interstitial with some elements of
alveolar
component.
Mediastinal and hilar lymphadenopathy, potentially reactive.
Status post aortic valve replacement.
Bilateral pleural effusion.
Brief Hospital Course:
Mr. ___ has a history of AVR on warfarin, HTN, and HLD who
presented with left tibial/fibular fracture and was found to
have severe aortic stenosis, s/p ORIF (___) now being medically
managed for aortic stenosis until further evaluation by cardiac
surgery.
ACUTE ISSUES:
# Distal tib/fib fracture: Now s/p ORIF. On heparin gtt bridge
back to warfarin for anticoagulation. On oxycodone and dilaudid
for pain.
# s/p AVR on Coumadin: Patient had AVR at ___ at age ___.
Previous to that, he had surgery for coarctation of the aorta at
age ___, and an aortic valve repair at age ___ (also at ___. On
home Coumadin. INR on ___ is 1.3. On warfarin 5 mg.
# Pericarditis/myopericarditis: Likely diagnosis due to URI
symptoms, dyspnea, mild troponinemia, and diffuse TWI on EKG.
The TWI are likely Stage III of the typical progression of EKG
changes in pericarditis. He is currently asymptomatic (no rub,
no chest pain), and this is likely resolving. No need for
further troponins given flat x 2 in our ED.
CHRONIC ISSUE:
# HTN: Continued Atenolol 50 mg PO/NG daily.
TRANSITIONAL ISSUES:
- Follow-up with Cardiac Surgery after leg is healed.
- Follow-up with cardiologist.
- Follow-up with PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY16
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. wheelchair 1 miscellaneous DAILY fracture Duration: ___
Weeks
Dx: distal tib-fib fracture
Prog: Good
Dur: ___ weeks
RX *wheelchair 1 Wheelchair daily Disp #*1 Each Refills:*0
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Warfarin 5 mg PO DAILY16
5. 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
6. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN breakthrough
pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours,
PRN Disp #*30 Tablet Refills:*0
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Fracture tibia/fibula
Aortic stenosis
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had a fracture to your tibia/fibula. Orthopedic
surgery has written specific instructions for you (see below).
You were also evaluated by cardiology and cardiac surgery
regarding your severe aortic stenosis and aortic valve
replacement. It was recommended that you continue on medical
management for your aortic stenosis and undergo evaluation for
possible aortic valve replacement once your leg fracture has
healed. Please make an appointment with Dr. ___ from
___ Surgery once your leg has healed (please see below for
details).
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for repair of your left ankle
fracture by 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:
- touchdown (<20 pounds) weight bearing on left leg in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take follow the anticoagulation plan outlined by your
primary care team.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10584670-DS-16 | 10,584,670 | 28,265,888 | DS | 16 | 2170-05-06 00:00:00 | 2170-05-07 15:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / BuSpar / trazodone
Attending: ___.
Chief Complaint:
Shortness of breath on exertion
Major Surgical or Invasive Procedure:
Chest tube placement and removal
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is an ___ female with past medical
history of hypertension, osteoarthritis, depression, and anxiety
who presents with 1 week of progressively worsening exertional
dyspnea. Patient was found to have massive right pleural
effusion and was transferred from ___ for further
evaluation.
Patient reports several weeks of generalized fatigue and feeling
ill beginning around ___, when she felt poorly for a few
days and had intermittent vomiting. She was diagnosed with a
UTI and completed a 10-day course of antibiotics. Over the past
week, she has noted new dyspnea on exertion but not at rest.
Patient went to her PCP and had ___ chest x-ray which showed right
pleural effusion. She went to outside hospital ED where CTA
chest showed large right pleural effusion with compressive
atelectasis causing complete collapse of the RML/RLL, as well as
partial collapse of the RUL. Patient reports intermittent
chills, mild sputum production, weight loss of 17 pounds over
the
past year, and chronic nausea. She has noted a small amount of
blood in her stool intermittently. Patient has never had a
colonoscopy. Last mammogram in ___ did not show evidence of
malignancy. Patient denies hemoptysis, chest pain, abdominal
pain, hematuria, dysuria, melena, lower extremity weakness,
rash.
In the ED, initial vitals: Temperature 97.2°F, HR 87, BP 160/81,
RR 22, SPO2 93% room air
- Exam notable for: Anxious appearing, RRR, crescendo
decrescendo systolic murmur, decreased breath sounds over the
right lung with decreased tactile fremitus, dullness to
percussion of right lung, trace pretibial edema bilaterally,
abdomen soft, nontender nondistended
- Labs notable for: Normal CBC, proBNP 100, normal count 10,
lactate 1.3
- Imaging notable for:
___ CXR PA/lateral: Large right pleural effusion with volume
loss. No midline shift.
- Pt given: No medications
- Vitals prior to transfer: HR 89, BP 151/68, RR 20, SPO2 93% on
2 L nasal cannula
Upon evaluation in the ED, the patient endorses the above
history. She has dyspnea only with activity. She denies SOB,
chest pain, orthopnea, fevers, chills, lower extremity swelling,
weakness, headaches, night sweats.
REVIEW OF SYSTEMS:
Positive per HPI. Otherwise, a 10 point review systems was
negative.
Past Medical History:
HTN
HLD
Anxiety
Depression
OA/arthritis
Osteopenia
GERD
Vertigo
Social History:
___
Family History:
Father - MI
Mother - metastatic liver cancer
Brother - colon cancer
Sister - brain cancer
Sister - MI
Sister - "broken heart syndrome"
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
PHYSICAL EXAM:
VITALS: HR 84, BP 156/65, RR 20, SpO2 92% on 2L NC
General: Elderly-appearing, alert, interactive, NAD
HEENT: NC/AT, sclera anicteric, EOMI, MMM, OP clear
CV: RRR, no m/r/g
Lungs: Decreased breath sounds of right posterior lung fields to
mid-back, trace inspiratory crackles of LLL, unlabored
respirations, no wheezes
Abdomen: soft, NTND, +BS
Ext: Warm, well perfused, no lower extremity edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CN II-XII intact, moving all four extremities with
purpose, A/Ox3
=======================
DISCHARGE PHYSICAL EXAM
=======================
PHYSICAL EXAM:
24 HR Data (last updated ___ @ 026)
Temp: 98.0 (Tm 98.3), BP: 147/72 (125-147/72-79), HR: 81
(81-118), RR: 18 (___), O2 sat: 93% (92-95), O2 delivery: Ra,
Wt: 157.4 lb/71.4 kg
GENERAL: Pleasant, elderly, lying in bed comfortably.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops.
PULM: breathing comfortably on RA, no accessory muscle use,
crackles in RLL, with slight crackles in LLL as well. Dullness
to percussion on right lower lung fields
ABD: Normoactive bowel sounds, soft, nondistended and nontender
to palpation.
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ radial pulses, 2+ ___ pulses.
NEURO: Alert and oriented. EOMI. Facial sensation in tact and
symmetric at rest and with activation.
Pertinent Results:
=====================
ADMISSION LAB RESULTS
=====================
___ 09:30PM BLOOD WBC-8.4 RBC-4.56 Hgb-13.7 Hct-41.1 MCV-90
MCH-30.0 MCHC-33.3 RDW-12.3 RDWSD-40.2 Plt ___
___ 09:30PM BLOOD Neuts-71.8* Lymphs-16.8* Monos-9.3
Eos-1.1 Baso-0.6 Im ___ AbsNeut-6.03 AbsLymp-1.41
AbsMono-0.78 AbsEos-0.09 AbsBaso-0.05
___ 09:30PM BLOOD Plt ___
___ 09:26AM BLOOD ___ PTT-26.3 ___
___ 09:30PM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-141
K-4.0 Cl-102 HCO3-25 AnGap-14
___ 09:26AM BLOOD ALT-20 AST-19 LD(LDH)-172 AlkPhos-85
TotBili-0.8
___ 09:30PM BLOOD proBNP-100
___ 09:30PM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8
___ 10:01PM BLOOD Lactate-1.3
___ 05:36AM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
___ 05:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 11:02AM PLEURAL TotProt-4.9 Glucose-39 LD(LDH)-345
Amylase-100 Albumin-3.1 proBNP-106
___ 11:02AM PLEURAL TNC-3058* RBC-2425* Polys-0 Lymphs-37*
Monos-0 Other-63*
=====================
DISCHARGE LAB RESULTS
=====================
___ 04:29AM BLOOD WBC-5.9 RBC-3.85* Hgb-11.6 Hct-34.7
MCV-90 MCH-30.1 MCHC-33.4 RDW-12.1 RDWSD-39.9 Plt ___
___ 04:29AM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-141
K-4.1 Cl-101 HCO3-27 AnGap-13
___ 04:29AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.0
====================
MICROBIOLOGY RESULTS
====================
___ 9:34 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
___ 9:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:36 am URINE
URINE CULTURE (Preliminary):
GRAM POSITIVE BACTERIA. >100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
___ 11:02 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
===============
IMAGING/REPORTS
===============
CHEST (PA & LAT) Study Date of ___ 11:38 ___
IMPRESSION: Large right pleural effusion with volume loss. No
midline shift.
EKG - ___ 21:23:19
signficant baseline artifact
Low voltage QRS throughout
probably sinus rhythm
probably Nonspecific intraventricular conduction delay
No previous ECGs available
CHEST PORT. LINE PLACEMENT Study Date of ___ 12:01 ___
IMPRESSION: Large right pleural effusion is slightly smaller
status post placement of a right basilar chest tube. No
pneumothorax. Left lung is clear.
CHEST (PORTABLE AP) Study Date of ___ 7:42 AM
IMPRESSION: There is a left-sided pleural pigtail catheter.
There has been decrease in the large right-sided pleural
effusion. There is an area of consolidation at the right base.
There is a small left-sided pleural effusion and some elevation
of the left hemidiaphragm. No pneumothoraces are identified.
CT CHEST W/O CONTRAST Study Date of ___ 9:29 ___
IMPRESSION:
1. Trace right pleural effusion, which is significantly
decreased compared to prior CT chest. Evaluation for a pleural
abnormalities limited by the absence of intra venous contrast.
Within this limitation, there are no suspicious
pleural lesions.
2. New consult ground-glass opacities in the right lung which
are favored to represent re-expansion pulmonary edema, although
multifocal infection could have a similar appearance.
3. A 5 mm pulmonary nodule in the right upper lobe. Please see
recommendations below.
CHEST (PORTABLE AP) Study Date of ___ 5:08 ___
IMPRESSION:
The left hemidiaphragm is elevated. The right basilar chest
tube has been
removed. A trace right pleural effusion is unchanged compared
to prior CT. There is no pneumothorax. There are patchy
parenchymal opacities in the right lung, which appear unchanged
compared to prior CT and may represent re-expansion pulmonary
edema or multifocal infection. Linear atelectasis is noted
within the left lung base. The cardiomediastinal silhouette is
stable in appearance. There are no acute osseous abnormalities.
CHEST (PORTABLE AP) Study Date of ___ 8:13 AM
IMPRESSION:
Reaccumulation of small right pleural effusion. Consolidative
abnormality, right lower lobe, either persistent re-expansion
edema or pneumonia
CHEST (PORTABLE AP) Study Date of ___ 8:06 AM
IMPRESSION:
Comparison to ___. Stable moderate bilateral
pleural effusions. Stable scoliosis with subsequent asymmetry of
the ribcage. Borderline size of the cardiac silhouette.
Minimal atelectasis at the right lung bases. No pneumothorax.
Brief Hospital Course:
===========================
BRIEF SUMMARY
===========================
Ms. ___ is an ___ female with past medical
history of HTN, HLD, depression, anxiety who presented with 1
week of progressively worsening DOE and a large right pleural
effusion. We placed a chest tube for drainage, supported her
temporarily with nasal cannula for hypoxemia, performed a CT
scan of the chest that did not reveal an underlying mass lesion,
and pleural fluid studies were consistent with an exudative
process (cytology pending at the time of discharge). She was
ultimately discharged to home, without oxygen, and follow up
with primary care and interventional pulmonary.
==========================
TRANSITIONAL ISSUES
==========================
- Patient discharged with ___ services to monitor for
redevelopment of hypoxemia; Please monitor ambulatory O2 sat and
resting O2 sat
- Please obtain CXR at next PCP visit to evaluate for
reaccumulating fluid
- Cytology of pleural fluid pending at time of discharge,
interventional pulmonary follow up in place for further workup
as outpatient
- A 5 mm pulmonary nodule in the right upper lobe was noted on
the CT chest. Given concern for malignancy, patient likely would
benefit for interval monitoring.
- Consider discontinuing temazepam given increasing age.
- Consider discontinuing ascorbic acid if not contraindicated
- Add Multivitamin with minerals
CODE STATUS: Full, presumed
CONTACT: ___, Daughter, p ___, cell
___
============================
PROBLEM-BASED SUMMARY
============================
#Acute hypoxic Respiratory Failure
#Right exudative pleural effusion
#Concern for malignancy
Ms. ___ presented with one week of progressive dyspnea on
exertion, with mild hypoxemia requiring NC found to have a
massive right pleural effusion on CXR. Chest tube was placed
___ which drained ~2400 cc serosanguinous fluid. Pleural
fluid analysis showed an exudative effusion, with high protein
and LDH, but no microorganisms were visualized on stain or
culture. Chest tube was removed ___. Given effusion size,
subacute symptoms, and pleural analysis with 63% other cells,
the pleural effusion most likely results from a chronic process,
concerning for malignant effusion. Further suspicion for
malignancy includes 15 pound weight loss over past year. CT
noncontrast of the chest did not demonstrate intrathoracic
malignancy or pleural malignancy but was limited study given
lack of contrast. Cytology pending at discharge. Review of
Symptoms and physical exam including breast exam did not
demonstrate signs or symptoms of malignancy. Given stability of
pleural effusion for >24 hrs on imaging and no oxygen
requirement, patient can be discharged home. She will follow up
with her PCP to discuss pending results of cytology as well as
with interventional pulmonology.
#Risk of malnutrition
Seen by nutrition for concern of adequacy of PO intake.
Recommended that she have ensure supplements twice daily.
Recommended checking Vitamin D which was pending at discharge.
#Insomnia
Discussed with patient risks associated with tamazepam as an
older woman. Encouraged to discuss stopping with PCP. Given
current clinical stability and patient and family strong
preference to resume medication while in house, it was
continued. Consider discontinuing as an outpatient.
# HTN:
- Continue home Diltiazem Extended-Release 240 mg PO DAILY
# ANXIETY:
# DEPRESSION:
- Continue LORazepam 0.5 mg PO DAILY:PRN Anxiety
#GERD:
-Continue Ondansetron 4 mg PO/NG BID:PRN Nausea/Vomiting
-Continue Omeprazole 20 mg PO DAILY
#Vitamin deficiency
-Continue vitamin D ___ UNIT PO/NG DAILY
-Continue ascorbic acid ___ mg PO/NG DAILY
Medications on Admission:
HOME MEDICATIONS:
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Temazepam 15 mg PO ___ CAPSULES ONCE DAILY, PRN Anxiety
3. Potassium Chloride 40 mEq PO DAILY
4. LORazepam 0.5 mg PO DAILY:PRN Anxiety
5. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
6. Prochlorperazine 25 mg PR Q12H:PRN Nausea/Vomiting - Second
Line
7. Omeprazole 20 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Ascorbic Acid Dose is Unknown PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. LORazepam 0.5 mg PO DAILY:PRN Anxiety
5. melatonin 3 mg oral QHS
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
8. Prochlorperazine 25 mg PR Q12H:PRN Nausea/Vomiting - Second
Line
9. Temazepam 15 mg PO ___ CAPSULES ONCE DAILY, PRN sleep
10. Vitamin D ___ UNIT PO DAILY
11. HELD- Potassium Chloride (Powder) 40 mEq PO DAILY This
medication was held. Do not restart Potassium Chloride (Powder)
until instructed to by your doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Right-sided exudative pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were having shortness of breath and an x ray showed fluid
around the right lung.
What did you receive in the hospital?
- We placed a tube in your chest to drain the fluid and your
breathing improved
- We still do not know why the fluid accumulated, and tests are
still pending.
What should you do once you leave the hospital?
- Follow up with your main doctor and the lung doctors
___ below)
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10584705-DS-6 | 10,584,705 | 23,339,486 | DS | 6 | 2188-03-10 00:00:00 | 2188-03-10 10:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lidocaine
Attending: ___
Chief Complaint:
Infected right femoral HD line
Major Surgical or Invasive Procedure:
Left femoral HD line placement ___
History of Present Illness:
___ incarcerated man with ESRD secondary to congenital
small kidneys on HD, with a recent hospitalization for L femoral
HD line infection (MRSA and Staph Epi Bacteremia) with course
complicated by R hemothorax after traumatic RIJ/RSC/LSC line
attempt, treated with 4 weeks of IV vancomycin, presenting with
displaced R femoral HD line with fevers and gross evidence of
line infection.
He was admitted at an OSH ___ with L femoral HD line infection
and was found to have MRSA bacteremia. Following unsuccessful
attempt at RIJ/RSC/LSC line placement and removal of L fem HD
line he developed a hemothorax requiring a chest tube. A right
femoral tunneled HD line was able to be successfully placed
(although actually in saphenous vein) but the line developed
significant oozing. However, the line was functional and he
resumed HD. TTE and TEE negative for endocarditis/vegetations.
He was treated with a 4 week course of vancomycin (end date
___ for his bacteremia and plan was for transplant surgery
follow up for AVF placement. He was discharged on ___ back to
his ___ facility.
He was transferred back to the ___ after reporting increasing
pain at the femoral line site, fevers, and chills. They noted
erythema at the site of his femoral line and sent him to ___
for evaluation of line infection. was transferred to, now
presenting with concern for infection at the site of the right
femoral line. Patient reports 7 hours of increasing pain, fever,
chills. Was scheduled for dialysis today when they noticed
subjective chills, apparently displaced right femoral line, and
erythema at the site of the line. Transferred here for concern
for infection of line site.
In the ED, initial VS were: 99.6 (Tmax - 103.0) 92 153/86 18 97%
RA
Exam notable for:
+erythema 10 cm around right femoral site w/ likely displaced
line +TTP in RLQ, well healed incisional scar
ECG: ___: Peaked T's, NSR
Labs showed: WBC 14.2, Cr 10.0, K 5.9 -> 5.8. Lactate 0.8
Imaging showed:
CXR: Right base opacities continue to improve, with some
residual remaining. Underlying infection is difficult to
exclude. No pleural effusion, pneumothorax, or pulmonary edema.
Persistent cardiomegaly.
CT A/P 1. Malpositioned right femoral central venous catheter
extending through the posterior wall of the right common iliac
vein which is new from CT in ___. No surrounding hematoma.
Possible tiny focal thrombus adjacent to the catheter in the
right external iliac vein versus artifact. 2. No right groin
drainable fluid collection. 3. Stable splenomegaly. Moderate
volume ascites increased from ___. 10 mm radiodensity in
the gallbladder fossa appears new from ___, of unclear
etiology and clinical significance.
Consults: ___: Patient may eat. Please make NPO after midnight -
will plan on procedure ___ call ___ (pager ___ after 9
AM for an updated time.
Renal: ESRD on HD TTS. Had hx of difficult access, recent HD
line infection, hemothorax from multiple attempts IJ line
insertion in ___. Presented to ED today after HD unit found
he might have displaced the line. He also has fever, chills,
pain at the line site. K 5.9 in ED. -Concern for HD line
infection. -Would temporalize K tonight while trying to obtain
new access. Please give insulin, glucose, kayexalate 30 g. If
patient is making some urine, may give Lasix 200 mg IV. -No
secured access for HD at this time. Will recommend to consult ___
for temp HD line if vascular surgery is not doing any
intervention. -Will plan to HD him in AM once he has his line
in. -Agree with blood c/s and empirical ATB.
Patient received: Insulin and dextrose, Calclium gluconate, 500
cc fluid, Sodium Polystyrene Sulfonate 30 gm, 200 mg IV Lasix.
Insulin dextrose and Ca gluconate x2 Vanc/Zosyn Transfer VS
were: 99.2 96 155/91 20 95% RA
On arrival to the floor, patient reports fever, chills, RLQ
abdominal wall pain. He also noted that the redness around his
line first appeared about two weeks ago. The line was
functioning appropriately during his prior HD's.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- ESRD ___ congenital small kidneys s/p DDRT ___
- HTN
- Anemia ___ CKD and iron deficiency on Procrit and iron
supplementation
- Vitamin D deficiency
- Secondary Hyperparathryoidism
- H/o of MRSA BACTEREMIA and STAPH EPIDERMIDIS BACTEREMIA
Social History:
___
Family History:
No family history of renal disease, heart disease; Mother has DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:101.5 PO 163 / 90 94 16 92 2L
GENERAL: Uncomfortable appearing
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: Bibasilar crackles, no wheezes, rhonchi, breathing
comfortably without use of accessory muscles
GI: abdomen soft, nondistended, tender superficial in RLQ. No
peritoneal signs or guarding.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS:
___ 0729 Temp: 97.9 PO BP: 136/82 L Lying HR: 68 RR: 18 O2
sat: 97% O2 delivery: RA
GENERAL: young man, sitting in bed
HEENT: anicteric sclera, moist mucous membranes
NECK: supple
CV: regular rate and rhythm, S1/S2, no gallops or rubs. ___
systolic murmur heard best at ___
PULM: clear to auscultation bilaterally in posterior lung
fields,
breathing comfortably without use of accessory muscles
GI: bowel sounds present, abdomen soft, nondistended,
nontender,
no rebound/guarding
EXTREMITIES: warm and well-perfused, no cyanosis, clubbing, or
edema
NEURO: alert and grossly oriented, moving all 4 extremities
Pertinent Results:
LABS:
___ 03:15PM GLUCOSE-91 UREA N-81* CREAT-10.0*# SODIUM-137
POTASSIUM-5.9* CHLORIDE-96 TOTAL CO2-19* ANION GAP-22*
___ 03:15PM WBC-14.2* RBC-3.09* HGB-9.1* HCT-28.2* MCV-91
MCH-29.4 MCHC-32.3 RDW-17.6* RDWSD-57.5*
___ 03:15PM PLT COUNT-227
___ 03:15PM NEUTS-86.5* LYMPHS-3.8* MONOS-5.5 EOS-3.3
BASOS-0.5 IM ___ AbsNeut-12.28* AbsLymp-0.54* AbsMono-0.78
AbsEos-0.47 AbsBaso-0.07
___ 03:19PM LACTATE-0.___bdomen and Pelvis ___
1. Malpositioned right femoral central venous catheter extending
through the posterior wall of the right common iliac vein which
is new from CT in ___.
No surrounding hematoma. Possible tiny focal thrombus adjacent
to the
catheter in the right external iliac vein versus artifact.
2. No right groin drainable fluid collection.
3. Stable splenomegaly. Moderate volume ascites increased from
___. 10 mm radiopaque structure (calcification or metallix)
adjacent to gallbladder fossa appears new from ___, of
unclear etiology and clinical
significance.
TTE ___
No 2D echocardiographic evidence for endocarditis. Mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global ystolic function. Borderline right
ventricular free wall systolic function. Mild aortic and mitral
regurgitation. Mild to moderate tricuspid regurgitation.
TEE ___
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is mildly depressed. No spontaneous echo
contrast or thrombus is seen in the body of the right
atrium/right atrial appendage. The right atrial appendage
ejection velocity is normal. There is no evidence for an atrial
septal defect by 2D/color Doppler. There are simple atheroma in
the aortic arch with no atheroma in the descending aorta. The
aortic valve leaflets (3) appear structurally normal. No masses
or vegetations are seen on the aortic valve. No abscess is seen.
There is very mild [1+] aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
No abscess is seen. There is physiologic mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. No
mass/ vegetation are seen on the tricuspid valve. No abscess is
seen. There is mild [1+] tricuspid regurgitation. There is no
pericardial effusion.
CTA CHEST ___
1. Focal stenosis at the upper SVC at confluence of the right
and left
brachiocephalic veins, where note is made of a 2.5 cm tubular
calcification at
lower right brachiocephalic. Distal left brachiocephalic vein
is narrowed as
it reaches the confluence. Extensive collaterals noted along
the upper chest.
Narrowing of the right subclavian vein as it crosses the first
rib.
2. Diffuse ground-glass opacities likely represent pulmonary
edema. Trace
right pleural effusion.
Brief Hospital Course:
___ yo M with PMH ESRD on HD with recent L femoral HD line
infection (+ for MRSA and staph epi) treated with 4 wks vanc,
who presented with displaced HD line and fever and was found to
have MRSA bacteremia, hypertensive emergency, and hyperkalemia.
His R femoral line was removed and HD was restarted through a
temporary L femoral catheter while vancomycin was administered
for MRSA bacteremia.
ACUTE ISSUES:
===============
# MRSA bacteremia with indwelling catheter
He presented with a displaced femoral HD line, fevers, and
chills. Subsequently found to have MRSA bacteremia. R femoral
line was removed and HD was restarted through a temporary L
femoral catheter while vancomycin was administered for MRSA
bacteremia. Given the observation of new onset systolic murmurs,
a TEE was performed which did not show any vegetations. ID was
consulted and stated that there was no need for line holiday
before placement of a more definitive line given several
negative blood cultures. ___ placed a R subclavian tunneled
catheter on ___. He will continue on vancomycin dosed with HD
until ___.
# Hypertensive urgency
He had an episode of hypertensive urgency requiring ICU transfer
for nitroglycerine drip. He was started on HD after a new
temporary L femoral line was placed and had improvement in his
blood pressures. He then remained on his home regimen with no
further issues.
# Hyperkalemia
He presented with hyperkalemia in the setting of a misplaced HD
line. This was temporized with calcium and insulin/dextrose on
the floor before being transferred to the ICU where he had a new
HD line placed. His potassium levels were subsequently within an
acceptable range after receiving HD.
# Anemia of chronic disease
Anemia of chronic disease was again noted. CBC was trended daily
Mr. ___ required a transfusion of 1u PRBCs in the ICU due to
Hgb below 7. His counts are stable above 7 on discharge.
# ESRD dependent on HD
Mr ___ received HD ___ while an inpatient. On admission, Mr.
___ was hyperkalemic but this resolved with HD. To control
phosphate levels, Mr ___ remained on ___ carbonate and
the dose was increased to 1200 mg PO TID w/ meals.
# Hypoxia of unclear etiology: resolved
Mr. ___ occasionally required ___ liters of O2 on nasal
cannula. The etiology of this requirement was unclear, but
seemed to improve with improvement in volume status after each
HD session.
# Anxiety
Mr ___ says that he was taking Klonopin daily in prison. This
medication was not listed on his PAML. Upon discussion, he was
unable to relate any symptoms of anxiety and explained that he
was feeling low and depressed. He was offered PRN hydroxyzine.
CHRONIC ISSUES:
===============
# HTN
Mr ___ had an episode of hypertensive emergency before transfer
to the ICU which was controlled with a nitroglycerine drip. He
was restarted on his home regimen with hydralazine, carvedilol,
clonidine, Nifedipine, and losartan.
# HCV
Untreated.
TRANSITIONAL ISSUES:
==================
[] He will start HD ___ in ___ at:
Dialysis Center: ___ (___)
___, Clinical Manager (main number above)
Dr. ___ (nephrologist)
- phone: ___
- fax: ___
[] He was started on aspirin as his new HD line is running
through an area of stenosis. Could also consider full
anticoagulation.
[] He should continue on vancomycin dosed with HD for MRSA
bacteremia until ___.
[] He will need a PCP in FL.
[] He may require an increased dose of sevalamer for his
hyperphosphatemia.
[] He should be treated for his HCV.
**Attending Physician at ___ is
Dr. ___. Contact information is as follows:
___, ___
CODE: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
3. Ferrous GLUCONATE 324 mg PO DAILY
4. HydrALAZINE 100 mg PO TID
5. Losartan Potassium 50 mg PO DAILY
6. NIFEdipine (Extended Release) 60 mg PO BID
7. ___ CARBONATE 800 mg PO TID W/MEALS
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. ___ CARBONATE 2400 mg PO TID W/MEALS
RX ___ carbonate 800 mg 3 tablet(s) by mouth three times
a day Disp #*270 Tablet Refills:*1
3. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
RX *clonidine [Catapres-TTS-3] 0.3 ___ patch weekly
on ___ QMON Disp #*4 Patch Refills:*1
5. Ferrous GLUCONATE 324 mg PO DAILY
RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*1
6. HydrALAZINE 100 mg PO TID
RX *hydralazine 100 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*1
7. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
8. NIFEdipine (Extended Release) 60 mg PO BID
RX *nifedipine 60 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
central line associated blood stream infection
MRSA bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- Your dialysis catheter was out of place and you had bacteria
in your blood.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received a temporary catheter for dialysis and received
antibiotics for your MRSA infection during dialysis.
- You later received a permanent catheter for dialysis in your
right chest.
- You were in the ICU for a short time because of very high
blood pressure, which was fixed with IV blood pressure medicine
and then stayed normal with oral blood pressure medicine.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue dialysis at your dialysis center in ___.
- Continue your antibiotics (vancomycin) with dialysis until
your doctor stops.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10584718-DS-6 | 10,584,718 | 24,841,021 | DS | 6 | 2164-10-21 00:00:00 | 2164-10-22 20:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa
Attending: ___.
Chief Complaint:
fall, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx notable for CKD IV (baseline? 2.4?) s/p renal
transplant ___ at ___), HTN, DM, PAD, diastolic HF, remote LUE
DVT off AC given GI bleeding history PUD, chronic anemia and
thrombocytopenia, multiple mixed arteriovenous ulcerations of
bilateral lower extremities and neuropathic foot ulcers c/b
chronic drainage and hx of pseudomonal colonization and heavy
drainage requiring dressing changes every other day (follows
closely at ___ Wound Care Dr. ___ who initially
presented to ___ on ___ after EMS was called after fall and pt
was unable to get up.
Per EMS paperwork, he was found sitting upright on the floor in
his bathroom. He noted he had slipped from the toilet and sat on
the floor and could not get up. The patient's wife confirmed the
story and denied head strike or LOC. With assistance, the
patient
was able to stand and walk using a walker. He appeared unstable
on his feet and had a difficult time remember his age, the date
or current events. His wife endorsed that he was recently
diagnosed with a UTI based on urine culture from ___ at
___
that grew VRE. Per wife, patient never started abx as
outpatient.
She also noted that he is often confused but over last previous
days he had difficulty remembering things.
On arrival to ___ on ___, pt was febrile to 102.5 and was
confused.
___ labs: leukocytosis 17 diff with 89% neutrophils , Cr 3.03
(of
note, Cr ~2.4 ___, 3.46 on ___ at ___), TNI 0.03; CRP 1.5
ESR 22 Tbili 1.7, UA negative
BIP imaging/reports:
- ___ renal ultrasound no hydro of transplanted kidney
- ___ EKG RBB (old)
- ___ NCCTH and Cspine negative (right maxillary sinusitis)
- ___ CT A/P w/o contrast - cirrhotic morphology liver,
transplant kidney in left pelvis with hydronephrosis and
hydroureter, no perinephric stranding. Splenomegaly.
Subcutaneous
stranding and skin induration involving the right pannus below
the small bowel containing umbilical hernia. No abscess.
- ___ RLE w/o contrast - erosion noted at anterior margin of
the
posterior calcaneous at the level of the ulcer bed, cannot
exclude osteomyelitis
- ___ CT head - No acute intracranial abnormality is
identified.
Right maxillary sinusitis.
- ___ CXR hypoinflated lungs, no evidence of PNA or edema
- ___ XR Tib/Fib bilateral soft tissue edema and vascular
calcification and diffuse osteopenia and degenerative changes;
no
clear osteo evidence.
BIP Micro:
- ___ UCx VRE, amp sensitive
- ___ Right heel deep wound culture pending
- ___ BCx pending
At ___, pt started on Unasyn and vancomycin to cover for chronic
___ wounds and UTI
Pt transferred to ___ for further care.
In ED, he is AAOx3. Reporting right heel pain for some time that
can have black and green drainage. Really doesn't want a foley
if
he doesn't need it. He doesn't remember context of the fall.
ED Vitals: T 98.1 P 84 BP 110/54 RR 18 O2 97% RA wt ___'8"
ED exam:
Gen: AAOx3, intermittently slow to respond to questions.
Ext: Chronic wounds to R lateral ankle and L anterior distal
tibia, covered by gauze. Lower extremity skin appears blue and
thin ___ likely chronic skin changes. No surrounding erythema or
purulent discharge. Skin feels warmer surrounding the leg
wounds.
Good distal pulses
ED labs notable for mild leukocytosis, anemia and
thrombocytopenia which are chronic, non-anion gap acidosis,
creatinine of 2.8, and troponin of .11, phos of 5
EKG with RBBB and sinus rhythm
The patient was given:
At ___ vanco 1500mg@ 0100, Unasyn 3gm 2300; in ___ ED only
got
unasyn and home meds
On arrival to the floor, the patient is confused about why he
was
transferred. He recalls having urinary urgency last week and was
only urinating small amounts. Generally he urinates regularly.
He
has had no fevers or pain with urination. He went to the doctor
on ___ and urine cultures were obtained. On ___ AM he was
informed about his UTI and his wife picked up antibiotics that
he
never got the chance to start taking.
History obtained from the patient's wife confirms this. She says
that he has not been acting like himself since ___ - he has
been
having a hard time focusing and understanding information. She
explains also that he did not really fall but became weak so
that
as she was helping him to the bathroom he sat down on the floor
and she could not get him up.
Past Medical History:
CKD 4
left renal transplant ___ at ___
___
DM
gout
PAD
diastolic HF
remote LUE DVT off AC given GI bleeding history
?PUD unclear
chronic anemia
chronic thrombocytopenia
multiple mixed arteriovenous ulcerations of bilateral lower
extremities and neuropathic foot ulcers c/b chronic drainage and
hx of pseudomonal colonization
s/p TURP
Dementia
Social History:
___
Family History:
father had leukemia in his ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Alert and oriented to person and place but not to time.
In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness. Lipoma noted over left trapezius
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. There is a large reducible
umbilical hernia. There is thickening of the skin of the
abdominal pannus but no evidence of cellulitis beneath the
hernia
or pannus.
EXTREMITIES: Has two 4 cm ulcers on the lateral aspect of the
right lower leg and one 5 cm ulcer on the lateral aspect of the
left leg. Right leg ulcer actively drains serosanguinous fluid.
Surrounding area is non-tender to light touch and the pt has
sensation. On the right heel is a black eschar, not draining,
does not appear acutely infected
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx2. Moving all 4 limbs spontaneously. ___ strength
throughout. Normal sensation. Has tremor with outstretched arms,
worse on the left. No pronator drift.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1237)
Temp: 97.9 (Tm 98.0), BP: 138/69 (114-138/52-69), HR: 73
(60-78), RR: 18 (___), O2 sat: 94% (94-100), O2 delivery: Ra
GENERAL: A+Ox2. Mental status fluctuates throughout the day.
This
morning patient was alert and appropriately responsive. In no
acute distress.
HEENT: Temportal wasting present. PERRL, EOMI. Sclera anicteric
and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: No wheezes, rales or rhonchi. No increased work of
breathing.
BACK: No CVA tenderness. Lipoma noted over left trapezius
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. There is a large reducible
umbilical hernia with thickening of the skin on the underside.
There is thickening of the skin of the abdominal pannus but no
evidence of infection beneath the hernia or pannus.
EXTREMITIES: Multiple legs ulcers present, pictures taken on
___. Surrounding area is non-tender to light touch and
sensation intact. On the right heel is a single ulcer, not
draining, does not appear acutely infected
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: Moving all 4 limbs spontaneously. ___ strength
throughout. Normal sensation. Has tremor with outstretched arms,
worse on the left.
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 06:50AM BLOOD WBC-10.5* RBC-2.72* Hgb-8.2* Hct-26.7*
MCV-98 MCH-30.1 MCHC-30.7* RDW-19.0* RDWSD-67.4* Plt Ct-67*
___ 03:10PM BLOOD ___ PTT-22.9* ___
___ 06:50AM BLOOD Glucose-112* UreaN-90* Creat-2.8* Na-134*
K-5.1 Cl-102 HCO3-18* AnGap-14
___ 06:50AM BLOOD ALT-33 AST-26 LD(LDH)-202 AlkPhos-127
TotBili-1.0
___ 06:50AM BLOOD CK-MB-2
___ 06:50AM BLOOD cTropnT-0.11*
___ 03:10PM BLOOD Calcium-9.5 Phos-5.0* Mg-1.8
___ 06:50AM BLOOD Albumin-3.0*
___ 06:50AM BLOOD Hapto-178
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 7:16 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:23 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ TRANSPLANT U.S.
1. Atrophic transplanted left kidney with no evidence of
obstruction.
2. Minimally elevated resistant index of intrarenal arteries,
ranging 0.73 to
0.79.
___ AP,LAT & OBL RIGHT
Chronic appearing remodeling of the calcaneus but without lysis.
___ EXT (REST ONLY)
Right lower extremity: Borderline elevated ABI consistent with
arterial
calcification artifact with a severely diminished toe pressure.
Waveforms
consistent with tibial disease.
Left lower extremity: Noncompressible distal vessels consistent
with arterial
calcification artifact with a mildly abnormal TBI. Waveforms
consistent with
mild obstructive tibial disease.
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 07:41AM BLOOD WBC-6.8 RBC-2.83* Hgb-8.4* Hct-28.4*
MCV-100* MCH-29.7 MCHC-29.6* RDW-18.6* RDWSD-68.1* Plt Ct-67*
___ 07:41AM BLOOD Glucose-88 UreaN-68* Creat-2.5* Na-143
K-5.4 Cl-114* HCO3-18* AnGap-11
___ 07:41AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.7
___ 06:20AM BLOOD tacroFK-3.6*
Brief Hospital Course:
SUMMARY:
===================
___ year old man with hx of CKD s/p left renal transplant and
chronic ___ ulcers transferred from ___ where he presented on
___t home. Patient with AMS in the setting of sepsis
from a UTI with VRE. Transferred to ___ for further care of
sepsis and ___ wounds.
ACUTE/ACTIVE ISSUES:
====================
# UTI complicated by sepsis
Patient found to have UTI at office visit, but was brought into
the hospital prior to picking up the antibiotic prescriptions.
While admitted, patient with fever, leukocytosis, delirium and +
urine culture for VRE, sensitive to ampicillin. Patient was
started on unasyn on ___ and transitioned to ampicillin on
___. Due to the patient becoming septic from the infection and
due to his immunocompromised state, it is important for the
patient to complete a 14 day course for treatment of complicated
UTI (end date ___.
# Multiple mixed arteriovenous ulcerations of bilateral lower
extremities
Patient with chronic bilateral leg and foot wounds. During this
hospitalization, patient was initially started on vancomycin but
soon discontinued due to low clinical and radiographic suspicion
for infection. ESR and CRP within normal limits. Patient was
seen by vascular surgery and ABIs and PVRs with bilateral toe
pressures were performed. Vascular surgery recommended adding
aspirin 81mg daily and continue patient on his home
atorvastatin. He was evaluated by Podiatry who recommended
against antibiotics or surgery, and recommended WTD dressings
with collagenase ointment to left leg. He was discharged home
with ___ and wound care services.
# ___ on CKD, hx of left transplanted kidney- on admission, the
patient's Creatinine was 2.8. Per chart review, his Creatinine
has often been around 2.4-2.5, but has been as low as 2.0. With
fluid resuscitation, his Cre improved to 2.4. He was noted to
have some hydronephrosis on CT at ___ but US performed at
___ did not show any hydronephrosis.
Renal transplant was consulted and managed the patient's
immunosuppression medications with daily tacrolimus levels. His
prednisone was decreased from 10mg daily to 5 mg daily. His
mycophenolate was held during this admission due to infection.
His diuretics were held during this admission due to ___.
# Fall - patient initially taken to the hospital due to a fall
while in the bathroom. Per his wife, who witnessed the fall,
this was purely a mechanical fall without LOC or head trauma. CT
head at OSH without evidence of intracranial bleed. An EKG was
performed during this admission without evidence of arrhythmia.
Patient worked with physical therapy during his stay and they
recommended that he be admitted to rehab, but the patient
declined. As an alternative, ___ recommended home ___ services
with 24 hr supervision for fall precaution. Patient's family has
been notified of his decision and of his monitoring requirement.
# Malnutrition - during this admission, patient was noted to
have some temporal wasting and overall poor nutrition status.
Nutrition services was consulted and recommended following
weights 3x/wk with Juven BID and Ensure daily for supplements.
Also recommended starting daily multivitamin with minerals.
# Cirrhosis - patient was noted to have cirrhosis on abdominal
CT. As patient had altered mental status, he was started on
lactulose 30ml daily. This should be titrated to ensure ___
bowel movements per day.
CHRONIC/STABLE ISSUES:
======================
#Chronic anemia, thrombocytopenia- patient's labs consistent
with anemia of chronic disease and thought to be related to this
CKD. Thrombocytopenia thought to be related to cirrhosis. He
received daily CBCs and his levels were stable.
# HFpEF- patient was continued on his home statin, metoprolol,
isosorbide mononitrite. Diuretics were held in setting of ___,
then restarted prior to discharge.
#DM- Per patient he does not take insulin or other DM
medications. Continue his home atorvastatin.
TRANSITIONAL ISSUES:
===================
[] Please encourage patient to follow up with his scheduled
appointments and to continue taking the medications as described
in the discharge packet.
[] Repeat a tacrolimus level next week after discharge, to be
sent to patient's nephrologist, Dr. ___ at ___
___.
[] Patient noted to have cirrhosis on abdominal CT. As patient
had altered mental status, he was started on lactulose 30ml
daily. This should be titrated to ensure ___ bowel movements per
day.
[] Please encourage patient to begin a multivitamin along with
Juven BID and Ensure daily for nutritional support. Also to
weigh himself 3x/wk.
[] Pleasure ensure that patient continues with home ___ services
and 24 hr supervision for fall precaution.
MEDICATION CHANGES:
==================
- Decreased prednisone from 10mg to 5mg daily
- Started multivitamins
- Started lactulose for altered mental status in setting of
cirrhosis
- Started collagenase ointment applied to left leg wound
- Started ASA daily for PAD
- Started ampicillin 500mg Q8H (END DATE ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. PredniSONE 10 mg PO DAILY
3. Tacrolimus 1 mg PO Q12H
4. Calcitriol 0.5 mcg PO EVERY OTHER DAY
5. Pantoprazole 40 mg PO Q24H
6. Gentamicin 0.1% Cream 1 Appl TP DAILY
7. Atorvastatin 40 mg PO QPM
8. Isosorbide Mononitrate 30 mg PO DAILY
9. Furosemide 40 mg PO BID
10. Mycophenolate Mofetil 500 mg PO BID
11. Linezolid ___ mg PO Q12H
12. Calcitriol 0.25 mcg PO EVERY OTHER DAY
13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
14. Spironolactone 25 mg PO DAILY
15. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
16. Epoetin ___ ___ units/ml SC 28 DAY SUPPLY 28 day supply
Discharge Medications:
1. Ampicillin 500 mg PO Q8H
Please take every 8 hours until the prescription is finished.
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Collagenase Ointment 1 Appl TP DAILY
Apply to left leg wound as instructed
4. Lactulose 30 mL PO TID:PRN cirrhosis
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth as needed
Disp #*1 Bottle Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
6. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus 0.5 mg 3 capsule(s) by mouth once a day Disp #*90
Capsule Refills:*0
8. Atorvastatin 40 mg PO QPM
9. Calcitriol 0.5 mcg PO EVERY OTHER DAY
10. Calcitriol 0.25 mcg PO EVERY OTHER DAY
11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
12. Epoetin ___ ___ units/ml SC 28 DAY SUPPLY 28 day supply
13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
14. Furosemide 40 mg PO BID
15. Gentamicin 0.1% Cream 1 Appl TP DAILY
16. Isosorbide Mononitrate 30 mg PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Mycophenolate Mofetil 500 mg PO BID
19. Pantoprazole 40 mg PO Q24H
20. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Urosepsis
Lower extremity wound ulcers.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had a complicated infection of
the bladder (urinary tract infection).
What happened while I was in the hospital?
- You were given antibiotics to treat the infection and there
was evaluation to ensure that the infection had not spread to
your kidney (it had not).
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Take Ensure drink daily and Juven twice daily to supplement
your nutrition
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10584750-DS-6 | 10,584,750 | 22,503,613 | DS | 6 | 2119-11-25 00:00:00 | 2119-11-25 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD/colonoscopy
History of Present Illness:
___ w/DM presents with one week of abdominal pain, nausea,
vomiting, diarrhea. Pt reports pain has been getting
progressively worse, is worse with food. +Abd distension, NBNB
emesis and nonbloody, watery diarrhea about 5 times per day. No
unable to tolerate p.o. Reports fever for the past 2 days with
Tmax 101.4. Pt reports having pancreatitis in the past which was
attributed to Januvia, last episode was ___. The
severity of the pain is similar to that episode but the location
is different. He reports that pain is diffuse and initally worse
epigastric and RUQ but now the worse pain is LLQ
In ED pt afebrile. Given morphine/zofran, toradol, 2Lns.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
HTN
DM 2
benign renal cysts
- s/p partial nephrectomy
ventral and inguinal hernias
Social History:
___
Family History:
no GI disease
Physical Exam:
Vitals: T:97.4 BP:110/76 P:65 R:18 O2:98%ra
PAIN: 7
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, distended, tender LLQ
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 05:40PM GLUCOSE-138* UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 05:40PM ALT(SGPT)-40 AST(SGOT)-23 ALK PHOS-66 TOT
BILI-0.2
___ 05:40PM LIPASE-76*
___ 05:40PM ALBUMIN-4.9
___ 05:40PM LACTATE-1.7
___ 05:40PM WBC-9.9 RBC-5.86 HGB-18.5* HCT-51.6 MCV-88
MCH-31.6 MCHC-35.8* RDW-14.2
___ 05:40PM NEUTS-68.6 ___ MONOS-4.9 EOS-1.4
BASOS-1.3
___ 05:40PM PLT COUNT-275
___ 12:05AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:05AM URINE RBC-4* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-5
CT Abd/Pel
1. Status post cholecystectomy and appendectomy.
2. Normal appearance of the pancreas.
3. Very few sigmoid diverticula, without evidence of
diverticulitis.
4. Bilateral renal hypodensities measure intermediate density,
and can be
further evaluated via renal ultrasound on a nonemergent basis.
CXR IMPRESSION: Hyperinflated, clear lungs
Colonoscopy:
Findings:
Protruding Lesions A single sessile 2 mm polyp of benign
appearance was found in the rectum. A single-piece polypectomy
was performed using a cold forceps in the rectal polyp. The
polyp was completely removed. Small internal hemorrhoids were
noted.
Other
procedures: Cold forceps biopsies were performed for histology
at the TI.
Cold forceps biopsies were performed for histology at the random
colon.
Impression: Polyp in the rectum (polypectomy)
(biopsy, biopsy)
Internal hemorrhoids
Otherwise normal colonoscopy to TI
Recommendations: follow-up biopsy results
EGD:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Erythema of the mucosa was noted in the antrum. These
findings are compatible with gastritis. Cold forceps biopsies
were performed for histology at the antrum.
Duodenum:
Mucosa: Erythema of the mucosa was noted in the duodenal bulb
compatible with duodenitis.
Other
procedures: Cold forceps biopsies were performed for histology
at the duodenum.
Impression: Erythema in the antrum compatible with gastritis
(biopsy)
Erythema in the duodenal bulb compatible with duodenitis
(biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results
Omeprazole 20mg BID
Avoid NSAIDs
Brief Hospital Course:
Mr. ___ is a ___ year old with a history of DM, HTN, hx ccy,
renal cysts (benign) and partial nephrectomy, ventral/inguinal
hernias who presented to the ED with one week of abdominal pain,
nausea, vomiting, diarrhea. He reported the pain had been
getting progressively worse, and is worse with food. He endorsed
abdominal distension, NBNB emesis and nonbloody, watery diarrhea
about 5 times per day prior to arrival. HE was unable to
tolerate p.o. He reported fever for with a Tmax 101.4 prior to
admission. He underwent CTAP in the ED (negative) then ruq u/s
(NEG).
He was managed conservatively with bowel rest and fluids,
narcotic analgesia and antiemetics for 36 hours. His diarrhea,
nausea and vomiting resolved. GI was consulted and recommended
EGD and colonoscopy. EGD showed gastritis and duodenitis.
Biopsies were sent. On colonoscopy, polyp was noted and removed.
Path is pending at discharge. All labs were normal.
He tolerated advancement of his diet. He had filled pain scripts
in the past ___ months for kidney stones and LBP. He also saw
his old PCP in ___, Dr. ___, in ___, where he was
given a script for clonazepam and percocet. He endorsed most,
but not all of these scripts.
He was at times emotional, tearful, and I question a component
of somatization. He was discharged on BID PPI, and a very short
script (5 tabs) of percocet, with no plans to continue opiates.
Transitional issues:
- Path pending from EGD and ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg 1 tablet(s)
by mouth every six (6) hours Disp #*5 Tablet Refills:*0
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:
Mr. ___ -
___ were admitted to ___ with acute abdominal pain, fever, and
diarrhea likely related to an infection. Those symptoms
resolved, but your pain and nausea persisted. ___ had an
endoscopy and colonoscopy which showed inflammation of your
stomach and small intestine. Biopsies were taken and the results
will be followed-up with ___.
Please keep ___ appointment below.
Followup Instructions:
___
|
10584942-DS-17 | 10,584,942 | 28,869,717 | DS | 17 | 2179-03-12 00:00:00 | 2179-03-13 17:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right lower quadrant pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with history of hypertension, GERD who
presents to ___ with abdominal pain. Patient states that he
has
been having 3 days of RLQ abdominal pain that occurs at night
primarily, occasionally awakening him from sleep. The pain is
insidious in onset, and has no associated symptoms that the
patient can recall. He denies fevers, chills, nausea, vomiting,
or diarrhea. He says his appetite has been at his baseline. He
has no history of abdominal surgeries or recent sick contacts.
His last colonoscopy was approximately ___ years ago and was
normal, per patient report.
Past Medical History:
Abdominal pain
Enlarged Prostate
Obstructive LUTS
urinary frequency which dates back to ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical exam: ___: upon admission:
Vitals: T 98.1, HR 55, BP 132/79, RR 18 100% RA
Gen: well appearing, NAD
CV: RRR, palpable peripheral pulses
P: nonlabored breathing on room air
GI: soft, nontender, nondistended; no rebound or guarding; no
tap
or shake tenderness
Ext: WWP, no CCE
Physical examination upon discharge: ___:
vital signs: t=98.5, hr=54, bp=103/64, rr=18, 95% room air
GENERAL: NAD
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: soft, non-tender, no rebound, no guarding
EXT: no pedal edema bil., no calf tenderness bil
SKIN: Left flank, localized area of erythematous papular
lesions, 2"x2", scattered papular lesions extending to abdomen,
no lesions face, arm, back, legs
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 06:20AM BLOOD WBC-4.8 RBC-4.50* Hgb-12.2* Hct-38.1*
MCV-85 MCH-27.1 MCHC-32.0 RDW-14.3 RDWSD-43.8 Plt ___
___ 06:35AM BLOOD WBC-5.2 RBC-4.66 Hgb-12.5* Hct-39.2*
MCV-84 MCH-26.8 MCHC-31.9* RDW-14.2 RDWSD-43.4 Plt ___
___ 10:07AM BLOOD WBC-5.9 RBC-5.10 Hgb-13.5* Hct-42.9
MCV-84 MCH-26.5 MCHC-31.5* RDW-14.1 RDWSD-43.2 Plt ___
___ 10:07AM BLOOD Neuts-50.9 ___ Monos-9.9
Eos-10.1* Baso-1.5* Im ___ AbsNeut-3.01# AbsLymp-1.62
AbsMono-0.59 AbsEos-0.60* AbsBaso-0.09*
___ 06:20AM BLOOD Plt ___
___ 06:35AM BLOOD ___ PTT-28.1 ___
___ 06:35AM BLOOD Glucose-128* UreaN-13 Creat-0.9 Na-142
K-4.2 Cl-105 HCO3-25 AnGap-16
___ 10:07AM BLOOD ALT-30 AST-40 AlkPhos-44
___ 06:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
___: cat scan abdomen and pelvis:
1. The appendix is enlarged measuring up to 1.3 cm with mild fat
stranding, compatible with uncomplicated appendicitis. There is
no drainable fluid collection or perforation.
2. Cholelithiasis
Brief Hospital Course:
___ year old male admitted to the hospital with three days of
right lower quadrant pain. Upon admission, the patient was made
NPO, given intravenous fluids, and underwent imaging. Cat scan
imaging of the abdomen showed an enlarged appendix with mild fat
stranding compatible with uncomplicated appendicitis. There was
no fluid collection or perforation. The patient was started on a
course of ciprofloxacin and flagyl. He underwent serial
abdominal examinations and monitoring of his white blood cell
count.
Cat scan findings were discussed with the patient. The
treatment options, including both surgical and medical
management, were addressed. The patient decided to undergo a
trial of medical management given his relatively benign
symptomatology.
On HD #2, the patient reported left flank discomfort and was
noted to have a localized herpetic rash. He was started on a
course of valacyclovir. He was transitioned from intravenous
antibiotics to augmentin for completion of a 2 week course. The
patient was discharged home on HD #3. His vital signs were
stable and he was afebrile. His white blood cell count was
normal. He was tolerating a regular diet and voiding without
difficulty. His abdominal pain had decreased in severity.
Discharge instructions were reviewed and questions answered. An
appointment for follow-up was made in the Acute Care clinic.
Medications on Admission:
LISINOPRIL - lisinopril 5 mg tablet. 1 (One) tablet(s) by mouth
once a day - (Prescribed by Other Provider; Dose adjustment -
no
new Rx)
SIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth
daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*25 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last dose ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*24 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. ValACYclovir 1000 mg PO Q8H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
7. Lisinopril 5 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Secondary:
herpes zooster
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital with right lower quadrant
abdominal pain. On review of the imaging, you were reported to
have acute appendicitis. Surgical and medical intervention was
reviewed with you. You were medically managed and placed on a
course of antibiotics. During your hospitalization, you
developed shingles and were started on medication. Your white
blood cell count and vital signs have been stable. You are
being discharged with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please follow-up with your primary care provider if the rash
increases in severity and you develop severe pain. If the rash
becomes weepy "wet", please cover the dry dressing. Wash hands
thoroughly and avoid touching the rash. ___ leave it uncovered
if it drys out and scabs form.
Followup Instructions:
___
|
10584975-DS-9 | 10,584,975 | 27,536,902 | DS | 9 | 2142-01-08 00:00:00 | 2142-01-08 17:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Phenothiazines
Attending: ___
Chief Complaint:
prolonged episode of vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a past medical history significant for
T-cell lymphoma with spontaneous remission in ___, right
choroid
fissure cyst with episodes concerning for seizures in ___ for
which she was treated with gabapentin for ___ years till ___ who
presents with a prolonged episode of vertigo. She is quite
active, playing tennis ___ times every day. She went on a long
walk earlier this morning with no problems then she went to go
play a game of tennis with her good friends. When she got to
the
tennis courts, she was using a broom to sweep away the puddles.
As she did that, she had the sensation of movement all around
her, as if she was walking on a ship. This started at 10:10 AM.
She started to feel a little bit ill but ignored this sensation
and started practicing her serving. She says she was able to
serve 9 balls
with no problems although she did feel off balance. She went to
sit down, as her friend entered the court the world started
moving profoundly all around her. She was unable to walk. She
laid down on a bench. She thought she was going to die. She
wondered if she was having a heart attack but she did not have
any chest pain. She started to feel very nauseous. She ended
up
throwing up twice. She did try to close her eyes, but it did
not
help with the sensation. Because she felt so poorly, she asked
her friend to call ___. She had an intense sense of movement
all
around and nothing made it feel better. She did not try to walk
because she knew she would fall, she did not even try to reach
out and grab things because she felt so ill. It is unclear if
she had any true difficulty with movement. EMS picked her up,
and brought her to ___. She thinks that the severe
vertiginous
feeling lasted from approximately 10:10 AM to 11:30 AM, 1 hour
and 20 minutes and then it started to resolve. On our
encounter,
at 3:30 ___, she feels 95% back to normal. She has never had an
episode like this in the past. She has had no ear fullness,
ringing in her ears, hearing loss. She has not had any recent
illnesses, no flus or colds. It was not associated with any
weakness, double vision, difficulty speaking or swallowing or
any
other focal neurological deficit that she could recognize. She
has not had any excessive alcohol/illicit intake. The
sensations
did not wax and wane, and there were not multiple episodes.
Rather it was one prolonged episode that has almost completely
resolved at the time of assessment. Neurology was consulted for
workup and management recommendations.
On neuro ROS, prolonged episode of vertigo as above. Otherwise
the pt denies headache, loss of vision, blurred vision,
diplopia,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, paresthesias. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, during the episode, she felt
intense nausea and vomited twice. The pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
- Familial tremor of the vocal cords with dystonic voice, she
developed this when she was around ___ years old
- Chronic T cell lymphoma in spontaneous remission, diagnosed in
___. She never had chemo or radiation or any other treatment
for this other than light therapy
- HLD
- choroid fissure cyst of unclear etiology thought to result in
episodes concerning for seizures in the early ___. She
reports
multiple lifetime episodes of loss of consciousness witnessed by
her family members, last in ___ there. She is unable to
describe these further, she does not know if she was shaking,
incontinence to urine or bowel, she denies aura or history of
trauma. She was seen by a neurologist at ___
for
these who prescribed Neurontin for ___ years which was then
stopped
for unclear reasons in ___.
Social History:
___
Family History:
She has 2 daughters and 5 granddaughters who are all
healthy. She has a ___ sister who is healthy. Her
mother passed at ___ from pancreatic cancer. Her father passed
at
___ from lung cancer.
Physical Exam:
GENERAL EXAM:
- Vitals: Pain 0 temperature 98.6 heart rate 80 blood pressure
154/74 respiratory rate 18 96% on room air
- General: Awake, cooperative, anxious.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to examiner. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. Able to register 3 objects
and
recall ___ and ___ with prompting at 5 minutes. There was no
evidence of apraxia or neglect.
- Cranial Nerves:
PERRL 3 to 2mm and brisk. VFF to confrontation. Head impulse
test performed with corrective saccades in both directions
regardless of which way the head was turned. EOMI with saccadic
intrusions. Facial sensation intact to light touch. No facial
droop. Hearing intact to finger-rub bilaterally. Palate elevates
symmetrically. ___ strength in trapezii and SCM bilaterally.
Tongue protrudes in midline and to either side with no evidence
of atrophy or weakness.
- Motor: Normal bulk and paratonia throughout. No pronator drift
bilaterally. No adventitious movements such as tremor or
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 0 0 2 2 0
R 0 0 tr 2 0
Plantar response was flexor bilaterally (although left toe
appears tonically up it does flex on stimulation).
- Coordination: No intention tremor or dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No overshoot on
mirroring. No dysmetria on finger tap. No posting. No truncal
ataxia when sitting at the edge of the bed.
- Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty or missteps.
Romberg absent.
Pertinent Results:
___ 04:40AM BLOOD WBC-7.7 RBC-4.46 Hgb-13.8 Hct-40.9 MCV-92
MCH-30.9 MCHC-33.7 RDW-12.2 RDWSD-40.1 Plt ___
___ 12:05PM BLOOD Neuts-62.4 ___ Monos-5.5 Eos-2.1
Baso-0.7 Im ___ AbsNeut-5.92 AbsLymp-2.74 AbsMono-0.52
AbsEos-0.20 AbsBaso-0.07
___ 04:40AM BLOOD Glucose-83 UreaN-15 Creat-0.5 Na-140
K-3.7 Cl-102 HCO3-26 AnGap-16
___ 12:05PM BLOOD ALT-23 AST-20 AlkPhos-82 TotBili-0.8
___ 04:40AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.1 Cholest-PND
___ 04:40AM BLOOD %HbA1c-5.6 eAG-114
___ 12:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brain MRI:
FINDINGS:
There is no abnormal focus of slow diffusion. There is no
infarction. No
hemorrhage. There is no parenchymal signal abnormality and no
evidence of
mass or mass effect. The ventricles and sulci are
age-appropriate. Principal intracranial vascular flow voids are
preserved. There is no abnormal parenchymal or meningeal
enhancement and dural venous sinuses are patent on postcontrast
MP-RAGE sequences.
There is diffuse mucosal thickening in the paranasal sinuses and
the left
frontal sinus is completely opacified.
IMPRESSION:
1. Normal brain MRI.
2. Diffuse paranasal sinus disease as described.
CTA Head and Neck:
IMPRESSION:
1. Unremarkable head and neck CTA.
2. No acute intracranial abnormality on noncontrast head CT.
3. Heterogeneous thyroid gland with multiple hypodense nodules,
the largest in the right thyroid lobe measuring up to 1.8 cm.
Nonemergent thyroid ultrasound can be obtained for further
evaluation.
Brief Hospital Course:
Pt was admitted to ___ Neurology Stroke service due to concern
for possible cerebellar stroke given symptoms of acute onset
vertigo. Although history was more consistent with peripheral
vestibulopathy, MRI/MRA and CT/CTA were ordered to rule out
stroke given several risk factors, but scans were negative. Pt
was discharged with instructions for coming back to the hospital
and f/u with PCP.
MRI Brain ___
1. Normal brain MRI.
2. Diffuse paranasal sinus disease as described.
CTA Head and Neck ___
1. Normal head and neck CTA.
2. Heterogeneous thyroid gland with multiple hypodense nodules,
the largest in
the right thyroid lobe measuring up to 1.8 cm. Nonemergent
thyroid ultrasound
can be obtained for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 5 mg PO QPM
2. Vitamin D Dose is Unknown PO DAILY
3. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Rosuvastatin Calcium 5 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vestibulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of vertigo resulting from
a transient vestibulopathy, a condition where some of your
nerves responsible for balance and posture are temporarily
impaired. Please follow up with your primary care physician as
listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10585013-DS-4 | 10,585,013 | 22,595,489 | DS | 4 | 2189-10-08 00:00:00 | 2189-10-08 21:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ history of appendectomy and multiple ovarian
surgeries p/w abdominal pain x 1 day found to have SBO. Patient
started having mid abdominal pain around 6pm yesterday, which
gradually worsened to the point where the patient was unable to
move. No nausea but had emesis due to the feeling of abdominal
pressure. No fevers, no dysuria, but did endorse decreased
appetite. Last BM was 2pm and last passed gas yesterday am. Of
note has had intermittently cramping and constipation the last
few months. Has had multiple abdominal surgeries, mostly ovarian
surgeries, last was a salpingoophrectomy ___ years ago. No
history
of previous bowel obstructions. Had history of alcohol
dependence. Last drink was 6 months ago. Does use xanax
regularly, now once every three days and uses naloxone prn. WBC
11.4, Cr 1.0, labs from ___. CT shows SBO with
transition point in the pelvis. NGT was placed in the ED with
100cc clear liquid output. +urinary frequency but no dysuria.
ECG
with inverted P waves and ST changes in II
Past Medical History:
ASEPTIC MENINGITIS
DEPRESSION
MELANOMA
ALCOHOL ABUSE
Social History:
___
Family History:
pancreatic and liver cancer
Physical Exam:
General-AAOx3, NAD
HEENT-AT, NC, sclerae anicteric
Heart-RRR, normal S1, S2
Lungs-CTA B/L
Abd-soft, NT, ND
extr.-no edema or cyanosis
Pertinent Results:
___ 01:30PM GLUCOSE-93 UREA N-12 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
___ 01:30PM estGFR-Using this
___ 01:30PM CK(CPK)-114
___ 01:30PM CK-MB-3 cTropnT-<0.01
___ 01:30PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 01:30PM WBC-6.0# RBC-4.44 HGB-14.0 HCT-42.1 MCV-95
MCH-31.5 MCHC-33.2 RDW-13.3
___ 01:30PM PLT COUNT-221
___ 01:30PM ___ PTT-35.4 ___
Brief Hospital Course:
Ms. ___ was transferred from outside hospital to ___ on
___ for further management of her small bowel obstruction
diagnosed on CT abd/pelvis. nasogastric tube was placed in the
emergency department which only drained 100cc of clear liquid.
The patient was admitted to acute care surgery service for
further management. She was kept NPO for diet and received
intravenous fluids. The NG tube was later removed. On HD2 she
was given regular diet which she tolerated well without nausea
and vomiting. Her INS and Outs as well as vital signs were
recorded adnn remained adequate.
The patient was discharged home with instructions to follow up
in ___ clinic.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Citalopram 40 mg PO DAILY
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. TraZODone 50 mg PO HS
Discharge Medications:
1. TraZODone 50 mg PO HS
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. Citalopram 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel
movement prior to your discharge which is acceptable, however it
is important that you have a bowel movement in the next ___
days. After anesthesia it is not uncommon for patients to have
some decrease in bowel function but you should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are expected. However, if
you notice that you are passing bright red blood with bowel
movements or having loose stool without improvement please call
the office or go to the emergency room if the symptoms are
severe. If you are taking narcotic pain medications there is a
risk that you will have some constipation. Please take an over
the counter stool softener such as Colace, and if the symptoms
do not improve call the office. If you have any of the following
symptoms please call the office for advice or go to the
emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or extended
constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10585182-DS-5 | 10,585,182 | 26,872,313 | DS | 5 | 2148-08-13 00:00:00 | 2148-08-13 18:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Aspirin / Simvastatin /
Singulair / lisinopril
Attending: ___.
Chief Complaint:
facial swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with asthma, DM, depression presents after waking
with swelling of face this morning accompanied by throat
tightness. She Took benadryl 25mg at 9 and 11 AM on morning of
presentation and felt that throat swelling had improved but
still was feeling SOB with exertion. She also reports feeling
epigastric discomfort and mild nausea (no vomiting) for past
several days leading up to acute presentation. Per patient, has
had similar experience ___ times in the past but was never told
it could be due to ACEI, usually due to other medications
(specifically penicillin). She has one sister who has had
similar episodes as well. She has been taking lisinopril for
several years.
In the ED, initial vitals: 97.0 111 116/73 18 95%. EKG showed
sinus tachycardia at 105, no ST changes. She was given 125
methylpred IV, famotidine, 20mg IV, diphenhydramine 50mg IV and
admitted to the ICU for closer monitoring overnight. Vitals were
99.0 100 122/54 24 99% RA prior to transfer.
On arrival to the MICU, Patient feels well, mouth still feels
full and throat still feels tight. Face in mirror appears more
swollen than normal to her. She is hungry and her mouth feels
very dry. No longer SOB. Denies any new medications, cosmetics,
pets, travel or other exposures.
Past Medical History:
1. DM type II
2. Asthma - other than last admission never required an
intubation, over all has been stable
3. HTN
4. HLD
5. GERD
6. Cutaneous Sarcoidosis (per biopsy of skin lesion ___ years ago
which subsequently disappeared)
7. DVT ___ (non provoked, was on HRT at the time, Rx coumadine
for a year)
8. Anaphylaxis ___ to bee sting ___
9. anxiety
10. depression
11. s/p Cesarean section: ___
12. s/p Myomectomy: ___
13. s/p Varricose veins stripping ___
14 angioedema to lisinopril
Social History:
___
Family History:
Mother: alive, DM, HTN.
Father: ___, MI. Deceased: at age: ___.
Siblings: HTN, T2DM, one sister with occasional facial swelling
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T:99.1 BP:127/71 P:101 R:26 O2:95%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL (cataracts bilaterally), MM
dry, periorbital fullness with loss of creases on upper and
lower lips, unable to fully visualize posterior oropharynx. No
gross abnormalities or tenderness of the ears
NECK: supple, JVP not elevated, no LAD
LUNGS: speaking in full sentences, prolonged expiratory phase,
diffuse expiratory wheezes, no rhonchi or crackles
CV: Mildly tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Mild epigastric
tenderness to deep palpation.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rash, specifically no urticaria
NEURO: CN II-XII intact and symmteric, visual acuity not tested
formally, BUE and BLE strength ___, LT sensation intact, A&Ox3
Discharge Exam:
unchanged with the exception of decreased periorbital and
oropharyngeal swelling
Pertinent Results:
ADMISSION LABS
=====================
___ 06:15PM GLUCOSE-159* UREA N-21* CREAT-0.8 SODIUM-138
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-23 ANION GAP-21*
___ 06:15PM ALT(SGPT)-17 AST(SGOT)-30 ALK PHOS-86 TOT
BILI-0.3
___ 06:15PM WBC-9.5 RBC-3.78* HGB-11.9* HCT-36.7 MCV-97
MCH-31.4 MCHC-32.4 RDW-13.2
___ 06:15PM BLOOD ALT-17 AST-30 AlkPhos-86 TotBili-0.3
___ 06:15PM BLOOD C3-205* C4-48*
Discharge Labs:
___ 04:52AM BLOOD WBC-9.6 RBC-3.79* Hgb-11.9* Hct-35.4*
MCV-93 MCH-31.3 MCHC-33.6 RDW-12.8 Plt ___
___ 04:52AM BLOOD Glucose-186* UreaN-19 Creat-0.8 Na-138
K-3.9 Cl-100 HCO3-25 AnGap-17
___ 04:52AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.6
Pending Labs:
___ 06:15PM BLOOD C1 INHIBITOR-PND
IMAGING:
======================
CXR ___
COMPARISON: ___.
Single frontal view of the chest. Linear left mid lung opacity
is
compatible with atelectasis. The lungs are otherwise grossly
clear. The
cardiomediastinal silhouette is stable. Lower thoracic
dextroscoliosis is
again noted. IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ with h/o diabetes, depression, asthma who presents with
acute onset new onset facial and mouth edema, admitted to the
MICU for airway monitoring, without event.
# Angioedema: Patient with similar episodes in the past but
never this significant, no signs of mast cell degranulation, so
most likely bradykinin-mediated process such as ACEI-induced,
which can present even after years of use. Acute onset would be
more consistent with allergic reaction but she reports several
days of abdominal discomfort/nausea which may have represented
early gut edema. Possible family history of similar episodes,
but less likely hereditary angioedema. Improved but not resolved
on arrival from ED after steroids, famotidine, and benadryl.
Monitored overnight in the MICU without breathing issues.
Lisinopril was discontinued on arrival and added to her allergy
list in OMR. Angioedema improved overnight and patient tolerated
a diet well before discharge. LFTs unremarkable. C3: 205, C4:
48. C1 inhibitor level pending on discharge.
# Asthma: Patient of Dr. ___. ___ ___ showing mixed
obstructive and restrictive picture (FEV1 58% pred, FEV1/FVC 90%
pred). Patient states she is only wheezing from missing her
evening medications, does not feel dyspneic. This admission we
continued albuterol, advair, flonase and claritin PRN,
hydroxyzine PRN.
Chronic problems:
# DM: Last A1c 7%. While in house, metformin was held, and
managed with ISS. Restarted metformin on discharge.
# HL: Continued atorvastatin.
# HTN: Stopped lisinopril given angioedema, but continued the
hydrochlorothiazide. Patient was given a new prescription for
hydrchlorothiazide only given she was on the combination pill
only.
# GERD: Continued PPI.
# Depression/anxiety: Continued bupropion, effexor, risperidone
for sleep.
TRANSITIONAL ISSUES:
-PCP and allergy follow up made
-BP monitoring off lisinopril
-C1 inhibitor pending
-consider evaluating tachycardia if not worked up before.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheeze
2. Atorvastatin 10 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO BID
4. Epinephrine 1:1000 0.5 mg SC ONCE for allergic reaction
5. Fluticasone Propionate NASAL ___ SPRY NU BID:PRN congestion
6. Flovent HFA (fluticasone) 220 mcg/actuation inhalation 2
puffs BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. HydrOXYzine 25 mg PO Q6H:PRN itch
9. lisinopril-hydrochlorothiazide 40mg-25mg oral daily
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. RISperidone 0.5 mg PO HS:PRN insomnia
13. Venlafaxine XR 300 mg PO DAILY
14. Citracal + D (calcium phosphate-vitamin D3) 600-400 mg oral
daily
15. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheeze
2. Atorvastatin 10 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO BID
4. Fluticasone Propionate NASAL ___ SPRY NU BID:PRN congestion
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Omeprazole 20 mg PO DAILY
7. RISperidone 0.5 mg PO HS:PRN insomnia
8. Venlafaxine XR 300 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Citracal + D (calcium phosphate-vitamin D3) 600-400 mg oral
daily
11. Epinephrine 1:1000 0.5 mg SC ONCE for allergic reaction
12. Flovent HFA (fluticasone) 220 mcg/actuation inhalation 2
puffs BID
13. HydrOXYzine 25 mg PO Q6H:PRN itch
14. Loratadine 10 mg PO DAILY:PRN allergies
15. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Angioedema
Secondary Diagnosis:
Diabetes, Type II
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you in the intensive care unit at
___ ___ ___. You were admitted for
swelling of your mouth, which we call "Angioedema" and is
considered an adverse reaction to lisinopril which you were
taking. You should not take lisinopril again, and this has been
added to your allergy list. You should see the allergy
specialists and you PCP in follow up regarding this issue.
Followup Instructions:
___
|
10585606-DS-13 | 10,585,606 | 22,134,041 | DS | 13 | 2148-10-27 00:00:00 | 2148-10-27 15:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mid back pain
Major Surgical or Invasive Procedure:
___: CT-guided spine biopsy.
History of Present Illness:
Mr. ___ is a ___ y/o M w/ notable hx of deaf/nonverbal
(communicates via writing, ?sign language) who presents with
worsening thoracic back pain.
Of note, he has ongoing chronic lumbar back pain but developed
thoracic pain over the past 2 months. For this pain, he has been
to the ED in ___ 5 times, with no resolution. He has also been
regularly following up with his PCP, most recently on ___ and
___. Initially he was started on tizanidine and etodolac which
helped. At the most recent visit (___) he was referred to the
ED given the severity of his pain. Pain is sharp and located in
the ___ his back. He denies any numbness going down his
legs are when he wipes. He endorsed urinary frequency ___
episodes/day) but no dysuria. On further questioning he reported
that he typically urinates frequently and he was drinking a lot
of water.
His PCP also documented concern for Tylenol and NSAID overuse.
Pt reports using 12 tablets of Tylenol daily with no improvement
to his pain.
He denies any fevers, chills, CP, SOB. He has not had an recent
surgeries, does not have any spinal hardware and denies
intravenous drug use.
- In the ED, initial vitals were:
97.8 | 92 | 135/77 | 18 at 100% RA
- Exam was notable for:
Mid-thoracic spine is tender to palpation. ___ strength in UE
and ___ with normal reflexes. LUQ LLQ tenderness.
- Labs were notable for:
WBC 12.5
Normal BMP
Normal LFTs
Urine tox screen ngt
Noninflammatory UA
- Studies were notable for:
CT A/P: "Endplate destructive changes at T8-9 with prevertebral
soft tissue stranding is highly concerning for
discitis/osteomyelitis. Thoracic spine MRI with and without
contrast is suggested for more complete assessment."
- No consults
On arrival to the floor, patient reported severe pain that is
worse with movement. He wrote that he cannot lie in bed due to
the pain. Pain is similar to previous. He denied any new
numbness. He reported that he did not want to receive any more
morphine.
Past Medical History:
-polyarthritic osteo arthritis, sciatica
-asthma, HTN, GERD
-hypothyroid, prediabetes, hypogonadism
-hearing impairment, deaf
-cognitive impairment, ___ grade reading level
-Surgery: right forehead lipoma removal, cleft lip repair
Social History:
___
Family History:
-Brother: liver disease, deceased
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
GENERAL: Mute, communicates via writing. In pain with movement
but otherwise in NAD when seated still.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
BACK: Spinal tenderness to palpation over thoracic spine.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No ___ lesions ___ nodes noted on hands.
No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout though lower extremity
exam limited by pain. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 042) Temp: 98.0 (Tm
98.4), BP: 119/75 (110-156/68-92), HR: 93 (86-98), RR: 18, O2
sat: 94% (94-96), O2 delivery: Ra
HEENT: L eye clouding. Sclera anicteric and without injection.
MMM. Poor dentition.
LUNGS: No increased work of breathing.
EXTREMITIES: No ___ lesions ___ nodes noted on hands.
No clubbing, cyanosis, or edema.
SKIN: No rashes.
NEUROLOGIC: Moving all 4 limbs spontaneously. Strength ___ on R;
less on L but limited by pain.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:32PM BLOOD WBC-12.5* RBC-5.09 Hgb-14.5 Hct-44.6
MCV-88 MCH-28.5 MCHC-32.5 RDW-14.5 RDWSD-46.3 Plt ___
___ 04:32PM BLOOD Neuts-76.6* Lymphs-13.6* Monos-8.1
Eos-1.0 Baso-0.2 Im ___ AbsNeut-9.60* AbsLymp-1.71
AbsMono-1.02* AbsEos-0.13 AbsBaso-0.02
___ 09:00PM BLOOD ___ PTT-38.4* ___
___ 04:32PM BLOOD Plt ___
___ 04:32PM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-141 K-4.5
Cl-101 HCO3-29 AnGap-11
___ 04:32PM BLOOD ALT-14 AST-21 AlkPhos-122 TotBili-0.8
___ 04:32PM BLOOD Albumin-4.4
___ 04:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
INTERVENING LABS:
=================
___ 05:42AM BLOOD CRP-36.9*
___ 06:17AM BLOOD CRP-17.0*
___ 07:51AM BLOOD CRP-13.9*
___ 04:35PM BLOOD Vanco-20.8*
___ 07:51AM BLOOD Vanco-18.2
___ 07:05AM BLOOD Trep Ab-NEG
DISCHARGE LABS:
===============
___ 06:19AM BLOOD WBC-7.3 RBC-4.29* Hgb-12.4* Hct-37.6*
MCV-88 MCH-28.9 MCHC-33.0 RDW-14.3 RDWSD-45.6 Plt ___
___ 06:19AM BLOOD Plt ___
___ 11:42AM BLOOD UreaN-10 Creat-0.7
___ 07:13AM BLOOD ALT-45* AST-28 AlkPhos-74 TotBili-0.3
___ 06:38AM BLOOD CRP-4.7
___ 05:19PM BLOOD Vanco-17.2
IMAGING:
========
___ CT CHEST W/CONTRAST
IMPRESSION:
1. No acute traumatic injuries in the chest, abdomen or pelvis.
2. Endplate destructive changes at T8-9 with prevertebral soft
tissue
stranding is highly concerning for discitis/osteomyelitis.
Thoracic spine MRI with and without contrast is suggested for
more complete assessment.
RECOMMENDATION(S): Thoracic spine MRI with and without
contrast.
___ MR ___ &W/O CONTRAST
IMPRESSION:
Evidence of osteomyelitis/discitis of T8-T9 with associated
prevertebral edema and an epidural collection, likely
representing phlegmon formation, causing severe canal narrowing
with effacement of the CSF space and probable increased signal
and swelling of the spinal cord at this level.
___ MR ___ W/O CONTRAST
IMPRESSION:
1. No evidence of infection within the cervical or lumbar spine.
2. Cervical degenerative changes are minimally worsened from
prior MRI ___. Right-sided disc herniation is C6-7 level severely
narrows the foramen and could affect the right C7 nerve root.
Other foraminal changes as described above.
3. Degenerative changes in the lumbar spine with moderate spinal
stenosis at L4-5 level and severe bilateral foraminal narrowing
at L5-S1 level with
compression of exiting L5 nerve root within the foramina
progressed from the previous MRI examination of ___.
4. Partially visualized prevertebral and paraspinal edema near
the level of T10, better characterized on recent MRI thoracic
spine.
___ CHEST (PA & LAT)
FINDINGS:
There are low lung volumes with atelectasis in the lung bases.
There is no
focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. The
osseous structures are unchanged and better evaluated on prior
MRI.
___ TRANSTHORACIC ECHO
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
If clinically suggested, the absence of a discrete vegetation on
echocardiography does not exclude the diagnosis of endocarditis.
Normal left ventricular wall thickness, cavity size, and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. Indeterminate pulmonary
artery systolic pressure.
___ CHEST PORT/LINE PLACEMENT
IMPRESSION:
1. The tip of the right-sided PICC line is within the mid to
distal SVC.
2. Trace right apical pneumothorax.
___ CHEST (PORTABLE AP) - Preliminary
IMPRESSION:
No appreciable pneumothorax and otherwise unchanged appearance
of the chest.
___ MRI C- T- AND L- SPINE W/ and W/O CONTRAST
IMPRESSION:
1. Redemonstration of discitis and osteomyelitis with
paravertebral and epidural small phlegmon formation at the
level of T8-T9; essentially unchanged since previous exam
2. No evidence of new infection
3. Multilevel disc degenerative disease as described more
pronounced at levels of C5-C6, C6-C7, L4-L5 and L5-S1.
Brief Hospital Course:
Mr. ___ is a ___ y/o M w/ notable hx of deaf/nonverbal
(communicates via writing, and limited sign language) who is
admitted for thoracic osteomyelitis and MRI concerning for cord
compression though exam not consistent for cauda equina.
ACUTE/ACTIVE ISSUES:
====================
#Thoracic osteomyelitis/discitis, concern for
#Cord compression
Presented with subacute back pain and CT c/f T8-9 discitis and
osteomyelitis. MRI was concerning for possible T8-9 compression
though exam was not concerning for neurologic deficits. MRI
___ and L-spine were negative for skip lesions. Infection
source is unclear; had some injections last month for chronic
back pain, but no recent surgeries or spinal hardware, pt denies
IVDU. TTE was without evidence of endocarditis. Had mild
leukocytosis on admission to 12, though remained afebrile. Blood
and urine cultures were obtained, which returned no growth. ID
was consulted and recommended treatment with empiric vancomycin
and cefepime, which were started on ___, with plans for a
6-week course. An ___ bone biopsy was performed on ___.
Gram stain showed PMNs with no microorganisms, no AFB were seen
on smear, and tissue culture was without growth. Fungal and AFB
cultures pending. Pain was controlled with Tylenol, lidocaine
patches, oxycodone, and gabapentin, after trying ketorolac and
ibuprofen (caused stomach burning) and tramadol (did not control
pain). Ortho spine recommended wearing a TLSO brace at all times
out of bed. He should wear this brace until he follows up with
ortho spine or unless instructed otherwise by the orthopedists,
who should be in touch with the rehab staff about followup.
Final OPAT recommendations are for Vancomycin IV 1000mg Q8h and
Ertapenem IV 1g Q24 through ___.
#Elevated transaminases
ALT to 65 and AST to 58 on ___ from 16 and 19 on ___. Likely
medication effect, trended LFTs. ALT 45 and AST 28 on discharge.
Should continue to trend weekly upon discharge.
#Apical pneumothorax
Tiny right apical pneumothorax seen incidentally on CXR
confirming ___ placement on ___. Patient was asymptomatic. It
had resolved on follow-up CXR on ___.
CHRONIC/STABLE ISSUES:
======================
#GERD
Continued home omeprazole
#HTN
Continued home losartan
#Hypothyroidism
Continued home levothyroxine
TRANSITIONAL ISSUES:
====================
[] Fungal/AFB blood cultures and anaerobic, fungal, and AFB
cultures from bone biopsy are pending
[] Please wean oxycodone as soon/as much as tolerated, this was
started in house for temporary acute pain relief but expect that
pain should improve with antibiotic treatment of his
osteo/discitis.
[] Please cross-titrate oxycodone with gabapentin
[] Pt should wear TLSO brace at all times when out of bed until
he follows up with the orthopedic spine service in about 6
weeks, unless otherwise instructed by ___
[] OPAT Antimicrobial Regimen and Projected Duration:
- Agent & Dose: Vancomycin IV 1000mg Q8h and Ertapenem IV 1g
Q24
- Start Date: ___
- Projected End Date: ___ - ___
- LAB MONITORING RECOMMENDATIONS:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK PHOS, CRP, vancomycin trough
- FOLLOW UP APPOINTMENTS: The ___ will schedule follow up
and contact the patient or discharge facility. All questions
regarding outpatient parenteral antibiotics after discharge
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
[] He should have a MRI ___ repeated toward the end of his
antibiotic course
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Time in care:
>30 minutes in discharge-related activities on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tizanidine 2 mg PO TID
2. etodolac 400 mg oral BID:PRN Pain
3. Simvastatin 20 mg PO QPM
4. Omeprazole 20 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ertapenem Sodium 1 g IV ONCE Spinal osteomyelitis Duration:
1 Dose
Please dose 1g Q24h with final dose ___ to complete a 6-week
course
3. Gabapentin 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*5 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 17.2 mg PO BID
8. Vancomycin 1000 mg IV Q 8H
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. NIFEdipine (Extended Release) 30 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Thoracic osteomyelitis/discitis with concern for cord
compression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
You came to the hospital because of back pain. We found an
infection in the bones of your spine. We took a sample of the
bone. You received antibiotics for the infection and medications
for your pain.
When you leave the hospital, please take your medications as
prescribed and go to your future appointments which are listed
below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10585646-DS-11 | 10,585,646 | 23,809,267 | DS | 11 | 2145-02-13 00:00:00 | 2145-02-13 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / fish derived
Attending: ___.
Chief Complaint:
left foot pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ RA, b/l ___ rest pain, and non-healing L toe ulcer
s/p R SFA PTA c/b PF thrombus s/p lysis and PF stent c/b acute L
MCA CVA ___ ICA occlusion now presenting with left toe gangrene
and cellulitis.
In ___, the patient had a complicated inpatient course
beginning with a diagnostic angiogram on ___. Over ___,
she had RLE SFA recannalization, attempted lysis of acute PFA
embolus over 24 hours, and PFA stent placement. On ___, she had
an acute left hemispheric watershed stroke with aphasia and
RT hemiparesis. Cerebral angio with neurointerventional showed
complete LICA occlusion, which was unable to be opened. At the
time, she needed a LLE CFA-peroneal bypass but this was put on
hold to allow time for stroke recovery.
She was placed on a lovenox bridge to coumadin for the arterial
thromboembolic event. She was discharged on 2 weeks of augmentin
for L toe wound. Per her paperwork, she went home home from
rehab
on ___ off of Abx. Yesterday, physical therapist noted that toe
looked more infected. Presented to ___ yesterday
because more convenient for family, where they were "unable to
palpate pulses in feet or with Doppler." She was bolused 5000
units of heparin then drip started at rate of 1000. XR showed no
evidence of osteo.
Per old notes, the patient stubbed her left toe in ___ and
it
became necrotic at the tip. She subsequently developed
ulceration
of the right heel. In ___, ABI was 0.54 on R and 0.5 on L.
It is noted that her hematocrit has decreased from 40 to 25.7 on
___ to 25.3 on ___ office visit with rheumatologist to 23.1
today. She has seen rheumatologists in the past who have not
wanted to start corticosteroids for what is likely
atherosclerotic disease without any other stigmata of
vasculitis.
She remains off of Humira. She is guiac negative in the ED.
Past Medical History:
PMH: RA, fibromyalgia, HTN, left CVA
PSH: lap cholecystectomy
___ lysis check, right profunda stent
___ right SFA PTA/stent, lysis catheter placement
___ bilateral lower extremity angiogram
Social History:
___
Family History:
Notes family history of hypertension, hyperlipidemia. Her father
had stents placed in his leg arteries.
Physical Exam:
Gen - NAD, alert but with severe word-finding difficulties
Heart - RRR
Lungs - breathing comfortably
Abd - soft, NT, ND
Extrem - warm, left toe nailbed with dry gangrene and
surrounding
blanching erythema of dorsum of foot; ~2x2 fibrinous ulcer on R
heel without purulence
Pertinent Results:
Left foot X-ray ___
FINDINGS:
Flatfoot. Small calcaneal plantar bone spur. Scattered mild
degenerative
changes midfoot, forefoot. No radiographic evidence of
osteomyelitis.
IMPRESSION:
No evidence of osteomyelitis.
CT Head without contrast ___
IMPRESSION:
No acute intracranial abnormality.
Small chronic infarcts are less apparent compared to prior.
Right Shoulder X-ray ___
IMPRESSION:
No fracture.
Soft tissue swelling lateral upper arm.
Lower Extremity Duplex ___
FINDINGS:
On the right, the common femoral artery is patent with a peak
velocity of 160.
The profunda is patent with velocities 166, 53cm/sec.
The SFA is patent with velocities of 99 to132 cm/sec. There is
no velocity
elevation to suggest stenosis.
The popliteal artery is patent with a highest velocity of 57-67
cm/sec.
On the left, the common femoral artery is patent with a peak
velocity of 127.
The profunda is patent with elevated velocities ranging from
134-229cm/sec.
The SFA is patent with velocities of 59 to282 cm/sec. There is
a 2.8x stepup
in mid SFA with velocity elevations to suggest stenosis >50%.
The popliteal artery is patent with a highest velocity of 190
cm/sec and a mid
stepup of 6.2x suggesting 50-99% stenosis.
The posterior tibial and peroneal arteries are both patent with
velocities of
21 to 24 cm/sec in the ___ and 9.8-14.5cm/sec in the peroneal.
IMPRPRESSION: Patent RT SFA stent. Patent left SFA with mid
SFA and
Popliteal stenosis.
___ 06:15AM BLOOD WBC-5.3 RBC-3.04* Hgb-9.0* Hct-28.2*
MCV-93 MCH-29.6 MCHC-31.9* RDW-13.0 RDWSD-44.3 Plt ___
___ 05:58PM BLOOD WBC-5.7 RBC-2.61* Hgb-7.6* Hct-23.8*
MCV-91 MCH-29.1 MCHC-31.9* RDW-13.0 RDWSD-42.8 Plt ___
___ 09:55AM BLOOD WBC-5.1 RBC-2.69* Hgb-7.9* Hct-24.6*
MCV-91 MCH-29.4 MCHC-32.1 RDW-13.2 RDWSD-43.7 Plt ___
___ 06:15AM BLOOD ___ PTT-72.2* ___
___ 06:15AM BLOOD Glucose-109* UreaN-4* Creat-0.7 Na-143
K-4.1 Cl-106 HCO3-22 AnGap-19
___ 09:55AM BLOOD Glucose-112* UreaN-5* Creat-0.7 Na-142
K-3.4 Cl-107 HCO3-25 AnGap-13
___ 06:15AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 Iron-35
___ 06:15AM BLOOD calTIBC-207* VitB12-PND Folate-PND
Hapto-___* Ferritn-290* TRF-159*
Brief Hospital Course:
On ___ the patient was seen and evaluated in the ED by the
consult resident. The patient was admitted to the hospital
under the care of the vascular surgery service. She was started
on a heparin drip for a subtherapeutic INR, and since she had
completed 30 days of Plavix she was started on ASA 81mg.
Intravenous vancomycin, cipro, and flagyl were initiated as
well.
On ___ while on CC6, she unfortunately tried to go to the
bathroom by herself and fell getting out of bed, unwitnessed,
but she reported striking her head and right shoulder. At this
time her PTT was therapeutic. Her heparin drip was stopped and
CT of her head and X-ray of her right shoulder were obtained.
The head CT was negative, and the shoulder x-ray showed soft
tissue swelling, which was also grossly visible on physical
exam. No new neuro deficits were noted on physical exam. There
was no change in her aphasic deficits. At this time, she was
transferred to ___ for closer proximity to residents as we
primarily work out of the ___ building.
On ___, non-invasive studies were obtained. Her lower
extremity arterial duplex showed a patent RT SFA stent, patent
left SFA with mid SFA and Popliteal stenosis. Gastroenterology
was consulted for a heme positive brown stool and a hematocrit
of 22, and GI recommended outpatient follow up. An appointment
was made for the patient to see GI, and is in her discharge
paperwork.
On ___ speech therapy worked with her, and they recommended
intensive outpatient speech rehab/therapy.
On ___ the patient was transitioned to oral antibiotics, her
heparin drip was discontinued and she was started on Lovenox,
and she was discharged to an acute care facility. She was
instructed to return to ___ ___, one day prior to her
procedure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. ___ ___ UNIT PO TID:PRN thrush
3. Pregabalin 50 mg PO BID
4. Cilostazol 100 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Docusate Sodium 100 mg PO BID
7. Sarna Lotion 1 Appl TP TID:PRN itch
8. FoLIC Acid 1 mg PO DAILY
9. Sertraline 100 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Frequency is Unknown
PRN pain
11. TraZODone 50 mg PO QHS
12. Losartan Potassium 50 mg PO DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
3. Enoxaparin Sodium 100 mg SC DAILY
RX *enoxaparin 100 mg/mL 1 mL SC once a day Disp #*7 Syringe
Refills:*0
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*18 Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*20 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cilostazol 100 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Losartan Potassium 50 mg PO DAILY
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. ___ ___ UNIT PO TID:PRN thrush
14. Pantoprazole 40 mg PO Q24H
15. Pregabalin 50 mg PO BID
16. Sarna Lotion 1 Appl TP TID:PRN itch
17. Sertraline 100 mg PO DAILY
18. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left foot cellulitis and gangrene
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at ___
___. You were admitted to the hospital ___ with
left toe/foot pain, cellulitis, with concern for gangrene.
While in the hospital you have received antibiotics and we have
had you systemically anticoagulated with a heparin drip, which
was switched to lovenox. Unfortunately you fell, but all
imaging was negative and you have seemingly recovered from that
fall. Dr. ___ has scheduled you for femoral to peroneal
bypass on ___, and you are now ready to be discharged from
the hospital. Please return ___ prior to your scheduled
surgery. You will be discharged with oral antibiotics for the
foot infection and lovenox for anticoagulation, please take both
of these medicines as prescribed. Please follow the
recommendations below to ensure a speedy and uneventful
recovery. Your course was complicated by the above mentioned
fall, but you have recovered well. Speech therapy has seen you,
and recommends outpatient speech rehab if possible.
Gastroenterology saw you for a low blood count and heme positive
stool, and they recommend following up with a gastroenterologist
for EGD and possibly colonoscopy as well.
Activity
-out of bed with assist
Wound care:
Site: right heel
Comment: dry dressing to heel, waffle boot at all times
Medications:
Continue Aspirin 81 mg PO daily.
Continue Atorvastatin 80 mg PO daily.
Antibiotics: Augmentin 875mg Twice per day
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
Followup Instructions:
___
|
10585793-DS-4 | 10,585,793 | 22,117,539 | DS | 4 | 2175-10-18 00:00:00 | 2175-10-19 09:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with PMHx of ___ disease,
depression and HLD presenting following a syncopal event
witnessed by his wife. The last thing the pt remembers is
cleaning himself in the shower. Per the pt's wife, she saw him
exit the shower and walk to sit on his shaving stool. She noted
that as he was preparing to sit down, his eyes were fixed
forward and he was not responding to her calling his name. He
then started leaning to the R and began to fall. She was able to
push him to the R further to prevent him from hitting the door
jam head-on, but the patient still landed on his R side,
striking his face, shoulder and chest. The patient was
unconscious for approximately ___ minutes, and confused
following that for ___ minutes. There was no rhythmic
movements, tongue biting, loss of bowel or bladder function.
The patient does have a history of syncope. Approximately ___
years ago the pt was admitted to ___ for a syncopal event
and found to be in afib. Additionally, the patient had an
episode of vasovagal syncope as a child when seeing his
grandfather in the hospital. Of note, the patient did have a
mechanical fall less than one week ago in which he fell and hit
his R shoulder. He denies LOC with that event.
In the ED, initial vital signs were: T 97.4 P 56 BP 138/86 R 18
O2 sat. 99% RA
- Exam notable for: abraisions to nose and R ___, full
ROM in all ext, nl rectal tone,
- Labs were notable for WBC 6.8, Chem7, UA, coags wnl's
- Studies performed include EKG in sinus brady, CXR negative,
NCHCT negative and CT c-spine with degenerative changes only
- Patient was given home levodopa-carbidopa, entacapone, and
dilt ER 120mg
- Vitals on transfer: 97.3 68 104/53 18 96% RA
Upon arrival to the floor, the patient is resting comfortably in
bed with his wife at bedside.
Past Medical History:
HYPERLIPIDEMIA
___ DISEASE- Urinary symptoms managed by Dr. ___ in
urology
Paroxysmal AF
DEPRESSION
Social History:
___
Family History:
Father and grandfather with CAD
Physical Exam:
====================
ADMISSION EXAM:
====================
Vitals- T 97.5 HR 61 BP 127/61 RR 14 SaO2 99%RA
General: Well nourished male with course tremor and multiple
lacerations on face in NAD
HEENT: small lacerations to nasal bridge and over R frontal
bone without associated ecchymosis, EOMI, senile arcus, PERRL,
MMM, OP clear
Neck: supple, no thyromegaly, no LAD
CV: rrr, nl s1 and s2, no MRG; chest non-ttp
Lungs: CTAB without wheezing or rhonchi
Abdomen: soft, nt, nd, no HSM
GU: no foley, R inguinal hernia palpated externally
Ext: wwp, no peripheral cyanosis or edema
Neuro: AOx3, CN2-12 intact, course tremor of all extremities
with axial tremor, shuffling, wide-based gait, moving all
extremities without issue, sensation intact throughout
Skin: lacerations as above to face, large linear ecchymosis
over R shoulder
====================
DISCHARGE EXAM:
====================
Vitals: T 97.7 BP 129/80 HR 58 RR 16 98 RA
General: Well nourished male with course tremor and multiple
lacerations on face in NAD, sitting in a chair at bedside
HEENT: small lacerations to nasal bridge and over R frontal bone
without associated ecchymosis, EOMI, senile arcus, MMM, OP clear
CV: rrr, nl s1 and s2, soft early systolic murmur along LSB;
chest non-ttp
Lungs: CTAB without wheezing or rhonchi
Abdomen: soft, nt, nd, no HSM
GU: condom cath
Ext: wwp, no peripheral cyanosis or edema
Neuro: AOx3, CN2-12 grossly intact, course tremor of all
extremities with axial tremor, mild cogwheel rigidity
Skin: lacerations as above to face, large linear ecchymosis over
R shoulder
Pertinent Results:
======================
ADMISSION LABS:
======================
___ 09:25AM BLOOD WBC-6.8 RBC-4.99 Hgb-14.8 Hct-45.0 MCV-90
MCH-29.7 MCHC-32.9 RDW-13.3 RDWSD-43.6 Plt ___
___ 09:25AM BLOOD Neuts-76.6* Lymphs-15.0* Monos-5.3
Eos-1.8 Baso-0.6 Im ___ AbsNeut-5.22 AbsLymp-1.02*
AbsMono-0.36 AbsEos-0.12 AbsBaso-0.04
___ 09:25AM BLOOD ___ PTT-29.7 ___
___ 09:25AM BLOOD Glucose-89 UreaN-29* Creat-1.1 Na-139
K-4.8 Cl-104 HCO3-26 AnGap-14
___ 06:40AM BLOOD Calcium-9.8 Phos-2.3* Mg-2.0
======================
PERTINENT RESULTS:
======================
Imaging:
=======================
CHEST (SINGLE VIEW)Study Date of ___ 9:53 AM
IMPRESSION:
No acute cardiopulmonary process.
GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHTStudy Date of
___ 9:58 AM
IMPRESSION:
No acute fracture or dislocation.
CT C-SPINE W/O CONTRASTStudy Date of ___ 10:09 AM
IMPRESSION:
1. No acute fracture of the cervical spine.
2. Multilevel moderate degenerative changes cervical spine.
Mild
anterolisthesis C7 on T1 and retrolisthesis of C4 on C5, likely
degenerative
in nature.
CT HEAD W/O CONTRASTStudy Date of ___ 10:09 AM
IMPRESSION:
No acute intracranial process.
=========================
DISHCARGE LABS:
=========================
None.
Brief Hospital Course:
Mr ___ is a ___ with PMHx of ___ disease and
depression presenting following a witnessed syncopal episode at
home. The patient's wife reports that he was ambulating from the
shower and then sat down. She then noted that he became
unresponsive and was staring forward, not answering to his name.
The patient then fell towards his R side and his wife pushed
him, preventing him from hitting his face on a door jam. The
patient was brought to the ___ ED where CXR, shoulder x-ray,
NCHCT and CT c-spine were negative for acute process. Thus the
patient was admitted to the medicine service for further work-up
and management. The patient has a history of paroxysmal afib
(which caused a previous syncopal event), but was in sinus
rhythm on presentation and remained in this rhythm on telemetry
throughout his admission. Given the history of blank,
non-responsive stare in conjunction with confusion following the
incident and possible tongue biting, the neurology service was
consulted who thought that he likely had atypical vasovagal
syncope and a resultant concussion from his head strike. His
hospital course was complicated by hospital delirium, which was
improving by time of discharge. He was assessed by ___ and OT who
felt the patient would be safe to discharge home following a
short course of inpatient ___ and OT. Thus the patient was deemed
safe for discharge to rehab for further strength and
coordination training, and he should have close neurologic
follow-up in the near future.
Transitional issues:
#Pt has had multiple falls at home, and may benefit from
uptitration of his medications for ___ disease
#The patient may benefit from home LifeAlert given multiple
recent falls
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO 5X/DAY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Donepezil 15 mg PO QAM
4. Entacapone 200 mg PO 5X/DAY
5. Myrbetriq (___) 50 mg oral DAILY
6. Pravastatin 40 mg PO QPM
7. Sertraline 100 mg PO DAILY
8. solifenacin 10 mg oral DAILY
9. Aspirin 81 mg PO DAILY
10. Docusate Sodium 100 mg PO TID
11. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO 5X/DAY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Docusate Sodium 100 mg PO TID
5. Donepezil 15 mg PO QAM
6. Entacapone 200 mg PO 5X/DAY
7. Myrbetriq (___) 50 mg oral DAILY
8. Pravastatin 40 mg PO QPM
9. Sertraline 100 mg PO DAILY
10. solifenacin 10 mg oral DAILY
11. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Syncope secondary to atypical vasovagal episode
Concussion
___ disease
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr ___-
You were hospitalized following an event where you passed out at
home. You hit your head, shoulder and chest when you fell and
were confused when you regained consciousness for about 30
minutes. You were brought to the emergency room where you had
imaging of your head, upper spine, shoulder and chest which
showed no fractures or other deep traumatic injuries. You were
admitted to the medicine service for further evaluation of you
passing out. Your EKG was in a normal heart rhythm, and on the
telemetry monitor you had no evidence of atrial fibrillation.
Given your staring spell before passing out and your prolonged
confusion, you were evaluated by the neurology service who felt
that you likely passed out and then had a concussion from
hitting your head, leading to your confusion. You were evaluated
by ___ and OT who felt that you would benefit from rehab.
You should continue to take all your medications as described
below and we wish you the best in the future-
-Your ___ Care Team
Followup Instructions:
___
|
10585793-DS-5 | 10,585,793 | 28,463,594 | DS | 5 | 2176-04-02 00:00:00 | 2176-04-02 12:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left patella fracture
Major Surgical or Invasive Procedure:
left patella open reduction internal fixation on ___
History of Present Illness:
___ with history of ___ disease presenting for left
patella ORIF on ___.
Past Medical History:
HYPERLIPIDEMIA
___ DISEASE- Urinary symptoms managed by Dr. ___ in
urology
Paroxysmal AF
DEPRESSION
Social History:
___
Family History:
Father and grandfather with CAD
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:30AM BLOOD WBC-9.0 RBC-4.63 Hgb-13.7 Hct-41.6 MCV-90
MCH-29.6 MCHC-32.9 RDW-12.8 RDWSD-42.3 Plt ___
___ 08:20PM BLOOD WBC-6.7 RBC-4.82 Hgb-14.2 Hct-43.9 MCV-91
MCH-29.5 MCHC-32.3 RDW-13.0 RDWSD-43.2 Plt ___
___ 06:30AM BLOOD Plt ___
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD ___ PTT-36.4 ___
___ 08:20PM BLOOD Glucose-111* UreaN-31* Creat-1.2 Na-139
K-4.8 Cl-102 HCO3-25 AnGap-17
___ 08:20PM BLOOD Calcium-9.7 Phos-3.1 Mg-2.2
___ 08:20PM BLOOD GreenHd-HOLD
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was unremarkable for the following:
Otherwise, pain was controlled with a combination of IV and oral
pain medications.. The patient received Lovenox for DVT
prophylaxis starting on the morning of POD#1. The foley was
removed and the patient was voiding independently thereafter.
The surgical dressing was changed on POD#2 and the surgical
incision was found to be clean and intact without erythema or
abnormal drainage. The patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
acceptable and pain was adequately controlled on an oral
regimen. The operative extremity was neurovascularly intact and
the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Mr. ___ is discharged to long term care facility in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Donepezil 15 mg PO QAM
5. ENTAcapone 200 mg PO 5X/DAY
6. Pravastatin 40 mg PO DAILY
7. Sertraline 100 mg PO QAM
8. Myrbetriq (mirabegron) 50 mg oral DAILY
9. solifenacin 10 mg oral DAILY
10. Psyllium Powder 1 PKT PO TID:PRN constipation
11. Docusate Sodium 100 mg PO BID constipation
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Donepezil 15 mg PO QAM
4. ENTAcapone 200 mg PO 5X/DAY
5. Pravastatin 40 mg PO DAILY
6. Sertraline 100 mg PO QAM
7. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
8. Enoxaparin Sodium 40 mg SC Q12H
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 (One) 40mg SC once a day Disp #*28
Syringe Refills:*0
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN break
through pain
RX *oxycodone 5 mg 0.5 (One half) to 1 (one) tablet(s) by mouth
every 4 to 6 hours as needed Disp #*60 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 to 2 tab by mouth twice a day
Disp #*60 Tablet Refills:*0
11. Aspirin 81 mg PO DAILY
12. Psyllium Powder 1 PKT PO TID:PRN constipation
13. solifenacin 10 mg oral DAILY
14. Myrbetriq (___) 50 mg oral DAILY
15. Docusate Sodium 100 mg PO BID constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left knee patella fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
appointment in two weeks.
10. ACTIVITY: Weight bearing as tolerated on the operative
extremity with the leg in the ___ brace locked in extension.
Physical Therapy:
WBAT LLE with knee in ___ brace locked in extension
Treatments Frequency:
continue dry sterile dressing changes
ice and elevation
inspect incision for sign of infection
staples/sutures to be removed at first post op visit.
Followup Instructions:
___
|
10585812-DS-12 | 10,585,812 | 28,338,297 | DS | 12 | 2178-09-25 00:00:00 | 2178-09-25 15:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Comminuted fracture of left distal radius/ulna
Major Surgical or Invasive Procedure:
___: External fixation of left distal radius/ulna, I&D
History of Present Illness:
Mrs. ___ is a ___ year old female s/p mechanical fall onto
outstretched hand, sustained a left open distal radius fracture.
Patient reports tripping while walking around an object.
Denies dizziness, lightheadness, syncope. Patient did not hit
her head, no LOC. She denies any numbness or tingling in LUE.
She initially presented to ___ where she recieved 1gm
Ancef & Tetanus injection. Imaging was obtained showing the
fracture. Patient was subsequently transferred for further
management.
Past Medical History:
Osteoporsis
s/p b/l TKA
s/p right wrist fx treated non operatively
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: AVSS
GEN: NAD
LUE: ex-fix in place, fingers wwp, SILT R/U/M, ___ EPL/FPL/DIO
Pertinent Results:
___ 09:30AM BLOOD WBC-9.2 RBC-3.79* Hgb-11.8* Hct-35.8*
MCV-94 MCH-31.2 MCHC-33.1 RDW-12.7 Plt ___
___ 01:30AM BLOOD Neuts-85.7* Lymphs-9.5* Monos-4.0 Eos-0.5
Baso-0.3
___ 09:30AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-129*
K-3.7 Cl-92* HCO3-27 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 comminuted fractures of the left distal radius and ulna
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for external
fixation of the left distal radius and ulna as well as I&D,
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. 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, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the left
upper extremity. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every four
(4) hours Disp #*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Comminuted fracture of left distal ulna and radius
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
- Do not remove external fixation device
ACTIVITY AND WEIGHT BEARING:
- NWB LUE
Physical Therapy:
NWB LUE
Treatments Frequency:
Sutures & staples will be removed at next orthopedic appointment
in 2 weeks.
Followup Instructions:
___
|
10586112-DS-22 | 10,586,112 | 25,332,194 | DS | 22 | 2190-10-19 00:00:00 | 2190-11-09 13:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with h/o symptomatic cholelithiasis recent
s/p laparoscopic cholecystectomy ___ Dr. ___ who now p/w
worsening diffuse abdominal pain. Briefly, patient underwent
uncomplicated lap CCY and was recently seen in ED for complaints
of BRBPR and R>L diffuse abdominal pain on POD5 (___). She
was found to be HDS and was given an aggressive bowel regimen
and discharged home from the ED. Today she reports consistently
worsening abdominal pain since surgery despite taking oxycodone
and Tylenol. Her pain acutely worsened ___ without obvious
inciting factor. She also reports N/V and inability to tolerate
PO, but denies diarrhea, constipation (last normal BM ___,
fevers/chills, CP/SOB, dysuria or urinary retention.
Past Medical History:
PMH:
- symptomatic cholelithiasis
- obesity
PSH:
- s/p lap CCY ___ Dr. ___
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.0 104 134/87 18 100% RA
Gen: A&Ox3, uncomfortable-appearing female
HEENT: No scleral icterus, no palpable LAD
Pulm: CTAB, no w/r/r
CV: NRRR, no m/r/g
Abd: soft, nondistended, diffusely TTP, most notably in
epigastrium/RUQ/pierumbilical region, no rebound/guarding, no
palpable masses
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Discharge Physical Exam:
VS: 98.2, 111/79, 64, 16, 97 RA
Gen: A&O x3, sitting up in chair in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, obese, NT/ND. Lap sites healed well.
Ext: No edema
Pertinent Results:
___ 06:05AM BLOOD WBC-6.9# RBC-4.22 Hgb-11.6 Hct-35.7
MCV-85 MCH-27.5 MCHC-32.5 RDW-13.7 RDWSD-42.4 Plt ___
___ 05:55AM BLOOD WBC-4.3 RBC-4.14 Hgb-11.2 Hct-35.3 MCV-85
MCH-27.1 MCHC-31.7* RDW-13.7 RDWSD-42.5 Plt ___
___ 05:49AM BLOOD WBC-4.9# RBC-4.05 Hgb-11.2 Hct-34.5
MCV-85 MCH-27.7 MCHC-32.5 RDW-13.5 RDWSD-42.1 Plt ___
___ 09:22AM BLOOD WBC-10.5* RBC-4.76 Hgb-12.8 Hct-40.6
MCV-85 MCH-26.9 MCHC-31.5* RDW-13.3 RDWSD-41.2 Plt ___
___ 06:05AM BLOOD Glucose-89 UreaN-4* Creat-0.5 Na-139
K-4.1 Cl-104 HCO3-25 AnGap-10
___ 05:55AM BLOOD Glucose-96 UreaN-4* Creat-0.6 Na-141
K-4.2 Cl-105 HCO3-27 AnGap-9*
___ 05:49AM BLOOD Glucose-95 UreaN-6 Creat-0.5 Na-140 K-3.7
Cl-103 HCO3-27 AnGap-10
___ 09:22AM BLOOD Glucose-100 UreaN-11 Creat-0.5 Na-139
K-4.6 Cl-103 HCO3-24 AnGap-12
___ 06:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.2
___ 05:55AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.5
Imaging:
___: CT A/P:
1. No evidence of acute abdominopelvic pathology.
2. Unchanged trace bilateral pleural effusions.
___: ABD XRAY:
Mild fecal and air content in the large bowel. Nonspecific
air-fluid levels in small bowel, without dilatation to indicate
obstruction or ileus.
MICRO:
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain after her
lap cholecystectomy on ___. Admission abdominal/pelvic CT
revealed no evidence of acute abdominopelvic pathology. Patient
was hemodynamically stable with normal labs and her imaging was
grossly unremarkable for intra-abdominal/postoperative process
to explain her degree of pain. The patient was admitted for
serial exams, pain control, and trial of diet.
On HD2, GI was consulted for concern of ulcers. They felt
abdominal pain and distention was most consistent with
narcotic-induced constipation. The patient was given
methylnaltrexone and an aggressive bowel regimen with good
effect and improvement in pain. 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, moving her bowels, 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. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
2. Acetaminophen 1000 mg PO Q8H pain
Discharge Medications:
1. Bisacodyl 10 mg PO QHS constipation
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*1
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
5. Simethicone 40-80 mg PO TID
RX *simethicone 80 mg 1 tab by mouth three times a day Disp #*30
Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q8H pain
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
worsening right upper quadrant pain since laparoscopic
cholecystectomy on ___
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 secondary to worsening right
upper quadrant abdominal pain since surgery. You received a
laparoscopic cholecystectomy on ___. A CT scan of your
abdomen was normal and did not show any post-operative
complications. Gastroenterology was consulted and recommended a
bowel regimen. You are now tolerating a regular diet and moving
your bowels. You are medically clear for discharge. You have
follow-up scheduled with Dr ___. We are recommending you get an
upper endoscopy to evaluate for gastritis. This can be done as
an outpatient and Dr ___ will follow-up on the results.
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.
Followup Instructions:
___
|
10586112-DS-24 | 10,586,112 | 20,858,425 | DS | 24 | 2192-06-12 00:00:00 | 2192-06-13 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
abdominal pain, nausea, and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with hx of H pylori who presents with
hyperacute onset of nausea, vomiting, and severe episodes of
hematemesis that is blood streak. She ate raw oysters and
chicken
wings for lunch 1 day ago and developed abdominal pain about 3
hours later. She then vomited and the pain got much worse which
prompted her to come to the ED. She states that the pain comes
and goes and it is an ___ and lasts for about ___ minutes. She
describes it as crampy and sometimes radiates to the back
(behind
upper epigastric region).
She states that no one else is sick and no one else ate the same
thing as her. She endorses some dizziness, weakness, sore
throat,
and central chest pain to palpation. She also has significant
epigastric pain without radiation and a sore throat that makes
it
very difficult to swallow. Her last BM was 2 days ago and it was
normal.
She denies any shortness of breath, cough, fevers, chills,
palpitations, diarrhea, constipation. She denies chest pain,
dyspnea on exertion, hematochezia, and melena.
Past Medical History:
PMH:
H Pylori
Esophagitis
Back pain, knee pain
Constipation
.
PSH:
- s/p lap CCY ___
- tubal ligation
- breast reduction surgery
Social History:
___
Family History:
Family history of HTN and DM2. No other known family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 151/96, HR 65, RR 18, 99% on RA, 98.1
GENERAL: Alert and interactive. Appears uncomfortable, rubbing
her stomach.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD. Tenderness to
palpation along anterior neck
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. Tenderness to palpation along midline
sternum.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness. No spinous process tenderness.
ABDOMEN: Hyperactive bowels sounds, non distended, tender to
palpation in upper epigastric area. No RUQ tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Grossly
normal.
DISCHARGE PHYSICAL EXAM:
=======================
VS: 24 HR Data (last updated ___ @ 103)
Temp: 98.4 (Tm 98.7), BP: 125/81 (109-127/78-89), HR: 71
(71-89),
RR: 16 (___), O2 sat: 98% (97-99), O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, slightly distended, active bowel sounds,
focally tender in epigastric region, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric; ___ ___ strength
Pertinent Results:
ADMISSION LABS
===============
___ 07:15PM WBC-9.4 RBC-4.32 HGB-11.5 HCT-36.7 MCV-85
MCH-26.6 MCHC-31.3* RDW-13.7 RDWSD-42.1
___ 07:15PM PLT COUNT-268
___ 08:19PM GLUCOSE-118* UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-21* ANION GAP-13
___ 08:19PM estGFR-Using this
___ 08:19PM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-111* TOT
BILI-0.4
___ 08:19PM LIPASE-31
___ 08:19PM cTropnT-<0.01
___ 08:19PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.7
MAGNESIUM-2.0
___ 08:19PM HCG-<5
___ 08:19PM WBC-14.3* RBC-4.70 HGB-12.5 HCT-39.5 MCV-84
MCH-26.6 MCHC-31.6* RDW-13.5 RDWSD-41.3
___ 08:19PM NEUTS-75.7* LYMPHS-16.9* MONOS-6.3 EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-10.82* AbsLymp-2.41 AbsMono-0.90*
AbsEos-0.05 AbsBaso-0.03
___ 08:19PM PLT COUNT-304
DISCHARGE LABS
================
___ 07:17AM BLOOD WBC-8.1 RBC-4.26 Hgb-11.4 Hct-36.2 MCV-85
MCH-26.8 MCHC-31.5* RDW-13.8 RDWSD-42.6 Plt ___
___ 07:17AM BLOOD Glucose-79 UreaN-8 Creat-0.7 Na-143 K-4.1
Cl-107 HCO3-23 AnGap-13
___ 07:17AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0
MICRO
================
None
IMAGING
================
CXR:
IMPRESSION: No evidence of pneumothorax. Normal appearance of
the mediastinum without evidence of pneumomediastinum.
CT ABD/PELVIS
IMPRESSION:
1. No acute findings in the abdomen or pelvis to explain
patient's symptoms.
2. The bladder is distended.
3. 1.7 corpus luteum noted within the left ovary.
4. Nonobstructing 3 mm stone in the upper pole of the left
kidney is unchanged
in appearance and positioning compared to prior. No additional
stones or
hydronephrosis.
EKG: Unremarkable, sinus rhythm.
Brief Hospital Course:
Ms. ___ is a ___ yo F with minimal past medical hx of
treated H.pylori, gastritis, who presented with acute onset of
epigastric abdominal pain, nausea, vomiting, and some blood
streaked emesis within hours of eating oysters. Given her
history of food allergies (has Epi pen but cannot remember the
provoking food groups), our working DDx includes shellfish
allergy (although less likely given isolated GI symptoms) but
also recurrent H. pylori gastritis or a chronic abdominal pain
syndrome such as cyclic vomiting syndrome (several prior ED
visits with similar symptoms in which she underwent a CT
abd/pelvis that were unrevealing of any acute pathology). She
noted not having a bowel movement in a few days, so was started
on senna and Miralax. Her course was complicated by urinary
retention (bladder scan with >700cc), likely provoked by
receiving IV morphine, which self-resolved with holding
narcotics and she voided spontaneously (with PVR <300) prior to
discharge. Within ___ days her appetite and pain improved with
conservative treatment with IV fluids, Tylenol, and Zofran.
Transitional Issues:
[] f/u H. pylori stool antigen test
[] assess response to trial of PPI (omeprazole 20mg/day started
___. Decide whether to continue or discontinue this med based
on suspicion of gastritis
[] f/u constipation on new Senna/Miralax regimen
[] if the food she is allergic to is unknown, she may benefit
from formal allergy testing, if it is known, she would benefit
from additional counseling and education re: what her allergy is
and how best to avoid that food
[] would advise caution with opioids in the future, as she has
demonstrated a tendency to develop acute urinary retention when
treated with opioids at least twice now: during this
hospitalization and during a prior hospitalization when she had
a surgery.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 dose by mouth
once a day Disp #*30 Packet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp
#*30 Tablet Refills:*0
5. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis (recurrent gastritis versus shellfish allergy)
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
You had abdominal pain, nausea, and vomiting. We do not know for
sure what caused this--it may be a shellfish allergy, or perhaps
irritation of your stomach from another H. pylori infection.
What did you receive in the hospital?
You received medication for your pain and nausea as well as IV
fluids. Your nausea and vomiting improved and you were able to
eat meals. We started you on a medicine called omeprazole which
should help with any stomach irritation ("gastritis"), in case
this is another H. pylori infection. We also gave you some
medication that may help with your constipation.
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10586112-DS-25 | 10,586,112 | 20,512,999 | DS | 25 | 2192-09-17 00:00:00 | 2192-09-23 00:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo ___ s/p recent ED visit for R>L pelvic/back pain
(___) re-presents with worsening symptoms.
Approx 10 days ago when she initially presented, her evaluation
revealed the following:
- CT A/P: Mesenteric fat stranding about the distal left gonadal
vein with a normal sized left ovary (on the concomitantly
acquired pelvic ultrasound) favors omental infarction with
reactive thickening of the left gonadal vein; gonadal
vein thrombosis or early pelvic inflammatory disease are less
likely.
- Pelvic US: 1. Although no vascular flow could be obtained
within the left ovary, its normal size and appearance make
ovarian torsion very unlikely. 2. No right ovarian torsion
She was afebrile, with no leukocytosis, and her exam was not c/f
ovarian torsion or PID. She was discharged home with outpatinet
gyn follow-up.
Today, pt re-presented to the ED endorsing worsening R sided
pain. The pain is constant, sharp, and severe. The pain is
present regardless of position, and is minimally improved with
oxycodone. She endorses nausea. Denies emesis. No CP, SOB,
dizziness. No dysuria or hematuria.
Past Medical History:
OBHx: G5P5
GynHx: LMP ___. sexually active with ___ male partner. denies
hx of fibroids, STIs, or abnl pap.
PMH: GERD, constipation
PSH: BTL, lsc CCY, left knee surgery, breast reduction
All: bactrim
Social History:
___
Family History:
Family history of HTN and DM2. No other known family history.
Physical Exam:
Discharge physical exam
Vitals: stable and within normal limits
Gen: no acute distress; alert and oriented to person, place, and
date
CV: regular rate and rhythm; no murmurs, rubs, or gallops
Resp: no acute respiratory distress, clear to auscultation
bilaterally
Abd: soft, minimal tender, no rebound/guarding;
Ext: no tenderness to palpation
Pertinent Results:
___ 11:11AM GLUCOSE-106* UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-11
___ 11:11AM estGFR-Using this
___ 11:11AM ALT(SGPT)-13 AST(SGOT)-16 ALK PHOS-114* TOT
BILI-0.5
___ 11:11AM LIPASE-32
___ 11:11AM ALBUMIN-4.0
___ 11:11AM WBC-10.3* RBC-4.37 HGB-11.6 HCT-37.3 MCV-85
MCH-26.5 MCHC-31.1* RDW-13.2 RDWSD-41.3
___ 11:11AM NEUTS-66.8 ___ MONOS-7.5 EOS-0.5*
BASOS-0.3 IM ___ AbsNeut-6.87* AbsLymp-2.52 AbsMono-0.77
AbsEos-0.05 AbsBaso-0.03
___ 11:11AM NEUTS-66.8 ___ MONOS-7.5 EOS-0.5*
BASOS-0.3 IM ___ AbsNeut-6.87* AbsLymp-2.52 AbsMono-0.77
AbsEos-0.05 AbsBaso-0.03
___ 11:11AM PLT COUNT-308
___ 10:52AM OTHER BODY FLUID CT-NEG NG-NEG
___ 10:23AM URINE HOURS-RANDOM
___ 10:23AM URINE HOURS-RANDOM
___ 10:23AM URINE UCG-NEGATIVE
___ 10:23AM URINE CT-NEG NG-NEG
___ 10:23AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:23AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:23AM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 10:23AM URINE MUCOUS-OCC*
Brief Hospital Course:
On ___, Ms ___ was admitted to they gynecological service
for inpatient management of pelvic pain concerning for pelvic
inflammatory disease v. nephrolithiasis. Please see H&P for
full details.
At time of admission, she was afebrile with WBC within normal
limit. Gonorrhea/chlamydia testing negative. CT abdomen/pelvis
from prior visit on ___ demonstrated fat stranding at distal
left gonadal vein possible omental infarction with reactive
thickening of left gonadal vein. CT abdomen/pelvis on ___ with
no findings to account for pelvic pain, however demonstrated
punctate nonobstructing stone within the upper pole of the left
kidney measuring approximately 3 mm. Pelvic ultrasound on ___
demonstrated 2cm right hemorrhagic corpus luteal cyst and normal
left ovary but no flow could be obtained with pelvic ultrasound
on with no evidence of torsion, normal appearance of ovaries,
and 5mm endometrial polyp.
She received one dose of IM ceftriaxone 250mg and was
transitioned to PO azithromycin 1g every week for two weeks
starting on ___.
On hospital day 1, her hospital course was complicated by
urinary retention possibly related to opioid use versus
nephrolithiais (with +blood on urinalysis). At this time,
patient endorse using oxycodone daily following orthopedic
surgery, with approximately 80 tablets already scripts filled
and remaining scripts at home. Had in-depth conversation on
cessation of narcotics that had been taken since an orthopedic
surgery ___.
On hospital day 2, patient failed formal trial of void.
Patient's pain was well controlled, ambulating voiding. Patient
was deemed stable and discharged home with close follow-up for
repeat voiding trial.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not exceed 4000 mg per day.
RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Azithromycin 1000 mg PO ONCE Duration: 1 Dose
RX *azithromycin 500 mg 2 (Two) tablet(s) by mouth once Disp #*1
Tablet Refills:*0
3. Ibuprofen 800 mg PO Q8H
Do not exceed 2400 mg per day. Take with food.
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
pelvic inflammatory disease
urinary retentions
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 gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking opioids (e.g. oxycodone,
hydromorphone)
* Take a stool softener such as colace while taking opioids to
prevent constipation.
* Do not combine opioid and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* abnormal vaginal discharge
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
Followup Instructions:
___
|
10586232-DS-8 | 10,586,232 | 28,882,786 | DS | 8 | 2135-06-08 00:00:00 | 2135-06-09 21:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetanus / Bactrim / Nsaids
Attending: ___.
Chief Complaint:
low back ___ and chills
Major Surgical or Invasive Procedure:
CT-guided biopsy of vertebral body and paraspinal soft tissues
PICC placement ___
History of Present Illness:
___ w/ decades-long h/o HIV (1 month suboptimal adherence, last
viral load 600, ___, prev undetectable), HCV s/p tx with
interferon, T2DM c/b peripheral neuropathy, on pioglitazone, and
chronic low-back ___ with progressive symptoms for last ___ years
after ___, presenting with 1 month of worsening low back ___
and chills
Approximately ___ years ago Mr. ___ suffered a ___
MVC during which he sustained rib fx, finger dislocations and a
spine injury that he believes was not well-diagnosed due to poor
quality employee ___. His ___ has been gradually
worsening over the last ___ years with intermittent urinary
incontinence and ___ weakness, as well as hip and knee ___, but
his back ___ has gotten acutely worse over the last 6 months,
with urinary incontinence now occurring several times per day,
severe ___ upon rising from bed that leads to pre-syncope and
falls, and at one point, inability to walk due to weakness and
lack of balance, although this improved with ___. Notes chronic
lower extremity neuropathy with mild numbness in bilateral feet,
currently at baseline. Urinary incontinence is typically
preceded by sudden urgency, and will be incontinent if unable to
get to restroom within 1 minute. Has occasional incontinence
without warning or sensation or urgency. Denies weak stream,
hesitancy, dysuria, hematuria, foul smelling urine.
Over the last 4 weeks, he has had shaking chills w/o subjective
fevers coinciding with spasms of back ___, and his symptoms
became so severe that he consulted Dr. ___ service, ___
for his back ___. Notably, he fell and suffered a small,
now-healed abrasion over his sacrum 4 weeks ago. An MRI spine
was performed ___ which revealed possible epidural
abscess/phlegmon and an enlarging renal mass. Dr. ___
recommended that Mr. ___ come to the ED for further
evaluation and treatment
In the ED, initial vitals were: 99.6 71 148/105 18 97%
Upon arrival to the floor, the patient was resting comfortably
in bed. Neurosurgery was consulted and felt he did not require
urgent surgery. ID also consulted. He received one dose
vanc/cefipime, which was then discontinued in order to obtain
tissue sample for microbiological culture.
Of note, patient endorses unintentional 30 lb wt loss over the
last month due to limited desire to rise from bed to get food.
He has had no N/V/D. He notes depressed mood and decreased
medication compliance as a result of ___ and low mood, but
denies SI. Finally, he is also at times short of breath due to
back ___ associated with breathing. He denies IVDU, recent
colonoscopy, but did have dental work 4 weeks ago. Denies fever,
cough, recent sexual activity. Pt also feels constipated with
last BM 4d ago. Endorses some history of fecal incontinence,
more in the setting of diarrheal illness; this has been going on
for years.
Past Medical History:
- HIV
- HCV s/p treatment
- Diabetes mellitus type 2
- Lower extremity neuropathy
-Chronic low back ___
-Diabetes mellitus type 2
-Chronic kidney disease
-Depression
-Anxiety
Social History:
___
Family History:
No liver disease
Mother is living and in good health. Father deceased age ___,
CHF, Diabetes, Asbestosis. One adopted sister. One brother, age
___ with many health problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
Vitals: T: T98.1, BP 114/56, HR 72, RR 20 SPO2 99RA
General: lying in bed, calm, but movement appears restricted due
to ___, stated age
HEENT: EOMI, PERRL, no palpable LN but pt reports tenderness at
angle of R mandible
Heart: Normal s1, s2, no murmurs, RRR
Lungs: Clear bilaterally
Abdomen: +BS, soft, nontender, nondistended, small reducible
umbilical hernia, no ascites
Genitourinary: no foley
Extremities: no edema in BLE, no ulcers. prominent superficial
veins
Neurological: CN ___ intact except diminished hearing in R,
strength ___ in upper and lower extremities. Sensation
diminished to pinprick in bilateral feet and up to mid calf on
right. toes downgoing bilaterally. Rectal tone normal, with area
of decreased sensation to pinprick in left perianal area.
Reflexes 1 at R patella, areflexic at L patella and bilateral
achilles. No tremor or dysmetria. Gait antalgic
DISCHARGE PHYSICAL EXAM:
================================
Vitals: T 97.9, BP 117/65, HR 67, RR 20, SPO2 100RA
General: lying in bed, calm, but movement appears restricted due
to ___
HEENT: EOMI, PERRL, no palpable LN
Heart: Normal s1, s2, no murmurs, RRR
Lungs: Clear bilaterally
Abdomen: +BS, soft, nontender, nondistended, small reducible
umbilical hernia, no ascites
Genitourinary: no foley
Extremities: no edema in BLE, no ulcers. prominent superficial
veins
Neurological: CN ___ intact except diminished hearing in R,
strength ___ in upper and lower extremities. Sensation
diminished to pinprick in bilateral feet and up to mid calf on
right. toes downgoing bilaterally. No tremor or dysmetria. Gait
antalgic.
Pertinent Results:
ADMISSION LABS:
===========================
___ 06:00PM BLOOD WBC-7.2 RBC-4.50* Hgb-15.0 Hct-42.6
MCV-95 MCH-33.2* MCHC-35.1* RDW-13.5 Plt ___
___ 06:00PM BLOOD Neuts-67.1 ___ Monos-9.6 Eos-0.7
Baso-0.2
___ 06:00PM BLOOD ___ PTT-34.6 ___
___ 06:00PM BLOOD Glucose-89 UreaN-22* Creat-1.5* Na-135
K-4.1 Cl-101 HCO3-23 AnGap-15
___ 06:00PM BLOOD Glucose-89 UreaN-22* Creat-1.5* Na-135
K-4.1 Cl-101 HCO3-23 AnGap-15
___ 06:00PM BLOOD ALT-52* AST-32 AlkPhos-50 TotBili-0.5
___ 06:00PM BLOOD Albumin-3.6
___ 06:53AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
___ 02:10AM URINE Color-Straw Appear-Clear Sp ___
___ 02:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:10AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 05:05PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS mthdone-NEG
PERTINENT LABS:
============================
___ 06:53AM BLOOD WBC-5.9 RBC-4.44* Hgb-14.6 Hct-42.9
MCV-97 MCH-33.0* MCHC-34.2 RDW-13.6 Plt ___
___ 07:50AM BLOOD WBC-5.8 RBC-4.76 Hgb-15.7 Hct-45.3 MCV-95
MCH-33.0* MCHC-34.6 RDW-13.6 Plt ___
___ 06:53AM BLOOD Glucose-80 UreaN-15 Creat-1.4* Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
___ 05:45AM BLOOD Glucose-86 UreaN-15 Creat-1.5* Na-135
K-3.9 Cl-101 HCO3-24 AnGap-14
___ 07:32AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.2
___ 06:00PM BLOOD CRP-39.4*
___ 08:51AM BLOOD Vanco-18.6
___ 07:50AM BLOOD Vanco-13.9
___ 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
============================
___ 08:51AM BLOOD WBC-5.9 RBC-4.36* Hgb-14.4 Hct-41.2
MCV-95 MCH-33.1* MCHC-35.1* RDW-13.7 Plt ___
___ 08:51AM BLOOD Glucose-96 UreaN-16 Creat-1.5* Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
MICROBIOLOGY:
=============================
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood Culture, Routine (Final ___: NO GROWTH
___ 7:32 am BLOOD CULTURE - Blood Culture, Routine
(Pending)
---------
___ 5:05 pm TISSUE PARASPINAL SOFT TISSUE ___ CORES.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
------------
___ 5:00 pm TISSUE BONE CORE BIOPSY (VERTEBRAL BODY).
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
-------------
___ 4:50 pm FLUID,OTHER BONE ASPIRATE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING:
==============================
#MRI RENAL W/WO CONTRAST ___:
3.4 x 1.8 cm lobulated lesion projecting from the posteromedial
aspect of the right kidney upper pole is a T2 hypointense with
intrinsic T1 hyperintensity. This lesion previously measured 2.1
x 1.9 cm on ___ and had a more rounded morphology.
This exam is slightly limited due to motion artifact and the
possibility of small enhancing papillary projections cannot be
excluded, but no obvious enhancing nodularity is present. The
left kidney contains a few simple cortical renal cysts and is
otherwise unremarkable. Multiple simple hepatic cysts is measure
up to 1.2 cm. The liver is otherwise unremarkable. The
gallbladder, intra and extrahepatic bile ducts, pancreas,
pancreatic duct, spleen, and adrenal glands are normal. The
stomach and imaged portions of small and large bowel are normal.
The abdominal aorta is normal caliber throughout. There are
single bilateral renal arteries. There is no retroperitoneal
mesenteric lymphadenopathy. No ascites. Extensive paraspinal
inflammatory changes related to known L4-5 diskitis and
osteomyelitis is better evaluated on the dedicated same-day
lumbar spine MRI. IMPRESSION: 1. Interval increase in size
of a now 3.4 x 1.8 cm exophytic lobulated lesion projecting from
the posteromedial right kidney. This exam is slightly
motion-limited but the lesion has intrinsic T1 hyperintensity
and no appreciable enhancement after contrast administration.
Findings are most compatible with a hemorrhagic cyst, though a
low-grade neoplasm as a source of bleeding into the lesion
cannot be entirely excluded.
#MRI LUMBAR SPINE W/WO CONTRAST ___:
Findings suggesting discitis at L4-5 and osteomyelitis of the L4
and L5 vertebral bodies are unchanged since the prior study.
Again seen is thickened soft tissue along the posterior margin
of these vertebral bodies within the spinal canal suggesting
epidural abscess. This material enhances nearly uniformly after
contrast administration. At its worst, at the level of the
intervertebral disc, this produces severe spinal canal
narrowing. The intervertebral disk itself enhances after
contrast administration, again compatible with the diagnosis of
diskitis. There is L4 and L5 vertebral bodies enhances,
consistent with the diagnosis of osteomyelitis. The prominent
paraspinal soft tissue abnormality described previously
demonstrates intense enhancement after contrast administration.
IMPRESSION: Findings confirmed the impression of diskitis at
L4-5 and and osteomyelitis of the L4 and L5 vertebral bodies
with intraspinal epidural abscess. Extensive paraspinal
inflammatory changes without evidence of paraspinal abscess.
#CXR ___
Portable radiograph of the chest demonstrates minimal platelike
atelectasis in
the left mid lung. Otherwise the lungs are well-expanded and
clear. The
cardiac silhouette is unchanged. No pneumothorax, pleural
effusion, or
consolidation.
Right upper extremity PICC ends in the low SVC.
IMPRESSION:
Right upper extremity PICC ends in the low SVC.
Brief Hospital Course:
Mr. ___ is a ___ w/ decades-long h/o HIV (1 month
suboptimal adherence, last viral load 600, ___, prev
undetectable), HCV s/p tx, T2DM c/b peripheral neuropathy, on
pioglitazone, and chronic low-back ___ with progressive,
compressive symptoms for last ___ years after MVC, 4 weeks of
worsening low back ___ and chills with MRI evidence of lumbar
osteomyelitis, discitis, and epidural abscess.
#Discitis/Osteomyelitis with epidural abscess
He presented with worsening of his chronic back ___ and
chills/rigors for approximately 1 month. MR imaging demonstrated
discitis, osteomyelitis, and epidural abscess at L4-5 level. He
had no evidence of new neurological dysfunction (neuro exam
documented above). He has chronic urinary incontinence, which
is difficult to characterize, but did not seem to have changed
from his baseline recently (discussed below). He received doses
of vancomycin and cefepime prior to ___ biopsy of the
lumbar spine and paraspinal soft tissue, which had not yielded
positive cultures at the time of discharge. Blood cultures were
negative, and he had no documented fevers during his admission.
He was started on vancomycin and ceftriaxone on ___, with
PICC in place for prolonged 6 week antibiotic course. He had
moderate back ___, worse with palpation over lower lumbar spine
and with ambulation, which was controlled on oxycodone 10mg Q6H
(takes 10mg Q8H at home).
CHRONIC DIAGNOSES:
============================
#Urinary incontinence:
He described approximately 6 months of progressively more
frequent urinary incontinence, currently reporting ___ episodes
per day. Primary symptom is urinary urgency, without dysuria,
hematuria, increased frequency, or other lower urinary tract
symptoms. It is possible that this represents bladder overflow
producing sensation of urgency in setting of partial nerve
compression/inflammation in setting of epidural abscess. No
neurosurgical intervention during this admission.
# HIV - Most recent CD4 count ~600 in ___, with undetectable
viral load. Mr. ___ HIV may be under questionable
control at present given his admittedly poor HAART adherence for
the last month due to ___ and low mood.
- Continue HAART (Emtricitabine-Tenofovir (Truvada) 1 TAB PO
DAILY
and Lopinavir-Ritonavir 4 TAB PO DAILY )
# Depression/Anxiety
Continue home Duloxetine 60 mg qd and PALIperidone ER 9 mg qd.
On home clonzepam 1mg QID
# Diabetes mellitus type 2:
Pioglitazone held on admission, treated with sliding scale
insulin.
# Low testosterone -received his weekly dose of Testosterone
Cypionate 200 mg IM ONCE EVERY ___
# Allergies - continued home fexofenadine
# Hepatitis C
Plans to start new antiviral treatments as outpatient; has
history of mild cirrhosis
**TRANSITIONAL ISSUES**
=============================
-home infusions of Vanc 1g Q12H and Ceftriaxone 2gm Q24H for 6
weeks; Projected End Date: ___ (prelim 6 week course)
-Code status: full code
-Imaging: will likely need follow-up imaging of spine, with date
to be determined in follow-up with infectious disease team
-Biopsy tissue sent for further testing to provide
microbiological diagnosis; follow-up pan-PCR study from ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pioglitazone 15 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. PALIperidone ER 9 mg PO DAILY
4. Lopinavir-Ritonavir 4 TAB PO DAILY
5. Dronabinol 2.5 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN ___
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
8. Voltaren (diclofenac sodium) 1 % topical DAILY
9. Baclofen 10 mg PO TID
10. ClonazePAM 1 mg PO QID
11. Fexofenadine 30 mg PO DAILY
12. Gabapentin 300 mg PO TID
13. Testosterone Cypionate 200 mg IM ONCE EVERY ___
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV Q24H Disp #*38 Vial Refills:*0
2. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1000 mg IV every twelve (12) hours Disp
#*76 Vial Refills:*0
3. Baclofen 10 mg PO TID
4. ClonazePAM 1 mg PO QID
5. Dronabinol 2.5 mg PO DAILY
6. Duloxetine 60 mg PO DAILY
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
8. Fexofenadine 30 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. Lopinavir-Ritonavir 4 TAB PO DAILY
11. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN ___
12. PALIperidone ER 9 mg PO DAILY
13. Testosterone Cypionate 200 mg IM ONCE EVERY ___
14. Diclofenac Sodium ___ ___ sodium) 1 % TOPICAL DAILY
15. Pioglitazone 15 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Lumbar epidural abscess
L4-5 osteomyelitis and discitis
Secondary diagnoses:
-HIV infection
-Hepatitis C
-Chronic low back ___
-Diabetes mellitus type 2
-Chronic kidney disease
-Depression
-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 caring for ___ at the ___.
___ were admitted with lower back ___ and the concern for an
abscess in your back. After performing an MRI with contrast, it
was found that ___ had an infection of your spine, the area
surrounding your spinal cord, and the discs that go between the
bones of your spine. We believe this is worsening your back ___
and incontinence.
___ then underwent biopsy of the bone and soft tissues with the
interventional radiology team at ___. Unfortunately the
results of that did not give us any information as to which
bacteria or other microbe is making ___ ill. Therefore, we began
treatment with broad-spectrum antibiotics, so that ___ would be
covered for any type of infection. The infectious disease
specialists here helped to decide exactly which antibiotics ___
would receive.
___ were discharged on two antibiotics, vancomycin and
ceftriaxone, which ___ will be taking for 6 weeks. In 4 weeks,
___ may have a repeat scan of your back to see how the treatment
is progressing; this will be determined in follow-up with your
infectious disease team as an outpatient.
We wish ___ all the best.
Regards,
Your ___ Team
Followup Instructions:
___
|
10586349-DS-9 | 10,586,349 | 29,662,386 | DS | 9 | 2143-06-23 00:00:00 | 2143-06-23 12:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Prednisone
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
ORIF left proximal femur fracture
History of Present Illness:
___ ___ speaking female transferred from outside hospital
presenting s/p mechanical fall with left intertrochanteric hip
fracture (lesser troch extension/fracture), neurovasc intact,
and no other injuries. This is an operative fracture.
Past Medical History:
GERD, high cholesterol, HTN, fibromyalgia, lumbar compression
fractures, lumpectomy
ABNORMAL ELECTROCARDIAGRAM
ANEMIA
BACK PAIN
FEVER
FIBROMYALGIA
GERD
HEADACHE
INSOMNIA
NEUROPATHY, IDIOPATHIC PERIPHERAL NOS
OSTEOARTHRITIS, UNSPECIFIED SITE
OSTEOPOROSIS
RIGTH CAROTID BRUIT
SOB
TINNITUS
Social History:
___
Family History:
nc
Physical Exam:
Left lower extremity
Incision CDI, no erythema, no swelling, compartments soft
SILT sp/p/s/s
Fires ___
WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of left intertrochanteric
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 <<>> was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up in two weeks per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NexIUM *NF* (esomeprazole magnesium) unknown Oral unknown
2. Lisinopril 2.5 mg PO DAILY
3. Acetaminophen Dose is Unknown PO Frequency is Unknown
4. Gabapentin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Gabapentin 100 mg PO TID
3. Lisinopril 2.5 mg PO DAILY
4. Enoxaparin Sodium 40 mg SC DAILY
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left intertrochanteric fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT left lower extremity
FOllow up:
Please follow up with ___ in the orthopedic trauma
clinic ___ days post-operation for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
WBAT LLE
Treatments Frequency:
dressing changes BID until wound clean
staples will be removed at follow up appointment
WBAT LLE
Followup Instructions:
___
|
10586946-DS-13 | 10,586,946 | 25,138,352 | DS | 13 | 2148-05-15 00:00:00 | 2148-05-15 12:41:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Cephalosporins / Sulfa (Sulfonamide Antibiotics) / oxycodone
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
___ Coronary artery bypass grafts x 2 Lima to LAD, SVG to OM;
Endovascular saphenous vein harvest LLE
History of Present Illness:
Mr. ___ is a ___ with PMH of GERD, asthma, with acute onset
chest pain on the left chest with radiation to the R arm. The
patient gradually increased to ___. Not associated with
diaphoresis, SOB, lightheadedness. He was treated with ASA with
improvement in his pain to ___. He denied abdominal pain,
dyspnea, orthopnea, PND, ___ edema.
In the ED initial vitals were: 96.2 64 93/57 16 100% RA
EKG: Transient sub1mm STE V2-V3 with sub mm ST depression in the
inferior and lateral leads
Labs/studies notable for: trop 0.16, HCO3 20, WBC 10.2, Hgb 10.7
Patient was given: SL nitro, then nitro gtt, morphine 2mg x2,
heparin 5000U then IV gtt,
Vitals on transfer: 88 96/63 25 99% Nasal Cannula
On the floor the patient reports improvement in his pain on
nitro gtt. He denies dyspnea. He endorses some chronic ___ edema
R>L
Past Medical History:
- Asthma/COPD
- gastritis, GERD (EGD ___ w/gastritis w/shallow ulcers,
c/w h pylori infection).
- hiatal hernia
- h/o h pylori infection s/p treatment
- s/p cataract surgery on L
Social History:
___
Family History:
Colon Cancer (in father), ___ Disease (in daughter and
his brother, dtr passed away from PD ___ years ago)
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: well appearing, NAD
HEENT: sclera anicteric, MMM
NECK: no JVD
CARDIAC: RRR, nl S1 S2, no murmurs/rubs/gallops
LUNGS: decreased breath sounds posteriorly, no
wheeze/rales/rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: L extremity slightly cool, 1+ edema L>R
SKIN: +prominent ___ veins
PULSES: DP 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-10.2* RBC-3.72* Hgb-10.7* Hct-34.7*
MCV-93 MCH-28.8 MCHC-30.8* RDW-13.4 RDWSD-45.9 Plt ___
___ 01:00PM BLOOD Neuts-52.8 ___ Monos-10.0 Eos-6.9
Baso-0.6 Im ___ AbsNeut-5.38 AbsLymp-3.00 AbsMono-1.02*
AbsEos-0.70* AbsBaso-0.06
___ 01:00PM BLOOD ___ PTT-25.9 ___
___ 01:00PM BLOOD Glucose-124* UreaN-33* Creat-1.1 Na-138
K-3.8 Cl-103 HCO3-20* AnGap-19
___ 02:42AM BLOOD ALT-31 AST-67* AlkPhos-75 TotBili-0.4
___ 01:00PM BLOOD cTropnT-0.16*
___ 03:40AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0
PERTINENT INTERVAL LABS:
___ 11:10PM BLOOD ALT-33 AST-51* AlkPhos-87 TotBili-0.3
___ 09:10PM BLOOD CK-MB-241* MB Indx-14.9* cTropnT-4.98*
___ 03:40AM BLOOD CK-MB-190* MB Indx-11.4* cTropnT-5.79*
___ 10:21AM BLOOD CK-MB-128* MB Indx-9.2* cTropnT-5.33*
___ 02:42AM BLOOD calTIBC-256* VitB12-919* Hapto-282*
Ferritn-84 TRF-197*
___ 11:10PM BLOOD %HbA1c-5.6 eAG-114
DISCHARGE LABS:
IMAGING/STUDIES:
CT CHEST W/O CONTRAST ___:
Small left and trace right nonhemorrhagic pleural effusions.
No consolidation concerning for pneumonia. Mild bibasilar
atelectasis.
Sequela of resolving pulmonary edema.
5 mm solid nodule in the left upper lobe. As per the ___
___
Pulmonary Nodule Guidelines, no follow-up chest CT is
recommended for low risk patients and option followup chest CT
is recommended in 12 months for a high risk patient.
CAROTID US ___
Less than 40% stenosis of the internal carotid arteries
bilaterally.
CXR ___
In comparison with the study of ___, the cardiomediastinal
silhouette is stable. There is indistinctness of pulmonary
vessels with Kerley lines, consistent with elevated pulmonary
venous pressure. Poor definition of the left hemidiaphragm is
consistent with small layering effusion and volume loss in the
left lower lobe. Otherwise little change.
TTE ___
The left atrial volume index is mildly increased. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
distal half of the anterior septum and anterior walls and apex.
The remaining segments contract normally (biplane LVEF = 45 %).
The estimated cardiac index is normal (>=2.5L/min/m2). No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction most c/w CAD (mid-LAD distributioin). Mild
mitral regurgitation. Mild aortic regurgitation.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
___ 04:42AM BLOOD WBC-7.4 RBC-2.95* Hgb-8.8* Hct-27.0*
MCV-92 MCH-29.8 MCHC-32.6 RDW-13.3 RDWSD-45.0 Plt ___
___ 06:57PM BLOOD WBC-15.2* RBC-3.15*# Hgb-9.5*# Hct-28.9*#
MCV-92 MCH-30.2 MCHC-32.9 RDW-13.2 RDWSD-43.7 Plt ___
___ 03:06AM BLOOD ___ PTT-34.6 ___
___ 04:42AM BLOOD Glucose-96 UreaN-60* Creat-2.4* Na-137
K-4.6 Cl-104 HCO3-22 AnGap-16
___ 05:00AM BLOOD Glucose-96 UreaN-58* Creat-2.7* Na-136
K-4.5 Cl-103 HCO3-21* AnGap-17
___ 04:54AM BLOOD Glucose-104* UreaN-54* Creat-2.8* Na-132*
K-4.7 Cl-100 HCO3-22 AnGap-15
___ 12:17PM BLOOD UreaN-49* Creat-2.9*
___ 04:40AM BLOOD Glucose-97 UreaN-47* Creat-2.9* Na-133
K-4.6 Cl-99 HCO3-20* AnGap-19
___ 05:15PM BLOOD Glucose-116* UreaN-45* Creat-2.4* Na-131*
K-4.7 Cl-98 HCO3-21* AnGap-17
___ 04:29AM BLOOD Glucose-95 UreaN-37* Creat-1.8* Na-135
K-5.0 Cl-102 HCO3-22 AnGap-16
___ 04:42AM BLOOD Mg-3.4*
Brief Hospital Course:
COURSE ON MEDICINE SERVICE ___:
___ with PMH of GERD, asthma, with acute onset chest pain on
the left chest with radiation to the R arm found to have NSTEMI,
with TTE showing left ventricular systolic dysfunction with
hypokinesis of the distal half of the anterior septum and
anterior walls and apex, evaluated with cardiac cath showing 90%
stenosis of proximal LAD referred for CABG which he underwent on
___
Cardiac Catheterization: Date: ___ ___
LMCA: minimally diseased
LAD: 90% narrowed at its origin.
LCX ___ marginal long 60%
RCA: serial 20% lesions
# NSTEMI: Patient presented with chest pain found to have
NSTEMI, with troponin peaking at 5.79. ECG notable for poor R
wave progression and transient sub1mm STE V2-V3 with sub mm ST
depression in the inferior and lateral leads which resolved
spontaneously. He was placed on nitro gtt and chest pain abated.
Patient was evaluated with TTE which showed left ventricular
systolic dysfunction with hypokinesis of the distal half of the
anterior septum and anterior walls and apex, in the distribution
of the LAD. He underwent cardiac catheterization on ___ which
showed 90% stenosis of the LAD at its origin and LCX with 60%
stenosis of the first marginal. The patient was referred for
CABG. He was continued on heparin gtt, as well as aspirin,
atorvastatin 80mg and metoprolol 12.5mg BID pre-operatively.
# Anemia: Hgb 10.7 on admission from prior ___ in ___. Iron
studies consistent with anemia of chronic disease. Stool was
guaiac negative, hemolysis labs negative, reticulocyte count
appropriate, vitamin studies WNL. The patients CBC was trended.
# H/o Gastritis: patient with h/o gastritis, followed by GI as
outpatient, found on EGD in ___ to have small hiatal hernia,
ulcers in stomach antrum, erythema in stomach body suggestive of
gastritis. He completed a course of treatment for H pylori
infection. As above, patient found to have guaiac negative stool
suggesting GI losses less likely etiology for his anemia.
# Asthma: continued home montelukast, fluticasone inh and nasal
spray. Held home nasonex as non-forumulary
# s/p cataract surgery: continued home ciprofloxacin, diclofenac
and prednisolone eye drops
TRANSITIONAL ISSUES:
- Noted to have 5 mm solid nodule in the left upper lobe. As per
the ___ Society Pulmonary Nodule Guidelines, no follow-up
chest CT is recommended for low risk patients and option
followup chest CT is recommended in 12 months for a high risk
patient.
=
=
=
=
=
=
=
=
=
=
================================================================
COURSE ON CARDIAC SURGERY SERVICE ___
The patient was brought to the Operating Room on ___ where
the patient underwent CABG x 2 ___. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. He developed acute kidney injury with peak creatinine
of 2.9. Diuresis was discontinued. Urine output remained
adequate and creatinine trended toward baseline prior to
discharge. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. He
developed a left sided pleural effusion which was tapped by IP
for 1L. By the time of discharge on POD 6 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to ___
___ Rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Omeprazole Dose is Unknown PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
6. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE TID
8. diclofenac sodium 0.1 % ophthalmic DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY
8. TraMADol 25 mg PO Q12H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every
twelve (12) hours Disp #*20 Tablet Refills:*0
9. Omeprazole 40 mg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
12. diclofenac sodium 0.1 % ophthalmic DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Montelukast 10 mg PO DAILY
16. Nasonex (mometasone) 50 mcg/actuation nasal DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease
Secondary:
Asthma
GERD
Hiatal Hernia
Anemia
Constipation
Hip fx
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- trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10587536-DS-12 | 10,587,536 | 27,532,058 | DS | 12 | 2171-10-11 00:00:00 | 2171-10-12 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending: ___
Chief Complaint:
code stroke for transient unresponsiveness/confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a very pleasant ___ woman with a history of cervical
spondylosis, hyperlipidemia, CAD with prior angioplasty, remote
history of breast cancer, depression and insomnia who presents
to the ED with her daughter and brought
in by ambulance for an episode of unusal behavior that happened
this morning.
Her health has been well lately. She does report that she is
supposed to wear a soft cervical collar per Dr. ___, but she hardly ever dose because it is
inconvenient. Lately, she has been experiencing some shooting
pains from her shoulder down to her fingers and it has been
equal
on both sides. She has not been excessively clumsy with her
hands. She has not had any falls, fractures, fevers or any other
new symptoms such as dysuria or chest pain.
She had been spending the night with her daughter to baby sit
her
grandchildren the night before. This morning, at around 8am, she
was noted to be doing well, folding some clothes. At around
915AM, the patient was noted to be acutely quite tired and pale
appearing while sitting on her chair. Her daughter noticed a
possible droopy right side of her mouth. She had a pill in her
mouth, and almost spit it out, which is very unusual for her.
Her
daughter brought her a glass of water, and she looked at the
glass and said "what is this?" After this, she was quite
unresponsive and was blinking aimlessly. Her daughter was
worried
about a stroke, and so she called the ambulance. Typically, her
mother would have fought this step but today there was no
objection on the mother's part. By the time EMS came, she was
starting to come back to herself. The whole episode perhaps
lasted about ___ minutes. The patient herself has NO
recollection of these events.
She has been compliant with her medications lately, and
compliant
with her MD visits. There are no new medications that have been
started. She does take fluoxetine daily as well as zolpidem for
night time insomnia. She did not take any more or less of these
medications recently. At baseline, she is a highly independent
woman who lives by herself and manages all of her own finances
and ADLs.
On general review of systems, as above, she denies any new
symptoms other than the bilateral shooting arm pains.
Past Medical History:
- Cervical spondylosis: Seen initially for a gait difficulty and
found by Dr. ___ colleagues to have cervical
spondylosis.
Gait difficulty thought to be related to posterior column
dysfunction with other signs of myelopathy noted earlier in
___. She had scheduled another appointment with Dr.
___
in the next few weeks to discuss her issues with bilateral
radicular pain. Poor surgical candidate, and thus surgery was
deferred.
- MI ___: S/p angioplasty ("there were no stents at the time").
Has since been followed by cardiology. Hypertension has not been
a problem. She has been compliant with her daily baby aspirin
for
prophylaxis, and has since had no heart attacks.
- Breast cancer: Over ___ y ago (see notes from H/O). Did receive
a radical mastectomy, does get a regular mammogram and those
have
been without recurrence. She reports radiation therapy, but not
noted in chart. Was on hormone suppression therapy as the lesion
was ER positive.
- Hypertension: Unmedicated, tends to have low blood pressures
these days
- Hyperlipidemia: Last LDL was <60
- Anxiety/Depression: Reports that she takes fluoxetine for
"nerves", "lots of stuff going on in my life"
- Insomnia: Takes 5mg of zolpidem nightly for insomnia,
sometimes
has to take another pill (prescribed trazodone as well in OMR).
Social History:
___
Family History:
Negative for history of stroke or other neurologic illness
Physical Exam:
___ Stroke Scale score was: 0
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
Physical Exam on Admission:
Vitals: Pain 0, 98.4, 64, 100/60, 18, 100%
General: Thin, small built, elderly woman who is no apparent
distres. Cooperative, pleasant and daughter at bedside
___: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, some mild tenderness to palpation just below the
umbilicus, no masses or organomegaly noted.
Extremities: warm and well perfused, moderate muscle atrophy
noted distally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to ___. Does not
recall the events surrounding this current ED visit. On
recalling
the ___ backwards, she switched ___ and ___, and then stopped.
She could not calculate 9+5 or 9x5, but could say that there
were
four quarters in a dollar. Language was fluent and comprehension
intact. Repetition was perfect. No anomia to NIHSS objects, and
reading was normal. No evidence of visual neglect or apraxia.
Registration of three words was ___, recall was only ___.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV and VI: EOM are intact and full, no 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: Some atrophy, diffuse and symmetric. Tone was normal. No
pronator drift. No adventitious movements, such as tremor,
noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___- ___ 5 5 5 5 5 4 4
R 5 ___- ___ 5 5 5 5 5 4 4
-Sensory: No deficits to light touch or pinprick throughout. JPS
intact at fingers, but impaired at toes. Negative troemners.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2 2 1
R 3+ 2 2 2 1
Plantar response: Mute
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF.
-Gait: Deferred.
Physical Exam on Discharge:
Vitals: afebrile, hemodynamically stable
exam unchanged from admission
Pertinent Results:
Labs on Admission:
___ 10:45AM WBC-6.6 RBC-4.43 HGB-13.4 HCT-41.6 MCV-94
MCH-30.2 MCHC-32.2 RDW-13.5
___ 10:47AM GLUCOSE-89 NA+-138 K+-3.9 CL--103 TCO2-25
___ 10:45AM UREA N-19
___ 10:50AM CREAT-0.9
___ 11:36AM ___ PTT-30.2 ___
___ 05:34PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:34PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 12:02PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 07:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:45PM TSH-1.6
___ 07:45PM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-1.8
___ 07:45PM CK-MB-2 cTropnT-<0.01
___ 07:45PM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-190
CK(CPK)-95 ALK PHOS-70 TOT BILI-0.5
___ 04:40AM BLOOD Triglyc-90 HDL-69 CHOL/HD-2.1 LDLcalc-60
LDLmeas-71
Imaging:
CT head w/o contrast
There is no evidence of hemorrhage, edema, mass effect, or large
territorial infarction. The ventricles and sulci are prominent,
compatible with age-related volume loss. Periventricular white
matter hypodensities are compatible with chronic small vessel
ischemic disease. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION: No intracranial hemorrhage or large territorial
infarction. If there is concern for acute stroke, MR would be
more sensitive.
MRA OF THE BRAIN:
The intracranial internal carotid and vertebral arteries are
patent. The basilar artery appears patent with normal. The
posterior cerebral arteries are patent. The P1 segments of the
posterior cerebral arteries are small due to robust bilateral
posterior communicating arteries.
The anterior and middle cerebral arteries have normal branching
pattern and appear patent.
There is no evidence of aneurysm, arteriovenous malformation, or
critical
stenosis in the anterior and posterior circulation.
MRA NECK:
There is a three-vessel arch. The origins of the vertebral and
common carotid arteries appear patent. The cervical internal
carotid arteries are patent. There is plaque at the proximal
left internal carotid artery. There is no evidence of stenosis.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. Predominantly fetal circulation of the bilateral posterior
cerebral
arteries. Unremarkable examination.
3. Normal MRA of the neck.
EEG:
This is a normal waking and drowsy EEG. No focal abnormalities
or epileptiform discharges are present. If clinically indicated,
repeat EEG with sleep recording may provide additional
information.
Brief Hospital Course:
___ RHW with a history of breast cancer in remission, well
controlled hyperlipidemia, well controlled hypertension and
prior MI who presented to the ED by
ambulance for an episode of altered behavior.
# Neuro: She is typically quite mentally sharp and independent
at baseline, and
lives at home and is medication compliant. On morning of
admission at approximately 9:15AM, she was noted to be appearing
pale and confused with a possible droop of the right side of her
mouth. When a glass of water was presented to her, she didn't
know what to do with it, and a few minutes later, this
progressed to just blank staring and wouldn't answer any simple
questions. The whole episode lasted for no more than 10 minutes.
Of note, patient does endorse poor sleep on previous night.
Also, says that she had "fits" when she was a teenager for
several years. Was never evaluated for seizures nor started on
medications. On examination approximately 75 minutes later, she
was alert but oriented to ___, and inattentive and with
___ word recall at 5 minutes. She had no recollection of the
above-described events. Her neurological examination was
otherwise unchanged from previous, with an UMN pattern of
weakness in her upper and lower extremities with preserved
reflexes. She did have some tenderness to palpation in the
infraumbilical region. A code stroke was called, and initial
labs and NCHCT were unremarkable.
The differential diagnosis for this event included a possible to
the left MCA
territory (? right facial droop, ? anomia) as well as seizure.
MRI head ruled out infarct and MRA head/neck showed normal
vessels. EEG was obtained and was normal. Nevertheless, given
patient's history of seizures in childhood, she likely had a
complex partial seizure. Since it was in the setting of sleep
deprivation and an isolated event, no AEDs were initiated. She
will follow up in neurology clinic.
# Cardio: Was monitored on telemetry, no aberrant rhythms
observed.
TRANSITIONS OF CARE:
- will follow up in neurology clinic
Medications on Admission:
- Aspirin 81 daily
- Atorvastatin 20 qHS
- Fluoxetine 20 qAM
- Zolpidem 5mg QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
RX *zolpidem [Ambien] 5 mg 1 tablet(s) by mouth HS Disp #*15
Tablet Refills:*0
5. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Complex partial seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after an episode of confusion
and amnesia. An MRI of your brain showed that you DID NOT have
a stroke. An EEG was obtained to check for seizures. The EEG
was NORMAL, which is reassuring. However, we do think that the
episode you experienced yesterday was due to a complex partial
seizure. Since it was an isolated event and provoked in the
setting of sleep deprivation, we will not start you on any
medications for seizures.
We have not made any changes to your medications.
As we discussed, you should attend outpatient therapy to help
with your walking. A prescription is included.
Please follow up with Dr. ___ in neurology clinic as
scheduled below as well as your other upcoming appointments.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10588094-DS-13 | 10,588,094 | 29,694,158 | DS | 13 | 2165-02-16 00:00:00 | 2165-02-17 10:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ lap cholecystectomy, uncomplicated
History of Present Illness:
Mr. ___ is a ___ w/ known symptomatic cholelithiasis and
ventral hernia
who presented with RUQ abdominal pain on ___. Initially
awoken morning
(___) w/ right back pain and this turned into RUQ abdominal
pain. Had been previously evaluated for chole and hernia repair
but elected not to undergo surgery at that time. Reports some
nausea w/o vomiting. No light stools or dark urine. No fevers or
chills. He took
several aspirins for his pain, and these helped slightly.
Past Medical History:
PMH:
Hypertension
Umbilical hernia
BPH
Achilles tendonitis
Arthritis R knee
Distant history of diverticulitis treated conservatively.
PSH:
Knee surgery
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: T97.9 HR86 BP136/89 RR18 Sat96RA
General: Patient awake, alert, oriented and interacting
appropriately.
CV: RRR, No MRG.
Lungs: CLAB
ABD: Soft, nontender to palpation except slight tenderness in
RUQ, minimal. No organomegaly. Exam notable for 3cm easily
reducible nontender umbilical hernia. Incisions c/d/i.
Extremities: no deformity, no edema.
Pertinent Results:
___ 03:30PM BLOOD Hct-42.6
___ 12:12PM BLOOD WBC-13.4*# RBC-4.64 Hgb-14.5 Hct-42.9
MCV-93 MCH-31.3 MCHC-33.8 RDW-12.5 RDWSD-42.2 Plt ___
___ 07:25PM BLOOD Lactate-1.3
Imaging
RUQ U/S ___: Cholelithiasis with gallbladder distention and
mild
pericholecystic fluid. Findings are suggestive of acute
cholecystitis. There is no intrahepatic biliary dilation. The
CBD
measures 5 mm.
Brief Hospital Course:
Mr. ___ is a ___ M with known history of umbilical hernia
and symptomatic cholelithiasis. He presented to ___ ED on
___ with complaint of worsening RUQ pain with radiation to
his back, as well as nausea/without vomiting. He denied
light stools or dark urine. No fevers or chills. He took several
aspirins for his pain, and these helped slightly.
Mr. ___ had previously been evaluated for elective
cholecystectomy and ventral hernia repair however he elected not
to have this done. At admission, an abdominal ultrasound was
completed which showed GB wall thickening and pericholecystic
fluid with GB stones suggestive of acute cholecystitis. Informed
consent was obtained and on ___ Mr. ___ underwent
laparoscopic cholecystectomy, which was uncomplicated and which
yielded a grossly infected and gangrenous GB. Prior to surgery,
elective repair of the ventral hernia was discussed however it
was decided that attempting this would likely increase Mr.
___ risk of postoperative infection. Mr. ___ was
counseled on this and was in agreement that the ventral hernia
repair not be repeated on this admission.
Following surgery Mr. ___ tolerated normal diet, was able
to ambulate comfortably, and experienced adequate pain control
on oral medications. After meeting the appropriate criteria Mr.
___ was discharged home with instructions to follow up
postoperatively in our clinic at a scheduled appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO BID
2. Glutamine 5 gm PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. garlic 1 mg oral DAILY
6. lecithin 1,000 mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
Take this medicine as needed. Do not take if you are having
regular bowel movements.
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every 4 hours
Disp #*8 Tablet Refills:*0
4. Senna 8.6 mg PO DAILY
Take this medicine only if you are having constipation.
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Glutamine 5 gm PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. garlic 1 mg oral DAILY
10. lecithin 1,000 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10588464-DS-3 | 10,588,464 | 27,958,936 | DS | 3 | 2113-02-27 00:00:00 | 2113-03-04 12:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
neck swelling
Major Surgical or Invasive Procedure:
___ - fine needle aspiration and core biopsy
___ - Bone marrow biopsy
History of Present Illness:
___ with COPD not on home O2, AF on rivaroxban, hypothyroidism,
presenting with new growing throat mass and concern for airway
compromise.
She initially saw her PCP two weeks ago due to neck mass. CT was
ordered which showed right thyroid mass. She was referred to ___
last week who recommended an FNA of the mass and asked her to
return in 5 days after holding her anticoagulation. She returned
today to ___ clinic. Given interval growth of the mass with
symptomatic compressive symptoms, she was referred to ED. She
recalls having fatigue and sore throat around the time when she
noticed the mass which she thought were swollen glands. The mass
became slightly tender but not painful. She has some trouble
breathing only in the supine position.
In the ED, initial vitals were T97.8 94 147/84 18 98RA. ENT
scoped in ED, narrow airway but stable. Recommended FNA/core
needle biopsy in AM. She was not given steroids in order to
maximize biopsy yield. Labs in ED showed normal CBC/DIFF, coags,
BMP. Lactate 2.7. Transfer vitals were T97.8 84 149/91 18 98 3L
NC.
On arrival to MICU, she has no acute complaints.
ROS: per HPI, otherwise negative.
Past Medical History:
-Neck mass, undergoing workup
-Atrial fibrillation, on rivaroxaban
-COPD, not on home O2
-Hypertension, diet-controlled
-Hyperlipidemia
-Hypothyroidism
Social History:
___
Family History:
Mother with melanoma. Husband with ___ lymphoma. Daughter
with leukemia. MGF with prostate cancer. PGM with cervical
cancer.
Physical Exam:
Admission
VS: BP139/92 HR86 RR18 94% 3L NC
GEN: Well appearing, obese woman, no distress.
HEENT: No scleral icterus. Tongue midline.
NECK: Large firm palpable circumferential anterior neck mass
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes or rlaes
ABD: Soft, nontender, nondistended, normal BS
EXT: No ___ edema
Discharge
Vitals: 98.1 ___ ___ 20 96%ra
Gen: Pleasant, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Thick, with firm circumferential mass at inferior portion
of neck, nontender; no stridor
CV: Distant sounds, Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No increased WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. Trace pedal edema b/l.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: PICC
Pertinent Results:
ADMISSION
___ 06:42PM BLOOD WBC-5.4 RBC-4.59 Hgb-13.6 Hct-42.1 MCV-92
MCH-29.6 MCHC-32.3 RDW-13.2 RDWSD-44.6 Plt ___
___ 06:42PM BLOOD Neuts-62.3 ___ Monos-7.5 Eos-2.4
Baso-0.7 Im ___ AbsNeut-3.33 AbsLymp-1.44 AbsMono-0.40
AbsEos-0.13 AbsBaso-0.04
___ 06:42PM BLOOD ___ PTT-29.5 ___
___ 06:10AM BLOOD ___ 06:42PM BLOOD Glucose-166* UreaN-14 Creat-1.1 Na-138
K-4.1 Cl-99 HCO3-29 AnGap-14
___ 06:42PM BLOOD ALT-17 AST-27 LD(LDH)-394* AlkPhos-86
TotBili-0.4
___ 06:42PM BLOOD Albumin-4.3 Calcium-9.5 Phos-2.8 Mg-2.0
UricAcd-6.3*
___ 06:42PM BLOOD TSH-10*
___ 06:47PM BLOOD Lactate-2.7*
DISCHARGE
___ 12:00AM BLOOD WBC-8.4 RBC-3.90 Hgb-11.4 Hct-35.7 MCV-92
MCH-29.2 MCHC-31.9* RDW-13.2 RDWSD-43.9 Plt ___
___ 12:00AM BLOOD Neuts-82* Bands-0 Lymphs-16* Monos-1*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-6.89* AbsLymp-1.34
AbsMono-0.08* AbsEos-0.08 AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-99 UreaN-21* Creat-1.0 Na-137
K-3.9 Cl-102 HCO3-27 AnGap-12
___ 12:00AM BLOOD ALT-21 AST-19 LD(LDH)-248 AlkPhos-56
TotBili-0.5
___ 12:00AM BLOOD Albumin-3.3* Calcium-8.1* Phos-3.1 Mg-2.3
STUDIES
L Thyroid Biopsy Surgical Pathology Report ___
The morphologic and immunophenotypic features are consistent
with involvement by a high grade B cell lymphoma best classified
as a diffuse large B cell lymphoma with a germinal center
phenotype (by the ___ algorithm). Cytogenetics work-up revealed
no evidence of an IGH/BCL2
gene rearrangement or rearrangements of the BCL6 and MYC genes
(see separate reports ___ and ___ for full details)
Bone Marrow Aspirate and Core Biopsy ___
NORMOCELLULAR BONE MARROW WITH MATURE TRILINEAGE HEMATOPOIESIS
(see note).
Note: No marrow involvement by large cell lymphoma is seen.
There is small non-paratrabecular lymphoid aggregate comprised
of small mature appearing lymphocytes (best seen on H&E level
1). The aggregate is ___ diminished on deeper levels, precluding immunohistochemical
characterization. The concurrent flow cytometry performed on
the aspirate material does not show any clonal B-cell
population. Please correlate with
cytogenetic findings.
Bone Marrow Cytogenetics ___
NEGATIVE HIGH GRADE LYMPHOMA PANEL.
No evidence of interphase thyroid biopsy cells with the IGH/BCL2
gene rearrangement or rearrangements of the BCL6 and MYC genes.
IMAGING
CT chest w contrast ___. Large left thyroid mass is incompletely evaluated on this
study. No
evidence of metastatic disease to the chest.
2. Calcified right hilar and mediastinal lymph nodes and
granuloma in the
right lower lobe suspicious for old TB.
3. Please see dedicated abdomen pelvis report for evaluation of
findings
below diaphragm.
CT Abdomen w/wo contrast ___
Indeterminate 1.6 cm left adrenal nodule, does not meet CT
criteria for
adenoma, although a lipid poor adenoma is statistically most
likely. However,metastatic disease cannot be entirely excluded.
Attention on follow-up recommended.
Brief Hospital Course:
___ with COPD not on home O2, AF on rivaroxban (held since
___, and hypothyroidism who presents with rapidly enlarging
throat mass, c/f carcinoma vs. lymphoma.
# Diffuse large b-cell lymphoma: The patient presented with a
rapidly growing thyroid mass with concern for airway compromise
with laryngeal displacement on laryngoscopy by ENT. She was
monitored clinically without any evidence of stridor and
initially complained only of orthopnea ___ physical compression
of her airway while lying flat. She underwent U/S guided biopsy
of this thyroid mass with ___ on ___ and was started on
dexamethasone following biopsy (10mg IV q8H). She also underwent
CT torso, which did not reveal any notable LAD or
metastatic-appearing lesions. On steroid therapy, the thyroid
mass quickly decreased in size and she was quickly weaned from
3L O2 per NC down to RA. She was monitored closely for TLS and
was started on IVF as well as allopurinol for prophylaxis. On
___, pathology resulted as atypical lymphoma and patient
was transferred to the oncology service for further care. She
underwent a bone marrow biopsy, which revealed diffuse large
b-cell lymphoma and cytogenetics were negative for high grade
lymphoma. She was started on EPOCH-R therapy (day 1 = ___
which she tolerated well.
# Adrenal Nodules: On CT torso to evaluate for metastatic
disease, patient was noted to have left adrenal nodule.
Dedicated CT abd/pelv on ___ showed an isolated, 1.6cm nodule,
likely adenoma given absence of widespread LAD or other signs of
metastatic disease. Per conversation with Radiology, continued
radiographic follow-up for this nodule was recommended. However,
as this nodule would likely be captured on imaging studies for
lymphoma, no dedicated imaging was felt necessary. Biopsy of
nodule could then be considered given any clinical/radiographic
change.
# Rash: Shortly after starting dexamethasone, the patient
developed a rash over her anterior cervical region. While
etiology was unclear, this rash was felt most likely to be ___
contact dermatitis from soap/towels/pillows vs. flushing related
to steroids vs. inflammatory reaction from local tumor
destruction. Her medications were reviewed, without any obvious
culprit identified. The rash quickly self-resolved within 48
hours and no other interventions were taken.
# Nocturnal desaturations: Patient with family hx of OSA and
personal risk factors including obesity and large neck
circumference. She has been desaturating to mid-80's at night,
asymptomatic. No prior dx of OSA or use of CPAP. She was
monitored on continuous O2 telemetry, with no prolonged
desaturations. She was placed on CPAP at night but could not
tolerate this because of poor mask fit. Outpatient sleep study
is recommended.
CHRONIC ISSUES
# Paroxysmal Atrial Fibrillation: The patient has a hx of pAfib
with CHADSVASc score of ___ (only "diet-controlled" HTN)". Her
home rivaroxaban was held prior to biopsy and per ENT, would be
ok to restart. However, given possible need for future biopsies,
rivaroxaban continued to be held throughout her stay on the
general medicine floor. She continued to be rate controlled on
metoprolol and monitored closely on tele without evidence of
conversion to afib. On transfer to oncology service, the
rivaroxaban was held for a bone marrow biopsy, and restarted on
___.
# Hypothyroidism: continued on levothyroxine.
# Hyperlipidemia. continued on atorvastatin.
TRANSITIONAL ISSUES:
- PICC line removed at discharge. She requires port placement
prior to cycle 2 of chemo.
- CT chest showing calcified right hilar and mediastinal lymph
nodes and granuloma in the right lower lobe suspicious for old
TB. Please send quantiferon gold as outpatient.
- Adrenal nodule should be re-assessed at next imaging study (no
dedicated imaging required)
- Noted to intermittently desat to ___ while sleeping. Please
consider outpatient sleep study.
- Requires lab check on ___ (at outside lab) and ___ (at clinic
appointment)
CODE: FULL CODE
CONTACT: daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO DAILY
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Rivaroxaban 20 mg PO DAILY
5. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*5
6. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*5
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*5
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*2
9. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*2
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*60 Tablet Refills:*3
11. Filgrastim 480 mcg SC Q24H Duration: 10 Doses
On 3 week cycles
RX *filgrastim [Neupogen] 480 mcg/0.8 mL 480 mcg sc daily Disp
#*20 Syringe Refills:*3
12. Outpatient Lab Work
ICD-10 code: ___
Please obtain CBC, chem 7, and LFTs on ___
Please fax results to:
ATTN: ___ NP
___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNSOSIS:
Diffuse Large B-Cell Lymphoma
SECONDARY DIAGNOSES:
atrial fibrillation
hypothyroidism
hyperlipidemia
skin rash
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 being found to have a rapidly
enlarging mass of your neck. You were initially in the
intensive care unit for close monitoring, and you underwent a
biopsy of the mass by the Ear-Nose-Throat doctors ___ ___.
You were started on steroids and transferred to the floor. The
biopsy showed that you have lymphoma, and you were transferred
to the oncology service and started on chemotherapy. You
tolerated the chemotherapy well and are discharged home.
Instructions:
- Please give yourself Neupogen shot once per day starting
___. This helps increase your white blood counts.
- Please attend all follow-up appointments
- Please follow-up with your primary care doctor to evaluate for
___ Apnea. You may need a sleep study as an outpatient.
- Please take all medications as prescribed.
It was very nice to be a part of your care team, and we wish you
the best of luck!
Followup Instructions:
___
|
10588654-DS-18 | 10,588,654 | 23,582,891 | DS | 18 | 2193-01-31 00:00:00 | 2193-02-02 07:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Grass ___ Blue, Standard / Mold/Yeast/Dust / Ragweed
/ Sage / Cat Hair Std Extract
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female-to-male with history of diverticulitis and
interstitial cystitis s/p neo-bladder who presented with
abdominal pain and nausea. He noted first having 5 hours of
abdominal pain on ___ that caused him to leave work. This
episode resolved without any intervention. The abdominal pain
subsequently returned on ___ and has since continued. He
described the abdominal pain as waxing and waning, changing
between crampy and sharp, and said that it lies predominantly
across the lower abdomen. This is different from his previous
episodes of diverticulitis, which presented with pain near the
left upper quadrant of the abdomen. His last bowel movement was
___, and was typical of his loose bowel movements s/p
ileal neo-bladder creation. He had since not passed gas. He had
been nauseous but denies any vomiting before presentation to the
ED. He had decreased appetite in setting of pain and nausea. He
presented to the ___ ED on ___ per recommendation of his PCP.
Of note, Mr. ___ has had previous infections of his
neo-bladder, but denies any recent cloudy urine or change in
urine smell that was typical of his previous infections. He does
self-catheterize. He denies recent fever, headache, rhinitis,
pharyngitis, chest pain, shortness of breath.
In the ED, patient continued to be nauseated. Had an episode of
wretching without emesis as he had nothing in his stomach. He
was started on ciprofloxacin and flagyl. He was also given
morphine and Zofran but remains unable to tolerate POs in
setting of pain and nausea.
In the ED, initial VS were:
T 98.2 HR 95 BP 120/93 RR 19
Exam notable for:
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, diffuse lower abdominal
tenderness
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Labs showed:
WBC 11.1
BMP wnl
UA unremarkable
Urine culture no growth
Imaging showed:
- Abdominal CT ___
IMPRESSION:
1. Sigmoid diverticulitis without perforation or abscess.
2. L1 vertebral body sclerotic lesion was not seen on ___ and demonstrates density more compatible with malignancy
rather than bone island. However, no primary malignancy is
identified in the abdomen or pelvis.
EKG - Rate 93. Sinus Rhythm. Normal Axis. No ST changes.
Received:
- PO Metronidazole 500mg x1
- PO Ciprofloxacin 500mg x1
- IV Morphine x4
- IV Ondansetron x2
- IV NS
Transfer VS were:
T 97.8 BP 128/80 HR 107 RR 18
On arrival to the floor, patient reports that he continues to
be nauseated but has improved abdominal pain after morphine
administration.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
PAST MEDICAL HISTORY:
Sinusitis
Interstitial cystitis
Nephrolithiasis
Plantar fasciitis
Hydronephrosis
Depression
Anxiety
Attention deficit disorder with hyperactivity
GERD
Fatty liver.
Herpes simplex
Restless leg
Asthma
SURGICAL HISTORY:
Removal of kidney stones
Cystectomy with creation of ileal conduit
Social History:
___
Family History:
Mother ___ ___ OVARIAN CANCER
Father ___ ___ PROSTATE CANCER
Sister Living SQUAMOUS CELL CARCINOMA
Aunt ___ ___ KIDNEY CANCER
Nephew with BRAIN TUMOR
Cousin with ___ Cancer
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T 97.8 BP 128/80 HR 107 RR 18
GENERAL: Resting comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +bs, soft, nondistended, tender to deep palpation in
left lower quadrant, no rebound/guarding, no hepatosplenomegaly
BACK: No CVA tenderness. No midline spinal tenderness
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAMINATION ON DISCHARGE:
VS: 98.1 PO 137 / 79 82 18 95 Ra
GENERAL: Resting comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: +bs, soft, nondistended, minimal tenderness to
palpation, no rebound/guarding, no hepatosplenomegaly
BACK: No CVA tenderness. No midline spinal tenderness
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 01:14AM BLOOD WBC-11.1*# RBC-4.69 Hgb-13.9 Hct-40.9
MCV-87 MCH-29.6 MCHC-34.0 RDW-13.1 RDWSD-41.1 Plt ___
___ 01:14AM BLOOD Neuts-77.7* Lymphs-12.9* Monos-8.1
Eos-0.7* Baso-0.3 Im ___ AbsNeut-8.65* AbsLymp-1.44
AbsMono-0.90* AbsEos-0.08 AbsBaso-0.03
___ 01:14AM BLOOD Plt ___
___ 01:14AM BLOOD Glucose-102* UreaN-9 Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-23 AnGap-14
DISCHARGE LABS:
___ 04:25AM BLOOD WBC-5.0 RBC-3.97* Hgb-11.8* Hct-35.2*
MCV-89 MCH-29.7 MCHC-33.5 RDW-12.9 RDWSD-41.8 Plt ___
___ 04:25AM BLOOD Glucose-90 UreaN-5* Creat-0.8 Na-139
K-3.5 Cl-99 HCO3-25 AnGap-15
___ 04:25AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.8
IMAGING:
CT ABDOMEN AND PELVIS WITH CONTRAST ___:
1. Sigmoid diverticulitis without perforation or abscess.
2. L1 vertebral body sclerotic lesion was not seen on ___ and
demonstrates density more compatible with malignancy rather than
bone island.
However, no primary malignancy is identified in the abdomen or
pelvis.
MICRO:
___ 5:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ year old female to male with history of diverticulitis and
interstitial cystitis s/p neo bladder, who presented with
abdominal pain and nausea, found to have sigmoid diverticulitis
on CT scan.
ACTIVE ISSUES:
#Diverticulitis:
He was started on ciprofloxacin and metronidazole, and his
abdominal pain improved. He had constipation, for which he was
treated with senna, colace, and miralax.
#Bone lesion:
CT showed incidental L1 vertebral body sclerotic lesion
concerning for potential malignancy. Notably, no primary
malignancy is identified in the abdomen or pelvis. Discussed
with patient who is aware of concern for malignancy. We
arranged for outpatient ___ bone biopsy.
CHRONIC ISSUES:
#Depression/Anxiety: Continued Buproprion SR 180mg BID.
# Resting Tachycardia: Patient reported history of increased
resting heart rate, which has been chronic. He is most
symptomatic on bedtime and takes atenolol for this. He was
continued on atenolol 25mg QPM.
#Restless Leg Syndrome: Continued ropinirole 25mg daily.
#Herpes simplex: Continued Acyclovir 400mg BID for prophylaxis .
#Loose Stools: Secondary to ileostomy and intermittent. Patient
asymptomatic at this time. We held home Colestipol 1mg bid prn
(nonformularly).
#Asthma: Continued pulmicort inh 180 mcg 2 puff BID (taking own
med).
#GU: Continued finasteride 1mg daily.
TRANSITIONAL ISSUES:
- Make sure patient completes a 10 day course of ciprofloxacin
and metronidazole (day 1 = ___, day 10 = ___.
- Patient was found to have an incidental L1 vertebral body
sclerotic lesion concerning for potential malignancy, patient
was arranged for outpatient ___ biopsy. Please follow up on this
issue.
- F/U pending SPEP/UPEP.
- Consider bone scan for further evaluation of the bone lesion.
- Patient was supposed to have a colonoscopy next week, which he
cancelled in the setting of diverticulitis. Please make sure to
re-schedule it.
#CODE: Full (presumed)
#CONTACT: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO BID
2. Atenolol 25 mg PO DAILY
3. BuPROPion (Sustained Release) 100 mg PO BID
4. Albuterol Inhaler 2 PUFF IH BID:PRN Wheeze
5. rOPINIRole 0.25 mg PO QPM
6. Testosterone Cypionate 125 mg injection MONTHLY
7. Finasteride 1 mg PO DAILY
8. Colestid (colestipol) 1 mg oral BID:PRN
9. budesonide 180 mcg/actuation inhalation BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
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. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Acyclovir 400 mg PO BID
7. Albuterol Inhaler 2 PUFF IH BID:PRN Wheeze
8. Atenolol 25 mg PO DAILY
9. budesonide 180 mcg/actuation inhalation BID
10. BuPROPion (Sustained Release) 100 mg PO BID
11. Colestid (colestipol) 1 mg oral BID:PRN
12. Finasteride 1 mg PO DAILY
13. rOPINIRole 0.25 mg PO QPM
14. Testosterone Cypionate 125 mg injection MONTHLY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Diverticulitis
SECONDARY DIAGNOSIS:
Constipation
Incidental sclerotic bone lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___! You came to the
hospital because you were experiencing abdominal pain. You were
found to have diverticulitis for which you were treated with two
antibiotics, ciprofloxacin and metronidazole. You should
continue taking these medications for a total of 10 days.
You also had constipation. We gave you medications to help you
have a bowel movement. Please make sure to eat a lot of fibers
and drink water to prevent constipation.
You were found to have a bone lesion in the spine. We are
arranging for an outpatient biopsy by the interventional
radiology team. Your primary care provider ___ follow up on
this issue.
Make sure to go to all your appointments as scheduled.
We wish you all the best.
Your ___ team
Followup Instructions:
___
|
10589010-DS-20 | 10,589,010 | 24,370,505 | DS | 20 | 2160-04-15 00:00:00 | 2160-04-15 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L Buttock Cellulitis
Major Surgical or Invasive Procedure:
Bedside I&D ___
Operative I&D ___
History of Present Illness:
The patient is a ___ y/o M with PMHx of HTN, DM2, asthma,
depression, morbid obesity, recurrent cellulitis of RLE, who
presented with 3 days of L buttock pain and erythema, concerning
for cellulitis.
The patient first noted L buttock pain 3 days prior to admission
(___). He was unable to visualize the area. However, his
___ came yesterday (___), saw the area, and recommended
presentation to the ED. The patient does endorse worsening pain
over the weekend. He states that he had not eaten and drank much
during that time, as he was focused on the pain. By the time he
presented to the ED, he had not urinated for ~24 hours. He
denies any fevers of chills during this time.
He initially went to an outside facility where initial lab work
revealed kidney failure. An ultrasound at the outside facility
was performed which showed cobblestoning but no indication of
abscess. Surgery was consulted as there was inability to obtain
CT given habitus. Surgery agreed that he should be transferred
for CT to track infection. Unfortunately, CT here is also unable
to accommodate pt.
ED Course:
Initial VS: 98.2 73 ___ 96% RA Pain ___
Labs significant for WBC 16.7. H/H 11.0/33.9. Lactate 2.6. Cr
3.0. Na 133. K 7.0 (hemolyzed), 5.0 on repeat. INR 1.5. UA with
14 WBCs and few bacteria.
Imaging: POC U/S with no evidence of fluid pocket per report
Meds given:
___ 20:54 IVF NS 1L
___ 22:12 IV Piperacillin-Tazobactam 4.5g
___ 22:24 IV Morphine Sulfate 4 mg
___ 23:29 IV Clindamycin 900 mg
___ 23:32 IVF NS 1L
___ 00:45 IV Vancomycin 1500 mg
___ 03:58 IV Morphine Sulfate 4 mg
ED Exam:
Alert and oriented x3
CV: RRR
Resp: CTAB
ABd: protuberant but NTND
MSK:
LLE: 15cm x 15cm indurated, erythematous (blanching) area with
mild TTP; no fluctuance or open area; no purulent drainage
RLE: erythematous with no TTP
Surgery saw patient ___ the ED: "low clinical suspicion for
necrotizing soft tissue infection based on labs. may add on CRP.
would admit to medicine for management of ___, cellulitis. ACS
will follow for wound eval."
Urology was also consulted ___ the ED given urinary retention and
inability of ED team to place catheter. Foley was placed by them
___ the ED.
VS prior to transfer: 83
112/47
18
96% RA Pain ___
On arrival to the floor, the patient endorses the above story.
Aside from worsening L buttock pain, poor PO intake, and
decreased UOP, the patient denies any other symptoms. He denies
fevers or chills.
ROS: As above. Denies headache, lightheadedness, dizziness,
chest pain, heart palpitations, shortness of breath, cough,
nausea, vomiting, diarrhea, constipation, urinary symptoms,
muscle or joint pains, focal numbness or tingling. The remainder
of the ROS was negative.
Past Medical History:
HTN
DM2
Asthma
Depression
Morbid obesity
Recurrent cellulitis of RLE
Social History:
___
Family History:
No major illness ___ immediate family members. He does endorse
cancer (lung, throat) ___ extended family members, as well as
possible history of heart disease ___ extended family members as
well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - ___ ___ Temp: 98.4 PO BP: 90/54 HR: 77 RR: 20 O2 sat:
96% O2 delivery: Ra
GEN - Alert, NAD
HEENT - NC/AT, face symmetric
NECK - Supple
CV - RRR, no m/r/g
RESP - CTA B, breathing appears comfortable
ABD - Mordibly obese, soft, non-tender
EXT - Chronic hyperpigmentation of the distal BLE's (R>L); no
TTP of the BLEs
SKIN - Circular area of induration and erythema extending across
entire L buttock not extending past outlined borders; there is
no fluctuance noted; the area is mildly tender to palpation; no
skin breakdown noted
NEURO - Nonfocal
PSYCH - Calm, appropriate
DISCHARGE PHYSICAL EXAM:
Patient examined on day of discharge. SBP 96-115/530-60,
otherwise stable. Erythema around wound has resolved, with a
minimal amount of purulent drainage.
Pertinent Results:
PERTINENT DATA
WBC: 17->16->11->11
Hgb ___ MCV ___
Plts 235->172->149->164
Cre 3.0->2.2->1.3->0.8
Phos 2.1->2.2->1.4
Urine cx neg
Buttock ultrasound ___
IMPRESSION:
No drainable fluid collection. Multiple punctate echogenic foci
with shadowing may reflect calcified granulomas or deep tissue
subcutaneous gas. Although the findings could be due to
cellulitis, given the concern for necrotizing fasciitis the
presence of air should be confirmed by CT.
Buttock ultrasound ___
IMPRESSION:
1. New heterogeneous fluidic material measuring up to 1 cm ___
thickness
interspersed among the subcutaneous fat is not well
circumscribed. No formed
collections are seen.
2. Re-demonstration of areas of increased echogenicity ___ the
deep
subcutaneous soft tissues, for which the possibility of
subcutaneous gas
cannot be excluded.
Discharge labs
___ 06:50AM BLOOD WBC-11.3* RBC-3.73* Hgb-10.4* Hct-35.3*
MCV-95 MCH-27.9 MCHC-29.5* RDW-16.5* RDWSD-55.8* Plt ___
___ 06:50AM BLOOD Glucose-95 UreaN-20 Creat-1.3* Na-143
K-4.4 Cl-106 HCO3-27 AnGap-10
___ 06:50AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.8
CULTURE DATA:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
ESCHERICHIA COLI. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
___ year-old man with supermorbid obesity and history of
recurrent cellulitis, presents with left buttock cellulitis. His
cellulitis was initially treated with IV antibiotics. He had an
ultrasound of the area which was concerning for subcutaneous gas
but was seen by the surgical service and felt not to require
intervention. However, he developed a worsening leukocytosis and
appearance of the area, and subsequent ultrasound was concerning
for developing phlegmon. He had a bedside I&D with copious
purulent drainage and was eventually taken to the OR for I&D.
Wound cultures were polymicrobial and he was ultimately narrowed
to a regimen of Augmentin. He will complete two weeks of
Augmentin. If at this time he continues to have purulent
drainage, a longer course should be considered per infectious
disease.
#Left buttock cellulitis w/ abscess
#Leukocytosis
Initially had an ultrasound with concern for subq gas but seen
by surgery and felt not to require intervention. A subsequent
ultrasound showed new collection and the patient had bedside I&D
___ by surgery with about 700cc of drainage. Wound was packed
with kerlex but still draining copious amounts of purulent
drainage and the patient then went to the OR ___ for I&D of
abscess. Since then packing and dressing changes per surgery and
he did not require further debridement. He had been initiated on
broad spectrum IV antibiotics and ___ conjunction with Infectious
Disease recommendations, he was narrowed to Augmentin. A wound
vac will need to be placed at rehab. Leukocytosis trended down
and was 11.3 by the time of discharge.
- Augmentin 875 mg BID x 2 weeks; if discharge continues, would
increase duration
- wound vac to be placed at ___
- follow up ___ ___ clinic
___
r 3.0 on admit and subsequently down to 0.7, but when infection
worsened he became borderline hypotensive/vol depleted and
developed ___ to 1.4. Hydration has improved Cr to 1.2, but
he has been having diarrhea and ___ is attributed to this.
Creatinine improved to 1.3 by the time of discharge.
#Diarrhea
Likely ___ the setting of antibiotics. A c diff was negative. He
was started on Imodium.
#Hypertension
Continue home lasix, atenolol. His lisinopril was held on
discharge because of improved blood pressure. If he again has
high blood pressures, it should be restarted.
#DM. Continue home metformin.
#Asthma. Continue home inhalers.
#Depression. Continue home metformin.
#Urinary retention. Initially had a foley catheter placed by
urology, but it was removed on HD#1 and he had no retention
after.
Time spent: > 35 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, SOB
2. Atenolol 100 mg PO DAILY
3. Clotrimazole Cream 1 Appl TP BID
4. Furosemide 40 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. triamcinolone acetonide 0.5 % topical DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH ___ BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Cellulitis with abscess
Urinary Retention
___
Leukocytosis
Diarrhea
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 presented with cellulitis of your L buttock. You were
treated with IV antibiotics but unfortunately an abscess
developed ___ this area. You were seen by the surgical team and
were taken to the operating room for drainage of this
collection. Ultimately your antibiotics were managed with the
Infectious Disease team and you will be discharged on oral
Augmentin.
During your hospitalization you also had worsening of your
kidney function which improved. You also have had some diarrhea
which is attributed to antibiotics and should resolve with time.
You will be transferred to rehab after discharge where you can
receive assistance ___ gaining your physical strength but also ___
helping pack your wound.
We wish you the best going forward.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10589164-DS-16 | 10,589,164 | 24,993,321 | DS | 16 | 2149-08-14 00:00:00 | 2149-08-14 10:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
L periprosthetic proximal femur fracture
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of left periprosthetic
femur fracture
History of Present Illness:
___ with Alzheimer's and HTN and history of bilateral THAs who
presents as OSH transfer from ___ s/p fall at nursing
home
with L periprosthetic proximal femur fracture. The patient got
up
from bed, walked to her dresser, opened a drawer and somehow
lost
her balance and fell onto her left side. She had immediate left
hip pain and inability to ambulate. Taken to ___ where
x-rays showed L periprosthetic proximal femur fracture.
Transferred to ___. Ortho consulted. Denies numbness/tingling
or weakness.
Past Medical History:
PMH:
Alzheimer's dementia
HTN
PSH:
s/p Bilateral THAs
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
Vitals: 98.1, 177/67, 74, 12, 96% RA
General: NAD, A&Ox2 (person, time)
Mini-cog assesment:
- ___ draw: could not complete (ie, failure)
- 3-word recall: could not complete (ie, failure)
Psych: flat affect, poor eye contact
Musculoskeletal:
Right Lower Extremity:
Skin clean - no abrasions, induration, ecchymosis
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
Left Lower extremity
+leg shortened and externally rotated
Skin clean - no abrasions, induration, ecchymosis
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
Exam on discharge:
___
Gen: NAD
Left Lower extremity
Dressings c/d/i
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
Pertinent Results:
___ 04:50AM BLOOD WBC-10.3 RBC-2.61* Hgb-8.3* Hct-25.0*
MCV-96 MCH-31.8 MCHC-33.2 RDW-14.7 Plt ___
___ 07:00AM BLOOD Neuts-87.2* Lymphs-8.2* Monos-3.7 Eos-0.4
Baso-0.6
___ 04:50AM BLOOD Plt ___
___ 02:24PM BLOOD ___ PTT-22.8* ___
___ 04:50AM BLOOD Glucose-131* UreaN-32* Creat-1.3* Na-143
K-4.0 Cl-109* HCO3-24 AnGap-14
___ 04:50AM BLOOD Calcium-7.9* Phos-1.9*# Mg-2.3
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, 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 rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch-down weight bearing in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 37.5 mg PO DAILY
3. Celebrex ___ mg oral Daily
4. Furosemide 40 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Mirtazapine 30 mg PO HS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Atenolol 37.5 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Lisinopril 2.5 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
7. Enoxaparin Sodium 30 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg SC once a day Disp #*14
Syringe Refills:*0
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*70 Tablet Refills:*0
9. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*50 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Confused - sometimes.
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:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing in he left leg
Physical Therapy:
TDWB LLE
ROMAT
Treatments Frequency:
Dressings can be changed as needed for drainage.
Staples will be removed at 2 week follow up clinic appointment
with Orthopaedic Trauma team.
Followup Instructions:
___
|
10589164-DS-17 | 10,589,164 | 21,446,151 | DS | 17 | 2152-03-16 00:00:00 | 2152-03-19 01:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
___ Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
- Percutaneous nephrostomy tube ___
History of Present Illness:
___ woman with dementia (reportedly non-verbal),
DNR/DNI, right nephrectomy (unknown why) and history of left
breast cancer treated with mastectomy in ___ who presented with
LLQ pain and fever, found to have urosepsis in setting of
obstructing stone.
Patient presented to ___, with a day of left sided
abdominal pain w/ radiation to the back, hallucinations (per
care giver), fever to 103, and multiple transient choking
episodes.
At ___, she was febrile to 103. Labs were notable
for WBC 16.3 (94.3% Neutrophils), BUN 24/Creat 1.8 (baseline Cr
1.0), UA (WBC > 100 (loaded), Moderate Bacteria, + Leuk
Esterase), lactate of 4.5. There was purulence on straight cath
w/ cultures in past positive for ESBL E. Coli so placed on
Ertapenem. CT scan was notable for a 7 mm obstructing kidney
stone and urology recommended stenting or percutaneous
nephrostomy tube. After discussion w/family who preferred to
avoid general anesthesia, she was transferred to ___ for PCN.
In ___ initial VS: 98.8, 80, 164/52, 16, 96% - placed on 2 L NC
Exam: Purulence on straight cath, Sleeping but awakens to
verbal stimuli, knows name/location, but lethargy is apparently
far worse than her baseline.
Patient was given:
___ 08:49 IVF LR ( 1000 mL ordered)
Labs notable for inc in ___ to 30.6 from 16, lactate
persistently elevated at 4.3.
Consults: Urology who agreed w/plan for urgent PCN placement.
___ took her for urgent PCN. ___ team discussed with family
possibility of needing intubation for procedure, and family
agreed to temporary intubtion if needed for procedure but
patient will remain DNI.
Repeat lactate 13, BP still stable prior to transfer.
On arrival to the MICU, patient was stable, verbal but unable to
follow commands. Per interventional radiology, thick drainage
from tube placement without pure purulence. No interventions by
anesthesia during the procedure. In the MICU, BP and HR are
within normal range.
Past Medical History:
PMH:
Alzheimer's dementia
HTN
PSH:
s/p Bilateral THAs
Social History:
___
Family History:
NC
Physical Exam:
VITALS: 98, 72, 118/86, 16, 95%
GENERAL: Alert, not oriented
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 S2
ABD: Soft, mildly tender near drain, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Cool, well perfused, normal capillary refill
NEURO: Grossly moving arms and legs, talking
Discharge Physical Exam
98.6 AdultAxillary 150/67 70 14 89 Ra
General: alert, oriented x1, NAD.
HEENT: sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB w/ no adventitious sounds
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no ebound tenderness or guarding, no organomegaly
Back: PCN in place draining scant clear urine with some blood
GU: no foley
Ext: warm, well perfused, minimal edema, multiple bruises
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 01:42PM BLOOD WBC-34.8* RBC-3.27* Hgb-10.8* Hct-32.9*
MCV-101* MCH-33.0* MCHC-32.8 RDW-13.2 RDWSD-49.1* Plt ___
___ 01:42PM BLOOD Neuts-80* Bands-11* Lymphs-5* Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-1* AbsNeut-31.67*
AbsLymp-1.74 AbsMono-0.70 AbsEos-0.00* AbsBaso-0.00*
___ 01:42PM BLOOD Glucose-98 UreaN-27* Creat-2.4* Na-136
K-4.0 Cl-101 HCO3-19* AnGap-20
___ 01:42PM BLOOD ALT-61* AST-65* LD(LDH)-257* AlkPhos-88
TotBili-0.4
___ 01:42PM BLOOD Albumin-2.9* Calcium-7.8* Phos-4.6*
Mg-1.8
___ 09:51AM BLOOD pO2-162* pCO2-22* pH-7.29* calTCO2-11*
Base XS--13
___ 06:17AM BLOOD Lactate-4.3*
___ 09:51AM BLOOD Lactate-13.0*
___ 01:54PM BLOOD Lactate-2.4*
Interval Labs:
___ 06:47AM BLOOD WBC-31.1* RBC-3.16* Hgb-10.3* Hct-31.1*
MCV-98 MCH-32.6* MCHC-33.1 RDW-13.2 RDWSD-48.0* Plt ___
___ 04:52AM BLOOD Glucose-119* UreaN-41* Creat-3.0*# Na-140
K-4.4 Cl-107 HCO3-18* AnGap-19
___ 01:42PM BLOOD ALT-61* AST-65* LD(LDH)-257* AlkPhos-88
TotBili-0.4
___ 06:47AM BLOOD HBsAg-Negative
___ 04:00AM BLOOD HBsAb-Negative
___ 04:00AM BLOOD HIV Ab-Negative
___ 04:00AM BLOOD HCV Ab-Negative
___ 09:51AM BLOOD Lactate-13.0*
___ 01:54PM BLOOD Lactate-2.4*
DISCHARGE LABS:
___ 05:29AM BLOOD WBC-12.9* RBC-3.08* Hgb-9.9* Hct-30.2*
MCV-98 MCH-32.1* MCHC-32.8 RDW-13.1 RDWSD-47.2* Plt ___
___ 05:29AM BLOOD Plt ___
___ 05:29AM BLOOD Glucose-103* UreaN-24* Creat-1.0 Na-145
K-3.7 Cl-108 HCO3-27 AnGap-14
___ 05:29AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0
Imaging:
___ Blood cultures x4 - ___
___ Urine:
Procedure Result
Verified
> URINE CULTURE Final
___
Organism 1 ESCHERICHIA COLI
COLONY COUNT >100,000 org/ml
CONFIRMED ESBL PRODUCER
1. ESCHERICHIA COLI
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
AMPICILLIN R
>=32
AMOX/CLAV S
4
CEFAZOLIN R
>=64
CEFTAZIDIME R
16
CEFTRIAXONE R
>=64
CIPROFLOXACIN R
>=4
ERTAPENEM S
<=0.5
ESBL +
POS
GENTAMICIN S
<=1
IMIPENEM S
<=0.25
LEVOFLOXACIN R
>=8
NITROFURANTOIN S
<=16
PIP/TAZ S
<=4
TOBRAMYCIN S
<=1
TRIM/SULFA R
>=320
Isolate # [1]
Reaction R*
This organism is an Extended-Spectrum Beta Lactamase
Producer (ESBL)
1. It is recommended not to use the following
antibiotics: all cephalosporins, penicillins, and
aztreonam.
2. PIP/TAZOBACTAM and ESBL isolates:
Despite sensitive in ___ MIC test results, there
may by treatment failures in some infections using
pip/tazobactam with ESBL isolates.
REPORTS:
___ IMAGING:
-------------------
CT A/P:
8 mm proximal left ureteral stone with extensive perinephric
stranding, concerning for pyelnephritis. Consultation with
urology is recommended given single kidney.
Status post right nephrectomy.
Diverticulosis. No bowel obstruction.
CT A/P
IMPRESSION: (final read)
1. Obstructing 5 mm proximal left ureteral stone with
hydroureteronephrosis, perinephric fat stranding, and
periureteral fat stranding of fluid. The right kidney is not
seen.
2. At the time of dictation, the patient had already undergone
percutaneous nephrostomy tube placement.
3. Colonic diverticulosis without evidence of acute
diverticulitis.
Interventional Radiology PCN placement ___
FINDINGS:
1. Scout ultrasound image demonstrates a mildly dilated left
renal collecting
system. Contrast was noted to flow to the level of the urinary
bladder.
2. Appropriate positioning of 8 ___ left-sided nephrostomy
tube.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the left.
Renal Ultrasound ___
FINDINGS:
The right kidney is again noted to be absent. The left kidney
measures 8.9 cm. No hydronephrosis is now seen in the left
kidney. The percutaneous nephrostomy tube is partially
visualized within the hilum of the left kidney. No perinephric
fluid collection is identified. No renal stone is seen.
The bladder is unremarkable but is only minimally distended.
IMPRESSION:
Resolved hydronephrosis in the left kidney post-percutaneous
nephrostomy tube placement. Absent right kidney.
___ PICC placement
FINDINGS:
Portable AP semi upright view of the chest is provided.
There has been interval placement of left-sided PICC which
terminates in the
right atrium. There has been interval worsening of moderate
pulmonary edema.
There is stable left pleural effusion. Cardiomediastinal
silhouette is
unchanged. There is no focal consolidation or pneumothorax. A
left-sided
percutaneous nephrostomy tube is noted.
IMPRESSION:
1. Left PICC line terminates in the right atrium. Recommend
retracting 2 cm
if termination at the cavoatrial junction is desired.
2. Interval increase in moderate pulmonary edema.
Brief Hospital Course:
___ woman with dementia, DNR/DNI, right nephrectomy
(unknown why) and history of left breast cancer treated with
mastectomy in ___ who presented with LLQ pain and fever, found
to have sepsis from a urinary source in setting of obstructive
stone, undergoing PCN on ___ and subsequent treatment for ___
and urosepsis.
#Sepsis from urinary source (present on admission) #L ureteral
nephrolithiasis #Acute Kidney Injury: Patient initially
presented with a a day of left sided abdominal pain w/ radiation
to the back, hallucinations (per care giver), fever to 103, and
multiple transient choking episodes. She demonstrated
tachycardia and a lactate elevation in setting of +UA, history
of MDR UTIs, and obstructing stone in left solitary kidney c/w
urosepsis at an outside hospital. A CT scan was notable for an
obstructing stone. Previously has had ESBL e coli warranting
initial broad management while urine culture was pending. Given
UA was nitrite negative, she was started on vancomycin and
meropenem. She had initially been treated at ___
___, but had been transferred to ___ after initial
discussions with urology. Patient's family wished for the
patient to avoid anesthesia/sedation if at all possible, so she
was transferred to ___ to receive consideration for PCN. At
___ she demonstrated signs of urosepsis with lab findings
significant for a lactate of 13. She was therefore brought to
the MICU following the percutaneous nephrostomy placement on
___. She has been treated with vancomycin and meropenem. Her
heart rate and blood pressure remained stable since admission.
She demonstrated a rising Cr several days after her PCN,
suggesting that in the setting of sepsis she experienced some
measure of ATN. Ultrasound demonstated proper placement of
previously placed PCN. Urine sediment analysis demonstrated some
muddy brown casts. Her white count remained >30, but afterwards
downtrended along with her lactate. Urine cultures from ___
returned demonstrating multiple antibiotic resistance.
Vancomycin was discontinued. She received a ___ line on ___,
with a recommended course of ertapenem though ___, for
completion of a 2 week course.
Patient was discharged with urology follow-up set up for further
considerations regarding PCN removal and definitive stone
retrieval if appropriate. Cr at time of discharge was 1.0.
# Hypertensive Urgency: Patient had serial trending of blood
pressures in the systolic 170s+ range following her percutaneous
nephrostomy, thought to likely be ___ ___ and tenuous volume
status. Her home antihypertensives appeared to have been
insufficient, and atenolol was thought to be less than ideal in
the setting of acute kidney injury. She was transitioned to
lisinopril and labetolol to bring blood pressure under 180 as
tolerated. Patient did not demonstrate overt signs/symptoms of
hypertensive emergency, so emergent lowering was still
contraindicated. She was discharged on lisinopril 10 mg qd and
labetolol 200 mg tid.
# Transaminitis: Along with patient's initial presentation of
lactatemia she presented with signs of transaminitis. This was
thought to represent mild hypoperfusion of liver in setting of
sepsis. This resolved prior to discharge back to her SNF.
# Subacute pulmonary edema with tachypnea: In the days following
her PCN placement patient demonstrated mild intermittent
tachypnea, intermittently requiring 2L of oxygen. Xrays
demonstrated slight evidence of volume overload. Her subacute
pulmonary edema was treated with lasix diuresis, and she was
ultimately discharged on Lasix 40 mg qd.
CHRONIC ISSUES:
#Breast cancer: continued anastrazole
#depression: continued sertraline
#dementia: continued donepezil
TRANSITIONAL ISSUES:
- patient was discharged on ertapenem 1g q24 (d1 = ___ She
should continue this for a 14 day course (last day = ___
- patient was discharged on lisinopril 10 mg qd and labetolol
200 mg tid for hypertensive urgency she demonstrated. She should
continue to have blood pressure checks every day for the first
few days after leaving the hospital, with titration of this
medication as needed.
- Per urology aspirin was restarted on discharge.
- Patient should maintain urologic follow-up for determination
whether definitive retrieval of stone is indicated.
# Communication: HCP: Daughter ___
# Code: DNR DNI
Greater than 30 minutes were spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Atenolol 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Donepezil 10 mg PO QAM
5. Sertraline 75 mg PO DAILY
6. TraZODone 25 mg PO QHS:PRN Insomnia
7. Vitamin D ___ UNIT PO DAILY
8. Anastrozole 1 mg PO DAILY
Discharge Medications:
1. ertapenem 1 gram intravenous DAILY
from ___ through ___
RX *ertapenem [___] 1 gram 1 gram IV daily Disp #*8 Vial
Refills:*0
2. Labetalol 200 mg PO TID
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Anastrozole 1 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Donepezil 10 mg PO QAM
7. Furosemide 40 mg PO DAILY
8. Sertraline 75 mg PO DAILY
9. TraZODone 25 mg PO QHS:PRN Insomnia
10. Vitamin D ___ UNIT PO EVERY 4 WEEKS (TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Nephrolithiasis
Urosepsis
SECONDARY DIAGNOSIS
Dementia
Hypertensive Urgency
s/p R nephrectomy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after presenting to the
hospital with nausea, fever, and left lower quadrant pain. You
were found to have evidence of a kidney stone in your left
ureter which was blocking flow of urine from your kidney.
Because of this it seemed you developed an infection of your
kidney. Due to ongoing concern about the need to potentially
drain your kidney, you were transferred to ___ for further
care.
You received care in the intensive care unit where you were
treated with antibiotics. You received a tube called a
percutaneous nephrostomy which helped drain urine from your
kidney.
You were treated on the medical floor for high blood pressures
and ongoing kidney infection. You will need to continue an
antibiotic course using the PICC line in your arm. You will need
to continue an antibiotic course through ___.
We recommend you have urology follow-up to consider ongoing
intervention for the stone in your ureter. You also may need to
have your blood pressure medications adjusted, as you
experienced some sensitive blood pressures.
It was a pleasure to be involved with your care at ___.
-Your ___ Care Team
Followup Instructions:
___
|
10589679-DS-12 | 10,589,679 | 27,248,293 | DS | 12 | 2172-06-23 00:00:00 | 2172-06-24 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Oxycodone / Codeine
Attending: ___.
Chief Complaint:
Left flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old woman w ___ pyelonephritis and
nepholethiasis, presenting with left flank pain, dysuria, and
fevers/chills x 3 days. The pain was ___ and constant,
strongest on the L flank, also wrapping around to her LLQ and
radiating down her L leg. The pain was so severe that she was
not able to walk or lie down without excrutiating pain. She also
noted pain with urination and some subjective fevers and chills
during the last 3 days. She also endorses some discolored urine
"maroon colored" for the past 3 days. She also had nausea and
vomiting >6 x the night prior to presentation. Vomit was non
bloody, no diarrhea.
In the ED, the patients VS were 99.6 95 120/73 18 100%, and she
spiked a temp in the ED with Tmax 102.7. UA showed large leuks,
moderate blood, >182 WBC, few bacteria. WBC 16.4 with 90%
neutrophils. She was kept in the ED for observation, and when
her pain got worse, she got a CT abd which showed duplicate
renal collecting system of the L kidney, small nephrolithiasis
(nonobstructing) in the lower pole. Urology was consulted and
will continue to follow the patient. In the course of 24 hours
she recieved morphine 4 mg IV x4, Cipro 400 IV, CTX 1 gram,
zofran, tylenol, and HCTZ.
Past Medical History:
Chronic back pain
Left shoulder pain
Migraines
PUD, +H pylori. Treated ___ with Aciphex, Amox and Biaxin for
2 weeks.
Atrophic vaginitis
Chronic abdominal pain
Constipation
Pyelonephritis 6 months ago
Social History:
___
Family History:
Mother: diabetes, hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - T: 99.9 BP: 116/69 HR: 86 RR: 18 O2sat: 100%/RA
GENERAL - Well-appearing female lying comfortably in no acute
distress, AOx3
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD,
LUNGS - Clear breath sounds bilaterally, no wheezes or crackles
HEART - RRR, normal S1-S2, no m/r/g
ABDOMEN - Normobowel sounds present, abdomen is soft, non
distended, moderately tended to deep palpation along LLQ
EXTREMITIES - warm and well perfused with 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact,
DISCHARGE PHYSICAL EXAM
VS T: 98.2 BP:136/84 HR:59 RR:18 O2sat: 98%/RA
GEN: Pleasant female lying in bed resting in no acute distress.
AOx3.
HEENT: Sclera anicteric, MMM
NECK: Supple, no JVD
PULM: Clear breath sounds bilaterally, no wheezes or crackles
CV: RRR normal S1/S2, no mrg
BACK: Moderate CVA tenderness
ABD: Soft, mildly tender to deep palpation along LLQ, non
distended. Normobowel sounds present.
EXT: warm and well perfused with 2+ pulses palpable bilaterally,
no edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: Keloid lesion on left shoulder/back
Pertinent Results:
___ 01:09PM LACTATE-1.7
___ 12:50PM GLUCOSE-82 UREA N-12 CREAT-0.9 SODIUM-140
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
___ 12:50PM estGFR-Using this
___ 12:50PM CALCIUM-9.5 PHOSPHATE-2.0* MAGNESIUM-2.1
___ 12:50PM WBC-16.4*# RBC-4.15* HGB-12.2 HCT-36.7 MCV-88
MCH-29.5 MCHC-33.4 RDW-14.4
___ 12:50PM NEUTS-90.4* LYMPHS-6.8* MONOS-1.6* EOS-0.9
BASOS-0.3
___ 12:50PM PLT COUNT-237
___ 12:50PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 12:50PM URINE RBC-26* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-1
___ 12:50PM URINE MUCOUS-RARE
CT ABD + PELVIS with Contrast ___
CT ABDOMENT: The lung bases are clear without focal
consolidation or pleural effusion. The heart and pericardium
are unremarkable. There is no pericardial effusion. The liver
enhances homogenously without any focal lesions or intra- or
extra-hepatic biliary dilatation. The portal vein is patent.
The gallbladder, pancreas, spleen, and adrenal glands are
unremarkable. The right kidney enhances and excretes contrast
symmetrically without any hydronephrosis. A 7 mm hypodensity in
the interpolar region likely represents a cyst and is unchanged
since ___.
There is a duplicated collecting system within the left kidney.
There is contrast seen being excreted from the upper pole
collecting system and there is no hydronephrosis; however,
multiple punctate stones are seen within the lower pole ureter
(2:49), 2-mm stone (2:53) and more distally punctate stone
(2:60, 64) unchanged from ___. There is now mild proximal
hydroureter with a small amount of periureteral enhancement
concerning for infection. Area of decreased enhancement in the
mid pole area (601B:40) is most consistent with pyelonephritis.
Multiple hypodensities within the left kidney, largest in the
lower pole measuring 7 mm, unchanged since ___ and likely a
cyst. There is also mild perinephric stranding on the left.
The intra-abdominal small and large bowel are unremarkable. The
stomach is unremarkable. There is no free fluid, free air, or
lymphadenopathy within the abdomen.
CT PELVIS: The bladder, rectum, and sigmoid colon are
unremarkable. There is no free fluid, free air, or
lymphadenopathy within the pelvis.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
lesions.
IMPRESSION:
1. Duplicated collecting system on the left with multiple
punctate stones within the left ureter and resultant proximal
hydroureter, pyelitis and focal pyelonephritis in the mid-pole
of the left kidney.
2. Bilateral renal cysts.
DISCHARGE LABS
___ 05:40AM BLOOD WBC-4.7 RBC-3.63* Hgb-10.9* Hct-31.9*
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.2 Plt ___
___ 05:45AM BLOOD Glucose-85 UreaN-11 Creat-0.9 Na-143
K-3.5 Cl-107 HCO3-26 AnGap-14
___ 05:45AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1
___ 08:44AM BLOOD Lactate-1.0
Brief Hospital Course:
#Sepsis secondary to pyelonephritis: The patient presented with
3 days of left flank/left lower quadrant pain with radiation to
her left groin as well as fever, chills, nausea, vomiting,
dysuria and maroon-colored urine. In the ED, laboratory findings
showed an elevated white blood cell count and urine culture
showed some bacteria and moderate hematuria. CT scan showed
duplicate left renal collecting system and small nephrolithiasis
non obstructing in the lower pole. Urology was consulted, she
was started on IV ceftriaxone and admitted to medicine for
further management. While on the medicine service,
pyelonephritis diagnosis was confirmed secondary to E.coli
(resistant to Bactrim and Cipro) in the setting of
nephrolithiasis. As such, she was maintained on IV ceftriaxone,
IV fluids and pain control with Tylenol and Dilaudid. White
blood cell count trended down and she remained afebrile and
hemodynamically stable throughout hospital course. E. coli was
found to be sensitive to Cefpodoxime, patient was discharged
with oral cefpodoxime 9-day course (total 14 days, 5 completed
during inpatient stay). PCP was updated regarding antibiotic
regimen upon discharge and patient was alerted that should any
symptoms return, she should alert her PCP.
- if worsening fever, chills, or flank pain, the patient was
instructed to call her PCP or return to the ED for possible
re-initiation of IV antibiotic therapy
- Will need UA once antibiotics complete to document resolution
of infection
#GERD: Patient has prior history of GERD. She developed a
worsening burning sensation along the epigastrium shortly after
admission. She had several episodes of nausea and vomiting prior
to admission and reported that the pain had manifested shortly
after the bilious, non-bloody emesis. Pain was primarily
elicited when lying flat, no pressure-quality and was not
associated with dyspnea. Given normal ECG, no elevated cardiac
enzymes, cardiac etiology was ruled out. In this setting,
patient was given omeprazole, ranitidine and Tums for pain
relief. Patient had no nausea, vomiting, chest pain or dyspnea
upon discharge.
#Yeast infection: She also developed some vaginal itching which
improved with empiric treatment for yeast infection ___
antibiotic therapy. Will complete 7 day course of therapy
#Constipation: Patient reported below baseline bowel movements.
This could have been secondary to pain management with opioids
or low oral intake. She was maintained on full bowel regimen
upon discharge.
Transitional issues:
- if worsening fever, chills, or flank pain, the patient was
instructed to call her PCP or return to the ED for possible
re-initiation of IV antibiotic therapy
-Follow up with primary care provider to monitor for resolution
of urinary infection. Will need UA once antibiotics complete to
document resolution of infection
-Follow up with PCP about GERD management, may consider repeat H
pylori testing outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
3. Ranitidine 150 mg PO HS
4. Omeprazole 20 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 1000 mcg Oral
daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Ranitidine 150 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. B-12 DOTS *NF* (cyanocobalamin (vitamin B-12)) 1000 mcg Oral
daily
5. Miconazole Nitrate Vag Cream 2% 1 Appl VG DAILY Duration: 7
Days
RX *miconazole nitrate [Miconazole 7] 2 % daily as needed Disp
#*1 Bottle Refills:*0
6. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every 12 hours
(twice a day) Disp #*36 Tablet Refills:*0
7. Outpatient Lab Work
please check urinalysis on ___ and fax results to PCP:
___
Phone: ___
Fax: ___
8. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*15 Tablet Refills:*0
9. Ondansetron 4 mg PO Q4H:PRN nausea, vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every four hours as
needed Disp #*25 Tablet Refills:*0
10. Acetaminophen 1000 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis
nephrolethiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital for pain in
your back and stomach as well as fevers, and you were found to
have an infection in your kidney as well as a small kidney
stone. You were treated with IV antibiotics and pain control and
you stopped spiking fevers after several days of treatment. Your
pain improved as well.
It is important that you keep all your follow up appointments,
and take all medications as prescribed. Please do not use
alcohol or drive while using Dilaudid for pain, as this can
cause dangerous sedation.
It is important that if your pain gets worse again or you being
to have fevers, chills, or night sweats, that you must call your
primary doctor or come to the emergency department immediately,
since you may need to be switched back to IV antibiotics.
You will need to get your urine checked once antibiotics are
complete to make sure the infections was fully treated.
Followup Instructions:
___
|
10589692-DS-15 | 10,589,692 | 23,085,480 | DS | 15 | 2154-03-26 00:00:00 | 2154-03-26 14:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left sided weakness, neglect
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with PMH of HTN, arthritis and
cataracts who was found down today by her son and brought to ED.
History is obtained from son/daughter as patient is unable to
give coherent history. Patient usually lives with her son during
the weekend and lives with her daughter during the week, but
this
week she wanted to stay in her own apartment (which is on the
___
floor above him). Son reports that he last saw her normal last
night around 7pm. He heard her in the bathroom as normal this
morning, and around 2pm, he noticed that she was knocking on the
floor and he didn't know why she was doing that. He had gone to
work and came back from work around 6pm. He noticed that she did
not open the door for him as she usually does, and heard her
yelling from her apartment and found her on the ground
complaining of pain. EMS was called.
She apparently has "many pills" but does not regularly take them
as she hides them away and does not remember where they are.
ROS: Patient states that she is "hard of hearing" and complains
of pain in right hip. Does not answer other questions.
Past Medical History:
- HTN
- paroxysmal atrial fibrillation
- cataract
- arthritis
- hernia repair
- HLD
- primary parathyroidism
Social History:
___
Family History:
noncontributory.
Physical Exam:
Vitals: 125 137/90 13 99% RA
General: Awake, somewhat agitated, yelling.
HEENT: NC/AT, eyes with conjuctival injection, no discharge
Neck: Supple. Unable to listen for carotid bruit due to patient
speaking.
Pulmonary: CTABL
Cardiac: tachycardic, unclear if regular, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated; complains of pain in
right hip and continuously rubbing it with right hand
Skin: no rashes or lesions noted.
Neurologic:
- Mental Status: Alert, oriented to self. Not able to relate
history. Inattentive. Language is fluent but some difficulty
communicating due to her baseline hearing loss. With repeated
command in loud voice, she can follow some simple command such
as
squeeze hand/close eyes. Speech is dysarthric. She seems to have
dense neglect on the left side.
-Cranial Nerves:
I: Olfaction not tested.
II: R 2 to 1mm and brisk, L 1.5 to 1mm, L cornea more cloudy.
Blinks to threat on R but not on left.
III, IV, VI: Gaze deviation to R in primary gaze, does not cross
midline.
V: unable to test
VII: L nasolabial flattening.
VIII: Hard of hearing at baseline - need to yell in her right
ear.
IX, X, XI: Unable to test
XII: Tongue protrudes in midline.
-Motor: Normal bulk, slightly increased tone in right, decreased
tone in left. Moves right arm and leg spontaneously and well
against gravity. No spontaneous movement of left arm/leg noted,
does withdraw from noxious stimuli.
-Sensory: With noxious stimuli, patient able to localize, much
better with right side. With repeatedly stimuli on L side, she
can eventually localize.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was mute bilaterally.
-Coordination: No obvious dysmetria when reaching for objects
with right hand but unable to test formally
-Gait: deferred.
DISCHARGE NEUROLOGIC EXAM
afebrile, SBP 130-140s
Mental Status: awake alert to self, hospital, year. She responds
to questions and follows simple and 2 step commands readily if
spoken loudly into her right ear (she has baseline hearing
loss). Speech is slightly disarthric. Evidence of left sided
neglect. No deficits of speech repetition or comprehension. No
anomia, or paraphasic errors.
Cranial Nerves: significant only for right gaze deviation that
can overcome midline, also left facial asymmetry, nasolabial
fold flattening. Baseline LEFT hearing loss, she can hear in
her left ear.
Motor: Normal bulk, decreased muscle tone in left. Moves right
arm and leg spontaneously and well against gravity. Minimal
spontaneous movement of left arm noted, although some movement
of left leg and she does withdraw left arm and leg from noxious
stimuli.
Sensation: Intact on the right with deficits to all modalities
on left. With noxious stimuli and with repeat stimuli on left
side, she can eventually localize.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was mute bilaterally.
-Coordination: No obvious dysmetria
-Gait: OOB with assist
Pertinent Results:
Studies:
___: ___ Chol 211 Trig 70 HDL 65 LDL 132
UA: negative
Utox: negative
Stox: negative
136 99 21
-------------< 127
4.4 25 1.3
Ca: 10.9 Mg: 1.7 P: 3.0
WBC-8.5 RBC-4.51 HGB-13.1 HCT-39.2 MCV-87 MCH-29.0 MCHC-33.4
RDW-13.5
Lactate:2.0
___: 12.3 PTT: 31.1 INR: 1.1
Carotid Ultrasound:
No evidence of hemodynamically significant internal carotid
stenosis on either
side.
MRI
IMPRESSION:
1. Late acute right temporoparietooccipital infarct with edema
and effacement
to the local sulci but without midline shift or herniation.
2. MRA sequence was terminated due to patient motion and is
nondiagnostic.
Echo:
The left atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets are moderately thickened.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild mitral regurgitation. Aortic valve sclerosis. Pulmonary
artery hypertension. Increased PCWP. No definite cardiac source
of embolism identified.
Brief Hospital Course:
___ yo RH woman with HTN, paroxysmal atrial fibrillation who
presented on ___ after being found down, exam showing dense
left hemiplegia and neglect suggestive of R MCA syndrome. MRI
confirmed large R MCA territory infact. Etiology thought
cardioembolic due to transient Afib in setting of infection.
She has vascular risk factors but no large vessels stenosis.
Previously during this hospitalization was febrile with CXR
suspicious for aspiration, UA with Enterococcus and E.coli UTI,
covered with ceftriaxone (started ___ and one dose of
Fosfomycin (total of 3 days for uncomplicated UTI). She passed
a swallow test and is pending placement for rehab.
#NEURO:
- CT showing right MCA territory hypodensity
- MRI confirmed right temporoparietooccipital infarct with edema
and effacement
- checking risk factors: fasting lipid panel (LDL- 122) now on
statin, HBA1c (5.1) and TSH (normal)
- Aspirin 325mg po daily, poor candidate for anticoagulation
despite her paroxysmal afib
- allow BP to autoregulate, goal SBP <180
- ___ consults: pending d/c to rehab
- Passed Formal speech swallow passed
#CV:
- r/o MI with CE; negative
- monitor on telemetry for afib. EKG confirms Afib. Mostly rate
controlled 90-110.
- allow BP to autoregulate with goal SBP < 180 (goal SBP
140-180s)
- hydralazine 10 mg IV q6h prn SBP > 180
- hold home antihypertensives
- trans-thoracic echo with bubble study showed mild symmetric
left ventricular hypertrophy with preserved regional and global
biventricular systolic function. Mild mitral regurgitation.
Aortic valve sclerosis. Pulmonary artery hypertension. Increased
PCWP. No definite cardiac source of embolism identified.
#PULM: CXR with bilateral opacities. Echo shows likely pulmonary
hypertension. CXR findings could be consistent with aspiration
PNA per read from ___ but patient is afebrile without
leukocytosis.
- Covering with ceftriaxone (UTI), we considered adding
clindamycin for aspiration PNA coverage, but she had no futher
fevers or WBC count elevation. She had no further signs of
infection.
#ENDO:
- check A1C 5.3
#TOX/METAB:
- LFTs wnl
- urine and serum tox screens wnl
#ID:
- UA suggestive of UTI. UCx negative ___. Repeat UA ___ again
dirty. Urine culture was positive for E. Coli and Enterococcus,
Added back CTX on ___, patient treated with fosfomycin per
ID recommendation.
#OPHTHO: history of cataracts
- continue home carteolol
#RENAL:
- monitor Cr
#MS: Right knee was reportedly warm/swollen overnight. Does not
appear warm on exam today. Pt has history of gout flares, but
this does not appear to be a monoarticular, erythematous
swelling. It may be more consistent with her known
osteoarthritis.
- Discharged on acetaminophen to 1000mg po q6hours prn
#FEN:
- passed speech/swallow
- monitor and replete electrolytes as needed
#PPx:
- Bowel regimen (BM yesterday ___
- SQ heparin/pneumoboots
- Precautions: fall and aspiration
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Pravastatin 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN arthritis pain
Discharge Medications:
1. Pravastatin 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN Bm
4. Carteolol 1% Ophth Soln ___ DROP BOTH EYES BID
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Ibuprofen 400 mg PO Q8H:PRN Pain
8. Metoprolol Tartrate 25 mg PO BID:PRN HR>120
9. Acetaminophen 650 mg PO Q6H:PRN arthritis pain
10. Amlodipine 5 mg PO DAILY
11. Labetalol 200 mg NG TID Hypertension
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA stroke
paroxysmal afib
gout
UTI
Discharge Condition:
Mental Status: Confused, able to speak, neglecting left side.
Level of Consciousness: Alert but perseverative.
Activity Status: Out of Bed with assistance to chair or
wheelchair, mostly in bed.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for new
left sided weakness that developed after you fell at home. We
did multiple tests icluding an MRI which showed you had a large
stroke on the right side of your brain. A number of laboratory
and imaging studies were performed that confirmed this
diagnosis. We know that you have a history of high blood
pressure and atrial fibrillation and it is likely that these
risk factors contributed to the stroke. At this time we due not
think it is appropriate to start anticoagulation given your
recent falls and history of poor compliance with medications.
During this hospital stay we found that you had a new urinary
tract infection and we treated you briefly with antibiotics. We
will arrange follow up in Neurology clinic as well as your
primary care doctor, ___. Please continue to take your
medications as they have been prescribed. Please follow up with
you primary care physician, ___, as well as Dr.
___ neurologist at ___
___.
It has been a pleasure caring for you, and we wish you a speedy
recovery.
Followup Instructions:
___
|
10589780-DS-20 | 10,589,780 | 27,003,323 | DS | 20 | 2125-04-29 00:00:00 | 2125-04-29 14:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Iodine / Biaxin / Flagyl / contrast agent (during imaging) /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
No Surgical intervention this admission, Last surgery was
___ LUMBAR MICRODISCECTOMY RIGHT L4-L5
History of Present Illness:
Ms. ___ is a ___ year old ___ speaking female s/p
Right L4-5 microdiskectomy for L4-L5 radiculopathy on ___
with Dr. ___. After surgery the patient continued with
right
lower extremity pain however it was 80% improved from her
pre-operative symptoms. 10 days ago she began having severe
throbbing R buttock pain radiating down her lateral right leg to
her ankle. She recently started walking with a cane for fear of
falling. She denies falls, trauma, heavy lifting, numbness,
tingling, incontinence of bowel and bladder, saddle anesthesia.
She has been managing her pain with 800mg Ibuprofen without
relief. The pain is worse with standing and improves with rest.
Past Medical History:
PMHx:
ASTHMA
GASTROESOPHAGEAL REFLUX
IRRITABLE BOWEL SYNDROME
PULMONARY EMBOLISM
S/P TAH
URINARY FREQUENCY
GASTROESOPHAGEAL REFLUX
SEASONAL RHINITIS
2MM NEPHROLITHIASIS l KIDNEY
HEADACHE
LUNG NODULE
BREAST MASS
ABDOMINAL PAIN
ABNORMAL CT SCAN
BACK PAIN
DEPRESSION
ANXIETY
H.PYLORI GASTRITIS ___
HYPERCHOLESTEROLEMIA
Past Surgical history
HYSTERECTOMY
L4-L5 microdiscectomy ___
Social History:
___
Family History:
Mother, father and son have hypertension.
Mother chronic gastritis, brother- ___ disease,
sister-gastritis (per patient report)
Maternal grandfather had CAD.
No history of blood clots or pulmonary embolism.
No known history of malignancy
Physical Exam:
On Discharge:
A+OX3, PERRL ___, ___ drift, MAE ___ except right IP
___.. Pain limited..Pain with movement of right leg- pain to R
buttock radiates laterally to R ankle. SILT. Proprioception
intact. Incision c/d/I no erythema, no tendernss edema, or
drainage
Pertinent Results:
UNILAT LOWER EXT VEINS RIGHT Study Date of ___ 10:38 ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
MR ___ SPINE W/O CONTRAST Study Date of ___ 2:39 AM
IMPRESSION:
1. Status post right L4-L5 hemilaminectomy and discectomy with
interval
progression of a central and right paracentral disc extrusion,
which may
represent residual or recurrent disc herniation.
2. New heterogeneous T2 signal abnormality within the right
L4-L5 lateral
recess at the surgical site, which may represent granulation
tissue but
difficult to assess further due to lack of contrast
administration. There is resultant severe narrowing of the
subarticular recess with displacement of the right traversing L5
nerve root.
3. New focal fluid collection within the posterior soft tissues
adjacent to the surgical site at L4-L5, measuring 1.9 x 1.5 x
3.9 cm. Given the lack of contrast administration, possibility
of an abscess is not excluded. There is edematous appearance of
the adjacent right paraspinal muscles, which may represent
postoperative inflammation; possibility of phlegmon is not
excluded.
4. Additional degenerative changes of the lumbar spine similar
to the prior study, as described above.
Brief Hospital Course:
Mrs. ___ is a ___ year old female who is s/p right L4-L5
lumbar microdiscectomy on ___ with Dr. ___. The
patient presented to the ED on ___ for right lower
extremity pain. The patient reports she began having the pain on
___ night which was worse when ambulating and standing. She
was admitted to the floor and was seen and evaluated by Dr.
___ inpatient. It was determined the patient would be
discharged to home and would be called for a follow up
appointment for an injection in an attempt to relieve the pain,
as well as to schedule a follow up appointment with Dr. ___
to discuss possible surgical intervention if pain is not relived
by outpatient injections within ___ weeks.
Medications on Admission:
ALBUTEROL SULFATE, ATORVASTATIN, BUDESONIDE-FORMOTEROL
[SYMBICORT], IBUPROFEN, KETOCONAZOLE, ZEGRID OMEPRAZOLE-SODIUM
BICARBONATE SERTRALINE, TRAZODONE, ACETAMINOPHEN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
6. Atorvastatin 80 mg PO QPM
7. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___)
8. Omeprazole 40 mg PO DAILY
9. Sertraline 125 mg PO DAILY
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
L4 Disk Herniation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
You were admitted to the hospital after you presented to the
Emergency department with right lower extremity pain. An MRI was
performed and demonstrated L4 disc herniation. You were seen and
evaluated by your Neurosurgeon Dr. ___ it was
determined you would be scheduled for an outpatient injection
for the pain and likely will need surgical intervention if the
pain is not relieved by the injection.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10590601-DS-21 | 10,590,601 | 20,095,647 | DS | 21 | 2117-01-07 00:00:00 | 2117-01-07 13:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
"ulcer infection"
Major Surgical or Invasive Procedure:
Debridement of ulcer over right greater trochanter
History of Present Illness:
Patient is a ___ year old male with a h/o thalamic CVA, cognitive
impairment, BPH, Htn, bedbound with flexion contractures, OA,
brought to emergency room by his daughter with concerns for
infected ulcer. Patient felt to be in his usual state of
health. Patient was interviewed with ___ interpreter, and
denies n/v/diarrhea/dysuria/myalgias/arthralgias. Patient has ___
visiting NP as part of ___ care
program.
Past Medical History:
Thalamic CVA
Cognitive impairment
BPH
Htn
Flexion contractures
Pressure ulcers
Social History:
___
Family History:
Patient unable to provide
Physical Exam:
VSS
Gen: Thin elderly male, NAD
Lung CTA B
CV: RRR
Abd: somewhat firm, soft, nabs, not distended, no hepatomegaly
Ext: No edema
Skin: 2 x 3 oval ulcer over right greater trochanter; + foul
smelling purulent discharge. I expressed approximately 15 cc of
pus on palpation of the ulcer. No surrounding erythema.
Smaller ulcer over left greater trochanter. No purulent. Can
probe to bone. Small ischial ulcer, packed. No drainage or
surrounding warmth.
+ flexion contractures on arms
Pertinent Results:
___ 12:10AM BLOOD WBC-17.3*# RBC-3.45* Hgb-9.7* Hct-30.9*
MCV-90# MCH-28.3# MCHC-31.5 RDW-14.7 Plt ___
___ 12:10AM BLOOD Neuts-81.0* Lymphs-13.1* Monos-4.9
Eos-0.6 Baso-0.4
___ 12:10AM BLOOD Glucose-142* UreaN-17 Creat-0.6 Na-137
K-4.5 Cl-103 HCO3-24 AnGap-15
___ 12:15AM BLOOD Lactate-1.8
___ 09:35AM BLOOD WBC-7.9# RBC-3.21* Hgb-9.5* Hct-29.1*
MCV-91 MCH-29.5 MCHC-32.5 RDW-15.1 Plt ___
___ 12:10AM BLOOD Glucose-142* UreaN-17 Creat-0.6 Na-137
K-4.5 Cl-103 HCO3-24 AnGap-15
Urine Cx: NGTD
Blood cx: ___ bottles Gram positive cocci in clusters
CT scan of pelvis
1. Bilateral cutaneous soft tissue defects in keeping with
history of known ulcers. Air is seen tracking within the
tissues adjacent and in communication with the left posterior
hip ulcer. No evidence of air within deeper tissues,
intermuscular fascia or within the intramuscular compartment.
2. Multilevel degenerative changes within the lumbar spine as
described
above.
3. Diverticular disease without diverticulitis.
CXR
Single AP radiograph through the chest was provided. Patient is
rotated to his left. Lungs are clear with no focal consolidation
convincing for pneumonia.
Lung volumes are low. Cardiomediastinal and hilar contours when
compared to prior study appear unchanged. No evidence of
pulmonary edema. A left
pectorally placed pacer is seen with leads in stable position.
No free air under the right hemidiaphragm is identified. There
is no large pleural effusion.
IMPRESSION:
No opacity convincing for pneumonia.
Brief Hospital Course:
___ year old male, bedbound, with h/o CVA, admitted with multiple
ulcers, right trochanter ulcer is infected.
1. Infected ulcer over right trochanter: Debrided at bedside
by surgery on ___, and a large amount of purulent material was
drained. Patient continued to have some pus expressed from
debrided site, so surgery re-evaluated the wound on ___, and
did not believe that a repeat debridement was necessary. The
surgical service felt that this wound would continue to express
small amounts of pus through the packing and that it would heal
from inside out. Patient tolerated the debridement well, and
only complained of pain when he was being repositioned.
Ulcer over left trochanter probes to bone and is therefore
concerning for osteomyelitis. This was discussed with his
healthcare proxy who did not want any additional
testing/treatment for this.
2. Leukocytosis: WBC count normalized after debridement. He
was not given antibiotics.
3. h/o CVA: Continued plavix.
4. BPH: On proscar.
5. Disposition: Patient will need ongoing wound care for the
debrided ulcer. Our wound care recommendations will be provided
to his ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Finasteride 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Infected ulcer over the right trochanter
2. History of stroke
3. BPH
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were brought to the hospital because your family was
concerned that the ulcer on your right hip was infected. You
were evaluated by the general surgery service and they performed
a debridement on the ulcer on your right hip and the infection
was treated. You will have ___ come daily to your house so that
the ulcer can be dressed properly and allowed to heal.
Followup Instructions:
___
|
10590766-DS-10 | 10,590,766 | 25,147,285 | DS | 10 | 2182-02-27 00:00:00 | 2182-02-28 09:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / ACE Inhibitors / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with history of HFrEF now with
recovered EF (Last LVEF = 59% ___, LBBB, obstructive sleep
apnea on CPAP, who presents for evaluation of dyspnea.
Patient was recently admitted from ___ for syncopal
events with associated bradycardia, thought related to
medication effect + vasovagal, hence home imdur 120 mg daily was
discontinued, home carvedilol dosing was decreased to 6.25 mg
BID from 12.6 mg BID and valsartan 40 mg BID was held. Her last
admission for CHF exacerbation was from ___ at ___, at
that time diuresed with 80 mg IV furosemide BID, and discharged
wih weight 92.5 mg and on PO torsemide 40 mg daily.
She went home approximately in the third week of ___ and
reports that she had been "behaving", avoiding salty foods,
soups or canned items. She notes that her SBP had been quite
high at home, averaging SBP 180s, such that home ___ was unable
to work with her, but that occasionally in the AM she would also
have episodes of orthostasis, although no further episodes of
syncope. Over the past week, she has been experiencing
progressive dyspnea, such that she had been unable to even walk
from bed to commode, and is only comfortable at rest (at
baseline is able to ambulate with walker). She is unable to see
the scale very well, hence does not really know how much she
weighs, but does not think that she has gained significant
weight. She denies orthopnea, noting that she sleeps on her
side. When asked about her medications, she notes that the rehab
had made changes, but she does not have updated list. In
addition, all of her medications are automatically filled, and
she does not think that her medication list was ever updated
with pharmacy after discharge. No chest pain, PND, orthopnea.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Known LBBB
- history of HFpEF with new sCHF as of ___
3. OTHER PAST MEDICAL HISTORY:
- Known left bundle branch block on EKG since ___
when she hospitalized with diastolic heart failure. Ischemia
workup in ___ showed no evidence of underlying
coronary artery disease.
- Subclavian steal syndrome
- Hypertension.
- Diabetes mellitus.
- Carotid artery disease with a carotid ultrasound done at
___.
- Sleep apnea, patient using CPAP.
- Giant cell arthritis/polymyalgia rheumatica.
- Anemia
- HLD
- Gout
- Depression
- Pulmonary nodules
- History of breast cancer
- Left-sided low back pain with sciatica
Social History:
___
Family History:
Father died of MI/CHF in ___. No family history of bradycardia
or
syncopal episodes
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T:98.5 BP: 166/74 L Lying HR: 82 RR: 22 O2 sat: 90% O2
delivery: 4L
GENERAL: Well developed, well nourished Caucasian lady in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP difficult to appreciate ___ habitus
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Crackles in
bilateral bases.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. Trace ankle edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
========================
VS: T: 97.6 BP: 145/61 HR: 70 RR: 18 94% RA
WEIGHT: 83.4 kg (189.81 kg on admission)
GENERAL: Well developed, well nourished Caucasian lady in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVD not elevated.
CARDIAC: PMI located in ___ intercostal space, mid-clavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Crackles in
bilateral bases. No wheezes/rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. Trace ankle edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
===============
ADMISSION LABS:
___
___ 07:50PM BLOOD WBC-9.4 RBC-3.32* Hgb-9.2* Hct-29.6*
MCV-89# MCH-27.7 MCHC-31.1* RDW-14.4 RDWSD-46.7* Plt ___
___ 07:50PM BLOOD Neuts-77.7* Lymphs-15.1* Monos-5.7
Eos-0.3* Baso-0.3 Im ___ AbsNeut-7.27* AbsLymp-1.41
AbsMono-0.53 AbsEos-0.03* AbsBaso-0.03
___ 06:12AM BLOOD ___ PTT-27.1 ___
___ 07:50PM BLOOD Glucose-132* UreaN-19 Creat-1.8* Na-146
K-3.7 Cl-101 HCO3-31 AnGap-14
___ 07:55PM BLOOD ___ pO2-26* pCO2-51* pH-7.39
calTCO2-32* Base XS-3
========================
PERTINENT INTERVAL LABS:
========================
___ 07:50PM BLOOD cTropnT-0.08* proBNP-4385*
___ 06:12AM BLOOD CK-MB-1 cTropnT-0.10*
___ 06:12AM BLOOD Calcium-10.3 Phos-4.7* Mg-1.6
___ 03:52PM BLOOD calTIBC-286 Ferritn-64 TRF-220
___ 07:50AM BLOOD VitB12-567
___ 07:50AM BLOOD %HbA1c-5.7 eAG-117
___ 07:50AM BLOOD TSH-1.5
___ 03:25PM BLOOD CRP-7.0*
___ 03:25PM BLOOD PEP-NO SPECIFI FreeKap-45.6*
FreeLam-43.5* Fr K/L-1.0
___ 03:25PM BLOOD SED RATE- 9
===============
DISCHARGE LABS:
===============
___ 08:20AM BLOOD WBC-10.4* RBC-3.29* Hgb-9.2* Hct-28.9*
MCV-88 MCH-28.0 MCHC-31.8* RDW-15.1 RDWSD-48.6* Plt ___
___ 08:20AM BLOOD Glucose-88 UreaN-41* Creat-2.0* Na-138
K-4.2 Cl-93* HCO3-27 AnGap-18
___ 08:20AM BLOOD Glucose-88 UreaN-41* Creat-2.0* Na-138
K-4.2 Cl-93* HCO3-27 AnGap-18
___ 08:20AM BLOOD Calcium-7.9* Phos-4.3 Mg-2.4
================
IMAGING STUDIES:
================
CXR (___):
There is no focal consolidation. There are small bilateral
pleural effusions and mild pulmonary edema. Calcific density
projecting over the right lung base is noted to be with the
breast on prior CT. Cardiac silhouette is enlarged but similar
to prior. No acute osseous abnormalities. IMPRESSION: Mild
pulmonary edema with small bilateral pleural effusions. No
focal consolidation.
TTE (___):
The left atrial volume index is moderately increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Mild symmetric left
ventricular hypertrophy with normal cavity size, and
regional/global systolic function (biplane LVEF = 73 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Diastolic
function could not be assessed. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
mild functional mitral stenosis (mean gradient 5 mmHg) due to
mitral annular calcification. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic regurgitation. Mild mitral stenosis due to annular
calcification. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
=============
MICROBIOLOGY:
=============
___ 2:23 pm URINE
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ STOOL
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Brief Hospital Course:
Ms. ___ is a ___ year old lady with history of HFrEF now with
recovered EF (55%), LBBB, and obstructive sleep
apnea on CPAP, who presented for dyspnea and heart failure
exacerbation. She improved with diuresis and was discharged home
with services.
# HFPEF (LVEF 55%):
Ms. ___ has history of non-ischemic cardiomyopathy, diagnosed
in ___, with recovered EF to 55% in ___. Admitted with
symptoms of volume overload, elevated BNP, and pulmonary edema
on CXR concerning for heart failure exacerbation. Repeat TTE
unchanged from prior, EF >55%. Most likely etiology is poorly
controlled hypertension (admission BP in 190s) vs. recent viral
illness. Other possible etiologies, include dyssynchrony given
known LBBB and ischemia given known history of coronary artery
disease. SPEP and UPEP negative for infiltrative process.
Patient underwent IV diuresis, responding well to Lasix drip,
however diuresis was limited by orthostatic hypotension as
below. Patient was transitioned to PO torsemide 40mg daily. Her
afterload reduction medications were adjusted to reduce
orthostatic symptoms during the day, and hopefully reduce risk
of falls and allow her to be more active at home. Her home
valsartan and carvedilol were discontinued, and she was started
on hydralazine 20mg QPM. She also was instructed to take an
additional 10mg hydralazine as needed for SBP > 160 at lunch
time. Plan for follow up with outpatient cardiologist Dr.
___.
# ORTHOSTATIC HYPOTENSION:
Patient has documented history of orthostatic hypotension, with
>20mmHg drop in systolic pressures upon standing. She reports
dizziness/lightheadedness and headache with standing, which
occurs multiple times daily at home. Likely an underlying
autonomic dysfunction which is contributing. Her symptoms have
been worsened recently by her anti-hypertensive regimen which
has been titrated multiple times as an outpatient. Her blood
pressures while inpatient have been high in the evening
(>150-160) and lower in the morning. Plan to transition to
evening doses of antihypertensives to prevent daytime symptoms
and reduce risk of falls as above. Discontinue valsartan and
carvedilol, and start hydralazine daily in the evening.
Compression stockings also recommended daily. Plan to follow up
with general neurology for further autonomic testing as an
outpatient.
# SUBCLAVIAN STEAL SYNDROME:
Patient has history of subclavian steal syndrome, diagnosed in
___ at ___ after asymmetric BPs noted (Ratherosclerosis and
calcification of her arteries along with recent deconditioning
rather than subclavian steal syndrome. However, if her
orthostasis improves and her symptoms persist, vascular surgery
may consider pursuing intervention to relieve the right
subclavian artery stenosis. Additionally, she does have a
history of PMR and giant cell arteritis can cause subclavian
artery stenosis however her ESR and CRP were normal to only
mildly elevated. Given her history of atherosclerosis this is
the more likely the cause of her stenosis as she reports it had
been noted prior to her diagnosis of PMR. Plan to continue home
ASA, and increase atorvastatin to 80mg QD. Also recommended
bilateral compression stockings daily. Follow up with Dr. ___
___ vascular surgery on discharge, as well as Dr. ___
vascular medicine.
CHRONIC ISSUES:
===============
# Coronary Artery Disease:
Intermediate LM and RCA disease noted on cardiac cath (___).
Continue home ASA 81mg, atorvastatin 40mg.
# Polymyalgia Rheumatica:
Continue home prednisone 5 mg.
# Depression:
Continue home citalopram 10mg daily.
# Fibromyalgia:
Continue home gabapentin, tocliziumab q 4weekly, tramadol PRN.
Patient had self-discontinued plaquenil 2 months prior as she
thought it may be causing her diarrhea. Will continue to hold
plaquenil given QTc prolonging risk when in combination with
citalopram. Plan for follow up with rheumatology as an
outpatient.
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 181.66lbs
DISCAHRGE CR: 2.0
[ ] On discharge, patient's blood pressure continues to be
variable, between sitting and standing and morning vs night.
High blood pressure should not limit her participation in ___ if
she is asymptomatic.
[ ] Stopped home valsartan and carvedilol due to orthostatic
symptoms
[ ] Transitioned to PO hydralazine 20mg QPM to hopefully reduce
orthostatic symptoms and fall risk during the daytime
[ ] She also was instructed to take an additional 10mg po
hydralazine for SBP > 170 at lunch time
[ ] Please continue to monitor blood pressures daily, goal BP
120-140 (in left arm) as we have discontinued many of her home
anti-hypertensives, would benefit from home telemonitoring of
BPO and weight
[ ] Home diuretic: torsemide 40mg daily
[ ] Please weigh patient daily, if increase > 3lbs in 2 days or
5lbs in 5 days, please notify cardiologist
[ ] Consider stress testing as outpatient for further CAD workup
as potential etiology for ___
# CODE STATUS: Full, limited life sustaining measures (please
continue to discuss)
# CONTACT ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Citalopram 10 mg PO DAILY
3. Gabapentin 200 mg PO QHS
4. PredniSONE 5 mg PO DAILY
5. Torsemide 20 mg PO DAILY
6. TraMADol 25 mg PO BID:PRN Pain - Moderate
7. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
8. Hydroxychloroquine Sulfate 400 mg PO DAILY
9. Carvedilol 6.25 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Valsartan 80 mg PO BID
12. tocilizumab 162 mg/0.9 mL subcutaneous every 4 weeks
Discharge Medications:
1. HydrALAZINE 20 mg PO DAILY 1600
RX *hydralazine 10 mg 2 tablet(s) by mouth Daily at 4pm Disp
#*60 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
6. Citalopram 10 mg PO DAILY
7. Gabapentin 200 mg PO QHS
8. PredniSONE 5 mg PO DAILY
9. tocilizumab 162 mg/0.9 mL subcutaneous every 4 weeks
10. TraMADol 25 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Acute on chronic diastolic Congestive Heart Failure
Secondary Diagnosis:
====================
Orthostatic hypotension
Subclavian Steal Syndrome
Fibromyalgia
Polymyalgia Rheumatica
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you were short of breath and you were
found to have extra fluid in your lungs. This was felt to be
due to your heart failure.
What happened while I was in the hospital?
- You were given medications through the IV to help you urinate
out the extra fluid. Your breathing improved considerably and
you are now ready to go to rehab.
- You were also seen by our vascular doctors for the ___ in
your subclavian artery. It is important that you continue to
wear compression stockings everyday to help your blood flow
return to your heart. You will also be scheduled for follow up
appointments with the vascular doctors after ___ leave the
hospital.
- Lastly, you were found to have a significant drop in your
blood pressure on standing. Common symptoms of this include
dizziness, light-headedness, blurred vision, weakness, fatigue,
nausea, palpitations, and headache. This can be common as people
get older, and put you at risk for falls. We adjusted your blood
pressure medications while you were in the hospital so you will
only be taking one medication at night (hydralazine). Hopefully
this will reduce your day-time symptoms. Please seek medical
attention if you continue to have these symptoms with standing.
What should I do after leaving the hospital?
- Please take your medications as listed in the discharge
summary and follow up at the listed appointments.
- Please stop taking your home carvedilol and valsartan
- Please start taking hydralazine, one tab, every evening
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or if you develop swelling in your legs, abdominal distention,
or shortness of breath at night.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10590766-DS-8 | 10,590,766 | 28,560,033 | DS | 8 | 2180-08-13 00:00:00 | 2180-08-13 17:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / ACE Inhibitors / hydrochlorothiazide
Attending: ___.
Chief Complaint:
SOB, orthopena
Major Surgical or Invasive Procedure:
Right and left heart catheterization (___)
History of Present Illness:
Patient is a ___ with a PMHx of HFpEF but now with reduced EF
of 35%, LBBB, HTN, carotid artery disease, DM, OSA on CPAP, HLD
who presents with dyspnea and orthopnea.
She was seen by her cardiologist on ___ with SOB and dry cough
for the past one month that progressively worsened over the past
week. She also has generalized fatigue. She denied any chest
pain, ___ edema or syncope. EKG in clinic showed sinus 80, with
known LBBB, unchanged from prior. Labs were obtained in clinic
which showed ___ 123000, neg trop, Cr 1.3. CXR in clinic
showed mild pulm edema and small R pleural effusion. TTE was
also performed after clinic which showed an EF 35% (previously
normal) and WMA, including apical akinesis, in LAD territory.
Given these findings, she was referred to the CHA ED. In the CHA
ED she was given IV Lasix 20mg and transferred for ___ for
consideration of cath.
In the ED initial vitals were:
97.9 82 193/91 (improved to 134/76 prior to transfer)18 97% NC
EKG: sinus 88. LBBB.
Labs/studies notable for: Cr 1.2, trop neg, ___ 12304. UA 10
WBCs, few bacteria, trace protein
On the floor patient states that she continues to feel somewhat
SOB and endorses orthopnea. No CP, arm pain, or jaw pain. She
states that she has had brisk UOP since receiving Lasix at OSH
ED. She is not currently on Lasix at home. No ___ edema. States
that she was in the hospital ___ with a dCHF exacerbation
but has had no recurrence ___ edema since then.
States that she took her valsartan and metoprolol this AM.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Known LBBB
- history of HFpEF with new sCHF as of ___
3. OTHER PAST MEDICAL HISTORY:
- Known left bundle branch block on EKG since ___
when she hospitalized with diastolic heart failure. Ischemia
workup in ___ showed no evidence of underlying
coronary artery disease.
- Hypertension.
- Diabetes mellitus.
- Carotid artery disease with a carotid ultrasound done at
___.
- Sleep apnea, patient using CPAP.
- Giant cell arthritis/polymyalgia rheumatica.
- Anemia
- HLD
- Gout
- Depression
- Pulmonary nodules
- History of breast cancer
- Left-sided low back pain with sciatica
Social History:
___
Family History:
Father: deceased from ___
Physical Exam:
On admission:
VS: T=97.6 BP=191/90 -> 157/72 HR=86 RR=18- mid ___ with
activity 02 sat=95-100/2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Dyspneic with movement
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP elevated to earlobe.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: mild crackles at bases
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
On discharge:
VS: T=98.6, 118/46 (102-145/42-59), 64, 18, 99%RA
Weight 72.8 kg (standing)
I/O: 1839 / 750 (+1000 x 24hrs), 0 / 1000 (-1000 x8 hours)
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
NECK: Supple with JVP 7
LUNGS: CTAB
EXTREMITIES: No edema
Pertinent Results:
On admission:
___ 07:45PM BLOOD WBC-9.2 RBC-3.23* Hgb-8.5* Hct-27.3*
MCV-85 MCH-26.3 MCHC-31.1* RDW-15.3 RDWSD-46.4* Plt ___
___ 07:45PM BLOOD Neuts-67.0 ___ Monos-6.9 Eos-2.1
Baso-0.3 Im ___ AbsNeut-6.17* AbsLymp-2.14 AbsMono-0.64
AbsEos-0.19 AbsBaso-0.03
___ 10:04PM BLOOD ___ PTT-34.6 ___
___ 07:45PM BLOOD Glucose-97 UreaN-18 Creat-1.2* Na-142
K-3.5 Cl-102 HCO3-27 AnGap-17
___ 07:45PM BLOOD CK-MB-2 cTropnT-<0.01 ___
___ 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:45PM BLOOD Calcium-9.5 Phos-4.3 Mg-1.8
On discharge:
___ 05:47AM BLOOD WBC-8.1 RBC-2.76* Hgb-7.3* Hct-23.9*
MCV-87 MCH-26.4 MCHC-30.5* RDW-15.9* RDWSD-49.8* Plt ___
___ 05:47AM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-139
K-4.0 Cl-100 HCO3-26 AnGap-17
___ 05:30AM BLOOD VitB12-1444* Folate->20
___ 06:05AM BLOOD TSH-2.3
___ 06:00AM BLOOD CRP-4.6
___ 06:05AM BLOOD ___
___ 06:05AM BLOOD PEP-HYPOGAMMAG IgG-406* IgA-200 IgM-36*
IFE-NO MONOCLO
Reports:
TTE (Complete) Done ___ at 12:24:51 ___ FINAL
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the anterior septum and anterior walls and
apex. The remaining segments contract normally (biplane LVEF =
34 %). The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction most c/w CAD (LAD distribution). Mild
mitral regurgitation. Increaed PCWP.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
___ Left and Right cardiac catheterization
Coronary Anatomy
Coronary anatomy:
LM: Distal eccentric 30% stenosis.
LAD: Tapers, no significant disease.
LCx: No significant disease.
RCA: Mid vessel 50-60% stenosis.
Interventional Details
Because the LM lesion was hazy and difficult to assess, FFR was
performed. ___ XB 3.5 guide. The
LAD was wired and intravenous adenosine given. Lowest FFR was
0.81.
Impressions:
Intermediate LM and RCA disease.
Normal filling pressures.
RHC pressures
RA 5
RV ___
PA 43/19(27)
W 13
CO/CI 5.7/3.1
MVO2 62%
CT CHEST W/O CONTRASTStudy Date of ___ 1:32 ___
IMPRESSION:
Small left calcified thyroid nodule.
Enlargement of the main pulmonary artery could suggest pulmonary
hypertension.
Mild centrilobular pulmonary emphysema. Substantial coronary
calcifications.
Several pulmonary nodules are non suspicious in size and
morphology.
CAROTID SERIES COMPLETEStudy Date of ___ 3:16 ___
IMPRESSION:
1. Mild to moderate bilateral heterogeneous atherosclerotic
plaque of the
extracranial internal carotid arteries associated with a
approximately 40-59%
stenosis, bilaterally.
2. Retrograde flow within the right vertebral artery,
suggestive of
subclavian steal syndrome.
CTA NECK (___):
1. Approximately 35% stenosis of the right internal carotid
artery at its
bifurcation by NASCET criteria.
2. Approximately 25% stenosis of the left internal carotid
artery at its
bifurcation by NASCET criteria.
3. Patent vertebral and subclavian arteries.
4. The visualized circle of ___ is patent.
Brief Hospital Course:
Ms ___ is a ___ with a PMHx of HFpEF, old LBBB, HTN, carotid
artery disease, DM, OSA on CPAP, HLD who presented with dyspnea
and orthopnea, found to have newly depressed EF (34%) and wall
motion abnormalities (severe hypokinesis of the anterior septum
and anterior walls and apex). Akinesis on TTE was concerning for
missed MI vs stress-induced CM. She was without CP, with neg
trop at OSH and in ___ ED and EKG did not meet sgarbossa
criteria. On admission she appeared volume overloaded with
elevated JVP and dyspnea with movement. She was diuresed to
euvolemia and was transitioned to oral diuretics. She was
started on a isosorbide dinitrate, valsartan, spironolactone and
carvedilol as she had poorly controlled hypertension (SBPs
180s-200s). Coronary angiography did not demonstrate any culprit
flow-limiting coronary lesions, though the patient does have CAD
(Intermediate LM and RCA disease). She was stabilized on a
maintenance diuretic dose of torsemide 10mg qday. Takotsubo's
cardiomyopathy is a possibility and the patient should have a
repeat TTE performed within about 3 months to look for recovery
of LVEF.
Right heart catheterization notable for mild pulmonary
hypertension with transpulmonary gradient of 14 (PCWP mean 13,
mean PA 27, RA mean 5), for which she will see pulmonologist as
an outpatient. She will continue using her home CPAP for her
OSA.
While attempting to tightly control her blood pressure in the
___ SBP for her new systolic heart failure the patient
developed dizziness with standing. Carotid ultrasound revealed
retrograde flow in the right vertebral artery c/w subclavian
steal syndrome, and R subclavian duplex study was consistent
with this. Indeed, she was found to have asymmetric blood
pressure readings ___ higher in the left arm). Vascular
surgery was consulted and a CTA was performed of the Circle of
___, carotids, and subclavian arteries. Vascular surgery
could not identify a culprit stenosis that would be amenable to
surgical correction and therefore recommended tolerating a
higher blood pressure target for her despite her systolic heart
dysfunction. A goal of SBP 120-140 was decided on since she
becomes symptomatic at ~110 SBP.
=== TRANSITIONAL ISSUES ===
- New systolic CHF: Needs repeat TTE in 3 months to look for
change/recovery in LVEF. Started on carvedilol, spironolactone,
valsartan, isosorbide and torsemide.
- Needs Chem-10 checked on ___. Results will be faxed to Dr.
___ and Dr. ___ office).
- Right subclavian steal syndrome: not amenable to surgical
correction. Will tolerate higher SBP goal of 120s-140s to avoid
dizziness / cerebral malperfusion. She is at slightly higher
risk of falling given intermittent mild dizziness even on this
BP regimen, however patient and medical team both agreed that
this risk could be appropriately managed by always using walker
for stabilization and rising slowly from seated position.
- Anemia: Hgb in 7's-8's. Stable during admission.Normal iron
studies, B12, folate. Reportedly normal colonoscopy within last
___ years. Please continue workup as outpatient.
- Dry weight on discharge: 72.8 kg.
- Diuretic regimen on discharge: torsemide 10mg PO qday
- Pulmonary follow up for OSA (on CPAP already) in setting of
newly depressed EF.
- ___ services for heart failure monitoring, vitals, medication
teaching. Should also be set up with a LifeLine bracelet or
similar way for patient to alert EMS if she falls.
- Please consider referral to ___ Pain ___ in attempt to
better manage her chronic back and leg pain. She is dramatically
affected by this.
- MRI (___) showed multiseptated lobular cystic mass without
enhancing nodules in the head of the pancreas and uncinate
process. Differential includes cystadenoma or
cystadenocarcinoma. Due for 6 month f/u (OVERDUE FOR F/U
IMAGING). This should be arranged for by her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Valsartan 160 mg PO BID
4. Citalopram 10 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qday Disp #*30
Tablet Refills:*0
3. Citalopram 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Valsartan 160 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Isosorbide Dinitrate 20 mg PO TID
RX *isosorbide dinitrate 20 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
9. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth qday
Disp #*15 Tablet Refills:*0
10. Torsemide 10 mg PO DAILY
RX *torsemide [Demadex] 10 mg 1 tablet(s) by mouth qday Disp
#*30 Tablet Refills:*0
11. Outpatient Lab Work
Date: ___
Indication / ICD-10 Code: ___.22
Labs: ___
Fax results to Dr. ___ (___) AND Dr. ___
___ (___).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute systolic heart failure
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Mild pulmonary hypertension
Diabetes mellitus
Hypertension
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___,
You were hospitalized at ___ after noticing some difficulty
breathing and having decreased heart function, or "heart
failure". You were given medications to help remove the excess
fluid, called diuretics, during your stay. You had a cardiac
catheterization which showed no evidence of blockages in the
arteries of your heart that would cause the decreased heart
function. You will need to continue the medications below, and
will have a repeat echocardiogram in 3 months to evaluate your
heart function.
We incidentally found that you had an abnormality of one of your
blood vessels. We believe this is causing the dizziness you
experience intermittently when your blood pressure is even at
appropriate levels. You were seen by vascular surgery for
consideration of whether a surgery was possible to correct this,
but no such procedure was recommended or deemed possible.
Instead, we have recommended a more liberal (higher) blood
pressure goal for you to help minimize your dizziness.
You should continue to take the diuretic, or water pill, called
torsemide, when you return home. Make sure to weigh yourself
everyday, and call your doctor if your weight increases more
than 3 pounds from your new "baseline" or "dry" weight of 72.8
kg.
You will need to have labs drawn on ___, the results of
which will be sent to and followed up by your cardiologist.
Please be sure to attend all follow-up appointments listed. It
was a pleasure taking part in your medical care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10590766-DS-9 | 10,590,766 | 28,647,792 | DS | 9 | 2182-01-03 00:00:00 | 2182-01-04 07:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / ACE Inhibitors / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old with a PMH HFrEF now recovered EF (had
newly reduced EF to 34% at ___ ___ admission but most
recent
TTE ___ EF 55%), LBBB, HTN, carotid artery disease, OSA on
CPAP, HLD, recent admission for acute HF exacerbation at ___ who
presents with episode of syncope found to be bradycardic by EMS
to ___ on arrival.
The patient reports leaving rehab 1 day prior. At rehab she
reports progressing off of oxygen and regaining her strength.
The
day after returning home, she was sitting in a chair with ___
present, felt lightheaded and had witnessed loss of
consicouness.
She had no chest pain, palpitations or SOB during the episode.
For the next several minutes, she had repeated episodes of loss
of consciousness with slurred followed by waking up with slurred
speech. Her ___ reported that her feet looked temporarily
purple.
She did complain of severe diffuse muscle weakness during these
episodes but her strength returned soon after. She has no prior
history of anything like this.
She was recently admitted ___ to ___ at ___ for CHF
exacerbation, diuresed with 80mg IV Lasix BID. Her weight on
discharge is 92.5 kg. She was discharged on PO torsemide 40mg
daily. Initially had ___ thought due to cardiorenal syndrome,
which improved to 2.0 with diuresis.
At this admission she had lethargy that was thought possibly due
to adrenal insufficnecy as she was on chronic prednisone and had
been off this medication prior to admission, though labs were
not
consistent with this diagnosis. Ultimately her lethargy improved
by time of discharge.
In the ED initial vitals were 97.6 64 154/64 16 96% on 3L. ECG
showed LBBB and sinus rhythm stable from prior. Exam notable for
no clear lungs on auscultation and trace pedal edema. Troponin
was 0.07 and BNP 1795. CXR showed moderate cardiomegaly without
edema or effusion. UA showed >182 WBCs with large leuk esterase.
Ceftriaxone was given. On recheck her BP was 192/76 but came
down
to 164/69 without intervention, and there was report of
incorrect
cuff being used.
Cardiology evaluated the patient and recommended syncope work-up
and admission for possible pacemaker.
On the floor the patient has no complaints and does not feel any
of the symptoms described above.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Known LBBB
- history of HFpEF with new sCHF as of ___
3. OTHER PAST MEDICAL HISTORY:
- Known left bundle branch block on EKG since ___
when she hospitalized with diastolic heart failure. Ischemia
workup in ___ showed no evidence of underlying
coronary artery disease.
- Subclavian steal syndrome
- Hypertension.
- Diabetes mellitus.
- Carotid artery disease with a carotid ultrasound done at
___.
- Sleep apnea, patient using CPAP.
- Giant cell arthritis/polymyalgia rheumatica.
- Anemia
- HLD
- Gout
- Depression
- Pulmonary nodules
- History of breast cancer
- Left-sided low back pain with sciatica
Social History:
___
Family History:
Father died of MI/CHF in ___. No family history of bradycardia
or
syncopal episodes
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.2 161 / 77 69 18 96 RA
Gen: well-appearing elderly woman in NAD
HEENT: PERRL, dentures present otherwise OP clear, symmetric
palate elevation; 1x1cm raised scaling lesion with central
clearing on L mid neck
CV: Unable to appreciate JVP, RRR, I/VI systolic murmur heard
best at LUSB without radiation
Lungs: Decreased breath sounds at LLB, otherwise CTAB, normal
WOB
ABD: Soft, NT, ND
EXT: Trace pedal edema, wwp
Neuro: speech fluent, CNII-XII intact, ___ L dorsiflexion
strength, 4+/5 symmetric strength in hip flexion b/l; otherwise
___ strength in UE and ___
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.4F, 81, 159/73, 16, 94% on RA.
Gen: well-appearing elderly woman in NAD
HEENT: anicteric, PERRLA
CV: RRR, no m/g/r
Lungs: clear to auscultation bilaterally
ABD: soft, non-tender, non-distended
EXT: trace ___ edema
Neuro: speech fluent, CNII-XII intact
Pertinent Results:
ADMISSION LABS
===============
___ 01:30PM BLOOD WBC-10.7* RBC-2.71* Hgb-8.0* Hct-24.9*
MCV-92 MCH-29.5# MCHC-32.1 RDW-15.7* RDWSD-52.5* Plt ___
___ 01:30PM BLOOD ___ PTT-25.8 ___
___ 01:30PM BLOOD Glucose-93 UreaN-34* Creat-1.8* Na-141
K-3.8 Cl-99 HCO3-28 AnGap-14
___ 01:30PM BLOOD proBNP-1795*
___ 01:30PM BLOOD cTropnT-0.07*
___ 07:33AM BLOOD Calcium-9.5 Phos-4.8* Mg-1.7
___ 03:47PM BLOOD Lactate-1.0
PERTINENT RESULTS
=================
___ TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is mild
functional mitral stenosis (mean gradient 4 mmHg) due to mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic regurgitation. Mild mitral regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
left ventricular regional wall motion abnormalities are not seen
and left ventricular systolic function is improved. Moderate
pulmonary hypertension is detected.
___ EP STUDY
___ yo WF with syncope, chronic LBBB presents for conduction
study.
No evidence of significant HV prolongation or infra-His Block.
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-8.5 RBC-2.96* Hgb-8.6* Hct-28.4*
MCV-96 MCH-29.1 MCHC-30.3* RDW-15.7* RDWSD-55.3* Plt ___
___ 06:00AM BLOOD Glucose-90 UreaN-27* Creat-1.8* Na-143
K-4.0 Cl-98 HCO3-29 AnGap-16
___ 06:00AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.4
Brief Hospital Course:
Information for Outpatient Providers: ___ F with PMH HFrEF now
recovered and LBBB who presented for syncopal events with
associated bradycardia found to be ___ orthostatic hypotension
and vasovagal event evaluated to not require a pacemaker by
electrophysiology.
ACUTE ISSUES
#SYNCOPE WITH BRADYCARDIA
Had a syncopal event at home, described to be vasovagal. Had
preceding dizziness. Had been having dizziness in the mornings
with medication regimen over the last few months. Etiology
thought to be because of medication regimen decreasing blood
pressure too much and causing symptoms. Concomitant E. coli UTI
also suspected to have contributed to orthostasis. EP study
negative for conduction deficits, and pacemaker was not
required. Her home medication regimen was adjusted to limit her
dizziness. Her imdur was discontinued, her home carvedilol was
decreased and valsartan was held. She was discharged with
negative orthostatic exam and recommended to rehab by ___.
#E. COLI UTI
She was found to have an E. coli UTI and was treated with four
day course of ceftriaxone.
CHRONIC ISSUES
#POLYMYALGIA RHEUMATICA:
She was continued on daily prednisone, her hydroxychloroquine
was held for QTc prolongation to greater than 500.
- Continue prednisone 5mg daily
TRANSITIONAL ISSUES
New Medications: Aspirin
Changed medications: Valsartan 80mg at 12pm, carvedilol 12.5mg
to 6.25 mg BID.
Stopped Medications: Imdur
- Valsartan 80 mg QNOON
- Carvedilol 6.25 mg BID
- Please Continue prednisone 5 mg daily
- F/u with PCP ___ ___ days after DC from rehab.
- F/u with Cardiology in ___ weeks if possible. Appointment in
___ otherwise.
- EKG within 1 week of discharge
- Torsemide 40 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Torsemide 40 mg PO DAILY
3. TraMADol 25 mg PO BID:PRN Pain - Moderate
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Valsartan 40 mg PO BID
6. Gabapentin 200 mg PO QHS
7. Atorvastatin 40 mg PO QPM
8. Carvedilol 12.5 mg PO BID
9. Citalopram 10 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
11. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
12. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 6.25 mg PO BID
3. Valsartan 80 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
6. Citalopram 10 mg PO DAILY
7. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
8. Gabapentin 200 mg PO QHS
9. PredniSONE 5 mg PO DAILY
10. Torsemide 40 mg PO DAILY
11. TraMADol 25 mg PO BID:PRN Pain - Moderate
12. HELD- Hydroxychloroquine Sulfate 200 mg PO DAILY This
medication was held. Do not restart Hydroxychloroquine Sulfate
until seen by your doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Syncope ___ orthostasis
Vasovagal Syncope
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
- You were admitted after you passed out (syncope)
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- Our electrophysiologist doctors examined your ___, and
determined you do not need a pacemaker.
- Your medicines were changed to decrease your dizziness.
- You were found to have a urinary tract infection, you were
given antibiotics to treat it.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- Please stop taking taking imdur, as it was causing your blood
pressure to be low without benefit.
- The following medicines were changed: your valsartan was
consolidated to 80mg to be taken every day at noon, your
carvedilol was decreased to 6.25 mg twice a day, and your imdur
was stopped.
- You were started on a medicine called aspirin. Please
continue to take one every day.
- Your paquenil was causing your heart rhythms to become
abnormal and prolonged, we stopped it during your hospital
course and you should wait until seeing your doctor until
restarting it.
- Please follow up with your PCP and cardiologist soon after you
are discharged from the rehab facility.
- Weigh yourself every morning, call your doctor if the weight
goes up more than 3 lbs.
We wish you the best in your recovery!
Your ___ Care Team
Followup Instructions:
___
|
10591033-DS-5 | 10,591,033 | 29,656,475 | DS | 5 | 2122-03-05 00:00:00 | 2122-03-18 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left arm weakness & left facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with past medical history of ischemic
stroke at the age of ___ (etiology reportedly unknown, maintained
only on baby ASA), squamous cell throat cancer s/p xRT (___)
and
diabetes with recent admission for stroke and CEA in ___.
Patient states that he is in usual state of health today his
last
known normal was 2:30 ___ on his left foot for work. When his
life came back from work at around 11:30 ___ or midnight she
noted
that his left arm seemed weaker and that there is perhaps a
worse
left facial droop. The patient himself denies noticing any
weakness. He says that perhaps he was not using his phone as
fluidly as normal, which is what his wife was concerned about.
There is no slurred speech. He denies headache. He presented
to
be a ___ for further evaluation and was found to have IPH,
likely hemorrhagic transformation of prior ischemic stroke.. He
also had a witnessed 2 min GTC while there, treated with 2 mg
Ativan and 1000 mg keppra. He denies any past history of
seizure
and does not recall this event. He states he feels like he is
at
baseline currently. He was noted to minimal facial droop on
evaluation at ___. and only somesome L arm weakness.
Was
initially on cardene drip, which was started at ___ as
his SBP was elevated in the 180-200s. This was able to be weaned
off in the emergency department.
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 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:
PMH:
Uncontrolled DM2
HTN
Diabetic Neuropathy
CVA at age ___, no intervention
Oropharyngeal SCC s/p radiation ___ years ago (L side)
Past Surgical History:
L supraclavicular LN biopsy - ___ years ago
R carotid endarterectomy ___
Social History:
___
Family History:
reviewed noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T98.1 HR 110 BP 136/95 RR 15 Spo2 95% 2L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-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.
mild anomia, not able to name ___ objects on the
stroke
card. Had difficulty reading, red words incorrectly on stroke
card, replace words with other words. Speech was not
dysarthric.
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: L NLFF, activates symmetrically
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 4+ 4+ 4+ ___ 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 4 2
R 3 3 3 4 2
few beats of clonus with patellar testing
Crossed adductor and suprapatellar present.
Few beats of clonus at ankles bilaterally.
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
====================================
DISCHARGE PHYSICAL EXAM:
Physical Exam:
Vitals: T 98.3 HR 97 BP 144/88 RR 18 SpO2 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: non-distended
Extremities: No ___ edema
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert and oriented. Blunted affect. Able to
relate history
without difficulty. Language is fluent. There were no paraphasic
errors. Speech was not dysarthric. Able to follow both midline
and appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: Pupils slightly asymmetric at 3.5 and 3 mm,
reactive to light. EOMI without nystagmus. Normal saccades. VFF
to confrontation.
V: Facial sensation intact to light touch.
VII: L NLFF, activates symmetrically
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.
-Motor: Normal bulk, tone throughout. Left arm parietal drift
(left arm drifts upward when both arms are extended with eyes
closed).
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA
L 4 ___ ___ 5 5
R 5 ___ ___ 5 5
-Sensory: No deficits to light touch
-DTRs: deferred
-___: deferred
-Gait: deferred
Pertinent Results:
ADMISSION LABS
================
___ 03:11AM BLOOD WBC-16.4* RBC-4.45* Hgb-13.5* Hct-40.0
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.5 RDWSD-44.1 Plt ___
___ 03:11AM BLOOD Neuts-88.5* Lymphs-4.2* Monos-5.9
Eos-0.8* Baso-0.2 Im ___ AbsNeut-14.50* AbsLymp-0.69*
AbsMono-0.96* AbsEos-0.13 AbsBaso-0.04
___ 03:11AM BLOOD ___ PTT-24.3* ___
___ 03:11AM BLOOD Glucose-430* UreaN-28* Creat-1.3* Na-139
K-4.4 Cl-99 HCO3-24 AnGap-16
___:11AM BLOOD ALT-36 AST-18 AlkPhos-97 TotBili-0.2
___ 03:11AM BLOOD Lipase-41
___ 03:11AM BLOOD cTropnT-<0.01
___ 03:11AM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.8 Mg-2.1
___ 03:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:55AM BLOOD Glucose-420* Na-135 K-3.9 Cl-102
calHCO3-26
___ 08:40AM BLOOD WBC-13.6* RBC-4.09* Hgb-12.6* Hct-37.6*
MCV-92 MCH-30.8 MCHC-33.5 RDW-13.8 RDWSD-46.5* Plt ___
___ 08:40AM BLOOD ___ PTT-25.4 ___
___ 08:40AM BLOOD Glucose-377* UreaN-23* Creat-1.2 Na-140
K-4.3 Cl-102 HCO3-24 AnGap-14
___ 08:40AM BLOOD ALT-31 AST-15 LD(LDH)-229 AlkPhos-90
TotBili-0.2
___ 08:40AM BLOOD GGT-30
___ 08:40AM BLOOD TotProt-5.4* Albumin-3.1* Globuln-2.3
Calcium-8.6 Phos-4.0 Mg-2.0 Cholest-146
___ 08:40AM BLOOD %HbA1c-10.8* eAG-263*
___ 08:40AM BLOOD Triglyc-138 HDL-41 CHOL/HD-3.6 LDLcalc-77
___ 08:40AM BLOOD TSH-1.3
DISCHARGE LABS
==============
___ 05:45AM BLOOD WBC-9.3 RBC-4.00* Hgb-12.1* Hct-37.3*
MCV-93 MCH-30.3 MCHC-32.4 RDW-14.0 RDWSD-47.9* Plt ___
___ 05:45AM BLOOD ___ PTT-25.4 ___
___ 05:45AM BLOOD Glucose-197* UreaN-12 Creat-1.0 Na-145
K-3.6 Cl-104 HCO3-25 AnGap-16
___ 05:45AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
IMAGING
CTA HEAD AND NECK ___
Stable hemorrhagic transformation of the right parietal MCA
territory infarct.
Multiple additional late subacute, chronic infarcts, stable. No
definite new infarcts.
Interval right carotid artery recanalization with a linear
filling defect in the posterior aspect of the proximal right
ICA, may represent residual
thrombus or intimal flap.
Approximately 35-40% stenosis of the left proximal ICA.
Significant areas of vertebral artery narrowing intracranially,
extra
cranially. Stable bilateral PCA narrowing.
MRI HEAD W/O CONTRAST ___
The study is degraded by motion artifact.
Multiple infarcts are again noted in the distribution of the
right MCA and
posterior right MCA/right PCA territories as described above
similar in
distribution to outside study done ___.
No new acute infarct.
Hemorrhagic transformation is again noted in the right high
parietal infarct as seen on prior CT.
Mild hemorrhagic transformation of the right frontal, right
caudate as well as right internal watershed area infarct, which
was not evident on prior CT (and is most likely CT occult).
CHEST PORTABLE AP ___
Lung volumes are low, making it difficult to exclude mild
interstitial edema, but there is no focal consolidation
concerning for malignancy. Heart size normal. No pleural
abnormality.
TRANS-THORACIC ECHOCARDIOGRAM ___
Mild symmetric left ventricular hypertrophy with normal chamber
size and dynamic systolic function. No ASD/PFO by color doppler
or aggitated saline contrast. No pathologic valvular flow.
Brief Hospital Course:
Mr. ___ is a ___ year old man with past medical history of
ischemic stroke at the age of ___ (etiology reportedly unknown,
maintained only on baby ASA), squamous cell throat cancer s/p
xRT (___) and diabetes with recent admission for right
parietal-occpital ischemic stroke secondary to symptomatic
carotid s/p and CEA ___ who presented as a transfer from and
outside hospital with slight L arm weakness, mild left facial
droop, and mild anomia found to have hemorrhagic transformation
of prior ischemic infarct and new generalized tonic-clonic
seizure.
# Hemorrhagic transformation of right parietal-occipital infarct
CT head at outside hospital showed intraparenchymal hemorrhage,
likely hemorrhagic conversion of previous ischemic stroke, that
occurred last admission in ___, although it was noted
that this hemorrhagic conversion occured later than would be
expected after an ischemic stroke. There was no evidence of AVM
on CTA head and neck. MRI head showed stable hemorrhagic
transformation of R parietal lobe infarct. SBP maintained less
than 150. He was restarted on aspirin 81mg and atorvastatin 80.
# Seizure
Patient had a witnessed generalized tonic-clonic seizure at
outside hospital that was controlled with Ativan and Keppra.
This was felt to be most likely due to the intracranial
hemorrhage into the parietal infarct in the setting of
hyperglycemia (glucose 430). He was started on Keppra 500 mg BID
as seizure prophylaxis and did not have any other seizures
during his hospital stay. He was counseled on driving
restrictions x 6 months.
# Hypertension
Patient has a history of hypertension and was found to be
hypertensive to 180s-200s at ___, where he was started
on a nicardipine drip. He was weaned off the nicardipine drip in
the emergency room at ___. His blood pressure was controlled
with home amlodipine 10 mg, home hydrochlorothiazide 12.5 mg,
and home losartan 100 mg, with labetalol ___ mg and
hydralazine ___ mg given as needed for SBP >150.
# Acute kidney injury
Patient's creatinine on admission was 1.5, up from his baseline
of 1.0. This ___ was felt to be most likely prerenal due to
hypovolemia. He was given maintenance IV fluids at 75 cc/hr and
kidney function was monitored over the course of the
hospitalization and had improved to baseline at discharge.
# Diabetes mellitus type 2, poorly controlled
Patient has a history of type 2 diabetes mellitus that appears
to be poorly controlled. Presented with glucose 430 and HbA1c
10.8. Patient is currently on metformin 850 mg BID, Lantus 24
units at breakfast and 34 units at dinner. Metformin was held
during this admission, and patient was placed on an insulin
sliding scale. ___ was consulted and recommended continuation
of current insulin regimen with Lantus 24 qAM/34 qPM (home
doses), Humalog 4 with meals, and Humalog sliding scale. Patient
will require close outpatient follow-up for diabetes management
and glucose control.
# Leukocytosis
Patient noted to have leukocytosis on admission (___ 16) with
abnormal UA but urine culture with no growth. Given patient
asyptomatic and afebrile, this was not treated, and patient was
monitored. ___ at discharge was down to 9.3.
Transitional Issues:
[] Follow up with PCP for DM 2 and HTN control
[] Follow up with neurology
[] Started on Keppra 500 mg BID for seizure ppx
[] Driving restrictions x 6 months
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Glargine 24 Units Breakfast
Glargine 34 Units Bedtime
7. MetFORMIN (Glucophage) 850 mg PO BID
Discharge Medications:
1. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
2. Glargine 24 Units Breakfast
Glargine 34 Units Bedtime
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hemorrhagic transformation of prior right parieto-occipital
stroke
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness and
seizure that were concerning for a stroke. Imaging of your brain
did not show a new stroke but did show new bleeding in one of
your old strokes. Your blood sugar was also very high on
admission and may have contributed to your weakness and seizure.
The brain is the part of your body that controls and directs all
the other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High blood pressure
- Diabetes mellitus (A1c 10.8)
- High cholesterol (LDL 77)
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10591267-DS-17 | 10,591,267 | 23,922,220 | DS | 17 | 2140-01-31 00:00:00 | 2140-02-01 16:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Garbled speech, difficult walking
Major Surgical or Invasive Procedure:
Nine
History of Present Illness:
Mr. ___ is a ___ yo male with
past medical history of anxiety, HTN, afib in xarelto, and more
recently s/p coiling of ACA aneurysm x2 (in ___. He
presents from the ED for evaluation of intermittent garbled
speech lasting for one month as well as progressive gait
instability.
Per Mr. ___ he has felt off since his last aneurysm repair
on
___. He says that before surgery he had clear speech
and
after he has completely garbled speech, progressive over the
last
month. He also endorses confusion mostly at night. Sometimes he
will wake up at 4 or 5 AM and think he has to go to work or he
wakes up and thinks he has a meeting. He has not worked in ___
years (previously worked in ___). He also has had 2 episodes
of "feeling unsteady on feet." He tells me he was at a meeting
one week ago and felt weak in his knees. He had to be escorted
by
friends to his car but felt better when he walked home. He had a
similar episode 2 weeks prior.
In ED, vital signs on presentation: Temp 97.2 HR 72 BP 130/99 RR
18 96% Nasal Cannula. Labs notable for UDS pos for
benzodiazepines and opiates (which patient takes at home),
sodium
138, unremarkable LFTs, Hb 13, WBC 7.4. He was given IV toradol
and his home medication, including Lisinopril and Diltiazem ER
240 mg (received at 9:21 AM). CT Head showed known embolization
coils but no acute intracranial abnormalities, as well as no
evidence of flow in the aneurysm sac. He was seen by neurology
team, who noted neurologic exam very limited by patient effort
but notable for dysarthria with guttural sounds, pain on
bilateral lower extremities and effort dependent motor testing.
CT and CTA were deemed reassuring. Patient was noted to be
falling asleep during exam, with slurred speech.
At 10:45, patient was noted to be tachycardic to the 130s in ED,
made worse with activity. He was given IVF with minimal
improvement. Also noted to be very short of breath when
attempting ambulatory sat. He is being transferred to the
medicine service for further management.
On transfer:
Temp 97.5 HR 69 BP 100/45 RR 14 SaO2: 99% RA
On the floor, patient's mental status seems to be improved. He
is
alert and oriented and gives a reliable history. He is
cooperative with my exam. He relays the history above and says
that he just hasn't felt right since his aneurysm repair.
Past Medical History:
Afib on xarelto/ASA
Hypertension
S/P L knee replacement
s/p Lumbar fusion x 4 (first in ___. All concentrated around
L5-S1 per patient)
anxiety
COPD
osteoarthritis
OSA- Recently prescribed CPAP
opioid dependence
BPH
Coiling of A- Comm aneurysm ___ repeat catheter guided
coiling ___
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: Temp 98.1 BP 103/57 HR 69 RR 16 93%RA
Gen: Slightly disheveled ___ year old male in no apparent
distress. Conversant and alert. Grossly garbled speech but
understandable.
HEENT: PERRLA, EOMI. Oropharynx clear.
Cor: no TTP of chest wall/sternum. Heart with NRRR. No murmurs,
rubs, gallops
Pulm: Lungs CTA b/l
Extrem: Warm and well-perfused. +1 pitting edema right ankle,
trace edema left leg. Calves symmetric, with no redness or
tenderness to palpation
Neuro: Alert and oriented to self, place (___) and time.
No pronator drift on extension. Able to ambulate to end of
hallway, hobbled gait, patient attributes to OA in right leg. 2+
biceps and patellar reflexes
DISCHARGE PHYSICAL EXAM
==================
VS: Temp 98.4 ___
Gen: Slightly disheveled ___ year old male in no apparent
distress. Conversant and alert. Speech through mostly closed
mouth, improves
during course of conversation
HEENT: PERRLA, EOMI. Oropharynx clear.
Cor: no TTP of chest wall/sternum. Heart with NRRR. No murmurs,
rubs, gallops
Pulm: Lungs CTA b/l
Extrem: Warm and well-perfused. +1 pitting edema right ankle,
trace edema left leg. Calves symmetric, with no redness or
tenderness to palpation
Neuro: Alert and oriented to person, place and time
Speech grossly garbled but normal prosody, normal word
selection, no scanning
in speech. He is able to perform labial and guttural sounds.
His tongue protrudes on midline, there is no facial weakness,
can
blow out cheeks, move tongue well. When asked to work on opening
his mouth more widely, his speech is much more intelligible.
Finally, the volume is reasonable and consistent.
He has clear giveaway in finger extensors bl but at times when
giving full effort has full strength. He initially reports
weakness in arms but then pushes himself up to stand from bed
unassisted. He walks hesitantly but with good foot placement
and
no ataxia.
Pertinent Results:
LABS ON ADMISSION
==============
___ 04:30AM BLOOD WBC-7.4 RBC-4.04* Hgb-13.0* Hct-39.9*
MCV-99* MCH-32.2* MCHC-32.6 RDW-15.1 RDWSD-54.9* Plt ___
___ 04:30AM BLOOD Neuts-43.0 ___ Monos-10.6 Eos-3.5
Baso-1.5* Im ___ AbsNeut-3.19 AbsLymp-3.05 AbsMono-0.79
AbsEos-0.26 AbsBaso-0.11*
___ 04:30AM BLOOD ___ PTT-32.2 ___
___ 04:30AM BLOOD Glucose-84 UreaN-16 Creat-0.8 Na-138
K-4.3 Cl-102 HCO3-27 AnGap-13
___ 04:30AM BLOOD ALT-11 AST-22 AlkPhos-87 TotBili-0.2
___ 04:30AM BLOOD Albumin-3.6
___ 04:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:30AM BLOOD GreenHd-HOLD
___ 05:00AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 05:00AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00AM URINE Color-Straw Appear-Clear Sp ___
LABS ON DISCHARGE
=============
___ 08:10AM BLOOD WBC-6.0 RBC-3.66* Hgb-11.4* Hct-35.7*
MCV-98 MCH-31.1 MCHC-31.9* RDW-14.7 RDWSD-52.9* Plt ___
___ 08:10AM BLOOD Glucose-113* UreaN-19 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
___ 11:20AM BLOOD ___ pO2-171* pCO2-47* pH-7.37
calTCO2-28 Base XS-1
MICROBIOLOGY
==========
___ 5:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
=====
CT HEAD WITHOUT CONTRAST (___):
Please note, study is limited due to patient motion artifact.
There is no evidence of infarction or hemorrhage. There is no
mass effect or
midline shift. Streak artifact related to anterior
communicating artery
aneurysm limits evaluation of the adjacent structures.
Incidental note is
made of a cavum septum pellucidum et vergae. There is a steeple
hyperdense
rounded nodule at the roof of the third ventricle/ foramen of
___, measuring
5 x 3 mm, similar to the prior study, and most suggestive of a
colloid cyst.
There is no hydrocephalus. There is mild mucosal opacification
of the right
maxillary sinus. The remaining paranasal sinuses and bilateral
mastoid air
cells appear clear. Periapical lucency is seen surrounding the
multiple
maxillary teeth with absence of multiple additional teeth. In
addition,
scattered dental caries are identified.
CTA HEAD (___): CTA is mildly suboptimal secondary to timing
of contrast bolus.
Streak artifact related to anterior communicating artery
aneurysm limits
evaluation of the adjacent structures. Otherwise, there is no
stenosis,
occlusion, or other aneurysms identified. The circle of ___
and the
principal intracranial vasculature otherwise appear
unremarkable. The basilar
artery and the vertebral arteries are patent. There are mild
vascular
calcifications of the cavernous segments of bilateral internal
carotid
arteries. The major dural venous sinuses are patent.
CTA NECK (___): CTA is mildly suboptimal secondary to timing
of contrast bolus.
There is patency of bilateral common, internal, and left
vertebral arteries
within the confines of this study. There is a common origin of
the
brachiocephalic and left common carotid artery. The origin of
the right
vertebral artery is poorly visualized secondary to adjacent
streak artifact
from venous reflux, otherwise the remainder of the right
vertebral artery is
patent. The mild vascular calcifications near the carotid
bifurcation without
stenosis per NASCET criteria.
OTHER:
There is a flap within the left lung apex with scattered
pleuroparenchymal
scarring. There is a 5 mm nodule in the left major fissure
(series 5, image
50) likely representing a fissural lymph node. The thyroid
gland appears
unremarkable. There is no lymphadenopathy per size criteria.
There are
degenerative changes of the cervical spine.
IMPRESSION:
1. No acute infarct, hemorrhage or mass effect on noncontrast
head CT.
2. Status post coil embolization of known anterior communicating
artery
aneurysm. Otherwise, no stenosis, occlusion, aneurysms.
3. Hyperdense cystic lesion at the foramin of ___ of the
third
ventricle, suggestive of a colloid cyst. This is unchanged from
___.
4. Periapical lucency surrounding of multiple maxillary teeth
and multiple
dental caries; dental exam is recommended.
CXR PA&LA (___)
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Mr. ___ is a ___ yo man with medical history of anxiety, HTN,
afib in xarelto, and more recently s/p coiling of ACA aneurysm
x2 (in who presented to the ED from OSH with one month of
continuously garbled speech and was also found to be tachycardic
and SOB. During the course of his hospital stay the following
issues were addressed:
# Conversion disorder. Mr ___ relays a history of
progressive dysarthria over course of last month and marks his
surgery on ___ as the moment he first noticed a decline. Also
with reported ataxia, hypnopompic disturbances and short term
memory loss. CTA of head and neck was performed in emergency
department and showed no evidence of aneurysm coiling failure
and no significant narrowing of carotid arteries that could
explain a structural cause of patient's symptoms. Patient also
presented somnolent and minimally interactive with providers but
was alert and interactive within 12 hours. UDS negative for EtOH
but positive for benzodiazepines and opiates (which patient
takes at home). Some concern that patient is overmedicated on
current regimen of opiates and benzodiazepines. No evidence of
toxic-metabolic encephalopathy. FSBG normal, electrolytes
normal. No signs infection (normal white count, urine culture
negative. We also considered TIA/stroke as patient ties start of
events to his aneurysm clipping, though patient had no focal
deficits and per a family member patient has actually had these
symptoms "for years." Neurology saw patient and noted speech
made through nearly closed mouth, exam with intermittent full
strength and effort and hesitant gait but no overt ataxia. We
were initially concerned that patient had early signs of a
progressive bulbar palsy such as ALS, but patient had no other
classic UMN or LMN findings and neurology feels that exam is
consistent with conversion disorder after his coiling.
# Tachycardia and a fib. Not witnessed while on floor. No events
on Tele. In ED tachycardia noted one hour after administration
of patient's home Diltiazem SR. Possibly RVR from afib in
setting of delayed medication vs. undermedication vs alcohol
withdrawal. Per patient he has had atrial fibrillation for some
time and that "they shocked my heart 8 months ago" (likely
failed cardioversion). EKG on floor shows NSR. Continued
Diltiazem SR 240 mg and home Xarelto 20 mg with dinner.
# COPD. Did not appear to be in acute exacerbation. Continued
Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID and
Tiotropium Bromide.
# OSA. Continued home CPAP and home oxygen as needed.
# Pain. Continued oxycodone and alprazololam despite concern for
mental status for fear of precipitating withdrawal. However,
doses were decreased to Alprazolam 1mg TID PRN instead of QID;
oxycodone 5mg q8h prn instead of TID.
#? of alcohol abuse. Patient has history of heavy alcohol use
after his wife died ___ years ago but per patient has been clean
and sober for past 6 months. Questionable history from night ___
that she sometimes sees bottles near his room though his
dysarthria may be mistaken for slurred speech. Patient placed on
Clinical Assessment for Withdrawal Protocol and did not require
supplemental benzodiazepine administration. EtOH was negative
but patient came from outside hospital and so presentation was
not acute.
CHRONIC ISSUES
===========
# Anxiety. Continued alprazolam 1 mg PO Q8 PRN
# Depression. Continued Venlafaxine XR 150 mg PO QHS and
Amitriptyline 25 mg PO/NG QHS
# CAD. Continued ASA 325 mg
# History of Acomm aneurysm. S/p placement of coils x 2, most
recently ___. Continued ASA 325
# GERD. Continued Omeprazole 20 mg PO DAILY
Overall patient discharged to rehab and length of stay expected
to be 30 days or less at rehab.
TRANSITIONAL ISSUES
===================
Overall patient discharged to rehab and length of stay expected
to be 30 days or less at rehab.
# MEDICATION CHANGES: Alprazolam 1 mg Q6H changed to Q8H
- Patient may benefit from an MRI brainstem as an outpatient to
rule out bulbar pathology
- Patient may benefit from outpatient sleep evaluation, as he
has history of hypnopompic hallucinations and disorientation in
early hours of the morning.
- He will benefit from close social work and psychiatric follow
up
- Please re-examine alprazolam as treatment of patient's
anxiety. With concurrent alcohol history and neurologic history,
use of this medication should be monitored and reassessed.
- Will need speech therapy evaluation
- Dental follow up recommended. Had multiple caries noted on
head CT
- Several incidental findings on imaging that require outpatient
follow-up:
-- Hyperdense cystic lesion at the foramin of ___ of the
third
ventricle, suggestive of a colloid cyst. This is unchanged from
___.
-- Periapical lucency surrounding of multiple maxillary teeth
and multiple
dental caries; dental exam is recommended.
# CONTACT: HCP, sister ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. ALPRAZolam 1 mg PO QID anxiety
3. Amitriptyline 25 mg PO QHS
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
10. Gabapentin 600 mg PO TID
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. Lisinopril 5 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Senna 17.2 mg PO QHS
15. Thiamine 100 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Venlafaxine XR 150 mg PO QHS
18. OxyCODONE (Immediate Release) 5 mg PO TID
19. Rivaroxaban 20 mg PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. melatonin 5 mg oral QHS
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QPM
3. ALPRAZolam 1 mg PO TID:PRN Anxiety
RX *alprazolam 1 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
5. Acetaminophen 325-650 mg PO Q6H
6. Amitriptyline 25 mg PO QHS
7. Aspirin 325 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Diltiazem Extended-Release 240 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
14. Gabapentin 600 mg PO TID
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
16. Lisinopril 5 mg PO DAILY
17. melatonin 5 mg oral QHS
18. Omeprazole 20 mg PO DAILY
19. Rivaroxaban 20 mg PO WITH DINNER DAILY
20. Senna 17.2 mg PO QHS
21. Thiamine 100 mg PO DAILY
22. Tiotropium Bromide 1 CAP IH DAILY
23. Venlafaxine XR 150 mg PO QHS
24. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
=======
Conversion disorder
Tachycardia
Secondary
=========
COPD
Anxiety
Depression
CAD
History of Anterior communicating artery aneurysm s/p coil
placement
Gastroesophageal reflux
Question of alcohol abuse
Obstructive sleep apnea on CPAP
Discharge Condition:
Mental Status: Clear and coherent but grossly dysarthric
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you here at ___
___. You came to us with one month of garbled speech,
confusion and unsteadiness on your feet. Imaging of your head
showed that the previous repair of your brain aneurysm is
functioning well, with no concerning findings in your brain. You
originally had racing heart but on monitors you did well once we
gave you your Diltiazem, which controls your heart rate. You
will benefit from physical therapy to help you gain strength and
speech therapy to help you with your speech. You were also found
to have several cavities and should follow with a dentist.
Please take all of your medications as detailed in this
discharge summary. If you experience any of the danger signs
below, please contact your primary care doctor or come to the
emergency department immediately.
Best Wishes,
You ___ Care Team
Followup Instructions:
___
|
10591484-DS-6 | 10,591,484 | 23,816,357 | DS | 6 | 2168-04-29 00:00:00 | 2168-04-29 19:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics) / Demerol / Alcohol /
Codeine / Aquaphor / latex
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
___ Right craniotomy for tumor resection
History of Present Illness:
This is a ___ yo woman with PMH significant for breast cancer,
sarcoidosis and atrial fibrilation who presents with one month
of
headache and fatigue. The patient and her husband report that
starting about 5 weeks ago she noticed a pain around her right
ear. She thought it was an ear infection and was evaluated at
___ with a clean otic examination (per pt report). The headache
persisted and starting about 1 mo ago she and her family noticed
that the patient was much more tired than usual. She was
sleeping
more than usual and was more low energy thoughout the day, which
is very unusual for the patient (who still works at a day care
center). In addition to the fatigue her family noticed that she
was becoming increasingly forgetful and confused at times.
repeating words multiple times and acting like she didnt know
where she was. For the past week her family notices dramatic
worsening of these issues along with moments of "glassy eyes".
They note that is was like an "on-off switch" one moment she
would be her usual self and the next she was starring off into
space. After considerable pressure from her children she finally
presented to our ED for evaluation.
Past Medical History:
sarcoidosis including pulmonary and liver involvement
Breast Cancer: Dx ___ years ago. DCIS. s/p radiation and
mastectomy on ___
atrial fibrilation
Social History:
___
Family History:
mother died at ___, lung cancer - second hand smoke
father died at ___, lung cancer, throat cancer, prostate cancer,
smoker
Physical Exam:
Exam on Admission:
General appearance: alert, in no apparent distress
HEENT: Sclera are non-injected. Mucous membranes are moist.
CV: Heart rate is regular
Lungs: Clear to auscultation bilaterally
Abdomen: soft, non-tender
Extremities: No evidence of deformities.
Skin: Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and time. Able
to relate history without difficulty. Attentive to
conversattion.
Language is fluent. Speech was not dysarthric.
Cranial Nerves: Pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia. Normal facial sensation. Left
nasolabial flattening - corrects somewhat with natural smile.
normal hearing. palate elevates symmetrically. Normal shoulder
shrug. No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. pronator drift on
the left.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ 5 4+ ___ 5 5 5 5 5
R 4 ___ 5 4+ ___ 5 5 5 5 5
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes are equivical bilaterally.
Sensory: normal and symmetric perception of light touch.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were symmetric with regard to cadence and
speed, no dysdiadochokinesia noted.
Exam on Discharge
R eye swollen shut/ R pupil smaller- post-op R third nerve palsy
on POC, appears to be improving , oriented x 3, full motor
Pertinent Results:
___ NCHCT
Right temporal lobe ill-defined 2.0 x 2.6 cm heterogeneous
partially calcified mass with extensive surrounding vasogenic
edema. This exerts mass effect with effacement of the right
frontal horn of the lateral ventricle and 7 mm leftward shift of
normally midline structures. Partial effacement of the
suprasellar cistern is concerning for impending uncal
herniation.
___ EKG
Sinus rhythm. Right bundle-branch block. No previous tracing
available for comparison.
___ CXR
No acute cardiopulmonary abnormality.
___ MRI brain with and without
Rim enhancing mass in the right temporal lobe, with internal
blood products (or less likely calcifications. Extensive
associated vasogenic edema results in effacement of the right
lateral and third ventricles, leftward shift of midline
structures, and borderline right uncal herniation. This lesion
is suspicious for glioblastoma, but a metastasis may also be
considered.
___ MRI brain with and without
No change in the large, heterogeneously rim-enhancing
intra-axial mass in the right temporal lobe, over the very short
interval. There is extensive
associated vasogenic edema with mass effect and subfalcine and
early uncal herniation. There is focal thickening and
enhancement of the overlying dura, suggestive of transpial
spread of tumor.
The MR imaging characteristics strongly favor the diagnosis of a
high-grade, hypercellular primary glial tumor. A metastatic
lesion is considered significantly less likely.
___ CTA head
1. No significant interval change in right temporal lobe mass.
2. Prominent vasculature noted in the region of the tumor and
displacement of the right MCA and anterior cerebral arteries
secondary to mass effect. No evidence of aneurysm, stenosis, or
occlusion.
___ CT Head
Status post right-sided craniotomy and resection of right
temporal lobe mass are expected postsurgical changes. No
evidence of new hemorrhage. 7 mm of leftward shift of normally
midline structures is not significantly changed from the prior
preoperative study.
MRI Brain ___ post-op:
The changes identified in the right temporal region with small
amount of
residual enhancement at the anterior medial aspect of the
resection cavity. Restricted diffusion seen at the margin of
resection cavity indicate ischemia.
Brief Hospital Course:
Ms. ___ was admitted from the emergency department to the
floor on ___ for evaluation and treatment of her right temporal
lesion. She had a NCHCT which showed an ill-defined 2.0 x 2.6 cm
heterogeneous partially calcified mass with extensive
surrounding vasogenic edema. She was started on Keppra and
Dexamethasone.
On ___, the patient had a MRI which showed a right temporal rim
enhancing lesion with internal blood products. The scan also
showed extensive associated vasogenic edema with effacement of
the right lateral and third ventricles, leftward shift of
midline structures, and borderline right uncal herniation.
___, Ms. ___ remained neurologically stable. She was
consented for surgery. She had an MRI wand study in preparation
for surgery.
On ___, her neurologic exam was stable. She complained of
headache and right ear pain. OR was cancelled secondary to
scheduling. She remained stable on ___ with plans to go to the
OR on ___ with Dr. ___ resection.
On ___ she was taken to the ___ for resection, frozen was GBM.
Post-operatively she was transferred to the ICU. She recovered
well and post-op CT showed good resection and stable edema.
neurologically she had LUE weakness and a mild intermittent
tremor. She remained stable overnight.
On ___ her exam was improved with very mild LUE weakness and a
CNIII palsy. She was tolerating a PO diet and was deemed fit for
trasnfer to the floor. As such transfer orders were written, her
areterial line was discontinued, and her foley catheter was
removed as well.
Patients remained stable on the floor and was evaluated by ___.
She was discharged on ___ with home ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Ursodiol 500 mg PO BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg half tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*90
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Ursodiol 500 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*1
9. Dexamethasone 3 mg PO Q6H Duration: 6 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
after tapered doses continue 2mg BID until instructed otherwise.
RX *dexamethasone 1 mg 3 tablet(s) by mouth Q6 hours Disp #*18
Tablet Refills:*0
10. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
Start: After 3 mg tapered dose
after tapered doses continue 2mg BID until instructed otherwise.
RX *dexamethasone 1 mg 3 tablet(s) by mouth every 8 hours Disp
#*18 Tablet Refills:*0
11. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
Start: After 3 mg tapered dose
after tapered doses continue 2mg BID until instructed otherwise.
RX *dexamethasone 1 mg 2 tablet(s) by mouth every 8 hours Disp
#*12 Tablet Refills:*0
12. Dexamethasone 2 mg PO Q12H Duration: 60 Doses
Start: After 2 mg tapered dose
after tapered doses continue 2mg BID until instructed otherwise.
RX *dexamethasone 1 mg 2 tablet(s) by mouth Twice daily Disp
#*120 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right temporal brain mass
Vasogenic edema (cerebral edema)
Uncal herniation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Have a friend/family member check your incision daily for signs
of infection.
¨ Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Dressing may be removed on Day 2 after surgery and the
incision can be left open to air.
¨ Your wound was closed with staples and you must wait until
after they are removed to wash your hair. You may shower before
this time using a shower cap to cover your head.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
¨ You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
¨ If you are being sent home on steroid medication, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as these medications can cause
stomach irritation. Make sure to take your steroid medication
with meals, or a glass of milk.
¨ Clearance to drive and return to work will be addressed at
your post-operative office visit.
¨ Make sure to continue to use your incentive spirometer
while at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ Any signs of infection at the wound site: increasing
redness, increased swelling, increased tenderness, or drainage.
¨ Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10591828-DS-6 | 10,591,828 | 25,872,954 | DS | 6 | 2193-10-05 00:00:00 | 2193-10-05 11:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Extremity redness and swelling
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
Ms ___ is a ___ with minimal PMH but for obesity and ___ in
setting of dysmenorrhea/fibroids, who presented with acute onset
left hand swelling.
She says she may have sustained a bite from something the night
prior to admission. She subsequently developed acute onset left
hand swelling and pain primarily including the index and middle
finger. Pain worsened despite ice, and now she has swelling on
the volar aspect of the wrist, as well as lymphangitic streaking
up the forearm. No fevers or chills, no antibiotics yet, no
systemic symptoms. No cough, ST, rhinorrhea, abd pain, nuas,
vom, diarrhea, dysuria.
In the ED, she had stable vitals. Labs generally unremarkable,
no leukocytosis. Hand X ray performed but not interpreted, no
gross abnormalities per EDMD. Hand surgery consulted. She was
given Unasyn. Admission to medicine was requested.
ROS is otherwise negative in 10 points except as noted.
Past Medical History:
Obesity
___ s/p myomectomy
Social History:
___
Family History:
No known history of immune deficiencies
Physical Exam:
Vitals AVSS
Gen NAD, quite pleasant
Abd soft, NT, ND, bs+
CV RRR, no MRG
Lungs CTA ___
Ext WWP, no edema
Skin anicteric; hand cellulitis, swelling, full ROM of all
digits
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, steady gait
Psych normal affect
Pertinent Results:
Labs on admission:
Heme
___ 02:42AM BLOOD WBC-7.1 RBC-4.56 Hgb-12.8 Hct-39.2 MCV-86
MCH-28.1 MCHC-32.7 RDW-13.0 RDWSD-39.8 Plt ___
___ 02:42AM BLOOD Neuts-57.8 ___ Monos-5.3 Eos-3.1
Baso-0.3 Im ___ AbsNeut-4.11 AbsLymp-2.36 AbsMono-0.38
AbsEos-0.22 AbsBaso-0.02
Chem
___ 02:42AM BLOOD Glucose-104* UreaN-13 Creat-1.0 Na-133
K-8.2* Cl-98 HCO3-19* AnGap-24*
___ 02:55AM BLOOD Lactate-1.6
Micro
Blood culture x2 obtained
Imaging on admission:
Hand x ray - read pending
Brief Hospital Course:
Ms. ___ presented with acute onset of left hand/wrist
cellulitis complicated by ascending lymphangitis and extensive
soft tissue edema. There was no obvious skin breakdown or portal
of entry, and although she does have a cat at home, she denied
any recent scratches or other trauma. She was treated
empirically for skin organisms, as well as Bartonella, and
followed closely by Hand Surgery. After 36 hrs of parenteral
therapy she improved sufficiently to transition to oral
antibiotics, and was discharged to home to complete another 7
days of augmentin, and will be seen in clinic early next week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Left hand/arm cellulitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with cellulitis (skin infection) of your left
hand that had extended up your arm. You responded well to
intravenous antibiotics and were followed closely by the Hand
Surgery team. You have now improved sufficiently that you can be
discharged to home and finish your treatment with oral
antibiotics.
Please take all your medication as prescribed and keep all of
the appointments listed below.
Followup Instructions:
___
|
10591889-DS-8 | 10,591,889 | 21,373,822 | DS | 8 | 2187-01-01 00:00:00 | 2187-01-02 18:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Loss of Consciousness
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Ms. ___ is a ___ yo woman with a significant PMH for history
HIV (CD4 351 HIV PCR 332), HCV (>1million copies), HTN, bipolar
deperssion and PTSD who recently began HIV therapy with Triumeq
who p/w a syncopal vs. seizure episode and 3 weeks of watery
diarrhea.
She was initially diagnosed with HIV in ___ (asymptomatic at
the time). Her CD4 at the time was 264 and VL was 98K. She was
initiated on Stribild and continued on treatment until ___
when her Creatnine was noted to rise from a baseline of 0.9 to
1.64. At this time she was transitioned to Triumeq and tolerated
this medication well. Her Labs in ___ reflected improvement on
threrapy and shw asnoted to have CD4 of 351, VL332, BUN7 Cr
0.93, ALT/AST of 83/34.
Then 3 weeks ago, she began having 2 loose large volume stools
per day a/w diffuse cramping. The diarrhea was never bloody or
melenic, but was associated with tenesmus. Began having episodes
of lightheadness, seeing stars, and diaphoresis with sudden
standing. The diarrhea has also been waking her from sleep. Last
night, she woke up from sleep with a sudden urge make stool.
When she stood up, she began having blurry vision,
lightheadedness, and sweating, and she passed out. Denies head
trauma. Found down by daughter with hands clenches, some arm
jerking, and swallowing her tongue. Ms. ___ believes she was
down roughly 10 minutes. When she awoke, her daughter called an
ambulance, and she was taken to this hospital.
In the ED, initial vitals: T:96 HR: 78 BP: 87/64 SpO2: 100%
Physical exam was unremarkable. Basic lab work notable for AG
20, Cr 1.1, BUN 15, lactate 3.2, WBC 5.3, Hct 32.2 with 58%
lymphs. ___ showed no bleed/fracture. CXR clear. XR hip, knee,
foot w/o fx. Because of concern for seizures ___ CNS pathology,
LP performed with 0WBC's and 0RBC's. She was treated with IVF
bolus of 2L with improvement in her blood pressure. She also
received 1g IV ceftriaxone and 40meq of K. Vitals prior to
transfer: T: 98.6 HR: 63 BP: 129/89 RR: 16 SpO2100% RA
She has not had N/V. No fevers/chills. Has had night sweats and
hot flashes since beginning menopause recently. Has had 20lb
weight loss since ___. Developed cough 1 week ago
productive of green sputum. Denies SOB/chest pain. No travel in
past year. No recent sick contacts. Has a dog, but the dog has
been healthy.
Currently, she denies light-headedness. She has mild lower
abdominal pain that is crampy in nature. Has not had diarrhea
since coming to the ED.
ROS:
No fevers, chills. No changes in vision or hearing, no changes
in balance. No shortness of breath, no dyspnea on exertion. No
chest pain or palpitations. No nausea or vomiting. No
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits. No rashes.
Past Medical History:
HIV (diagnosed ___
HCV
HTN
PTSD
Bipolar Depression
Polysubstance abuse including IV drugs since age ___.
Tubal ligation
right hand abscess
Social History:
___
Family History:
- mother passed away at age ___ from gastric cancer also with
hypertension, and had polysubstance abuser
- father has alcohol abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T: 99.2 HR 76 BP: 135/96 RR: 18 SpO2: 100 RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, PERRL bilaterally, no conjunctival
injection. MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD. Thyroid not enlarged.
trachea midline
RESP: CTAB without advential sounds, diaphragmatic excursion was
equal
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, mildy tender in the hypogastrium but w/o
rebound/guarding. ND. Mildly hyperactive bowel sounds present,
no hepatosplenomegaly.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Normal skin turgor. Cap refill ~1 second.
NEURO: Speech Coherent. Cognition intact. No dysdiokinesia, no
pronator drift. CNs2-12 intact, strength ___ in b/l upper and
lower extremities. Gait not assessed. Heel to shin normal.
SKIN: No excoriations or rashes.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Tm 99.4 HR 64-102 BP 135/90-156/117 RR 18 SpO2 100%
RA
I/O's: 2430/brp wt: 50.1 kg
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CHEST: CTAB, no wheezes, crackles, or rhonchi
CV: Loud heart sounds. RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND. Mildly hyperactive bowel sounds present, no
hepatosplenomegaly.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Normal skin turgor. Cap refill ~1 second.
NEURO: Speech Coherent. Cognition intact. Difficult to engage in
conversation.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:21AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0
___ ___ 10:20AM CEREBROSPINAL FLUID (CSF) PROTEIN-36
GLUCOSE-67
___ 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 08:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-SM
___ 08:45AM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-6 TRANS EPI-<1
___ 06:49AM LACTATE-3.2* NA+-140 K+-3.0*
___ 06:44AM GLUCOSE-160* UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-26 ANION GAP-20
___ 06:44AM ALT(SGPT)-52* AST(SGOT)-112* CK(CPK)-141 ALK
PHOS-84 TOT BILI-0.4
___ 06:44AM LIPASE-183*
___ 06:44AM ALBUMIN-3.5 CALCIUM-9.5 PHOSPHATE-3.6
MAGNESIUM-2.1
___ 06:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:44AM WBC-5.3 RBC-3.24* HGB-11.2* HCT-32.2* MCV-99*
MCH-34.6* MCHC-34.8 RDW-12.7
___ 06:44AM NEUTS-30* BANDS-0 LYMPHS-58* MONOS-11 EOS-1
BASOS-0 ___ MYELOS-0
___ 06:44AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 06:44AM PLT SMR-NORMAL PLT COUNT-201
DISCHARGE LABS:
===============
___ 06:47AM BLOOD WBC-4.5 RBC-3.34* Hgb-11.9* Hct-32.7*
MCV-98 MCH-35.7* MCHC-36.5* RDW-12.5 Plt ___
___ 06:47AM BLOOD Neuts-37.1* Lymphs-46.5* Monos-13.6*
Eos-2.3 Baso-0.6
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-77 UreaN-7 Creat-0.9 Na-134 K-3.6
Cl-99 HCO3-24 AnGap-15
___ 06:47AM BLOOD ALT-46* AST-84* LD(LDH)-221 AlkPhos-87
TotBili-0.6
___ 06:47AM BLOOD Calcium-9.6 Phos-3.8 Mg-1.6
PERTINENT LABS:
===============
___ 06:44AM BLOOD Lipase-183*
___ 06:49AM BLOOD Lactate-3.2* Na-140 K-3.0*
___ 08:14AM BLOOD Lactate-1.6
___ 10:21AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 10:20AM CEREBROSPINAL FLUID (CSF) TotProt-36 Glucose-67
___ 10:20AM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-Test
___ 10:20AM CEREBROSPINAL FLUID (CSF) ___ VIRUS,
QUAL TO QUANT, PCR-PND
MICROBIOLOGY:
=============
___ 6:44 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 10:20 am CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
___ 10:20 am CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 1:48 pm STOOL CONSISTENCY: FORMED Source:
Stool.
MICROSPORIDIA STAIN (Preliminary):
CYCLOSPORA STAIN (Preliminary):
FECAL CULTURE (Preliminary):
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Preliminary):
FECAL CULTURE - R/O YERSINIA (Preliminary):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Preliminary):
VIRAL CULTURE (Preliminary):
IMAGING:
========
CT HEAD W/O CONTRAST ___:
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect.
Correlate clinically to decide on the need for further workup
with MRI if not contraindicated. Enlarged adenoids, narrowing
the nasopharynx along with fullness in the fossae of ___
on both sides, partly included and not completely targeted.
RIGHT HIP FILMS ___:
IMPRESSION:
No evidence of acute fracture or dislocation. Sclerotic lesion
involving the distal right femur is most consistent with a bone
infarct or osteochondroma
RIGHT FOOT FILMS ___:
IMPRESSION:
No acute fracture or dislocation. Moderate midfoot degenerative
change.
CXR PA/LATERAL ___:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
MRI HEAD W/O CONTRAST ___:
IMPRESSION:
1. There is no evidence of mass, hemorrhage or infarct.
2. Nonspecific T2/FLAIR white matter hyperintensities. This may
be seen in the setting of chronic microangiopathy, chronic
headache, inflammatory/infectious process, prior trauma or
demyelinating process. Clinical correlation is recommended.
EEG ___: pending
CARDIOVASCULAR:
===============
EKG ___:
Sinus rhythm. Prolonged QTc interval. Compared to the previous
tracing
of ___ QTc interval now appears more prolonged.
TRACING #1
EKG ___:
Sinus rhythm. Prolonged QTc interval. Compared to the previous
tracing
of ___ no change
Brief Hospital Course:
___ yo woman with a significant PMH for history HIV (CD4 351 HIV
PCR 332), HCV (>1 million copies), HTN and PTSD who recently
began HIV therapy with Triumeq who p/w a syncopal vs. seizure
episode and 3 weeks of watery diarrhea.
ASSESSMENT & PLAN: ___ yo woman with a significant PMH for
history HIV (CD4 351 HIV PCR 332), HCV (>1 million copies), HTN
and PTSD who recently began HIV therapy with Triumeq who p/w a
syncopal vs. seizure episode and 3 weeks of watery diarrhea.
# Syncope vs. Seizure: Patient's presentation is most consistent
with orthostatic hypotension in the setting of volume depletion
from significant diarrhea resulting in syncopal episode, as well
as a potential seizure disorder. She came in hypotensive,
orthostatic, with elevated lactate that responded to IVF. The
report of rigidity and prior episode raised concern for possible
seizure and neurology was consulted, LP results nl ___ nl,
crypto nl, pending EBV/toxo/OP), CT/MRI head w/o notable
pathology, EEG not concerning, however neurology felt Keppra
should be started and recommended follow up in 8 weeks with
them. EKG nl. DDx also included medication-related (striuvec)
vs. EtOH abuse vs. Postural orthostatic tachycardia syndrome
(but doesn't explain hypovolemia) vs. cardiogenic syncope (nl
exam/EKG/24hr tele).
# Subacute loose Diarrhea: Has had 2 BM's/day for past 3 weeks.
Describes as loose, not watery, nonbloody, not melena, no
travel. She has had significant volume depletion as a result.
DDx includes infectious diarrhea in immunocompromised host vs.
medication related (stribeld highly a/w diarrhea) vs.
inflammatory vs. irritable bowel syndrome (although doesn't
explain marked volume depletion). 1 large solid bowel movement
yesterday, stool studies not sent as patient had no further
diarrhea on the wards.
# Abnormal CBC: WBC 5.3 (30% Neut)->3.2 today, smudge cells
present on peripheral smear. Hct stable at 32.3, plt stable at
211. Concerning for CLL with smudge cells and relatively low
neutrophil count. H
# HIV: Stable. Most recent CD4 351 VL 332. Received Triumeq in
house.
# Transaminitis: AST/ALT and lipase slightly elevated,
downtrended through this hospitalization. Possibly related to
anti-retroviral therapy vs. alcohol intake as she notes she has
at least 8 alcoholic drinks per week. Stable
# HTN: On amlodipine at home, although hasn't been taking it.
SBP's in 150's here. Restarted on her home amlodipine.
#Alcohol abuse: Patient has significant alcohol abuse history.
Labs show macrocytosis as well. No w/d seizures or DT's or
hospitalizations in the past. No known history of withrdrawal or
seizures. CIWA=0, given thiamine, folate, MVI. She was seen by
social work and noted to be in the contemplation stage of
change; she acknowledges that she is concerned about her alcohol
use, but has indefinite plans to pursue treatment. She was
provided with resources to help her pursue treatment.
CHRONIC ISSUES:
===============
# HCV: Chronic hep C with genotype 1A, initially diagnosed in
the ___, status post interferon x 3 injections. She is
currently untreated and her last viral load was greater than 1
million copies. She has missed outpatient Infectious disese
appointments.
# Anemia: Hct 32.2, MCV 99. New since ___. Ddx for anemia
includes EtOH, folate/B12 deficiency, chronic HIV infxn, and
infiltrative marrow process
- F/U vitamin studies as outpatient
# PTSD: Previously on divaloprex and risperidone, however the
patient denies taking these medications recently. Not restarted
in hospital.
# Bipolar Depression: Previously on Citalopram, divaloprex, and
risperidone. Currently reports no medications. No
suicidial/homicidal ideation. Meds not restarted in hospital.
TRANSITIONAL ISSUES:
======================
[]Outpatient POTS ___ consider tilt table testing and
autonomic neurology follow up.
[]Patient started on Keppra 1000mg BID
[]Neurology follow up scheduled for possible seizure disorder.
Patient should be reminded to attend this appointment.
[]Please follow up CBC and lymphocytosis. Patient had smudge
cells noted in house. Outpatient work up for anemia also
recommended.
[]Patient with possible alcohol abuse. Started on MVI, thiamine,
folate.
[]Repeat LFTs and CBC recommended in one week.
[]Recommend continued compliance with Compression stockings for
orthostasis.
[]Consider uptitrating antihypertensive medications as needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Citalopram 40 mg PO DAILY
3. RISperidone 1 mg PO QHS
4. TraZODone 50 mg PO QHS insomnia
5. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
6. Divalproex (DELayed Release) 500 mg PO QHS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. TraZODone 50 mg PO QHS insomnia
3. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
4. LeVETiracetam 1000 mg PO BID seizure ppx
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth qdaily Disp
#*30 Tablet Refills:*3
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Citalopram 40 mg PO DAILY
8. RISperidone 1 mg PO QHS
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
========
Syncope
?Seizure
Dehydration
Chronic Diarrhea
Alcohol Abuse
Secondary:
==========
HIV
Macrocytic Anemia
HCV cirrhosis
Transaminitis
Hypokalemia
Bipolar Disorder
Hypertension
PTSD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for an
episode of loss of consciousness. You were evaluated structural
brain disease by MRI, which was normal. You were evaluated for
seizures with electroencephalogram which was pending . It is
most likely that you fainted from having too little fluid in
your body from weeks of diarrhea. You received intravenous
fluids which helped your blood pressure. You recovered very
well. The neurologist fel
-You will need to have a follow up appointment with your primary
care doctor to discuss further ___ to help us understand why
you had diarrhea, as well as for treatment.
-You will need to also need to have a follow up appointment with
a neurologist to evaluate you for a seizure disorder.
-Please wear the TEDS stockings as much as possible to prevent
fainting.
-Please limit your EtOH use, as this may have contributed to
your loss of consciousness, as well as greatly increases your
risk for cirrhosis given your hepatitis C infection.
Followup Instructions:
___
|
10592091-DS-10 | 10,592,091 | 20,898,128 | DS | 10 | 2187-01-02 00:00:00 | 2187-01-03 05:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending: ___.
Chief Complaint:
Syncope, GI bleeding
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with a PMH of ETOH use disorder, esophageal varices, GIB,
chronic pain on Suboxone, seizure disorder, frequent syncopal
episodes, prior ___ p/w 1D of melena and syncopal episode.
Patient has chronic abdominal pain, but the day prior to
admission reported more constant pain located in the right lower
quadrant. The pain comes and goes in intensity, worse with
position change. He had 2 episodes of dark red stool, one at 730
and one at 9 AM patient had 3 falls today with dizziness. He
denies fever, chills, numbness, tingling, weakness.
Patient also reports continued dizziness and syncopal episodes.
Reports that he will occasionally wake up on the ground, though
denies recent headstrike. These epsisodes always occur when
standing and ambulating and never occur at rest.
Patient was initially hypotensive at outside hospital, given 2 L
of fluid and Protonix with improvement of blood pressure. Stable
H&H.
Past Medical History:
ETOH use disorder
Esophageal varices
___
HTN
Seizure disorder
Social History:
___
Family History:
Strong family history of alcoholism. No known family history of
cirrhosis.
Physical Exam:
ADMISSION EXAM:
VS: T 97.4 BP 115/82 HR 74 RR 16 O2 sat 93%RA
GENERAL: Patient is lying in bed, arouses to voice, no acute
distress
HEENT: AT/NC, ruddy face, PERRL, anicteric sclera, moist mucus
membranes
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Crackles to midfields bilaterally, otherwise clear to
auscultation
ABDOMEN: mildly distended, minimally TTP in RLQ without rebound
or guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CNII-XII intact, moving all 4 extremities with
purpose, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: T 97.6-98.2F BP ___ P ___ RR ___ O2 93-95% RA
General: Comfortable, NAD.
HEENT: MMM, EOMs intact, anicteric sclerae.
Neck: Supple.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, mild tenderness in epigastrum and RLQ; no rebound or
guarding. NABS.
Ext: Warm and well-perfused. No edema.
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS
___ 12:12AM BLOOD WBC-6.8 RBC-4.50* Hgb-14.4 Hct-43.8
MCV-97 MCH-32.0 MCHC-32.9 RDW-13.2 RDWSD-47.2* Plt Ct-73*
___ 09:11AM BLOOD WBC-5.0 RBC-4.16* Hgb-13.6* Hct-40.7
MCV-98 MCH-32.7* MCHC-33.4 RDW-13.1 RDWSD-46.6* Plt Ct-61*
___ 06:10AM BLOOD WBC-3.8* RBC-4.28* Hgb-13.9 Hct-41.7
MCV-97 MCH-32.5* MCHC-33.3 RDW-13.2 RDWSD-46.8* Plt Ct-60*
___ 12:12AM BLOOD ___ PTT-25.0 ___
___ 06:10AM BLOOD Plt Ct-60*
___ 12:12AM BLOOD Glucose-101* UreaN-8 Creat-0.8 Na-143
K-5.1 Cl-104 HCO3-23 AnGap-16
___ 12:12AM BLOOD ALT-43* AST-80* AlkPhos-62 TotBili-0.5
___ 09:11AM BLOOD ALT-39 AST-46* LD(___)-176 AlkPhos-69
TotBili-0.7
___ 06:10AM BLOOD ALT-35 AST-38 AlkPhos-68 TotBili-0.4
___ 12:12AM BLOOD cTropnT-<0.01
___ 12:12AM BLOOD Lipase-37
___ 09:11AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8
___ 12:12AM BLOOD Albumin-3.9
LABS ON DISCHARGE:
___ 04:30AM BLOOD WBC-4.2 RBC-4.19* Hgb-14.1 Hct-41.1
MCV-98 MCH-33.7* MCHC-34.3 RDW-13.5 RDWSD-47.0* Plt Ct-58*
___ 04:30AM BLOOD Glucose-134* UreaN-13 Creat-0.9 Na-145
K-3.7 Cl-104 HCO3-23 AnGap-18*
___ 04:30AM BLOOD ALT-31 AST-30 LD(___)-165 AlkPhos-62
TotBili-0.4
___ 04:30AM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.1 Mg-1.9
STUDIES:
CHEST X-RAY ___:
No acute cardiopulmonary process.
CT HEAD ___:
Stable small right parietal subdural hematoma. No significant
mass effect or midline shift. No fractures are identified.
EGD ___ 04:30AM BLOOD WBC-4.2 RBC-4.19* Hgb-14.1 Hct-41.1
MCV-98 MCH-33.7* MCHC-34.3 RDW-13.5 RDWSD-47.0* Plt Ct-58*
___ 04:30AM BLOOD Glucose-134* UreaN-13 Creat-0.9 Na-145
K-3.7 Cl-104 HCO3-23 AnGap-18*
___ 04:30AM BLOOD ALT-31 AST-30 LD(LDH)-165 AlkPhos-62
TotBili-0.4
___ 04:30AM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.1 Mg-1.9
MICRO:
NONE
Brief Hospital Course:
Mr. ___ is a ___ y/o man with a PMH of alcohol use disorder c/b
seizures and ?esophageal varices, frequent falls/syncope w/ SDH
___, chronic pain on Suboxone, alcohol use disorder, HTN, and
anxiety, who presented with syncope concern for upper GI bleed.
# CONCERN FOR UPPER GI BLEED
# MELENA
# HEMATOCHEZIA
Self-reported history of varices and gastritis, although no
known history of cirrhosis. Reported EGD at ___
last month. ___ score of 6 on admission. Empirically
initiated on octreotide gtt and BID PPI. Evaluated by GI and
underwent EGD on ___, which demonstrated no evidence of varices,
gastritis, or bleeding. s/p ceftriaxone x1. Octreotide was
discontinued and his was returned to his PO daily PPI.
# FREQUENT FALLS
# SYNCOPE.
Ongoing issues with syncope and dizziness since initial
diagnosis of SDH in ___. No focal neurologic deficit; has
likely post-concussive syndrome, given repeated falls and recent
fall with SDH. Orthostatic vital signs were normal, and there
was no evidence of alcohol withdrawal. His sedating medications
(intermittent benzodiazepines, cyclobenzaprine, and gabapentin)
likely contributed. Will plan for slow outpatient taper of
clonazepam. No events on telemetry. CT head stable from prior.
___ recommended rehab, however patient firmly refused. He was
advised on the risk of falls and repeat intracranial bleeding
with headstrike, which he understood. He was therefore arranged
for home physical therapy.
# SDH. OSH CT notable for SDH s/p fall. Stable on repeat head
CT. Per neurosurgery eval no surgical intervention indicated.
Repeat Head CT on ___ was stable.
# ALCOHOL USE DISORDER
# HISTORY OF WITHDRAWAL SEIZURES.
Previously drinking up to 25 beers per day, with significant
reduction over the past several months; did not score on CIWA
while in-house. Discharged on thiamine and folate.
# THROMBOCYTOPENIA
# ELEVATED LIVER ENZYMES (resolved). Suspect underlying liver
disease given long history of alcohol abuse. Reports history of
varices, however no evidence of varices on EGD at ___. LFTs
downtrended, and INR/albumin normal. Spleen mildly enlarged at
15 cm, raising concern for possible portal hypertension.
Baseline platelet count confirmed with ___ of
approximately 50-60,000. Will plan for outpatient follow-up.
CHRONIC ISSUES:
===============
# HTN. Holding home lisinopril in setting of GI bleed.
# GERD. Transitioned to home PO omeprazole.
# Anxiety. On clonazepam PRN for anxiety, however outpatient
prescriber unclear. Upon review of prescriptions, he does not
appear to have been prescribed this since ___. Recommend
outpatient taper of this medication as clinically indicated,
given his falls.
# ?ADHD. Reports previously using methylphenidate. Will not
prescribe at this time and plan for outpatient psychiatry
follow-up.
# Chronic Pain. Intermittent Suboxone use given history of
heroin use ___ years ago. Will return to outpatient ___
clinic.
.
TRANSITIONAL ISSUES
===================
# Neurosurgery follow-up. Arranged to see neurosurgery in
___. If necessary, referral has also been placed for
follow-up with neurosurgery at ___ in ___. Will require
non-contrast head CT on or around ___ to evaluate for
interval change in subdural hematoma.
# Thrombocytopenia/?Portal hypertension. Please continue to
monitor CBC and consider outpatient hepatology follow-up for
possible development of liver disease.
# Anxiety/?ADHD. Previously on methylphenidate and clonazepam,
however he does not appear to have had recent prescriptions for
these. Please taper clonazepam as clinically indicated. Please
refer to outpatient psychiatry as needed to manage these
prescriptions.
# Alcohol use disorder. Please continue to address substance use
with patient.
# Medication changes. Lisinopril held given normotension. Please
restart as necessary. Discharged on thiamine.
# CODE: Full (presumed)
# CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Lisinopril 10 mg PO DAILY
5. CloNIDine 0.1 mg PO BID:PRN anxiety
6. DiphenhydrAMINE 50 mg PO BID:PRN insomnia/anxiety
7. Omeprazole 20 mg PO QAM
8. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
9. Lunesta (eszopiclone) 3 mg oral QHS
10. Ondansetron ODT 4 mg PO Q8H:PRN nausea
11. Cyclobenzaprine 10 mg PO BID:PRN spasm
12. Gabapentin 800 mg PO TID
Discharge Medications:
1. Thiamine 100 mg PO DAILY
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. ClonazePAM 1 mg PO TID:PRN anxiety
4. CloNIDine 0.1 mg PO BID:PRN anxiety
5. Cyclobenzaprine 10 mg PO BID:PRN spasm
6. DiphenhydrAMINE 50 mg PO BID:PRN insomnia/anxiety
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Lunesta (eszopiclone) 3 mg oral QHS
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO QAM
12. Ondansetron ODT 4 mg PO Q8H:PRN nausea
13. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until directed by your physician.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
- Syncope
- Hematemesis
- Melena
- Subdural hematoma
SECONDARY DIAGNOSES
===================
- alcohol use disorder
- anxiety
- depression
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 because you had blood in your
stool and vomit and loss consciousness resulting in a fall. You
were initially seen at ___, then transferred to
___ for further evaluation. You were evaluated by our
neurosurgery team given your subdural hematoma, which was
stable. You were admitted to the medicine service and were seen
by our gastroenterologists.
You underwent endoscopy (EGD) on ___ that showed no evidence of
bloeeding. Please follow up with your doctor to discuss further
management. We strongly recommended that you go to a rehab
facility to become stronger and decrease your risk for falls,
however you refused. We have therefore arranged for home
physical therapy for you.
Please follow up with your doctors to discuss ___ for
clonazepam and Ritalin. Your discharge follow-up appointments
are outlined below. Please continue to take all medications as
prescribed.
We wish you the very best!
Warmly,
Your ___ team
Followup Instructions:
___
|
10592426-DS-7 | 10,592,426 | 26,422,429 | DS | 7 | 2146-04-27 00:00:00 | 2146-04-27 12:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea, dry heaves
Major Surgical or Invasive Procedure:
None
TEE: The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal with moderate global hypokinesis (biplane
LVEF = 33 %). Apical function is relatively preserved. Left
ventricular cardiac index is depressed (<2.0 L/min/m2). Right
ventricular chamber size is normal with moderate global free
wall hypokinesis. 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. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with very mild [1+]l mitral
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is a very small inferolateral pericardial
effusion wiithout echocardiographic signs of tamponade.
IMPRESSION: Normal biventricular cavity sizes with moderatel
global biventricular hypokinesis in a apatern most suggestive of
a non-ischemic cardiomyopathy. Mild aortic regurgitation. Very
mild mitral regurgitation.
Compared to prior study (___), biventricular systolic
function is now improved.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of coronary artery
disease, dilated cardiomyopathy, hyperlipidemia, and obesity. He
underwent coronary artery bypass grafting x 4 with Dr. ___ on
___. His postoperative course was complicated by prolonged
pressor requirement due to low ejection fraction. He was
evaluated by heart failure service for cardiomyopathy and apical
aneurysm. He developed postoperative atrial fibrillation which
was treated with Amiodarone, Coumadin, and Digoxin. He was
discharged to home on postoperative day 9. He presented to the
emergency department on ___ with a three day history of
nausea, dry heaves, and general malaise. He was admitted for
further evaluation and care.
Past Medical History:
Atrial Fibrillation, postoperative
Coronary Artery Disease
Dilated Cardiomyopathy
Hyperlipidemia
Obesity
Right Bundle Branch Block
Social History:
___
Family History:
Premature coronary artery disease.
Father - first MI and CABG x 4 at age ___, died at age ___ from an
MI. He was heavy smoker.
Physical Exam:
HR: 68. BP: 102/69. RR: 18. O2 Sat: 97% RA.
General: Pale, ill appearing
Skin: Dry [x] intact [x] Poor turgor
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []x
Chest: Lungs clear bilaterally []x
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit: none
Discharge exam
Skin: Dry [x] intact [x] Poor turgor
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []x
Chest: Lungs clear bilaterally []x
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit: none
Pertinent Results:
Transthoracic Echocardiogram ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses and cavity size
are normal with moderate global hypokinesis (biplane LVEF = 33
%). Apical function is relatively preserved. Left ventricular
cardiac index is depressed (<2.0 L/min/m2). Right ventricular
chamber size is normal with moderate global free wall
hypokinesis. 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. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with very mild [1+]l mitral
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is a very small inferolateral pericardial
effusion wiithout echocardiographic signs of tamponade.
IMPRESSION: Normal biventricular cavity sizes with moderatel
global biventricular hypokinesis in a apatern most suggestive of
a non-ischemic cardiomyopathy. Mild aortic regurgitation. Very
mild mitral regurgitation.
___ 04:20AM BLOOD WBC-8.7 RBC-4.22* Hgb-12.6* Hct-35.3*
MCV-84 MCH-29.9 MCHC-35.7 RDW-14.3 RDWSD-43.1 Plt ___
___ 11:30AM BLOOD WBC-11.0* RBC-4.74 Hgb-13.5* Hct-38.9*
MCV-82 MCH-28.5 MCHC-34.7 RDW-14.0 RDWSD-41.4 Plt ___
___ 04:10AM BLOOD Glucose-116* UreaN-20 Creat-1.1 Na-138
K-4.2 Cl-99 HCO3-25 AnGap-18
___ 04:15AM BLOOD Glucose-103* UreaN-24* Creat-1.3* Na-134
K-4.3 Cl-96 HCO3-25 AnGap-17
PA/Lateral CXR: ___
Persistent but improved lung volumes with essential
complete resolution of the small left pleural effusion.
No focal consolidation to suggest pneumonia.
Brief Hospital Course:
He was admitted ___ for dehydration and Cr of 1.4 Was
found to have an elevated Dig level, and a few episodes of
Mobitz II. EP was consulted and ___ and Dig were discontinued.
He will remain on Coumadin and follow up with his PCP and
___. An echocardiogram demonstrated improved
biventricular function. A KUB revealed a non-obstructive bowel
gas pattern with moderate to large stool burden throughout the
colon. He was rehydrated with IV fluids, Lasix and Metformin
held due to rising Cr. Rehydration continued while on the floor,
he was started on OTC Zofran and BID Protonix. He will follow up
with GI as an outpt. On day of discharge he is ambulating
freely, taking po food and fluids without issue. He has been in
NSR x 24 hours and feels well enough to go home.
Medications on Admission:
Aspirin 81mg QD
Amiodarone 200mg QD
Atorvastatin 40mg QD
Carvedilol 3.125mg BID
Digoxin 0.25mg Daily
Lasix 60mg BID: discharge from ___ on this dose
Lisinopril 5mg Daily
Metformin 500mg BID
Zantac 150mg BID
Coumadin goal INR ___ last dose owas ___ of 1mg
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 3.125 mg PO BID
4. Lisinopril 2.5 mg PO DAILY
5. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
6. Ondansetron ODT 4 mg PO QIDACHS
RX *ondansetron 4 mg 1 tablet(s) by mouth four times a day Disp
#*60 Tablet Refills:*0
7. Potassium Chloride 20 mEq PO DAILY
Hold for K >4.5
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
8. Warfarin 0.5 mg PO ONCE Duration: 1 Dose
9. Furosemide 20 mg PO DAILY
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery bypass graft x4, left internal mammary
artery to left anterior descending artery, and saphenous
vein grafts to ramus. Obtuse marginal and posterior
left ventricular branch arteries.Endoscopic harvesting of the
long saphenous vein.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisions: without erythema, well approximated
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10592647-DS-11 | 10,592,647 | 24,923,762 | DS | 11 | 2164-03-09 00:00:00 | 2164-03-09 15:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / lisinopril
Attending: ___.
Chief Complaint:
HMED Admission H&P
Cough, fatigue, urinary frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a medically complex ___ with pAF on Coumadin, CAD s/p
CABG, prior AVR, diastolic CHF (prior systolic but resolved),
prior ICD now removed, DM, HTN, CKD with Cr 2.2, morbid obesity
with OSA, chronic osteoarthritis related pain, depression, who
presents with cough, fatigue, dysuria.
She was in her usual state of health until about 10 days ago.
She tells me she has a homemaker who cleans the house and makes
her meals most days, and that this person was sick with a cold,
and that other people in her building had colds as well. She
developed similar symptoms, which then settled as a very
bothersome cough. Cough progressively worsened, much worse at
night, became associated with some central sharp chest pain, she
sought medical care and was given a cough suppressant. This has
had only modest effect.
Around this same time, she has noticed some modest weight gain
of 3 or so pounds, by her report. Denies orthopnea, PND. Does
have some DOE.
Two days ago, she had worsening dysuria and incontinence. She
went to the doctor's office and was referred to the ED out of
concern for an infection.
In the ED, she was stable. UA negative. Foley was placed. EDMD
felt CXR was "ambiguous" and treated with CTX for possible CAP.
Labs generally reassuring. She was subsequently admitted to
medicine.
10 point ROS is otherwise negative except as above
Past Medical History:
pAF on Coumadin
CHF, preserved EF
CAD s/p CABG x3 with AV replacement
DM
HTN
HL
CKD
Morbid obesity with OSA
Gastritis
Chronic low back pain and hip pain from osteoarthritis
Bilateral rotator cuff impingmenet
Chronic gait unsteadiness
Depression
Ovarian cyst
Colon polyps
Bilateral TKR
Diverticulitis s/p partial colectomy with primary anastomosis
Prior BRVO
More detailed cardiac history as follows:
* CABG (LIMA->LAD, G-AM->PDA) with bioprosthetic AVR (___)
* Last LHC (___): Patent LIMA->LAD, patent RCA, totally
occluded mPDA, 40% LCx, occluded acute marginal branches, 70-80%
pLAD senosis s/p DES to LAD
- Ventricular tachycardia post-CABG
* Inducible at EPS
* S/P ICD (___) with ___ dual-chamber ICD
* ICD discharged in ___ for VT/SVT at 170 (only time it fired)
* Pulse generator erosion (___) s/p explantation
* Device was not replaced since her EF had improved
* Last echo ___ with LVEF 55%
* Transient systolic dysfunction thought to be due to
pacemaker-induced tachycardia
Social History:
___
Family History:
None
Physical Exam:
Admission PE:
Vitals AVSS
Gen NAD, quite pleasant
Abd soft, NT, ND, bs+
CV very distant and difficult to auscultate sounds, but RRR, no
MRG; JVP is mildly elevated
Lungs bibasilar crackles
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities
Psych normal affect
Discharge PE:
Vitals: T 98 HR 77 BP 153/89 RR 20 98% RA Wt: 106.4 kg
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, trace edema; JVP
approximately 8 cm
Resp: normal effort, no accessory muscle use, mild bibasilar
crackles
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Very pleasant.
GU: no foley
Pertinent Results:
SIGNIFICANT LABS ON ADMISSION:
___ 03:45AM BLOOD WBC-8.2 RBC-3.58* Hgb-10.4* Hct-32.9*
MCV-92 MCH-29.1 MCHC-31.6* RDW-13.9 RDWSD-47.0* Plt ___
___ 12:35AM BLOOD ___ PTT-42.6* ___
___ 03:45AM BLOOD Glucose-259* UreaN-38* Creat-2.2* Na-139
K-3.7 Cl-101 HCO3-30 AnGap-12
___ 12:35AM BLOOD ALT-19 AST-25 CK(CPK)-172 AlkPhos-107*
TotBili-0.4
___ 12:35AM BLOOD Lipase-40
___ 12:35AM BLOOD CK-MB-3 cTropnT-0.02* proBNP-4634*
___ 08:50AM BLOOD cTropnT-0.02*
___ 12:35AM BLOOD Albumin-3.7
___ 08:50AM BLOOD TSH-PND
SIGNIFICANT IMAGING:
CTAP FROM ADMIT
1. No acute intra-abdominal process.
2. Large complex ventral hernia containing fat and a small
portion of
transverse colon with mild associated soft tissue stranding. No
evidence of upstream obstruction pneumatosis to suggest bowel
ischemia.
3. Enlarged left ovary for which dedicated pelvic ultrasound or
pelvic MRI is recommended. Please note that ovarian carcinoma
cannot be excluded and further evaluation with MRI or ultrasound
is recommended. Please note that the patient has undergone a
bowel resection. If there is a history of malignancy, the
lesion in the left ovary could represent metastatic disease
4. Moderate apparent thickening of the bladder wall may be
related to
underdistention. Correlation with urinalysis is advised.
5. Moderate atherosclerotic disease.
6. Severe multilevel degenerative changes of the lumbar spine.
CXR FROM ADMIT
1. NEW MILD PULMONARY EDEMA AND SMALL RIGHT PLEURAL EFFUSION.
CHRONIC SEVERE CARDIOMEGALY AND PULMONARY VASCULAR CONGESTION.
2. POSSIBLE ENLARGED LEFT THYROID.
Discharge labs:
___ 07:39AM BLOOD WBC-8.6 RBC-3.61* Hgb-10.4* Hct-33.6*
MCV-93 MCH-28.8 MCHC-31.0* RDW-14.3 RDWSD-47.7* Plt ___
___ 07:39AM BLOOD Plt ___
___ 07:39AM BLOOD Glucose-153* UreaN-41* Creat-2.2* Na-139
K-4.1 Cl-98 HCO3-31 AnGap-14
Brief Hospital Course:
This is a medically complex ___ with pAF on Coumadin, CAD s/p
CABG, prior AVR, diastolic CHF (prior systolic but resolved),
prior ICD now removed, DM, HTN, CKD with Cr 2.2, morbid obesity
with OSA, chronic osteoarthritis related pain,
depression, who presents with cough, fatigue, dysuria.
Workup notable for CXR with edema, elevated BNP, bibasilar
crackles, recent history of weight gain all suggestive of CHF;
also with bronchitic cough but no signs of true pneumonia. No
reason for dysuria identified, though no longer an issue s/p
foley catheterization in ED.
# Cough: Most likely bronchitis. At this point given time
course,
it could be a bacterial process. Flu negative.
- Finished a 5 day course of Azithromycin.
- Tessalon and guaifenesin/dextro PRN
# Acute exacerbation of chronic diastolic CHF: BNP quite
elevated at 4000 in spite of obesity. She has ruled out for MI
by Tn. EKG nonspecific diffuse TW flattening, AF with normal
rate. TSH WNL. Diuresed well with Lasix 80 mg IV BID. A foley
catheter was placed on admission, removed prior to discharge and
she voided without difficuly.
- Transition back to torsemide 40 mg BID on discharge
- Counselled on importance of medication adherence and daily
weights.
# Thickening of left ovary on CT: Will need outpatient followup
with either pelvic ultrasound or MRI. Findings and
recommendation explained to patient.
# Dysuria: Uncertain etiology. Resolved s/p foley.
# CAD s/p CABG
# HTN: Stable.
- Cont home meds
# AF on Coumadin: Stable. Rates controlled.
- Cont Coumadin, titrate to INR daily
# Anemia: Takes iron at home. Hct is stable and slightly better
than remote baselines.
- CTM
# CKD: Cr stable and around baseline.
- Cont calcitriol
# Chronic osteoarthritis with pain: Stable.
- Continue oxycodone PRN
- Tylenol PRN
PPX: Coumadin
Dispo: home with services.
Code: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Valsartan 160 mg PO DAILY
11. travoprost 0.004 % ophthalmic QHS
12. Torsemide 40 mg PO BID
13. Warfarin 2.5 mg PO DAILY16
14. Potassium Chloride 10 mEq PO DAILY
15. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
16. Calcitriol 0.25 mcg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
5. Calcitriol 0.25 mcg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
7. FoLIC Acid 1 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
12. Torsemide 40 mg PO BID
13. Valsartan 160 mg PO DAILY
14. Warfarin 4 mg PO DAILY16
15. Ferrous Sulfate 325 mg PO DAILY
16. Potassium Chloride 10 mEq PO DAILY
Hold for K >
17. travoprost 0.004 % ophthalmic QHS
18. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Acute on chronic diastolic CHF exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with cough and shortness of breath. You were
found to have a congestive heart failure exacerbation and were
treated with diuretic medications to remove the built up fluid.
Your shortness of breath and cough improved. It is very
important that you take your medications every day. Weigh
yourself every morning, call your doctor if your weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10592815-DS-14 | 10,592,815 | 20,621,538 | DS | 14 | 2121-01-03 00:00:00 | 2121-01-03 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Shellfish Derived / Tetracycline Analogues
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
open cholecystectomy
History of Present Illness:
___ h/o auto-immune pancreatitis presents with abdominal
pain. Patient reports 3 days of nearly constant epigastric pain.
He reports this pain has not been exacerbated by PO intake. No
associated fevers/chills. No nausea/vomiting/diarrhea.
Past Medical History:
Hypertension
Pancreatitis, recent MRCP suggestive of autoimmune pancreatitis
with distal common bile duct stricture
Impaired glucose tolerance secondary to prednisone
RUL nodule, stable on imaging
?latent TB with granulomatous calcifications, pt reports he took
9 months of medication
Social History:
___
Family History:
Father died of old age. Mother still alive at age >___. All
brothers and sisters healthy.
Physical Exam:
Physical Exam: ___:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mild epigastric and RUQ tenderness,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Physical Exam upon discharge:
VS: 98.1, 61, 135/81, 16, 96/RA
Gen: NAD, resting in bed.
Heent: EOMI, MMM
Cardiac: Normal S1, S2. RRR
Pulm: Lungs CTAB No W/R/R
Abdomen: Soft/nondistended/mildy tender upon palpation at
surgical incision
Ext: + pedal pulses
Neuro: AAOx4
Pertinent Results:
___ 08:15AM BLOOD WBC-7.2 RBC-4.01* Hgb-11.8* Hct-34.9*
MCV-87 MCH-29.5 MCHC-33.9 RDW-12.8 Plt ___
___ 07:40AM BLOOD WBC-6.4 RBC-4.11* Hgb-11.6* Hct-36.6*
MCV-89 MCH-28.1 MCHC-31.6 RDW-12.4 Plt ___
___ 08:50AM BLOOD WBC-20.2*# RBC-4.84 Hgb-14.4 Hct-42.6
MCV-88 MCH-29.8 MCHC-33.8# RDW-12.7 Plt ___
___ 08:15AM BLOOD Plt ___
___ 12:35PM BLOOD ___ PTT-33.6 ___
___ 08:50AM BLOOD Plt ___
___ 08:15AM BLOOD Glucose-157* UreaN-12 Creat-0.8 Na-141
K-3.1* Cl-101 HCO3-29 AnGap-14
___ 08:50AM BLOOD Glucose-141* UreaN-23* Creat-1.2 Na-134
K-3.7 Cl-95* HCO3-27 AnGap-16
___ 08:50AM BLOOD ALT-20 AST-27 AlkPhos-57 TotBili-1.4
___ 08:50AM BLOOD Lipase-15
___ 08:15AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.8
___ 09:02AM BLOOD Lactate-2.2*
___: EKG:
Artifact is present. Sinus rhythm. Incomplete right
bundle-branch block.
Non-specific S-T wave changes. No previous tracing available for
comparison.
___: liver or gallbladder ultrasound:
IMPRESSION:
1. Cholelithiasis with a distended gallbladder and mural edema.
No
sonographic ___ sign. Findings are highly concerning for
acute
cholecystitis, although gallbladder wall edema can be seen with
other entities including third spacing, hypoproteinemia, or
pancreatitis. Clinical correlation is recommended.
2. No intra- or extra-hepatic biliary ductal dilatation.
3. Limited assessment of the pancreas due to overlying bowel
gas.
___: chest x-ray:
Left lower lung opacification which may represent atelectasis,
although pneumonia cannot be excluded. Mild cardiomegaly.
___: chest x-ray:
No acute cardiopulmonary process.
Brief Hospital Course:
The paient was admitted to the hospital with epigastric pain.
Upon admission, he was made NPO, given intravenous fluids, and
underwent imaging. On ultrasound, he was reported to have
gallstones with gallbladder wall edema. On HD # 2, he was taken
to the operating room where he underwent a cholecystectomy for a
gangrenous gallbladder. The operative course was stable with a
50 cc blood loss. At the close of the procedure, a #19 ___
drain was placed in the gallbladder bed. The patient was
extubated after the procedure and monitored in the recovery
room. His post-operative course has been notable for abdominal
distention and delayed return of bowel function. The patient
underwent an x-ray of the abdomen on POD # 4 and was reported to
have non dilated bowel loops with no abnormal air-fluid levels.
A moderate amount of fecal matter was identified. The patient
was started on a bowel regimen with return of bowel function.
His vital signs have been stable and he has been afebrile. His
white blood cell count has normalized. On POD #5, the ___
drain was removed and the patient was discharged home in stable
condition. A follow-up appointment was made with the acute care
service.
Medications on Admission:
unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.( ___ spesking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent an ultrasound and you were found to have
cholecystitis. You were taken to the operating room where you
had your gallbladder removed. You are slowly recovering from
your injuries and you are now preparing for discharge home with
the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10593359-DS-10 | 10,593,359 | 25,968,044 | DS | 10 | 2174-10-19 00:00:00 | 2174-10-22 12:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Acute-onset confusion, expressive aphasia, and right sided
weakness.
Major Surgical or Invasive Procedure:
- Endotracheal intubation (___)
History of Present Illness:
___ is a ___ old ___ man with
a past medical history of HTN who presents with acute onset
confusion, expressive aphasia and right sided weakness found to
have a left IPH. History is obtained from OSH records only as
there is no family contact info available.
Per report, patient was at work when he developed confusion and
difficulty speaking. He was unable to move his right leg, but
was able to squeeze EMS' hand on the right. He was also able to
follow simple commands by nodding. He was taken to ___
___ where he had a CT head which showed a large
left frontal IPH with 4mm midline shift, but no evidence of
herniation. He was subsequently intubated for airway protection
with midaz and etomidate, and then started on propofol for
sedation. He was given 270mL of 3% HTS at 17:54 and transferred
to ___ for further management.
Unable to obtain neuro ROS.
Past Medical History:
HTN
Social History:
___
Family History:
Unknown
Physical Exam:
==============
ADMISSION EXAM
==============
Physical Exam: (off prop x 10 minutes)
Vitals: T: afebrile P: 74 R: 16 BP: 135/78 SaO2: 100% vent
___: Arouses to voice, does not track or regard
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Lungs CTA bilaterally, ETT in place, lots of
secretions
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Arouses to loud voice, does not track or regard.
Follows commands in ___, such as open eyes, stick out tongue
and lift arm. Does not follow commands on the right.
-Cranial Nerves:
PERRL 2mm and not reactive (?med effect). + skew (left eye
hypertropia). Gaze conjugate. + corneals. No BTT bilaterally. +
VOR. No obvious facial droop around ETT. +cough and gag.
-Sensorimotor: Normal bulk, tone throughout.
LUE spontaneous and purposeful anti-gravity.
LLE withdraws to noxious in the plane of the bed.
RUE/RLE: no movement to noxious stimuli
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor on the left, mute on the right.
-Coordination and gait: Unable to assess
=========================
EXAM ON TRANSFER FROM ICU
=========================
-GEN: Awake in bed, NAD
-HEENT: NC/AT
-NECK: Supple
-CV: RRR, no m/r/g
-PULM: CTA anteriorly.
-ABD: Soft, NT/ND. Bowel sounds present.
-EXT: Warm, well-perfused. No clubbing, cyanosis, or edema.
-MS: Eyes open spontaneously, closes/opens to command.
Non-verbal. Does not nod to answer questions.
-CN: PERRL ___. Left gaze preference, Face grossly symmetric but
could not elicit activation. Tongue appears midline.
-MOT: Moves LUE/LLE at least antigravity. RUE no movement. RLE
withdraws to noxious stimulus.
-DTR: R toe mute. L toe down.
Exam on ___:
-GEN: Sitting up in bed in NAD.
-CV: skin warm, well-perfused.
-PULM: breathing comfortably on RA, no tachypnea.
-ABD: Soft, ND
-EXT: symmetric, no edema.
-MS: Awake, alert, oriented x3. Oriented to medical situation.
Speaks in short, often ___ word phrases. Sometimes nods/gestures
to avoid speech. Follows all simple axial and appendicular
commands.
-CN: PERRL 3->2. EOMI without nystagmus R facial droop. No
dysarthria.
-Sensorimotor: LUE and LLE spontaneous briskly antigravity.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ Toe
flex
R 4 4+ 4 4+ 4+ 4+ 4 4 4- 0 0 2
Pertinent Results:
====
LABS
====
___ 07:20PM BLOOD WBC-4.8 RBC-4.46* Hgb-13.7 Hct-41.5
MCV-93 MCH-30.7 MCHC-33.0 RDW-12.7 RDWSD-43.4 Plt ___
___ 02:14AM BLOOD WBC-6.1 RBC-4.51* Hgb-13.8 Hct-41.6
MCV-92 MCH-30.6 MCHC-33.2 RDW-13.2 RDWSD-44.1 Plt ___
___ 02:56AM BLOOD WBC-8.5 RBC-4.45* Hgb-13.5* Hct-41.3
MCV-93 MCH-30.3 MCHC-32.7 RDW-13.1 RDWSD-44.7 Plt ___
___ 07:20PM BLOOD Neuts-60.1 ___ Monos-6.2 Eos-1.5
Baso-0.6 Im ___ AbsNeut-2.89 AbsLymp-1.49 AbsMono-0.30
AbsEos-0.07 AbsBaso-0.03
___ 07:20PM BLOOD ___ PTT-21.7* ___
___ 02:14AM BLOOD ___ PTT-19.0* ___
___ 02:56AM BLOOD ___ PTT-26.5 ___
___ 07:20PM BLOOD Glucose-95 UreaN-20 Creat-1.1 Na-140
K-4.7 Cl-105 HCO3-23 AnGap-17
___ 02:14AM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-139
K-3.5 Cl-103 HCO3-25 AnGap-15
___ 02:56AM BLOOD Glucose-151* UreaN-9 Creat-0.8 Na-139
K-3.5 Cl-102 HCO3-27 AnGap-14
___ 02:14AM BLOOD ALT-30 AST-30 AlkPhos-38* TotBili-0.4
___ 07:20PM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:20PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
___ 02:14AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0 Cholest-231*
___ 02:56AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0
___ 02:14AM BLOOD %HbA1c-6.1* eAG-128*
___ 02:14AM BLOOD Triglyc-428* HDL-28 CHOL/HD-8.3
LDLmeas-155*
___ 07:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:42PM BLOOD ___ pO2-92 pCO2-36 pH-7.43
calTCO2-25 Base XS-0
___ 07:27PM BLOOD ___ pO2-124* pCO2-43 pH-7.41
calTCO2-28 Base XS-2
___ 05:05AM BLOOD WBC-4.7 RBC-4.45* Hgb-13.8 Hct-41.3
MCV-93 MCH-31.0 MCHC-33.4 RDW-11.8 RDWSD-39.9 Plt ___
___ 05:05AM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-136
K-4.6 Cl-98 HCO3-27 AnGap-16
___ 02:14AM BLOOD %HbA1c-6.1* eAG-128*
___ 02:14AM BLOOD Triglyc-428* HDL-28 CHOL/HD-8.3
LDLmeas-155*
___ 02:14AM BLOOD TSH-5.7*
=======
IMAGING
=======
- CTA Head & Neck (___)
1. Slightly increased size and edema associated with the left
medial frontal intraparenchymal hematoma as compared to the
prior
examination. No new hemorrhage.
2. Unremarkable head and neck CTA. Specifically, there is no
evidence of an aneurysm or vascular malformation in the region
of
the left frontal intraparenchymal hemorrhage.
- MRI Head WWO Contrast (___)
1. Stable size of lobar intraparenchymal hemorrhage within the
left centrum semiovale with surrounding edema and rightward
midline shift. No evidence of abnormal enhancement or
arteriovenous malformation.
2. Nonspecific white matter signal abnormality, which may be
related to chronic small vessel microangiopathy or possibly
demyelinating disease.
3. Paranasal sinus disease with partial opacification of
bilateral mastoid air cells.
___ Renal art u/s:
1. Normal renal ultrasound. No evidence of renal artery
stenosis.
2. Incidental note of a 1.4 cm bladder stone.
3. Moderately enlarged prostate.
___: Unchanged appearance of left frontal intraparenchymal
hemorrhage withincreased associated edema and slight increase in
midline shift. No new hemorrhage identified.
Brief Hospital Course:
___ is a ___ old ___ man with
a history of HTN who presented to ___ with
acute-onset confusion, expressive aphasia and right sided
weakness and was found to have a left lobar IPH with 4mm midline
shift. His exam was significant for expressive aphasia, right
visual field deficit, inability to cross midline to right, and
right-sided paresis/plegia.
He was intubated, started on hypertonic saline, and transferred
to ___ for further management. He was started on amlodipine
and captopril (which is being titrated). He was extubated the
following day on ___ and stable on room air. Hypertonic
therapy was stopped, and he was subsequently transferred to the
neurology floor.
Given the location and shape of hemorrhage, it was felt to be
most likely hypertensive in etiology. There was no evidence of
underlying AVM on CTA head and neck. No evidence of underlying
neoplasm on MRI brain with/without contrast, however to fully
evaluate for any underlying neoplasm recommend repeat MRI brain
approximately 2 months after initial hemorrhage.
His blood pressure was initially quite difficult to control, and
was uncontrolled on maximal doses of amlodipine, lisinopril, and
HCTZ. Renal artery ultrasound was performed to evaluate for
possible secondary causes of hypertension given resistance to
multiple therapies, which was normal. Carvedilol was
subsequently started, and he responded to this incredibly well,
allowing downtitration to off of multiple other
antihypertensives. His blood pressures remained stable and
normotensive throughout the remainder of his hospitalization on
2 antihypertensives.
On ___ he reported sudden onset headache, and the exam was
unchanged, noncontrasted head CT was performed, which showed no
change in his hemorrhage. He continued to have intermittent
headaches throughout his hospitalization, well controlled with
Tylenol.
He initially experienced dysphagia, requiring a dysphagia diet,
however this improved and later in his hospitalization he was
cleared by speech and language therapy for a regular diet with
thin liquids.
Due to insurance concerns, he was not eligible for discharge to
acute rehabilitation, however he continued to work with ___
while inpatient, and progress to the point of ambulating safely
with a cane. Patient and family were educated through multiple
in person ___ sessions and he was subsequently deemed stable
to be discharged to home.
Due to slight risk of hemorrhage, statin therapy was started on
admission and was started several weeks after admission, on
discharge.
===============================
Transitional issues:
[ ] Continue to monitor blood pressure; if he becomes
hypertensive, recommend uptitrating carvedilol.
[ ] MRI brain in 2 month, approximately ___.
[ ] PCP: ___ TSH in approximately 2 months after initial
injury, approximately ___ (TSH was 5.7 on presentation)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime (antes de
dormir) Disp #*30 Tablet Refills:*11
2. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice daily (dos
veces al dia) Disp #*60 Tablet Refills:*11
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily (diariamente)
Disp #*30 Tablet Refills:*11
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal intraparenchymal hemorrhage
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:
Sr. ___,
___ fue ___ hospital debido ha ___ y
___. Un MRI demonstro un derrame cerebral, lo cual es
una condition ___ las arterias ___ proporcionan oxigeno al
___ son ___. El ___ del ___
controla y dirije todas las otras partes ___, asi ___
cuando alguna ___ del ___ de oxigeno y
sangre, ___ resultar en varios sintomas. Un derrame cerebral
___ muchas causas, y por ___ fue evaluada
para determiner si tiene alguna condicion medica ___
___ el derrame cerebral. Para
poder prevenir un derrame cerebral en el futuro, planeamos
modificar sus riesgos. ___ ___ son ___:
___ - ___ de HbA1C es 6.1
Hiperlipidemia - ___ de lipidos malos son 155
Hipertension
Estamos cambiando sus medicamentos, ___.
Por favor tome sus medicamentos como recetados.
Por favor ___ con Neurologia y con ___ medico de
atención primaria.
Si experimenta alguno de ___, por favor
___ medica llamando al 911. En particular, ___
un derrame cerebral ___ ocurrir de nuevo, por favor ponga
attention ___ o rapida progression de ___ :
- Parcial o completa perdida de vision ___ occur repentinamente
- Repentina inabilidad de producir ___ boca
- Repentina inabilidad de comprender cuando ___
- Repentina ___ en ___
- Repentina ___
- Repentina perdida de ___
Sinceramente,
___ de Neurologia de ___
Followup Instructions:
___
|
10593685-DS-10 | 10,593,685 | 21,734,457 | DS | 10 | 2145-08-18 00:00:00 | 2145-08-18 14:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___.
CC: dyspnea, leg swelling
HISTORY OF PRESENT ILLNESS: ___ female with medical
history notable for hypertension, type 2 diabetes, HLD, right
hemiparesis secondary to gunshot wound, who presents with
subacute worsening shortness of breath and bilateral ___ edema
Per the patient's daughter, the patient's daughter has been
worsening over the past 6 months and has become more labored.
Today, the patient was unable to make it to the bathroom in time
and soiled herself. When her daughter put her in the shower, the
daughter noticed that the patient had significant bilateral
lower
extremity swelling. The daughter asked the patient how long this
___ swelling had been ongoing for and the patient was unsure but
daughter estimates about ___ weeks. While in the shower, the
patient's breathing became increasingly labored, for which her
daughter decided to bring her to the ED. Her daughter also feels
that the patient's face has become more puffy.
Per the patient's daughter, over the past week, the patient has
appeared more tired, not been attending church, eating less, and
too tired to put on her shoes, all behaviors that are
uncharacteristically off from her baseline. At baseline, she is
fully independent in ADLs and lives with her daughter and niece.
Patient is unable to perform ADLs because of her dyspnea and ___
edema.
In the ED:
Initial vital signs were notable for:
Temp 97.1 BP 120/75 HR 127 RR 28 100% RA
Exam notable for: pitting edema ___, crackles on auscultation at
bases, guiac + red stool
Labs were notable for:
142 105 44
=========<115 AG 17
5.1 20 2.1
9.2
8.5 >===<365
29.9
proBNP 2806
Trop-T: 0.02
Alb 4.0
EKG: low voltages, Afib, HR 127, no concerning ST changes
Studies performed include:
CHEST PA AND LATERAL ___
Mild to moderate pulmonary edema. Enlarged cardiac silhouette.
Small right pleural effusion. 1.1 cm radiopaque likely retained
foreign body projects over the posterior left lateral upper
chest.
Patient was given:
IV Pantoprazole 40 mg
PO/NG Labetalol 200 mg
Consults: None
Vitals on transfer: 99.0 125 110/71 22 100% RA
Upon arrival to the floor, patient denies chest pain,
palpitations, sick contacts, cough, fevers, lightheadedness,
dizziness, abdominal pain, nausea, vomiting, diarrhea, changes
in
her urination, or blood loss. She denies recent immobility,
flights, or recent surgeries. She denies history of blood clots.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY:
-Hemiparesis and equinovarus deformity since sustaining a gun
shot wound to the head (fired by ex-boyfriend of her daughter to
whom she would not reveal her whereabouts). He subsequently
committed suicide.
-Controlled type 2 diabetes mellitus without complication,
without long-term current use of insulin
-Cataract, nuclear sclerotic senile
-Prolapse of vaginal vault after hysterectomy
-Neuropathy, peripheral
-Hypertension, essential
-Hypercholesterolemia
-Hearing loss, sensorineural
-Colonic polyp
-Carpal tunnel syndrome
-Venous stasis ulcer (right ankle)
-Urinary incontinence without sensory awareness
Social History:
___
Family History:
Son with DM. No FHx of blood clots
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.8PO 92 / 54 111 16 94 Ra
GENERAL: Alert and interactive. In no acute distress. AAOx3
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Cataracts noted bilaterally
NECK: No cervical lymphadenopathy. JVP is elevated
CARDIAC: Irregular rhythm, tachycardic. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bibasilar crackles, R > L. Mildly increased work of
breathing
BACK: No spinous process tenderness.
ABDOMEN: Soft, non distended, non-tender to deep palpation in
all
four quadrants. No organomegaly.
EXTREMITIES: ___ pitting edema bilaterally. Equinovarus
deformity is present
SKIN: Warm to touch. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE PHYSICAL EXAM:
GENERAL: Alert and interactive. In no acute distress. AAOx3
HEENT: Sclera anicteric and without injection.
MMM. Cataracts noted bilaterally
CARDIAC: Regular rate and rhythm. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bibasilar crackles, decreased BS at bases
ABDOMEN: Soft, non distended, non-tender to deep palpation in
all
four quadrants. No organomegaly.
EXTREMITIES: R > L Pitting edema bilaterally. Equinovarus
deformity is present
SKIN: Warm to touch. No rash.
NEUROLOGIC: Alert, conversant, right ___ ___
Pertinent Results:
ADMISSION LABS:
___ 05:08PM BLOOD WBC-8.5 RBC-3.53* Hgb-9.2* Hct-29.9*
MCV-85 MCH-26.1 MCHC-30.8* RDW-14.9 RDWSD-45.4 Plt ___
___ 05:08PM BLOOD Neuts-62.2 ___ Monos-12.8 Eos-4.3
Baso-0.8 Im ___ AbsNeut-5.27 AbsLymp-1.67 AbsMono-1.08*
AbsEos-0.36 AbsBaso-0.07
___ 05:08PM BLOOD Glucose-115* UreaN-44* Creat-2.1* Na-142
K-5.1 Cl-105 HCO3-20* AnGap-17
___ 05:08PM BLOOD ALT-15 AST-17 AlkPhos-97 TotBili-0.4
___ 06:35AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.8*
OTHER NOTABLE LABS:
___ 05:08PM BLOOD proBNP-2806*
___ 05:08PM BLOOD cTropnT-0.02*
___ 11:14PM BLOOD CK-MB-4 cTropnT-0.02*
___ 05:08PM BLOOD Albumin-4.0
___ 06:35AM BLOOD Iron-22*
___ 06:35AM BLOOD calTIBC-312 Ferritn-164* TRF-240
___ 06:35AM BLOOD TSH-2.4
___ 09:44PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 07:16AM BLOOD WBC-6.6 RBC-3.43* Hgb-8.9* Hct-29.3*
MCV-85 MCH-25.9* MCHC-30.4* RDW-14.5 RDWSD-44.4 Plt ___
___ 07:16AM BLOOD Glucose-88 UreaN-33* Creat-1.5* Na-144
K-4.2 Cl-105 HCO3-27 AnGap-12
___ 07:16AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2
IMAGING:
CXR ___:
Mild to moderate pulmonary edema. Enlarged cardiac silhouette.
Small right pleural effusion.
1.1 cm radiopaque likely retained foreign body projects over the
posterior
left lateral upper chest.
TTE: ___
CONCLUSION:
The left atrial volume index is moderately increased. The right
atrium is mildly enlarged. There is a small
secundum-type atrial septal defect. The estimated right atrial
pressure is >15mmHg. 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 low normal. There
is beat-to-beat variability in the left ventricular
contractility due to the irregular rhythm.
The visually estimated left ventricular ejection fraction is
50%.
Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2).
There is no resting left ventricular
outflow tract gradient. No ventricular septal defect is seen.
Normal right ventricular cavity size with low
normal free wall motion. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter
for gender. The aortic arch diameter is normal. There is no
evidence for an aortic arch coarctation. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is moderate [2+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There
is no right atrial systolic or right ventricular diastolic
collapse, suggesting absence of tamponade physiology.
IMPRESSION: Normal biventricular cavity size and low normal
systolic function in the context of
atrial fibrillation with a rapid ventricular response. Small
secundum ASD. Mild pulmonary
hypertension. Increased right atrial pressure. No prior TTE
available for comparison. Smll
pericardial effusion without echo evidence of tamponade.
Brief Hospital Course:
SUMMARY STATEMENT
=================
___ female with medical history notable for
hypertension,
type 2 diabetes, HLD, right hemiparesis secondary to gunshot
wound, who presented with subacute worsening of shortness of
breath
and bilateral ___ edema concerning for new-onset acute
decompensated diastolic heart failure, which may have been
triggered by new atrial
fibrillation.
ACUTE ISSUES:
=============
#HFpEF exacerbation (EF 50%)
Presented with ___ weeks of worsening shortness of breath and
bilateral ___
edema with elevated BNP and pleural effusion on CXR. TTE showing
EF 50%, mild pulmonary HTN, moderate TR, and a small pericardial
effusion. Patient's acute heart failure
exacerbation possibly in the setting of new-onset atrial
fibrillation. Alternatively, patient may have had a small
pulmonary embolism, which would explain the pulmonary HTN and
new-onset a-fib. CTA was deferred as patient will
require lifelong anticoagulation regardless of diagnosis, so the
risk of worsening ___ not worth the benefit of obtaining a more
definitive diagnosis. Additionally, patient noted to have small
pericardial effusion on TTE, but no pulsus paradoxus. Patient
was diuresed with IV furosemide ___ mg daily, with significant
improvement in dyspnea and lower extremity edema. She was
transitioned to torsemide 20 mg daily for discharge.
#Atrial fibrillation CHADSVASC = 6.
Patient notes palpitations for about one month. Previously wore
ambulatory heart monitor as directed by PCP, but no official
diagnosis of a-fib. She was started on Apixiban 2.5 mg BID.
Patient continued to have occasional runs of RVR to 130s-140s
despite escalating metoprolol dose (up to 50 mg q6h). EP was
consulted, who recommended TEE/cardioversion, which was done on
___. Cardioversion was successful, and patient remained in NSR
on telemetry monitoring. Increased her apixaban to 5 mg twice
daily because, although her creatinine clearance is marginal for
full dose, she still does not technically meet criteria for
reduced dose. Additionally, she was noted to have "smoke" on her
TEE, so would prefer to ensure adequate anticoagulation.
#Hypotension
#Weakness
Her hypertension was initially thought to be secondary to
receiving a dose of her home labetalol in the emergency
department; however, she continued to have mild hypotension
throughout the course of her admission. Her hypotension is
likely secondary to acute decompensated heart failure with
atrial fibrillation. She did not have any signs of cardiogenic
shock or hypovolemia. We held her home labetalol, amlodipine,
and enalapril.
___. Cr baseline appears to be ~1.2, per Atrius records.
Improved with diuresis suggesting cardiorenal syndrome. However,
creatinine bumped again prior to discharge to 1.5, possible in
the setting of being diuresis while being NPO for cardioversion.
#RLE ulceration. Most likely in the setting of her previous leg
brace with component of venous stasis. Of note, she had a
noninvasive arterial study
on ___ which showed no evidence of hemodynamically
significant arterial occlusive disease in the right or left
lower extremities. Patient was followed by wound care with
improvement of ulceration.
#Anemia. Does not endorse signs of active blood loss. Iron panel
c/w mixed iron-deficiency and chronic inflammation.
Would consider starting PO iron supplementation
#Foreign body. CXR c/f 1.1 cm radiopaque retained foreign body
over posterior left lateral upper chest. Possibly represents
retained bullet.
CHRONIC ISSUES:
===============
#Type II DM. A1c in ___ was 6.6, not currently on
medications, appears to be diet controlled.
CORE MEASURES
=============
#FEN: IVF prn, replete electrolytes prn, regular/heart
healthy/DM
diet
#PPX: Apixaban
#ACCESS: PIVs
#CODE: Full code presumed
#CONTACT: ___ (daughter) ___
TRANSITIONAL ISSUES:
=====================
Discharge Weight: 63.7 Kg
Discharge Cr: 1.2
[] Consider starting PO iron supplementation
[] Patient needs new brace as original brace causes lower
extremity ulceration and cannot ambulate without brace. Daughter
states podiatry has a new brace for her, but could not dispense
while inpatient for insurance reasons.
[] Please weigh patient daily every morning after she empties
her bladder and call doctor if >3lbs
[] Patient should have a CBC and chem 7 checked in 3 days to
evaluate for signs of bleeding. If her creatinine is improving
(< 1.4) and she is still clinically volume overloaded, then
restart torsemide at 10 mg daily. ___ be titrated further based
on daily weights.
[] Holding home antihypertensives given recent soft blood
pressures (amlodipine 10 mg daily, enalapril maleate 20 mg BID,
hydrochlorothiazide 25 mg daily, labetalol 200 mg BID). Please
continue to hold until patient sees her primary care physician.
[]Patient is on full dose apixiban (5mg BID), but her Creatinine
Clearance is borderline for reduced dose. If her renal function
continues to decline to CrCl < 25, then she should be
dose-reduced to 2.5 mg BID.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Lovastatin 40 mg oral DAILY
3. Enalapril Maleate 20 mg PO BID
4. Labetalol 200 mg PO BID
5. Hydrochlorothiazide 25 mg PO Frequency is Unknown
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Lovastatin 40 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Acute decompensated heart failure with preserved ejection
fraction
SECONDARY:
-Acute kidney injury
-Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___.
You came into the hospital because you were having shortness of
breath and swelling in your legs. We gave you a water pill to
help you get rid of the extra fluid in your body causing these
symptoms.
You were also found to have a fast heart rhythm called atrial
fibrillation. You were initially given a medication to slow down
your heart rate. Since your heart rate was still fast, you had a
cardioversion, which is an electrical shock that put your heart
back into a normal rhythm. We also started you on a blood
thinner called apixaban (or Eliquis) to prevent blood clots from
forming.
When you leave the hospital, you should take all of your
medications as prescribed and attend all of your scheduled
follow-up appointments. Please weigh yourself every morning and
call your doctor if your weight increases by 3 or more pounds.
Please also call your doctor if you have shortness of breath,
leg swelling, weight gain, or chest pain.
We wish you all the best,
Your ___ care team.
Followup Instructions:
___
|
10593956-DS-18 | 10,593,956 | 22,225,253 | DS | 18 | 2119-11-21 00:00:00 | 2119-11-22 11:39:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal Pain, LLE Cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o M with PMH significant for HTN, HLD, Afib (not on
coumadin), IBS who comes to the ED complaining of lower
abdominal pain x 14 days. Pain began after no clear
precipitating event. He reports the pain has gradually increased
over the last 2 weeks, and improved with IVF in the ED, now ___
after the fluids. He reports the pain waxes and wanes, but is
unable to further characterize the pain. He believes the pain to
be exacerbated by food, but cannot further specify. He has not
taken any medications to help relieve the pain and cannot
describe any alleviating factors. He presented to his PCP's
office on the day of admission, where he described anorexia and
nausea for the last two days, culminating in lightheadedness,
and his PCP sent him to ___ ED. He reports chills, back pain
which he feels is unrelated, but denies fevers, vomiting,
diarrhea, constipation, melena, hematochezia. He denies chest
pain, SOB, orthopnea. He reports that he previously had a
similar pain ___ year ago. He has hx of IBS, but reports this does
not feel similar to his current sx. Last bowel movement was "a
few days ago." Unsure when he last had colonoscopy, but believes
it was less than ___ years ago.
In the ED, initial vs were: T99.7 HR:97 BP:143/97 RR:14 96% RA.
Labs were remarkable for WBC 23.6 with N:92.1. Chem 7 with Cr
1.4 with BUN 25. AST 44, Alk Phos 137. UA was unremarkable with
the exception of Hyaline casts. Blood cultures were sent.
Lactate 2.0 EKG showed A.fib without ST changes. He underwent
CTA for concern for mesenteric ischemia which was unremarkable.
He was administered 3L IVF as well as cefazolin and doxycycline.
On exam, patient was also found to have LLE cellulitis. Of note,
the patient was previously admitted to ___ in ___ for LLE
cellulitis.
On the floor, vs were: 99.3 82 156/78 16 99% RA. He reports
improvement in his abdominal pain with IV fluids. He reports
irritability, headache currently. Denies confusion.
Review of sytems:
(+) Per HPI. Reports arthralgias, unchanged from baseline.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies cough. Denies dysuria, hematuria. Ten point review of
systems is otherwise negative.
Past Medical History:
Hypertension
Hyperlipidemia
Afib (not on coumadin)
Obesity
Aflutter
colonic polyp
hearing loss
anxiety
IBS
Social History:
___
Family History:
Mother, father, and grandmother with unknown cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.9 P 82 BP 135/86 R 19 O2 sat100%RA
General: Well-appearing, sitting up in bed, AOx3
HEENT: Sclera anicteric, PERRL, Dry MM
Neck: Supple, No cervical Lymphadenopathy
Lungs: CTAB b/l poor inspiratory effort, No wheezes, crackles,
rhonchi
CV: Nl S1, S2, Irregular rate, No MRG
Abdomen: Soft, NABS, NT/ND
Ext: LLE erythematous, minimally tender to palpation area of
approximately 8cm x 6cm. No fluctuance noted. L ___ toe 1 cm
laceration. 2+ Dp.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.9 P 82 BP 135/86 R 17 O2 sat100%RA
General: Well-appearing, sitting up in bed, AOx3
HEENT: Sclera anicteric, PERRL, MMM
Neck: Supple, No cervical Lymphadenopathy
Lungs: soft bibasilar crackes, otherwise CTAB. No wheezes,
rhonchi
CV: Nl S1/S2, Irregular rate, No MRG
Abdomen: Soft, NABS, NT/ND. Involuntary guarding with deep
palpation in RLQ.
Ext: LLE erythematous, nontender to palpation area of
approximately 8cm x 6cm and receeding from previously drawn
borders. No fluctuance noted. L ___ toe 1 cm laceration. 2+ Dp.
No ___ edema.
MS: AOx3
Pertinent Results:
ADMISSION LABS
___ 08:25PM BLOOD WBC-23.6*# RBC-5.29 Hgb-16.3 Hct-47.0
MCV-89 MCH-30.8 MCHC-34.6 RDW-12.1 Plt ___
___ 08:25PM BLOOD Neuts-92.1* Lymphs-3.4* Monos-3.7 Eos-0.5
Baso-0.3
___ 08:25PM BLOOD Glucose-107* UreaN-25* Creat-1.4* Na-139
K-4.4 Cl-100 HCO3-26 AnGap-17
___ 08:25PM BLOOD ALT-32 AST-44* AlkPhos-137* TotBili-1.2
___ 08:25PM BLOOD Lipase-25
___ 08:25PM BLOOD Albumin-4.3
___ 11:53PM BLOOD Lactate-2.0
___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 09:00PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 09:00PM URINE CastHy-10*
___ 09:00PM URINE Mucous-FEW
INTERVAL/DISCHARGE LABS
___ 07:25AM BLOOD WBC-14.1* RBC-4.65 Hgb-14.6 Hct-41.0
MCV-88 MCH-31.4 MCHC-35.6* RDW-12.2 Plt ___
___ 07:25AM BLOOD Glucose-78 UreaN-23* Creat-1.3* Na-136
K-3.9 Cl-102 HCO3-22 AnGap-16
___ 07:25AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
MICROBIOLOGY
___ Blood cultures x2 pending
IMAGING
___ CTA IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. Diverticulosis.
3. Fat containing umbilical hernia.
4. Multiple renal hypodensities most likely simple renal cysts,
although the smallest are too small to accurately characterize.
Brief Hospital Course:
___ y/o M PMH significant for HTN, HLD, Afib (not on coumadin),
and IBS who is presenting to ED with 2wks of unspecified
abdominal pain, localized to RLQ on exam, found to have LLE
Cellulitis.
ACTIVE ISSUES
# Abdominal Pain: Patient admitted with abdominal pain. His
exam, labs, and imaging were unrevealing. Given fecal load
evident on CT scan and lack of recent bowel movement, it is
possible that his lower abdominal pain is related to
constipation. Patient was given IV fluids and started on a bowel
regimen with senna, colace, miralax, and suppositories. This was
supplemented with tramadol, acetominophen, and zofran for pain
and nausea. He reported improvement in his abdominal pain, had a
bowel movement and was able to tolerate a diet prior to
discharge. He was discharged with colace and miralax to take as
needed for constipation.
# LLE cellulitis: Patient presented with LLE erythema and
leukocytosis consistent with cellulitis. Patient was started on
IV cefazolin and doxycycline in the ED, with improvement in
leukocytosis and erythema overnight. He was then transitioned to
po doxycycline and keflex with plans to complete a ___nd follow up with his PCP.
# Leukocytotis: Presented with profound leukocytosis (23.6)
which improved overnight (14.1). Attributed to cellulitis.
Should have repeat CBC as outpatient to ensure full resolution.
# CKD: He was at his elevated baseline Cr of 1.3-1.5 (per Atrius
records). Home furosemide was held and medications were renally
dosed. He was advised to continue to hold furosemide until his
PCP appointment in 2 days given that he appeared dry and had
decreased po intake. If and when to restart his lasix should be
addressed at follow up on ___.
CHRONIC ISSUES
# Atrial fibrillation: He has CHADS2 score=1. He is not on
coumadin but rate controlled. He was continued on his home
verapamil and aspirin.
# Hypertension: He was continued on home verapamil. Lasix was
held as above.
# Anxiety: He was continued on home lorazepam.
TRANSITIONAL ISSUES
# CODE: full
# CONTACT: Patient
# PENDING STUDIES: blood cultures x2
# ISSUES TO DISCUSS WITH OUTPATIENT PROVIDERS:
- ___ check that WBC normalizes
- Please evaluate blood pressure and volume status at follow up
to decide if and when to restart lasix.
- monitor left lower extremity cellulitis to ensure that it has
resolved with antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO Q4H:PRN anxiety
2. Verapamil SR 240 mg PO Q24H
hold for SBP<100
3. TraMADOL (Ultram) 50 mg PO BID:PRN pain
hold for sedation, rr<10
4. Furosemide 20 mg PO BID
hold for SBP<100
5. Aspirin 162 mg PO DAILY
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Lorazepam 0.5 mg PO Q4H:PRN anxiety
3. Verapamil SR 240 mg PO Q24H
4. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
6. TraMADOL (Ultram) 50 mg PO BID:PRN pain
7. Acetaminophen ___ mg PO Q8H:PRN pain
do not exceed 4g/day
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 gram by mouth
daily Disp #*39 Each Refills:*0
9. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*24 Capsule Refills:*0
10. Doxycycline Hyclate 100 mg PO Q12H
last day ___
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*12 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Irritable bowel syndrome (constipation predominant)
Cellulitis
Secondary
Hypertension
Hyperlipidemia
Atrial fibrillation
Anxiety
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 hospitalized at ___
for abdominal pain and left leg cellulitis (skin infection). The
abdominal pain is likely related to irritable bowel syndrome and
constipation, as there were no concerning findings on the CT
scan except for extensive stool in the bowels. You were treated
with intravenous fluids, and stool softeners and suppositories,
which helped you have a bowel movement. The cellulitis was
treated with an antibiotic called doxycycline and another called
keflex. You will need to continue to take these antibiotics
until ___.
Given that you were dehydrated on admission, you should not take
your lasix today or tomorrow. You should discuss if and when it
is safe to restart your lasix at your follow up appointment on
___.
You should also have your blood work repeated at your follow up
appointment to ensure that your white blood cell count
normalizes.
It was a pleasure to take care of you during your stay.
Followup Instructions:
___
|
10594172-DS-4 | 10,594,172 | 25,623,214 | DS | 4 | 2184-08-07 00:00:00 | 2184-08-08 22:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / Penicillins
Attending: ___
Chief Complaint:
Ventral hernia
Major Surgical or Invasive Procedure:
___: Ventral hernia repair
History of Present Illness:
___ PMHx for HIV last viral load 5000 who presents to the ED
with abdominal pain found to have ventral hernia. Patient's only
abdominal surgery is a C-section. Otherwise, patient has been
doing well. Her last viral load per patient was 5000. Patient's
last CD4 count was within normal limits. Patient states that for
the past 2 days she has not been able to tolerate oral intake.
She states that everytime she eats, she has dry heaving. Ms.
___ symptoms worsened today and started to complain of
significant abdominal pain, at its worst ___. She denies
gas/bms. Patient also denies fever/chills.
Past Medical History:
PMH:
Hyperlipidema
HTN
Asthma
OSA
Left sided sciatica
Obseity
HIV
PSH:
___: Left total knee replacement.
___: Right total knee replacement
C-section
Tubal ligation
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS: 98.4 80 93/61 18 95% RA
GEN: NAD, AOx3
HEENT: Trachea midline no LAD or thyromegaly, voice hoarse
CV: RRR no MRG
RESP: CTAB no WRC
ABD: Soft, non-tender, non-distended
EXT: warm and well-perfused, 2+ peripheral pulses, no CCE
WOUND: CDI no erythema or induration
Pertinent Results:
IMAGING:
CT Abdomen/Pelvis ___
1. 2.3 cm rim enhancing fluid collection within the anterior
body wall abutting the umbilicus likely represents a small
abscess. Adjacent small fat containing hernia noted.
2. 1.8 x 1.7 cm (02:19) left adrenal lesion is stable since
___. Consider nonurgent dedicated adrenal imaging for further
evaluation if not previously obtained.
PATHOLOGY:
Surgical specimen: Hernia sac ___
Report pending
MICROBIOLOGY:
___ 4:08 am TISSUE HERNIA CONTENTS ABDOMEN.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
Reported to and read back by ___, ___ @
07:13AM
(___).
TISSUE (Pending):
ANAEROBIC CULTURE ((Pending):
LAB VALUES:
___ 01:45AM BLOOD WBC-14.1* RBC-3.72* Hgb-11.9 Hct-34.4
MCV-93 MCH-32.0 MCHC-34.6 RDW-13.5 RDWSD-45.8 Plt ___
___ 01:45AM BLOOD ___ PTT-27.6 ___
___ 01:45AM BLOOD Glucose-131* UreaN-19 Creat-1.2* Na-140
K-4.6 Cl-105 HCO3-24 AnGap-16
___ 04:38PM BLOOD ALT-31 AST-37 AlkPhos-161* TotBili-0.4
___ 01:45AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.2
___ 03:06PM BLOOD Lactate-2.2*
Brief Hospital Course:
Ms. ___ was admitted from the ED on the evening of ___
and taken to the OR on the morning of ___ for repair of her
ventral hernia, which appeared to have an incarcerated lobule of
fat within it. Upon opening the defect some frank pus was
appreciated, but the case was otherwise uncomplicated. For
details please see the operative note. Following the case Ms.
___ was extubated and taken back to the PACU ___ stable
condition per routine. She was subsequently transferred to the
general surgical floor where her pain was well controlled and
she was able to tolerate a regular diet. Her only complaint at
that time was a hoarse throat likely ___ endotracheal
intubation, for which she was given lozenges and chloraseptic
spray. She was started on a 7 day course of Bactrim as a result
of the pus that had been appreciated during surgery, and was
able to tolerate oral antibiotics well. On POD 1, as goals of
care were met, Ms. ___ was discharged to home with plans to
follow up ___ the ___ clinic ___ approximately 2 weeks.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. efavirenz-emtricitabin-tenofov ___ mg oral QHS
2. albuterol sulfate 90 mcg/actuation inhalation 2 Puffs PRN
3. Acetaminophen 325 mg PO Q6H:PRN Pain
4. Cyanocobalamin 2500 mcg PO QHS
5. Docusate Sodium 100 mg PO BID
6. Hydrochlorothiazide 25 mg PO QHS
7. Nortriptyline 25 mg PO QHS
8. Pravastatin 40 mg PO QHS
9. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN Pain
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 25 mg PO QHS
4. Nortriptyline 25 mg PO QHS
5. Pravastatin 40 mg PO QHS
6. Senna 8.6 mg PO BID
7. efavirenz-emtricitabin-tenofov ___ mg oral QHS
8. Cyanocobalamin 2500 mcg PO QHS
9. albuterol sulfate 90 mcg INHALATION 2 PUFFS PRN SOB
10. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*13 Tablet Refills:*0
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Duration: 10 Days
Do not combine with other narcotics or alcohol. Do not drive
while taking
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ventral hernia
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 ___ and
underwent repair of your ventral hernia. 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 ___ your
urine, or experience a discharge.
*Your pain ___ 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 ___ 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:
___
|
10594218-DS-17 | 10,594,218 | 21,696,853 | DS | 17 | 2118-12-30 00:00:00 | 2118-12-30 11:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Bilateral leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old right-handed man with past medical
history significant for hyperlipidemia, coronary artery disease
and multiple orthopedic injuries who presents today for
evaluation of headache and bilateral leg weakness.
Briefly, he states that yesterday at ___ he was sitting and
working on his radios and when trying to get up he started to
feel acutely light headed and saw stars. Also at the same time
both of his gave out and he fell to the ground on his right
side. There was no head strike and no LOC. He states he could
not get back up because he could not feel his legs. When he
tried to get up again he fell again and this time his wife heard
it. There were no other associated neurological deficits. She
helped him into the chair and EMS was called and he was brought
to an OSH ED where he had a CT head and L-spine that identified
no acute intracranial findings, chronic left sphenoid sinusitis,
no acute injury to L-spine, and a small disc osteophyte at L4-L5
causing mild spinal canal narrowing. He was transferred to ___
for further evaluation.
Upon arrival he endorses back in his mid and low back. He states
he cannot feel his legs but when touched can feel pressure. He
notes chronic shortness of breath which he attributes to COPD.
He denies any current headache, confusion, vision changes, chest
pain, abdominal pain, N/V/D, or numbness in the upper
extremities. He states that he produces much of his own food
including beef and cans his own vegetables.
Of note, patient has had several visits to ___ neurology
in ___ for tremors and ataxia. His work up including MRI brain,
MRA, MRI spine, and LP. He was ultimately diagnosed with a
"functional neurological disorder."
Of note, he was previously seen by Dr. ___ in Neurology for a
series of events. These are thoroughly described in Dr. ___
___, but essentially: In ___ he was walking in his
house, when he "saw stars", and fell. He was admitted to
___. Cardiac catheterization showed some
narrowing but no significant occlusion.
He then underwent Tilt table testing in ___ was positive
despite being on fludrocortisone Sometime later he developed a
sensation of abnormal visual perception, described as things
dropping off or moving in front of him.
In ___ while pulling something down from the rafters, he
felt an instant overwhelming feeling of spinning. CT head and
MRI brain were unremarkable.
In ___ he had a fall with somewhat unclear
circumstances. He was noted to have gait instability and a
positive Romberg. MRI was again unremarkable.
Electronystagmogram was also normal. Cardiac workup was also
unremarkable. MRI C-spine was apparently normal. He had a lumbar
puncture with a protein of 63, normal glucose, 1 white cell, 1
red cell, negative infectious studies.
He sought a second opinion from neurology. Autonomic testing did
not show any evidence of autonomic neuropathy. EEG in ___ was normal. He also had a spinocerebellar ataxia panel
sent, which was negative.
Dr. ___ was notable for normal strength, slightly
decreased pinprick sensation on the right at the C8-T1 level on
the back, extending down into the L5 dermatome, brisk reflexes
throughout, downgoing toes, some difficulty with heel-knee-shin
on the right, wide-based gait, and difficulty with tandem gait.
MRI of the spine with contrast was obtained, and showed
multilevel degenerative disease, with a mild degree of central
canal stenosis and neuroforaminal narrowing most notable at
C4-7. Other investigations included ___, SPEP/UPEP, and
histoplasmosis antibody, all of which were normal. He was also
seen in the movement disorders clinic by Drs. ___,
who again noted some axial as well as right appendicular ataxia.
Though the etiology of his symptoms was thought to be unclear, a
small ischemic stroke in the lateral medulla was thought to be
high on the differential.
He was seen by movement specialist who thought that his ataxia
was possibly due to an MRI negative brainstem stroke given
acuity of the symptom onset. Per their note his exam at the time
was notable for normal eye movements including saccades and
normal visual fields. Had some decreased perception to
temperature on the left face and right body. There was no
evidence of parkinsonism on exam. Minimal appendicular ataxia on
the right, possibly a sensory ataxia. Patient's gait was
cautious and unsteady but narrow based. He was able to tandem
fairly well but does appear to have a midline ataxia.
It was felt that this was a fairly unusual constellation of
symptoms, but that the acute onset with accompanying vascular
abnormalities implied a vascular etiology. Patient's prodromal
symptoms during the initial event were thought to be due to
hypotensive episode. Their thougt was that this hypotensive
episode along with possible vertebrobasilar insufficiency may
have led to a small ischemic infarct in the brainstem versus the
cervical spine. There was reportedly possible signal
hyperintensity in the lateral medulla on the left (only seen on
T1 axial) which was thought to line up fairly well with the
patient's symptoms of vertigo and crossed sensory loss. The
patient's new orthostatic hypotension as of unclear etiology.
MSA-C was considered given his orthostatic intolerance and
cerebellar findings, however there was no parkinsonism on exam.
Other degenerative ataxias seemed unlikely given the acute onset
of symptoms and relative stability over the past year and a
half.
His visual symptoms were discussed with Dr. ___ it was
thought that his symptoms are unusual and hard to put all
together. There was question re: visual allesthesia, which is
usually an acute response (to a brainstem event) though this is
resolves pretty quickly and patients ongoing symptoms were
unusual for this. At the she also thought this his symptoms
might be due small brainstem stroke. The other possibility
considered was that he had vestibular concussion as a result of
the initial fall for which vestibular ___ was recommended.
Past Medical History:
RESTLESS LEGS
CORONARY ARTERY DISEASE
LUMBAR SPINAL STENOSIS
HYPERLIPIDEMIA
DEPRESSION
Social History:
___
Family History:
Adopted. FH unknown to him
Physical Exam:
ADMISSION
- General: Awake, cooperative, NAD, poorly groomed, appears
older
than stated age
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
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. BUE were drifting
outwards.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ 5 5 2 2 2 2 2 2 2
R 5 ___ 5 5 5 2 2 2 2 2 2
-DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
-Sensory: Deficits to light touch, pinprick, cold sensation,
starting from mid thigh down to toes worse lateral aspect of
both
legs. Impaired vibratory sense, and proprioception. No
extinction
to DSS.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred
===========
DISCHARGE
- General: Awake, cooperative, NAD, poorly groomed, appears
older
than stated age
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
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.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ 5 5 5 5 5 5 ___
R 5 ___ 5 5 5 5 5 5 ___
*giveway weakness but when distracted is full strength
throughout
+Hoover sign
-DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
-Sensory: Deficits to light touch, pinprick, cold sensation,
starting from mid thigh down to toes worse lateral aspect of
both
legs not in specific dermatome. Impaired vibratory sense, and
proprioception. No extinction to DSS.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred
Pertinent Results:
==========================
IMAGING:
MRI SPINE ___
FINDINGS:
Cervical spine: The alignment is anatomic. The vertebral body
and disc heights are preserved. No vertebral or intervertebral
disc signal abnormality. No cord signal abnormality. Disc bulge
and ligamentum flavum thickening cause mild moderate spinal
canal stenosis at C4-5 and C5-6 without cord compression. No
definite underlying cord signal change. Uncovertebral and facet
osteophytes cause mild left neural foraminal narrowing at C3-4,
severe bilateral neural foraminal narrowing at C4-5, severe
right and moderate left neural foraminal narrowing at C5-6. No
epidural collection. The thyroid is unremarkable.
Thoracic spine: The alignment is anatomic. The vertebral body
and disc heights are preserved. No vertebral or intervertebral
disc signal abnormality. The vertebral body and disc heights are
preserved. No substantial disc bulge. No spinal canal or neural
foraminal narrowing. No cord compression or cord signal
abnormality. No epidural collection. The visualized lungs
demonstrate no focal consolidation or pleural effusion.
Lumbar spine: The alignment is anatomic. The vertebral body and
disc heights are preserved. No vertebral or intervertebral disc
signal abnormality. The conus terminates at T12-L1. No terminal
cord signal abnormality. No epidural collection. At T12-L1,
there are ligamentum flavum thickening mild facet osteophytes
without spinal canal stenosis or neural foraminal narrowing. At
L1-L2, there are ligamentum flavum thickening and bilateral
facet osteophytes without spinal canal stenosis or neural
foraminal narrowing. At L2-L3, there are mild disc bulge,
ligamentum flavum thickening, and facet osteophytes without
spinal canal stenosis or neural foraminal narrowing. At L3-L4,
there are mild disc bulge, ligamentum flavum thickening, and
bilateral facet osteophytes without spinal canal stenosis or
neural foraminal narrowing. At L4-L5, there is similar disc
bulge and worsening right-sided protrusion extending into the
right neural foramen, contacting the exiting L4 nerve root as
before. Right-sided disc protrusion along with worsening right
facet osteophytes cause worsening moderate right neural
foraminal narrowing. No spinal canal stenosis or left neural
foraminal narrowing. At L5-S1, there is disc bulge and facet
osteophytes without spinal canal stenosis or neural foraminal
narrowing. Limited visualization of the abdominal organs are
unremarkable except for a simple cyst in the interpolar region
of the left kidney.
IMPRESSION:
1. Minimal progression of L4-5 right-sided disc protrusion and
facet osteophytes cause slightly more prominent moderate right
neural foraminal narrowing, remodeling/impinging the exiting L4
nerve root.
2. There is no high-grade spinal canal narrowing.
3. Moderate degenerative changes in the cervical spine with
neural foraminal narrowing at C3-4 and C4-5 and mild spinal
canal stenosis C4-5 and C5-6.
4. No cord compression or neural foraminal narrowing of the
thoracic spine.
5. Additional findings as described above.
CT ABDOMEN ___
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 attenuation
throughout. Small subcentimeter hypodense nodules scattered
throughout the liver, too small to characterize (02:11 and 15).
There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
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. Simple
renal cyst measuring 2.3 cm (02:26) in the left kidney, mid
third. Other small subcentimeter hypodense nodules are noted in
the left kidney for over for example series 2, image 31, too
small to characterize.. There is no hydronephrosis. There is no
nephrolithiasis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The visualized
small bowel loops demonstrate normal caliber and wall thickness.
The visualized colon is unremarkable.
LYMPH NODES: There is no evidence of retroperitoneal or
mesenteric lymphadenopathy.
VASCULAR: There is no upper abdominal aortic aneurysm. Moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Moderate thoracolumbar spondylosis. SOFT
TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Moderate atherosclerotic calcification along the aorta.
2. No acute urgent findings.
Brief Hospital Course:
___ year old right-handed man with past medical history
significant for hyperlipidemia, coronary artery disease,
multiple orthopedic injuries and a history of intermittent neuro
deficits with multiple negative work-ups who presented for
evaluation of acute bilateral leg weakness.
#Functional Neurologic Disorder
Patient has had multiple extensive work-ups since ___ for
various neurological complaints by different providers which has
all been unremarkable (has seen epilepsy, movement, autonomic
and cardiology specialists). He has carried a diagnosis of
function neurologic disorder in the past. He presented this
admission with acute onset bilateral leg weakness and sensory
loss. MRI total spine revealed worsening degenerative disease in
the cervical and lumbar spine without any acute pathology. These
findings are out of proportion to his complaints/examination. On
confrontational testing has at least 4+/5 strength in his lower
extremities, a positive Hoover sign, and sensory loss in a
non-dermatomal distribution consistent with functional disorder.
Given his history of vascular risk factors, spinal AVM is on the
differential but is unlikely. CT abdomen shows severe
atherosclerotic disease.
#CAD
Continue ASA 81mg daily. Start statin per below
#Atherosclerosis
LDL is 190. Patient has been on atorvastatin in the past.
Restart statin
#DJD
Restart amitriptyline and escitalopram (last filled in ___
Transitional Issues:
Follow-up with PCP regarding lipid management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO QHS
2. Escitalopram Oxalate 10 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Nicotine Patch 7 mg/day TD DAILY
2. Atorvastatin 80 mg PO QPM
3. Amitriptyline 25 mg PO QHS
4. Aspirin 81 mg PO DAILY
5. Escitalopram Oxalate 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Functional Neurologic Disorder
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 hospital for leg weakness. Imaging of
your spine showed known arthritis, but otherwise nothing
concerning. We did imaging of your abdomen (stomach area) to
look at the blood vessels, which show a lot of plaque. Because
you have heart disease, we are recommending that you start a
statin to help decrease the amount of plaque in your body. Your
bad cholesterol level is very high. Your symptoms will get
better over time, with physical therapy and stress reduction.
Thank you for involving us in your care.
Sincerely,
___ Neurology
Followup Instructions:
___
|
10594556-DS-16 | 10,594,556 | 26,829,455 | DS | 16 | 2119-02-22 00:00:00 | 2119-02-22 19:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea and hypotension
Major Surgical or Invasive Procedure:
Chest tube
endobronchial biopsy
History of Present Illness:
This is a ___ year old female patient, former smoker, h/o RCC s/p
nephrectomy in ___, and DCIS s/p right mastectomy and
reconstruction in ___ who originally presented to ___
___ on ___ with worsening DOE and cough and is now
being admitted to the ICU with hypotension in the setting of a
large PTX during a pleuracentesis today.
.
Current course begins with her DOE starting about 1 month ago
and a mild cough that started a few weeks ago. At the time her
husband had a URI and she thought she had caught his infection.
She continued to have dyspnea on exertion (never at rest). No
chest pain with exertion. No fevers, chills or night sweats. No
orthopnea or PND. She also notes that about 3 weeks ago she
significantly lost her appetite.
.
Yesterday she decided to go to the ___ for further
evaluation (of note she is in between PCPs). At the ___ a
CXR there showed a large left pleural effusion. She was referred
to ___ for a pulmonology consult and thoracentesis. She
subsequently got a thoracentesis by IP earlier today. 2L of
fluid removed. Post-procedure CT showed large left PTX (40-50%)
and concern for an endobronchial lesion. She was subsequently
sent to the ___ for chest tube placement.
.
On arrival to the ___, initial vitals were 98.2 110 137/79 20 98%
RA. A chest tube was placed by ___. She received several doses
of IV dilaudid. She was going to be admitted to the floor when
she all of a sudden felt light-headed and diaphoretic. No chest
pain or worsening of her SOB at that time. Her family asked that
they check her BP and it was 52/47. She was given 2L and her
blood pressures went back up to the low 100s. Her symptoms
quickly resolved and she appeared well looking throughout the
rest of her ___ course. Her BPs however remained somewhat labile
and so it was decided to send her to the ICU instead of the
floor. No fevers. Received total of 2L. Chest tube with 250cc
serosangenous fluid. VS prior to transfer were 105/58 23 98%.
.
On arrival to the MICU she appears well and is breathing
comfortably on room air and surrounded by her family.
Past Medical History:
RCC s/p nephrectomy ___
DCIS s/p right mastectomy and breast reconstruction ___ with
silicone implant
HTN
Hyperlipidemia
chronic renal insufficiency
s/p hysterectomy (still has both ovaries)
s/p cervical fusion
Social History:
___
Family History:
None pertinent to this hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 102/60 Hr 70 RR 19 975 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreasedbreath sound at left lung base. chest tube on
left side hooked to suction draining serosanguinous fluid
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred
DISCHARGE PHYSICAL EXAM
Vitals: T 97.4 BP 117/67 P 79 RR 18 O2 sat 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased breath sound at left lung base (unchanged from
yesterday). chest tube on left on water seal
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred
.
Pertinent Results:
ADMISSION LABS
___ 05:45PM BLOOD WBC-22.4* RBC-5.25 Hgb-15.0 Hct-46.3
MCV-88 MCH-28.6 MCHC-32.4 RDW-13.0 Plt ___
___ 05:45PM BLOOD Neuts-87.6* Lymphs-8.1* Monos-3.1 Eos-0.6
Baso-0.5
___ 05:45PM BLOOD Plt ___
___ 05:45PM BLOOD Glucose-95 UreaN-35* Creat-1.6* Na-138
K-4.5 Cl-99 HCO3-24 AnGap-20
Relevant Studies
Pleural Fluid Studies
___ 03:25PM PLEURAL WBC-400* RBC-280* Polys-16* Lymphs-17*
___ Meso-4* Macro-50* Other-13*
___ 03:25PM PLEURAL TotProt-5.5 Glucose-128 LD(LDH)-124
Albumin-3.4 Cholest-
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Pleural fluid: NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, and lymphocytes.
___ 11:39 am BRONCHIAL WASHINGS Site: LOWER LOBE
LT LOWER LOBE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary):
___ 11:39 am BRONCHIAL WASHINGS Site: LOBE LOWER
LOBE.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
IMAGING:
___ CXR
FINDINGS: Single portable view of the chest compared to
previous exam from
earlier same day at 6:32 p.m. There has been interval placement
of a
left-sided chest tube seen projecting over left lung base, side
port within
the thoracic cavity. Overlying subcutaneous gas is identified.
Pneumothorax
seen at the lower chest on prior has resolved. There is still
subtle lucency
adjacent to the AP window suggesting persistent pneumothorax,
although no
discrete pleural line is identified. Right lung remains clear.
Cardiomediastinal silhouette is stable as are the osseous
structures.
IMPRESSION: Interval placement of left-sided chest tube with
decrease in size
of pneumothorax which may persist medially.
___ CXR
Comparison is made with the prior study performed four hours
earlier.
Left chest tube has been removed. There is no evident
pneumothorax.
Cardiomediastinal contours and left lower collapse are
unchanged. Right lower
lobe atelectasis is stable.
CT CHEST:
1. The patient has prior history of breast cancer and renal
cell carcinoma. Thoracocentesis was done today for left pleural
effusion. There is a pneumothorax that measures up to 3 cm.
Left upper lobe opacities are compatible with re-expansion
edema. Residual left pleural effusion is small.
2. Left lower lobe is completely collapsed by an endobronchial
lesion.
Bronchoscopy is suggested.
3. Few less than 4-mm soft tissue lung nodules are seen in
right lung. There is also one dominant ground glass opacity in
right upper lobe measuring 9 mm.
These nodules will have to be followed up in three months and
they are
indeterminate.
Brief Hospital Course:
Ms. ___ is a ___ with a h/o RCC (s/p nephrectomy in ___ and
DCIS (s/p right mastectomy and reconstruction in ___ who
originally presented to ___ on ___ with
dyspnea and was found to have a new pleural effusion of unclear
etiology. She was admitted to the MICU for hypotension after a
large volume thoracentesis complicated by pneumothorax.
#. Hypotension: The patient was noted to have SBPs in the ___ on
presentation to the ___. The hypotensive reading most likely a
false reading, given repeats were higher in the ___. Symptoms of
lightheadedness resolved with fluids and patient remained
asymptomatic overnight and during the remainder of the hospital
course.
#. Pneumothorax: A result of her procedure. The patient had a
chest tube placed in the ___ which was put to suction -20mmHg.
Interventional pulm provided recommendations regarding chest
tube management during the hospital course. The chest tube was
initially hooked to suction -20mmHg on hospital day 1 and 2.
Repeat CXR showed millimetric left apical lateral pneumothorax
without evidence of tension of the pneumohthorax. The chest tube
was then hooked to water seal on hospital day 3. Repeat CXR
showed a small pneumothorax with near complete resolution. On
hospital day 4 the chest tube was clamped for 2 hours and follow
up CXR showed an unchanged tiny left apical pneumothorax. The
chest tube was subsequently removed and final CXR showed no
evident pneumothorax.
# Pleural Effusion, presumed malignant: The patient pleural
fluid studies are consistent with an exudative process by
Light's criteria. There was initial concern for a malignant
effusion given history of RCC and DCIS. She could also have a
new lung cancer given smoking history and possible endobronchial
lesion seen on CT. Cytology was ultimately negative for
malignant cells.
# Endobronchial lesion-The patient was found to have an
endobronchial lesion on CT chest, with concern for possible
metastatis in the setting of previous RCC and breast CA. or a
possible primary lung malignancy given patient's smoking
history. The patient underwent an endobronchial biopsy for
further evaluation of the lesion and BAL washings were sent. She
will follow up with Dr. ___ in THORACIC ___ to for
follow up the biopsy results.
- Biopsy results pending, but her IP, consistent with
malignancy. She has close follow up with IP to discuss these
findings
Chronic Issues
Hyperlipidemia: continue home lipitor
Transitional Issues
-follow up endobronchial biopsy results and BAL washings
-follow up with IP
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth 6Qh Disp #*20 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis-Pneumothroax
Secondary Diagnosis- endobronchial lesion
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 to the hospital because you had a partially collapsed
lung (pneumothorax). You had a chest tube placed which helped
the lung re-expand. You were also noted to have a lesion in the
lung which was biopsied by interventional pulmonary. The results
of this test are still pending; you can follow up with your
pulmonologists to discuss the results at your upcoming
appointment (see below).
Followup Instructions:
___
|
10594556-DS-20 | 10,594,556 | 28,732,227 | DS | 20 | 2119-10-15 00:00:00 | 2119-10-30 22:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meropenem
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Flexible Bronchoscopy
History of Present Illness:
___ with RCC s/p R nephrectomy (___), R breast DCIS CA (s/p
mastectomy in ___, and recently diagnosed non-small cell lung
cancer (Dx in ___ by biopsy, 30 pack-year history of
smoking, last Chemo was cycle 5 of pemetrexed given on
___, presents with increased shortness of breath and fever
of 102.
Patient was recently discharged ___ (12 days PTA) for LLL
pneumonia (cavitation within left lower lobe lesion) and was
d/c'ed home on Piperacillin-Tazobactam for a planned two week
course (to end on ___. During that admission never had
drainage by IP as it was suspected that she had an abscess (per
ID recs). Of note, She received transfusion of 1 unit PRBC for
Hct 21 on that admission.
In regards to this presentation, Patient states that her on
___ she first noted low grade fevers of 100.1 - 100.6, then
she started to feel shortness of breath. On ___ and ___
her fevers were up to 101.9 and her shortness of breath was
worse, with tachypnea and requiring to rest frequently between
short walks. At baseline she does not require oxygen. She
called her oncologist on ___ who wanted her to come in for
evaluation.
Pt has a chronic cough that is still present and not worse from
before, non productive of sputum but can induce emesis. Pt
Denies any CP, denies ___ Edema or any other swelling. Does
endorse diarrhea that started after discharge but in last
several days has become a little more formed. No blood in stool,
no blood in urine. Denies HA, change in gait, and no confusion.
No skin breakdown or new rash. No urinary symptoms. No
abdominal pain. Also, Pt had PICC line that was placed on ___
during last admission but denies any pain/purulence.
Saw Dr. ___ in office ___ who planned to start chemo end
of this week or next.
In the ED, initial VS: 98.9 65 153/75 16 98% RA, did require 2L
NC after she was dyspneic. Labs notable for WBC 11 with 87N,
Hct 25 (baseline 25 - 33), lactate 1.3, Cr 0.9, K 3.1.
CXR showed stable L sided opacity with air-fluid level and
effusion both stable from prior imaging. Blood cultures were
drawn peripherally x1 and from ___ and then PICC was removed
and tip sent for culture. She was given Tylenol, Vanco IV,
Cefepime, Benadryl, KCl, Codeine for cough. She developed a rash
at infusion site with Vanco so rate was slowed down and Benadryl
given.
VS at transfer: 101.0 69 145/94 16 93% RA.
On arrival to the floor, patient is not in acute distress and is
a good historian. Her husband is at bedside. She is afebrile,
with 2L NC, minimal accessory muscle use. Recounts above
information
Past Medical History:
PAST MEDICAL HISTORY:
___ s/p R nephrectomy in ___
DCIS s/p R mastectomy and breast reconstruction with silicone
implant in ___
Hypertension
Hyperlipidemia
Chronic kidney disease
S/p hysterectomy (still has both ovaries)
S/p cervical fusion
PAST ONCOLOGIC HISTORY: (adapted from Dr. ___ ___
progress note):
___: Presented to ___ with SOB and cough, and was
found to have a left sided pleural effusion.
___: Underwent diagnostic and therapeutic
thoracentesis complicated by pneumothorax and hypotension. She
was admitted to ___ for chest tube placement and management.
Pleural fluid and cultures showed no evidence of infx. Pleural
cytology was negative for malignant cells. CT showed complete
LLL collapse and an endobronchial lesion. She underwent
bronchoscopy, BAL cx showed no pathologic organism for infx, but
bx showed lung adenocarcinoma.
___ Chest CT: LLL remains collapsed. LLL bronchus ends
abruptly as it enters the collapsed lung and irregular contour
is concerning for an underlying mass at this region. LUL has re
expanded from prior imaging on ___. Few GGO and nodules in
lungs. Several < 1 cm lymph nodes in the mediastinum and some
are calcified suggesting granulomatous exposure.
___ Brain MRI: No evidence of metastatic disease
___. Large, necrotic, FDG avid left lower lobe
mass with mildly FDG avid moderate sized left pleural effusion,
which has slightly increased from the prior study. The left
pleural air has decreased with minimal residual pneumothorax. 2.
FDG avid mediastinal lymph nodes as described above. 3. 1-cm
left adrenal nodule with mild FDG avidity may represent an
adrenal metastasis.
___ EBUS-TBNA of 7 and 2-level lymph nodes which were
consistent with malignancy
___ Wk 3 of ___
___ Developed drug rash
___ Chemo changed to Navelbine
___ Chemotherapy held for fevers and low counts
___ No additional chemotherapy recommended at this time
___ Completion of radiation therapy w/ 5400 cGy total dose
___ C1D1 pemetrexed
Social History:
___
Family History:
Mother - Cardiac
Father - ___
Brother - CLL
Nephew - ___
3 children, 5 granddaughters, and 1 grandson in good health.
Physical Exam:
VITALS: 98.8/101, 158/64, 62, 18, 96 2L, 164 lbs.
I/O: none, admitted, notes 1BM today, and urinating well today
LAST Fever: ED 101.0 (___)
GENERAL: Looks chronically ill but not acutely in distress.
Huisband at bedside. Fully oriented.
HEENT: Conjuctival pallor appreciated, EOMI, PERRLA, anicteric
sclera, Dry mucosa.
NECK: supple, no JVD
CARDIAC: rhythm is regular, rate in the ___, +S1/S2, no extra
sounds
AXILLA: Dry
LUNG: Speaking in full sentences, 2L NC in place, minimal
accessory muscle use. Rate in the upper teens, Expiratory
wheezing appreciated medially, Crackles appreciated at bases
more on the left with dullness to percussion on the left base to
about ___.
ABDOMEN: Liver appreciated about 4 finger breaths inferior to
costal margin, no fluid wave, non tender and without rebound,
+BS, no rebound/guarding
EXTREMITIES: Skin is dry and warm. No ___ Edema. 2+ DP pulses
bilaterally
NEURO: CN ___ intact, moving all extremities, Oriented x 3
fully.
========================
DISCHARGE:
ITALS: 98.___.3, 142/72, 72, 95RA
I/O: 200/900 (8h), 1.1/1.7 (24h), 3BM yesterday
LAST FEVER: 101.0 (___)
GENERAL: Awake this morning. Looks well. Says she feels well and
ready about going home
HEENT: Anicteric sclera, mucosa moist compared to yesterday.
NECK: supple, no JVD
CARDIAC: rhythm is regular, hr ~ 80s, +S1/S2, no extra sounds
LUNG: Speaking in full sentences, on Room air and comfortable,
no accessory muscle use, Overall unchanged from yesterday and
looks well. Left base still decreased sounds compared to Right,
unchanged. Expiratory wheezing not appreciated again
ABDOMEN: Non tender, +BS, no rebound/guarding
EXTREMITIES: Skin is dry and warm. No ___ Edema. 2+ DP pulses
bilaterally
NEURO: CN ___ intact, moving all extremities, Oriented x 3
fully, gets out of bed on her own
ACCESS: Right Portacath
Pertinent Results:
ADMISSION:
___ 12:00PM BLOOD WBC-11.0 RBC-2.70* Hgb-7.9* Hct-25.7*
MCV-95 MCH-29.4 MCHC-30.9* RDW-15.1 Plt ___
___ 12:00PM BLOOD Neuts-86.8* Lymphs-6.8* Monos-5.4 Eos-0.5
Baso-0.5
___ 06:35AM BLOOD ___
___ 12:00PM BLOOD Glucose-83 UreaN-15 Creat-0.9 Na-141
K-3.1* Cl-104 HCO3-25 AnGap-15
___ 06:35AM BLOOD proBNP-3473*
___ 06:35AM BLOOD ALT-13 AST-15 LD(LDH)-158 AlkPhos-139*
TotBili-0.2
___ 12:11PM BLOOD Lactate-1.3
MICRO:
___ B-GLUCAN-Test NEG
___ ASPERGILLUS GALACTOMANNAN ANTIGEN NEG
___ BLOOD CX: NGTD, Pending
___ PICC TIP CX: Negative
- CDIFF: NEG
- AFB: No AFB seen
- Legionella Urine: NEG
___ BAL:
___ 11:00 am BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. ~1000/ML.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)
(Pending):
IMAGING:
(___) CXR PA/LAT:
FINDINGS: PA and lateral chest radiographs were provided. A left
PICC terminates in the upper SVC. Compared to the most recent
radiograph, there is again dense consolidation in the left lung
with air bronchograms in the upper lobe, similar in appearance
to the prior exam. Again seen is a lucency with an air-fluid
level in the left lower lobe corresponding to the cavitary
lesion seen on the chest CT. There is a layering left pleural
effusion, similar in size to the prior study. There is no
pneumothorax. The right lung is essentially clear. The
cardiomediastinal silhouette is unchanged. The bones are intact.
IMPRESSION:
1. Left PICC in the upper SVC.
2. Dense consolidation in the left lung, similar to the prior
exam.
3. Cavitary lesion in left lower lobe as seen on the prior CT.
4. Layering left pleural effusion
(___) CT:
-- Left lung: Since the prior study there has been further dense
consolidation of virtually the entire left lung. Small areas in
the left upper lobe of aerated lung that are not completely
consolidated also demonstrate extensive infection with numerous
nodular opacities. The cavitated part of the lesion in the left
lower lobe grossly measures 4.1 x 2.3 cm. This is overall
similar in size compared to the prior study.
- Right lung: Since the prior study, there are new areas of
both consolidation and ___ opacities in the posterior
basal segment of the right lower lobe as well as the right
middle lobe.
The parenchymal findings are most consistent with worsening
overall infection. As postulate0d earlier the cavitation within
the left lower lobe lesion may be due to treatment response and
bronchial parenchymal fistula rather than abscess.
(___) Flex Bronch: L-sided pneumonia, extrinsic compression
of LLL bronchus. Estimated blood loss = zero. No specimens were
taken for pathology.
DISCHARGE:
___ 06:02AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1*# Hct-28.0*
MCV-91 MCH-29.7 MCHC-32.5 RDW-15.1 Plt ___
___ 06:02AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-137 K-3.7
Cl-96 HCO3-32 AnGap-13
___ 06:02AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9
Brief Hospital Course:
HOSPITAL COURSE:
___ yo female with NSCLC (Dx ___ who was recently d/c'd on IV
Zosyn x 2weeks for LLL cavitation presented with Sepsis (fevers,
oxygen requirement, wbc elevated). Again source of sepsis was
LLL Necrosis/abscess/post obstructive pneumonia. Started on
broader ABX (Vanc+Imipenem). Also, PICC Line was removed and
tip culture was negative. Flex Bronch done by Pulm (not IP), and
saw frank obstruction with consolidation in left lobe, no area
to intervene, sampled tissue. Recommendation was to discharge
with long course of ABX(Meropenem). ID recommended 2 weeks of
Carbapenem alone. Also, patient was hypertensive so started on
HCTZ + Captopril, transitioned to Lisinopril
TRANSITIONAL
- BAL Labs pending on discharge
- Pulm follow up in ___ weeks
- F/U on Hypertension as an outpatient (discharged with HCTZ and
Lisinopril)
- Two weeks of Antibiotics (meropenem) will end on: ___
# HYPOXEMIA - Admitted to floor with 3L NC. Patient is on RA at
home. Etiology likely worsenign pulmonary infection as above.
No history of COPD exacerbations and patient was witout wheezing
on exam. We restarted the patient's home HCTZ. We weaned the
patient to room air during her stay. On Ambulatory pulse ox,
patient had SaO2 of 86-88% on Room Air, and 92%+ on 2L. She
will require 2L NC for ambulation on discharge.
- TRANSITIONAL
--- NC Oxygen required for ambulation at home
--- Pulm toilet with acapella
--- ABx as above
# Hypertension: On HD2 and 3 patient's SBP was 160s-170s.
Responded to HCTZ + Captopril, which was transitioned to
Lisinopril. For two days prior to discharge the SBP range was
130-150 on 10mg Lisinopril
- TRANSITIONAL
--- Continue HCTZ 25mg/day
--- Continue Lisinopril 10mg/day
--- Monitor electrolytes and BP at subsequent PCP visits
-------------------
CHRONIC OR RESOLVED
-------=-----------
## Non Small Cell Lung Cancer - ECOG 2. The goal is palliative
to decrease symptoms and prolong life span. The median survival
ranges between 10 and 12 months.
Last appointment with Dr. ___ on ___ and at that time
plan was to delay chemotherapy for another week, until after she
completed IV ABx.
DIAGNOSIS:
1. Metastatic nonsmall cell lung cancer (adenocarcinoma with
KRAS G12C mutation)
TREATMENT:
1. Status post weekly carboplatin 2 AUC and paclitaxel 50 mg/m2
from ___ to ___
2. Status post vinorelbine 30 mg/m2 D1, D8 and D15 of 21 day
cycle; last dose on ___
3. Status post 4500 cGy of radiotherapy to left lower lobe lung
and mediastinum from ___ to ___
4. Status post 5 cycles of pemetrexed 500 mg/m2 from ___ to
___.
## Elevated INR - 1.5 on admission, was 1.3 after 3 days of PO
Vitamin K. Never had any bleeding episodes. Etiology likely
related to nutrition.
## GERD - We continued home omeprazole + famotidine
## Chronic Anemia - Hct on admission 25.7 (prior range 25 - 33).
etiology likely chemo and disease related. We never transfused
the patient on this admission as her Hct range was 23.7 - 25.7.
Stools Guaiac NEG, hapto elevated, Fe studies show ACD.
## CODE: FULL
## EMERGENCY CONTACT: ___ (Daughter, HCP): ___
Cell phone: ___ n
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Piperacillin-Tazobactam 4.5 g IV Q8H
the visiting nurses and infusion company ___ train you to give
the antibiotic
2. Citalopram 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lorazepam 0.5 mg PO Q4H:PRN nausea, anxiety
5. Omeprazole 40 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
8. Heparin Flush (10 units/ml) 5 mL IV DAILY
PICC flush + SASH
9. Codeine Sulfate ___ mg PO Q4H:PRN cough
This medication is constipating. you may need more bowel
medications to stay regular
10. Acetaminophen 650 mg PO Q6H:PRN fever or pain
Keep a record of your fevers, when and how high, to review with
Dr. ___
11. Benzonatate 100 mg PO TID
12. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<110
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever or pain
2. Benzonatate 100 mg PO TID:PRN cough
3. Citalopram 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Heparin Flush (10 units/ml) 5 mL IV DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Lorazepam 0.5 mg PO Q6H:PRN nausea, anxiety
8. Omeprazole 40 mg PO DAILY
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
10. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
11. traZODONE 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth HS Disp #*15 Tablet
Refills:*0
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
14. Guaifenesin ___ mL PO Q6H:PRN cough
15. Imipenem-Cilastatin 500 mg IV Q6H
RX *imipenem-cilastatin 500 mg 1 injection IV every six (6)
hours Disp #*54 Vial Refills:*0
16. Home oxygen
Please wear supplemental O2 with ___ via NC with ambulation
only for SpO2 < 88%. Patient recovers to 92+% on 2L NC
ambulating. Resting RA SpO2 94%. Pulse dose for portability. Dx
pneumonia, lung cancer.
17. Psyllium Wafer 1 WAF PO BID
RX *psyllium [Metamucil] 1 wafer by mouth daily Disp #*15
Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- Sepsis
- Post Obstructive Pneumonia
- Hypertension
SECONDARY
- Non Small Cell Lung Cancer Metastatic mediastinal and right
supraclavicular lymph nodes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted due to fever and difficulty breathing. You
were found to have a severe infection in your left lung. We
removed your prior PICC Line and we treated you with antibiotics
through the vein, and these will continue after you are
discharged. We used a camera to look into the lungs
(bronchoscopy) and saw an obstructing pneumonia that will
require more IV antibiotics. We placed a new PICC Line for the
antibiotics to be given when you are at home.
Please continue using the breathing machine (Acapella device),
and continue physical therapy to regain your strength.
You should wear oxygen when walking around or exerting yourself
or when you feel short of breath. You do not otherwise need to
wear the oxygen at rest.
Have a great rest of your Spring and Summer!
Followup Instructions:
___
|
10594556-DS-22 | 10,594,556 | 22,079,141 | DS | 22 | 2119-12-03 00:00:00 | 2119-12-13 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meropenem
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ tobacco abuse with history of RCC s/p right nephrectomy
(___), right DCIS s/p right mastectomy in ___, KRAS+ ___
diagnosed ___ (stage IIIb) currently undergoing cycle 6 of
Pemetrexed, history of multiple recent necrotic pneumonias
secondary presumed suprainfection of necrotic tumor in her left
lung presenting with fever. She was recently admitted for fevers
from ___. She was started on broad-spectrum
antibiotics (vancomycin, cefepime, ciprofloxacin in the ER,
imipenem while on floor). ID and pulmonary were consulted for
recommendations given chronic pneumonias related to her left
necrotic lung. Per pulmonary, the patient's previous unambiguous
response to antibiotic leaves little doubt that she had
necrotizing bacterial pneumonia during prior admissions. It was
advised to consider prolonged antibiotic therapy as if
presentation were lung abscess. ID was consulted with impression
that absence of pulmonary symptoms as well as findings on CT are
not suggestive of recurrent pneumonia. It was ultimately decided
to watch her for 24 hours off of antibiotics. She was afebrile
and subsequently discharged.
The patient had called Dr. ___ on ___ stating that the
patient spiked a fever to >101 (specifically 102.3) the evening
of ___. It was advised that she present to the ER for IV
antibiotics and further work-up given low cardiopulmonary
reserve. The patient and her husband decided to stay home and
monitor her temperature from home. Overnight ___, her
temperature again was >102. Her husband thought she was
wheezing in her sleep. The patient reports she feels well and
has not had any symptoms at all except for fever, including no
wheezing or dyspnea that she's been aware of.
Currently the patient states that she feels well and is not
dyspneic. She has a mild cough that is unchaged from baseline
with no chest pain or other associated symptoms. Per prior
discharge summaries in ___ and ___, the patient has had
prior complex hospital courses. Please see prior OMED accept
note for full details.
In the ED, initial VS were: 10:27 0 99.6 105 124/58 18 96%
She received:
- NS 1000 mL bolus x 1
- imipenem-cilastatin 500 mg IV x 1
- ciprofloxacin 400 mg IV x 1 during which there was itching at
the IV site, so the medication was stopped
(- she was ordered for vancomycin, but never received it)
Labs were performed:
- WBC 7.6 Hgb 10.2 (10.6 - 11.8) Plt 263 Diff N90.9 L5.2
- ___ 13.7 INR 1.3
- Na 134 K 3.9 Cl 99 HCO3 24 BUN 25 Cr 1 (baseline Cr 0.7,
recently 0.7 - 0.8) Ca 9.9 Ph 2.3 Mg 1.5
- lactate 0.7
- urinalysis with trace leuks, negative nitrites, 30 protein,
trace ketones, <1 RBC, 2 WBC, no bacteria, 1 epi
- urine, blood cultures sent
- B-glucan, aspergillus galactomannan antigen were obtained
CXR was performed: near complete opacification of left
hemithorax unchanged in appearance from prior exam with air
bronchograms. Right lung appears to be clear.
VS on transfer: 13:59 99.1 84 111/71 18 99%
Past Medical History:
PAST ONCOLOGIC HISTORY:
From Dr. ___ dated ___
___: Presented to ___ with SOB and cough, and was
found to have a left sided pleural effusion.
___: Underwent diagnostic and therapeutic
thoracentesis complicated by pneumothorax and hypotension. She
was admitted to ___ for chest tube placement and management.
Pleural fluid and cultures showed no evidence of infx. Pleural
cytology was negative for malignant cells. CT showed complete
LLL collapse and an endobronchial lesion. She underwent
bronchoscopy, BAL cx showed no pathologic organism for infx, but
bx showed lung adenocarcinoma.
___ Chest CT: LLL remains collapsed. LLL bronchus ends
abruptly as it enters the collapsed lung and irregular contour
is concerning for an underlying mass at this region. LUL has re
expanded from prior imaging on ___. Few GGO and nodules in
lungs. Several < 1 cm lymph nodes in the mediastinum and some
are calcified suggesting granulomatous exposure.
___ Brain MRI: No evidence of metastatic disease
___. Large, necrotic, FDG avid left lower lobe
mass with mildly FDG avid moderate sized left pleural effusion,
which has slightly increased from the prior study. The left
pleural air has decreased with minimal residual pneumothorax. 2.
FDG avid mediastinal lymph nodes as described above. 3. 1-cm
left adrenal nodule with mild FDG avidity may represent an
adrenal metastasis.
___ EBUS-TBNA of 7 and 2-level lymph nodes which were
consistent with malignancy
___ Wk 3 of ___
___ Developed drug rash
___ Chemo changed to Navelbine
___ Chemotherapy held for fevers and low counts
___ No additional chemotherapy recommended at this time
___ Completion of radiation therapy ___/ 5400 cGy total dose
On ___ she had her first dose of Pemetrexed. On ___ she was hospitalized because of weakness, fever,nausea and
vomiting. The fever resolved spontaneously. She underwent an EGD
which showed only gastritis. She slowly improved and was
discharged on ___. Subsequently she received four more
doses of Pemetrexed.
She had an admission in ___ with culture negative pneumonia
treated with zosyn.
She had a recurrent pneumonia in ___ and was discharged with
imipenem. Her antibiotics were stopped ___.
PAST MEDICAL HISTORY:
___ s/p right nephrectomy ___
DCIS s/p right mastectomy and breast reconstruction ___ with
silicone implant
HTN
Hyperlipidemia
chronic renal insufficiency
s/p hysterectomy (still has both ovaries)
s/p cervical fusion
Social History:
___
Family History:
Mother - Cardiac
Father - ___
Brother - CLL
Nephew - ___
3 children, 5 granddaughters, and 1 grandson in good health.
Physical Exam:
Admission:
Vitals: 98.6, 100/58, 90, 18, 96% RA
General: well appearing elderly female, sitting in chair,
speaking in full sentences, appears comfortable
HEENT: fair to poor dentition, no oral lesions, no lip or tongue
swelling
CV: RR, nl rate, flow murmur
Lungs: largely clear to auscultation bilaterally, decreased
sounds left base
Abdomen: soft, nontender, nondistended, positive bowel sounds
GU: no foley
Ext: warm, well perfused, no edema
Neuro: grossly intact, alert
Skin: no rashes
Psych: pleasant
Discharge:
Vitals: 100.0/98.8, 102/50-129/71, 68-77, 14, 96-99% RA
General: well appearing elderly female, speaking in full
sentences, appears comfortable
HEENT: fair to poor dentition, no oral lesions, no lip or tongue
swelling
CV: RR, nl rate, flow murmur
Lungs: largely clear to auscultation bilaterally, decreased
sounds left base
Abdomen: soft, nontender, nondistended, positive bowel sounds
GU: no foley
Ext: warm, well perfused, no edema
Neuro: grossly intact, alert
Pertinent Results:
LABS:
___ 11:10AM BLOOD WBC-7.6 RBC-3.70* Hgb-10.2* Hct-31.2*
MCV-84 MCH-27.4 MCHC-32.6 RDW-15.8* Plt ___
___ 11:10AM BLOOD Neuts-90.9* Lymphs-5.2* Monos-3.4 Eos-0.3
Baso-0.3
___ 06:10AM BLOOD WBC-4.4 RBC-3.42* Hgb-9.5* Hct-28.7*
MCV-84 MCH-27.7 MCHC-33.0 RDW-16.2* Plt ___
___ 06:15AM BLOOD WBC-3.9* RBC-3.48* Hgb-9.7* Hct-29.6*
MCV-85 MCH-28.0 MCHC-32.9 RDW-16.3* Plt ___
___ 06:05AM BLOOD WBC-2.6* RBC-3.49* Hgb-9.8* Hct-29.6*
MCV-85 MCH-28.1 MCHC-33.1 RDW-15.9* Plt ___
___ 06:05AM BLOOD Neuts-75.5* Lymphs-16.5* Monos-6.9
Eos-0.8 Baso-0.3
___ 11:40AM BLOOD ___ PTT-29.1 ___
___ 06:10AM BLOOD ___ PTT-28.8 ___
___ 11:10AM BLOOD Glucose-109* UreaN-25* Creat-1.0 Na-134
K-3.9 Cl-99 HCO3-24 AnGap-15
___ 06:10AM BLOOD Glucose-93 UreaN-18 Creat-1.0 Na-134
K-4.7 Cl-101 HCO3-25 AnGap-13
___ 06:15AM BLOOD Glucose-81 UreaN-17 Creat-0.9 Na-134
K-5.1 Cl-98 HCO3-27 AnGap-14
___ 06:05AM BLOOD Glucose-81 UreaN-15 Creat-1.0 Na-134
K-4.9 Cl-99 HCO3-27 AnGap-13
___ 11:10AM BLOOD ALT-17 AST-12 LD(LDH)-151 AlkPhos-93
TotBili-0.3 DirBili-0.1 IndBili-0.2
___ 06:10AM BLOOD ALT-18 AST-10 LD(___)-113 AlkPhos-90
TotBili-0.3 DirBili-0.1 IndBili-0.2
___ 11:10AM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.3*
Mg-1.5*
___ 06:10AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.4 Mg-2.2
___ 06:15AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8
___ 06:05AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8
___ 11:40AM BLOOD Lactate-0.7
___ 11:10AM BLOOD B-GLUCAN--negative
___ 11:10AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN--negative
___ 02:13PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:13PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-TR
___ 02:13PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
___ 02:13PM URINE CastHy-4*
___ 02:13PM URINE Mucous-RARE
.
MICRO:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
___ URINE Legionella Urinary Antigen -FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
.
CXR PA and Lateral ___:
IMPRESSION: Unchanged opacification of the left hemithorax with
leftward shift of mediastinal structures. Right lung is grossly
clear.
Brief Hospital Course:
___ tobacco abuse with history of ___ s/p right nephrectomy
(___), right DCIS s/p right mastectomy in ___, ___+ ___
diagnosed ___ (stage IIIb) currently undergoing cycle 6 of
Pemetrexed, history of multiple recent necrotic pneumonias
secondary to presumed suprainfection of necrotic tumor in her
left lung re-admitted for fever 2 days after discharge for a
similar admission for fever during which time patient was
discharged without antibiotics. During this admission, the
patient initially received antibiotics, but continued to spike
fevers without exhibiting other symptoms. Eventually, the
antibiotics were stopped because the fevers were thought to be
related to necrotic tumor in the lung, rather than to infection.
# Fevers: Patient recently came into the hospital the day after
having a fever to 102 and then had a fever to 100.4 in the ER.
She was initially treated with cefepime, levofloxacin, and
vancomycin in the ED on that admission and then received one
dose of imipenem on the floor on ___. She looked very well,
had no fevers on the floor, and had no oxygen requirement. CT
chest without contrast showed unchanged appearance of the left
lung, with extensive consolidations, air bronchograms and a left
lower lung cavitary lesion. ID and pulmonary were consulted.
Pulmonary was concerned about ongoing abscess in the lung, but
ID recommended watching the patient off antibiotics, which we
chose to do. She had no further fever or SOB, so we discharged
the patient on ___ she had not had antibiotics since the
imipenem on ___. She's been intermittently febrile to >102
since discharge 48 hours before her current admission. She
received imipenem in the ED on the day of admission (___), and
received a partial dose of ciprofloxacin. On admission to the
floor, she looked well and was afebrile. The cavitary lesion on
CT chest was thought to potentionally related to ongoing lung
abscess. The only active pulmonary symptoms are mild cough and
wheezing noted by husband, but not by patient herself. She has
nothing localizing to the abdomen, mouth, GU tract, skin, limbs,
or CNS. Drug fever is unlikely. She's had fevers with her
cancer that were attributed to the cancer itself, but never this
high without concurrent infection. CXR is unchanged, but not
likely to be sensitive for change in cavitary lesion or lung
abscess. Therefore, we initially treated with imipenem and
consulted pulmonary and ID. ID thought the fevers were very
likely to be related to tumor fever (from necrotic tumor in
lung) and not likely to be due to an infection. Therefore, we
stopped antibiotics. Her respiratory status remained excellent
throughout. She was discharged with ID follow up. Beta glucan
and galactomannan were negative, respiratory viral panel was
negative, and cultures were without significant growth.
# Acute Renal Insufficiency: Her baseline Cr is 0.7 with
admission Cr 1.3 on recent admission, currently 1.0. Seems to
have improved from 1.3 to 1.0 with PO fluids. We continued to
encourage PO fluids, and creatinine remained stable at 0.9-1.0.
# Possible Allergic Reaction to Medication: During last
hospitalization, patient had reaction to vancomycin (? Red man's
syndrome). She also had itchiness during this ER course with
ciprofloxacin infusion. On the floor, she had no signs or
symptoms of allergic reaction.
# Malignancy of Lung, KRAS+ Lung Adenocarcinoma, Stage IIIB: She
is followed by Dr. ___ with goal to provide palliative
approach to symptoms and prolong life span if possible. No
administration of chemotherapy during this admission.
# Hypertension, Benign: She has been off her ACEi. We held HCTZ
during and after last admission given renal function. She was
normotensive during that admission and is normotensive now. We
continued to hold HCTZ.
# GERD: Home omeprazole was continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN cough
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. FoLIC Acid 1 mg PO DAILY
6. Guaifenesin ___ mL PO Q6H:PRN cough
7. Lorazepam 0.5 mg PO Q6H:PRN nausea, anxiety
8. Omeprazole 40 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Acetaminophen 650 mg PO Q6H:PRN fever or pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever or pain
2. Atorvastatin 20 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin ___ mL PO Q6H:PRN cough
8. Lorazepam 0.5 mg PO Q6H:PRN nausea, anxiety
9. Omeprazole 40 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: fever
Secondary: renal cell carcinoma
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 fever. You were seen and
evaluated by pulmonary and infectious disease for your fevers.
It is thought that the fever may represent tumor fever after
your chemotherapy and less likely a recurrent pneumonia. It is
important to continue to monitor your symptoms. For instance, if
you spike high fevers (> 101 degrees F), have shortness of
breath, lethargy, or other concerning symptoms, it is important
to call your physician and discuss these symptoms as you do have
risk factors for recurrent pneumonias.
Followup Instructions:
___
|
10594674-DS-11 | 10,594,674 | 24,925,023 | DS | 11 | 2201-04-14 00:00:00 | 2201-04-14 15:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old right-handed ___ speaking woman with
HTN, HLD, T2DM who presents with right leg weakness upon
awakening at ~1am. Exam was limited by her inattentiveness.
Family member by bedside to provide history.
She was last known well at 10pm on ___ when she went to bed.
She
woke up to go to the bathroom but found that she could not move
her right leg. She thought the right arm was a bit weak but
much
less so then the leg. She noted some right face droop also.
She denies difficulty with understanding language. Denies
slurred
speech. She lives with a family member who called for the
ambulance.
On neuro ROS, denies headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia. Denies difficulties producing
or
comprehending speech. Denies numbness, parasthesiae.
On general review of systems, the pt denies recent fever or
chills. Denies chest pain or palpitations.
Past Medical History:
-GERD
-hypertension,
-cardiac ___ Sima pacemaker imlanted ___ ___lock below His. checked last ___ okay.
-aortic stenosis,
-spinal decompression fracture in ___
-aortic valve replacement on ___ with a 21mm magna
pericardial
valve and coronary artery by-pass.
-hyperlipidemia,
-cataracts bilaterally,
-appendectomy
-distant history of tuberculosis
-frequent urination
-mid DM A1C 7 ___
-EGD ___
-refused colonoscopy.
-shingles vaccine ___
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.1 P: 66 R: 16 BP: 168/95 SaO2: 96% RA
General: lethargic NAD.
HEENT: NC/AT, MMM
Neck: Supple
Pulmonary: CTA
Cardiac: RRR,
Abdomen: soft, NT/ND
Extremities: warm
Neurologic:
-Mental Status: Alert, oriented to self and year. Grossly
inattentive. Language is fluent with normal prosody per family
member. Not dysarthric. Unable to cooperate with reading, naming
and repetition. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect though I
was unable to formally test due to inattention.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right face droop with decreased activation
VIII: unable to test. Grossly intact
IX, X: Palate elevates symmetrically.
XI: poor effort. At least 5- bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
5- to 5 in RUE, LUE, LLE in no particular pattern and limited by
lack of effort and inattention
On initial exam (1:50am), RLE only withdraws versus triple flex
to noxious. Then, After CT scan (~2:10am), RLE able to move side
by side on the bed. Towards the end of my exam (~2:30am), she
lifted her RLE antigravity briefly.
-Sensory: No deficits to light touch throughout. Unable to
cooperate with extinction
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response: w/d on right. Mute on left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
DISCHARGE PHYSICAL EXAM:
Exam notable for no weakness in the leg. R nasolabial fold
flattening also resolved. She was able to walk with a walker (as
she does at home), during which circumduction of the right leg
was noted.
Pertinent Results:
ADMISSION LABS:
___ 02:20AM BLOOD WBC-4.0 RBC-3.31* Hgb-10.1* Hct-30.0*
MCV-91 MCH-30.6 MCHC-33.8 RDW-14.3 Plt ___
___ 06:29AM BLOOD WBC-5.0 RBC-3.10* Hgb-9.2* Hct-28.2*
MCV-91 MCH-29.8 MCHC-32.8 RDW-14.5 Plt ___
___ 02:20AM BLOOD Neuts-54 Bands-0 ___ Monos-18*
Eos-3 Baso-0 Atyps-3* ___ Myelos-0
___ 02:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 02:20AM BLOOD ___ PTT-35.1 ___
___ 02:20AM BLOOD Plt Smr-LOW Plt ___
___ 06:29AM BLOOD Plt ___
___ 02:20AM BLOOD Glucose-119* UreaN-23* Creat-1.1 Na-134
K-5.8* Cl-98 HCO3-24 AnGap-18
___ 06:29AM BLOOD Glucose-127* UreaN-21* Creat-1.1 Na-134
K-4.4 Cl-100 HCO3-26 AnGap-12
___ 02:20AM BLOOD ALT-18 AST-44* AlkPhos-48 TotBili-0.5
___ 02:20AM BLOOD Lipase-50
___ 06:29AM BLOOD cTropnT-<0.01
___ 02:20AM BLOOD Albumin-3.6
___ 06:29AM BLOOD Calcium-8.7 Phos-7.2*# Mg-2.0 Cholest-94
___ 06:29AM BLOOD %HbA1c-6.1* eAG-128*
___ 06:29AM BLOOD Triglyc-85 HDL-33 CHOL/HD-2.8 LDLcalc-44
___ 02:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CTA head and neck ___ (Preliminary Report):
1. No evidence of acute intracranial process. Diffuse deep and
periventricular white matter hypodensities likely reflect
chronic microvascular ischemic disease.
2. CTA head demonstrates no evidence of significant stenosis,
dissection or aneurysm greater than 3 mm.
3. CTA neck shows no high-grade stenosis, dissection or
aneurysm. No evidence of internal carotid artery stenosis by
NASCET criteria.
Ct head ___
No evidence of acute vascular territorial infarction;
sensitivity for small infarcts is quite limited, in the setting
of sequelae of chronic small vessel ischemic disease.
TTE ___
Well seated, normal functioning bioprosthetic aortic valve. Mild
symmetric left ventricular hypertrophy with preserved regional
and global biventricular systolic function. Increased PCWP.
Brief Hospital Course:
Ms. ___ is a ___ year-old right-handed ___ speaking woman
with HTN, HLD, and
T2DM who presented with right leg weakness and right face droop.
She was last known well at 10pm on ___, 3 hours and 50
minutes prior to arrival to ED. NIHSS was initially 5 but
decreased to 3 in roughly 40 minutes. Exam was notable for right
face droop, decreased activation, mild RUE weakness (no drift
and by the time of formal eval was not weaker than the LUE), and
improving RLE weakness (from withdrawal to noxious to moving
spontanesouly antigravity). CT head showed no bleed or large
territory infarct. Given her risk factors, she likely had an
ischemic stroke vs TIA either in the ACA territory or
subcortical region, involving part of the posterior limb of the
internal capsule. We favor the explanation of a subradiographic
ischemic stroke Given her age we opted not to administer IVtPA
beyond 3 hours. She receieved aspirin 325x1 in the ED. Her home
antihypertensives were held and she received halved dose of home
beta-blocker.
Upon admission, we switched ASA to Plavix 75mg daily. The
following day she had essentially no weakness in the leg and
resolved R nasolabial fold flattening. She was able to walk with
a walker, as she does at home, during which circumduction of the
right leg was noted. Repeat CT did not show any obvious
abnormality. CTA revealed some atherosclerosis in bilateral
carotids, but no significant stenosis or occlusion. She was
unable to receive MRI given her pacer. Stroke risk factors
included fasting lipid panel (LDL 44) and HBA1c were
unremarkable except for mildly elevatd HBA1c at 6.1. Myocardial
infarction was ruled out with cardiac enzymes within normal
limits. Trans-thoracic echo revealed a well seated, normal
functioning bioprosthetic aortic valve, mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function, and increased PCWP.
She was evaluated by ___, who recommended discharge to a facility
with skilled rehab services or home with assist.
# Transitional issues:
[ ] Please keep sBP < 140
[ ] Mildly elevatd HBA1c at 6.1
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 44) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - (Plavix 75mg) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
====================================================
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Valsartan 80 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Vitamin D Dose is Unknown PO DAILY
6. esomeprazole magnesium 40 mg oral PRN
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Valsartan 80 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized due to symptoms of right sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
Your risk factors are:elevated blood pressure. While admitted
your blodo pressures were stable. You had an echocardiogram of
your heart that was unremarkable. You were seen by physical
therapy who recommended rehabilitation.
The following changes were made to your medications:
START:
Clopidogrel (Plavix) 75mg by mouth daily
STOP:
Aspirin
Followup Instructions:
___
|
10594674-DS-12 | 10,594,674 | 21,140,732 | DS | 12 | 2201-09-16 00:00:00 | 2201-09-27 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Referred in for pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a very pleasant ___ y/o woman with hx of CABG/AVR
___, remote TB hx, cerebrovascular disease referred into ED
by Dr. ___ ongoing symptoms of cough and general malaise.
She was just seen in clinic by Dr. ___ on ___ for 3 days of
cough productive of green sputum, subjective weakness, and
fatigue. Exam revealed crackles over left lower lung fields. She
was treated for pneumonia with a 5-day course of azithromycin,
however her symptoms have persisted.
Of note, she had a 10-day course of productive cough back in
___ which seems to have responded to a course of
azithromycin.
In the ED, initial vs were: 98.4 57 134/81 18 97% RA
O2 sats remained 95-100% on RA, breathing comfortably.
Labs were notable normal CBC, normal basic chemistries save for
mild hyponatremia 132, lactate 0.7, and bland urinalysis.
CXR on initial ED interp raised concern for RUL opacity.
Patient was given 750mg IV levofloxacin.
The patient was then admitted to the ___ service under
Dr. ___ further management.
Vitals on Transfer: 98.4 60 128/59 19 99% RA
On the floor, vs were: 98.3 140/71 67 18 98%RA
She was lying in bed in NAD, breathing comfortably.
Past Medical History:
-GERD
-hypertension,
-cardiac ___ Sima pacemaker implanted ___ ___lock below His. checked last ___ okay.
-aortic stenosis,
-spinal decompression fracture in ___
-aortic valve replacement on ___ with a 21mm magna
pericardial
valve and coronary artery by-pass.
-hyperlipidemia,
-cataracts bilaterally,
-appendectomy
-distant history of tuberculosis
-frequent urination
-mid DM A1C 7 ___
-EGD ___
-refused colonoscopy.
-shingles vaccine ___ with some shortness of breath. She had
cardiac
testing showing ejection fraction that was normal at 70 percent
on SPECT images and a mild reversible ischemic area involving
three percent of the myocardium. She was discharged on new
medications, isosorbide ER 30 milligrams and given nitroglycerin
tablets 0.4 mg to take PRN. The nitroglycerin caused vomiting so
she stopped it
-CVA symptoms of right sided weakness ___ resulting from an
ACUTE ISCHEMIC STROKE. CT did not show any obvious
abnormality. CTA revealed some atherosclerosis in bilateral
carotids, but no significant stenosis or occlusion. She was
unable to receive MRI given her pacer
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION:
Vitals: 98.3 140/71 67 18 98%RA
General: well-developed, well-appearing, elderly female lying
comfortably in bed in NAD. fully oriented.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, measured at about 6cm at 45
degrees
Lungs: asymmetric crackles in left lower posterior lung field >
right, trace crackles at right base. otherwise clear
CV: normal rate, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
afebrile, vital signs stable. essentially unchanged from above.
breathing comfortably on room air, speaking full sentences
without difficulty.
Pertinent Results:
ADMISSION:
___ 01:30PM BLOOD WBC-5.6 RBC-3.79*# Hgb-11.0* Hct-32.9*
MCV-87 MCH-28.9 MCHC-33.3 RDW-13.1 Plt ___
___ 01:30PM BLOOD Neuts-57.8 ___ Monos-9.0 Eos-2.5
Baso-0.3
___ 01:30PM BLOOD Glucose-115* UreaN-17 Creat-1.0 Na-132*
K-5.1 Cl-97 HCO3-30 AnGap-10
___ 01:45PM BLOOD Lactate-0.7
___ CXR:
FINDINGS:
Patient is status post median sternotomy, CABG, and aortic valve
replacement.
Heart size is top normal. The aorta remains tortuous.
Mediastinal hilar
contours are otherwise unchanged. A left-sided dual-chamber
pacemaker device
is noted determine the right atrium right ventricle, unchanged.
The pulmonary
vasculature is normal. Apart from minimal atelectasis at the
lung bases and
fibronodular scarring within the right upper lobe, the lungs are
clear. No
focal consolidation, pleural effusion or pneumothorax is seen.
Wedge
compression deformity of a vertebral body at the thoracolumbar
junction is
unchanged.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ y/o woman with hx of CABG/AVR ___, remote TB hx,
cerebrovascular disease admitted for ongoing symptoms of cough
and general malaise with question of persistent pneumonia.
ACTIVE ISSUES:
# Cough, malaise, concern for pneumonia: She remained afebrile
and hemodynamically stable without signs of sepsis or
respiratory compromise. Diagnosis of pneumonia in her clinic
appt was evidenced by subjective fevers/sweats, productive
cough, and crackles at left base. While her symptoms have
improved after her course of azithromycin, she is still having
productive cough with persistent left lower lobe crackles. Given
her lingering symptoms, decision was made to treat with
levofloxacin for total 7-day course with renal dosing. Viral
etiology certainly possible but difficult to distinguish. No
exam findings to suggest current CHF or other etiology of SOB.
With levofloxacin and cough medicines, she remained stable and
was discharged home to complete her total 7-day antibiotic
course.
# Constipation: Starting standing colace and senna BID. Likely
related to codeine-guiafenesin cough syrup use recently along
with decreased po intake.
CHRONIC ISSUES:
# HTN: Continued home atenolol and valsartan.
# HLD: Continued home atorva.
# GERD: Pantoprazole while in-house and discharged on home
nexium.
# CAD: Continued home ASA, plavix, atenolol.
# DMII: Continue home metformin since only stayed overnight
without any contrast studies planned.
# CONTACT: Name of health care proxy: ___
Phone number: ___
Cell phone: ___
TRANSITIONAL ISSUES:
- ensure resolution of cough; consider repeat CXR in ___ weeks
after resolution of her respiratory symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. NexIUM (esomeprazole magnesium) 40 mg oral daily
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Valsartan 80 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
8. Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID:PRN
otitis
9. Lactulose 60 mL PO DAILY:PRN constipation
10. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Valsartan 80 mg PO DAILY
8. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth Three times a day
Disp #*30 Capsule Refills:*1
9. Cepastat (Phenol) Lozenge 1 LOZ PO Q4H:PRN cough
RX *phenol [Cepastat] 14.5 mg 1 lozenge by mouth every 4 hours
Disp #*30 Lozenge Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
12. Levofloxacin 750 mg PO Q48H Duration: 3 Doses
Your course of antibiotics will be completed on ___.
RX *levofloxacin 750 mg 1 tablet(s) by mouth Every other day
Disp #*3 Tablet Refills:*0
13. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
14. Lactulose 60 mL PO DAILY:PRN constipation
15. Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID:PRN
otitis
16. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Ongoing pneumonia
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 on ___ due to symptoms of ongoing
pneumonia. You have been given an additional course of
antibiotics to help clear this infection. You were also given
cough medications and bowel medications.
Please be sure to complete the antibiotics as prescribed below.
If you develop any worsening cough, sputum production, fevers,
chills, SOB, chest pain, or other concerning symptoms, please
call your doctor right away.
Followup Instructions:
___
|
10594674-DS-15 | 10,594,674 | 25,345,564 | DS | 15 | 2203-05-05 00:00:00 | 2203-05-05 21:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cough, Gait Instability
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ speaking ___ year old woman with a
complex medical history including CAD s/p CABG, CVA ___ on
plavix, h/o TB, hypertension, AV block s/p pacemaker placement,
aortic stenosis s/p AVR ___ who presents with cough and
fatigue. She has been having a seven day history of cough,
productive, though without hemoptysis. Her son states that she
had a fever to ___ today. Her symptoms are associated with
fatigue, malaise, and night sweats. Her son also feels that she
has been having hallucinations. She has had gait instability,
though no falls. Denies chest pain, nausea, vomiting, diarrhea,
recent travel or sick contacts. She lives home alone, but her
family has been staying with her while she is ill. She did have
a flu vaccine this year. An outpatient provider (unclear per ___
records) prescribed her promethazine with codeine to help with
the cough with minimal relief.
Initial vital signs in the ED: T 99.2 HR 68 BP 120/80 RR 20 96%
RA
Labs were notable for: WBC 5.6 Hgb 9.3 Plt 166. Na 121, Cr 1.0.
Lactate 0.9. Flu swab negative.
She received 500cc NS bolus for hyponatremia. She also received
albuterol and ipratropium neb
On arrival to the floor vitals: 98.8 128/57 83 16 98% RA
She denies chest pain, dyspnea, abdominal pain, nausea,
diarrhea, though endorses constipation. She has been drinking
more in recent days in the setting of her illness- her son
states she has been drinking about ___ oz bottles of water as
well as orange juice. She denies melena/hematochezia. She does
endorse increased urinary frequency, though no dysuria.
Past Medical History:
-GERD
-hypertension,
-cardiac ___ Sima pacemaker implanted ___ ___lock below His. checked last ___ okay.
-aortic stenosis,
-spinal decompression fracture in ___
-aortic valve replacement on ___ with a 21mm magna
pericardial
valve and coronary artery by-pass.
-hyperlipidemia,
-cataracts bilaterally,
-appendectomy
-distant history of tuberculosis
-frequent urination
-mid DM A1C 7 ___
-EGD ___
-refused colonoscopy.
-shingles vaccine ___ with some shortness of breath. She had
cardiac testing showing ejection fraction that was normal at 70
percent on SPECT images and a mild reversible ischemic area
involving three percent of the myocardium. She was discharged on
new medications, isosorbide ER 30 milligrams and given
nitroglycerin tablets 0.4 mg to take PRN. The nitroglycerin
caused vomiting so she stopped it
-CVA symptoms of right sided weakness ___ resulting from an
ACUTE ISCHEMIC STROKE. CT did not show any obvious
abnormality. CTA revealed some atherosclerosis in bilateral
carotids, but no significant stenosis or occlusion. She was
unable to receive MRI given her pacer
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.8 128/57 83 16 98% RA
General: Sitting up, mask covering her face, ill/tired
appearing. Very hoarse voice. Cough throughout exam.
HEENT: Dry mucous membranes
Neck: Soft, supple, full ROM, no JVP
CV: Regular rate and normal rhythm, no m/r/g
Lungs: Diffuse rhonchi bilaterally
Abdomen: Soft, non-tender, nondistended
GU: No foley
Ext: Warm, no ___ edema
Neuro: Alert. Oriented to self and hospital but not date. CN
II-XII intact. Strength ___ in the upper and lower extremities
bilaterally.
Skin: Warm and dry, no rash
DISCHARGE PHYSICAL EXAM:
===========================
VS: 98.4F BP 114-124/68-71 HR ___ RR18 ___ RA
___ ml//910/925ml ++
General: Sitting up, hoarse voice, moving all extremities
HEENT: EOMI, +b/l cataracts, Dry mucous membranes, erythematous
posterior OP,
Neck: Soft, supple, full ROM, no tender lymphadenopathy, no JVP
CV: Regular rate and normal rhythm, no m/r/g
Lungs: clear to auscultation aside from diffuse rhonchi, trace
crackles at bases
Abdomen: Soft, non-tender, nondistended
Ext: Warm, no ___ edema
Neuro: Alert. Oriented to self and hospital still . CN II-XII
intact. Strength ___ in the upper and lower extremities
bilaterally.
Pertinent Results:
ADMISSION LABS:
==================
___ 12:42PM BLOOD WBC-5.6 RBC-3.07* Hgb-9.3* Hct-27.0*
MCV-88 MCH-30.3 MCHC-34.4 RDW-13.2 RDWSD-42.0 Plt ___
___ 12:42PM BLOOD Glucose-151* UreaN-16 Creat-1.0 Na-121*
K-4.3 Cl-85* HCO3-27 AnGap-13
___ 07:20PM BLOOD Mg-1.9
PERTINENT LABS:
===============
___ 05:35AM BLOOD Osmolal-266*
___ 05:40AM BLOOD proBNP-1065*
___ 05:40AM BLOOD T4-8.7
___ 05:35AM BLOOD Cortsol-17.4
DISCHARGE LABS:
================
___ 05:35AM BLOOD WBC-2.9* RBC-2.91* Hgb-8.5* Hct-25.8*
MCV-89 MCH-29.2 MCHC-32.9 RDW-13.3 RDWSD-43.1 Plt ___
___ 05:35AM BLOOD Glucose-115* UreaN-9 Creat-0.9 Na-130*
K-4.1 Cl-
MICRO:
======
FluAPCR and FluBpCR negative
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
IMAGING:
=========
___ CXR: Left chest wall dual lead pacing device is again
seen. Cardiomediastinal silhouette is within normal limits.
Prosthetic aortic valve and median sternotomy wires are again
noted. There is right apical scarring. The lungs are otherwise
clear without consolidation, effusion, or edema. Severe lower
thoracic compression deformity is unchanged from prior.
94* HCO3-25 AnGap-15
___ 05:35AM BLOOD Calcium-8.7 Phos-6.0* Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a complex medical
history including CAD s/p CABG, CVA ___, h/o TB, hypertension,
AV block s/p pacemaker placement, aortic stenosis s/p AVR ___
who presents with cough and fatigue admitted for workup of
hyponatremia and gait instability.
# Hyponatremia: Ms. ___ has a history of recurrent
hyponatremia, though on admission, lower than her usual
baseline, which may have contributed to her confusion reported
by her family as well as gait instability, though has other
likely culprit factors as noted below. Her urine lytes were
consistent with SIADH, likely triggered by intrapulmonary
process. She appears to be taking adequate PO intake at home,
and in fact has increased her fluid intake at home. We suspected
acute worsening of hyponatremia due to low solute intake in the
setting of acute illness; this is supported by correction in
serum Na after IVF challenge. However there is also likely a
degree of SIADH present, which may explain the chronicity of her
hyponatremia. Her volume status was difficult to determine,
especially since she has som basilar crackles on physical exam
and an elevated BNP ~1000 which may suggest volume overloaded,
but trace ___ edema and CXR w/o an acute process and no pulmonary
edema. Her Na initially improved with fluids, but once
euvolemic, improved with a 1.5 L fluid correction. Her nutrition
was also recommended to be optimized by increasing protein
intake with Ensure TID. Other causes of inappropriate ADH
release, with normal thyroid function and cortisol.
# Bronchitis and Laryngitis: Patient had pngoing productive
cough for the week prior to admission which was worsening. She
reported temperature at home to ___. CXR did not show any clear
pneumonia, no clear bacterial foci. Differential included viral
pneumonia (given relative leukopenia) vs atypical pneumonia vs
legionella (given hyponatremia although chronic). She likely had
component of viral laryngitis causing hoarse voice. She was
initially treated empirically for community acquired pneumonia
given no improvement over the past week, ill appearance on exam,
age, and comorbidities. Patient also with some trace crackles
and has received fluids during admission and was given one dose
of oral diuretis, and improved symptomatically. She completed a
course of Azithromycin. She was symptomatically treated with
mucolytics, bronchodilators.
# UTI: UA in the ED was notable for moderate leukocytes and few
bacteria, was initially treated with ceftriaxone as above, but
urine culture was contaminant.
# Gait instability: This was likely multifactorial and secondary
to acute illness, possible UTI, and hyponatremia. Neurological
exam is otherwise non-focal, though mental status was somewhat
off from her baseline. She returned to baseline and was able to
work with physical therapy, with good capacity to be able to go
home on discharge.
Chronic Issues:
# Hyperlipidemia: Continued on atorvastatin
# Hypertension: Continued on atenolol, valsartan
# H/O CVA: Continued on plavix
TRANSITIONAL ISSUES:
===================
-Discharge Na: 130
-Please continue 1.5 L fluid restriction from presumed SIADH
-Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lactulose 60 mL PO DAILY PRN constipation
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Valsartan 80 mg PO DAILY
7. NexIUM (esomeprazole magnesium) 40 mg oral daily
8. Calcium+D (calcium carbonate-vitamin D3) 0 unknown ORAL
Frequency is Unknown
9. Alendronate Sodium 70 mg PO Frequency is Unknown
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lactulose 60 mL PO DAILY PRN constipation
5. Valsartan 80 mg PO DAILY
6. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN Sore throat
RX *benzocaine-menthol [Sore Throat (benzocaine-menth)] 15
mg-2.6 mg 1 lozenge every four hours Disp #*20 Lozenge
Refills:*0
7. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Alendronate Sodium 70 mg PO WEEKLY
10. Calcium+D (calcium carbonate-vitamin D3) ___ unknown ORAL
DAILY
11. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Hyponatremia/SIADH
-Viral bronchitis and laryngitis
Secondary Diagnosis:
-Hyperlipidemia
-Hypertension
-History of CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ after you started
having worsening cough and weakness. You were covered for a
possible pneumonia, but your infection workup and chest xray did
not show any clear infection. You likely had a viral illness
causing irritation of your throat.
While you were here, you were seen by the kidney specialist
about your low sodium. We recommend you limit your fluid intake
to about 1.5 liters.
We wish you the best
Your ___ care team
Followup Instructions:
___
|
10594674-DS-17 | 10,594,674 | 26,246,312 | DS | 17 | 2203-09-30 00:00:00 | 2203-09-30 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dysuria, fatigue, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ CAD s/p CABG, CVA, AVR, AV block s/p PPM, and HTN, with
complicated recent admit for neutropenic fever and diagnosis of
LPL, with DVTs on lovenox nowpresents with worsening cytopenias
requiring transfusion while treated w/ linezolid for UTI at
rehab and continued dysuria. Her daughter notes she is starting
to eat and more alert, talking and making sense, not confused,
knows where she is. She has ongoing leg weakness since last
hospitalization. she moves
legs on commands but when asking about getting up says "I cant".
denies any other pain, SOB, cough. has been afebrile.
Past Medical History:
-GERD
-hypertension,
-cardiac ___ Sima pacemaker implanted ___ ___lock below His. checked last ___ okay.
-aortic stenosis,
-spinal decompression fracture in ___
-aortic valve replacement on ___ with a 21mm magna
pericardial
valve and coronary artery by-pass.
-hyperlipidemia,
-cataracts bilaterally,
-appendectomy
-distant history of tuberculosis
-frequent urination
-mid DM A1C 7 ___
-EGD ___
-refused colonoscopy.
-shingles vaccine ___ with some shortness of breath. She had
cardiac testing showing ejection fraction that was normal at 70
percent on SPECT images and a mild reversible ischemic area
involving three percent of the myocardium. She was discharged on
new medications, isosorbide ER 30 milligrams and given
nitroglycerin tablets 0.4 mg to take PRN. The nitroglycerin
caused vomiting so she stopped it
-CVA symptoms of right sided weakness ___ resulting from an
ACUTE ISCHEMIC STROKE. CT did not show any obvious
abnormality. CTA revealed some atherosclerosis in bilateral
carotids, but no significant stenosis or occlusion. She was
unable to receive MRI given her pacer
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PE:
VITAL SIGNS:
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: mild crackles at bases
GI: BS+, soft, NTND, no masses or hepatosplenomegaly. Large
ecchymoses where she has been injecting heparin
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of upper extr and pt able to bend
knees of both legs and slightly lift off the bed but not lift
much more than that or resist force; per DTR this has been this
way since last hospitalization.
DISCHARGE PE:
VITAL SIGNS: TM 100.5 ___ TC 98.9 122/59 89 18 100%RA
GEN: NAD, awake and alert
HEENT: MMM, no OP lesions, dentition poor, no ulcers
CV: RR, NL S1S2 no S3/S4 MRG
PULM: mild crackles at bases otherwise clear, non-labored
GI: BS+, soft, NTND, no masses or hepatosplenomegaly. Large
ecchymoses secondary to heparin injections
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. strength is ___ of upper extr and pt able to
bend knees of both legs and slightly lift off the bed but not
resist force, wiggles toes, sensation to light touch intact
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-3.6* RBC-2.65* Hgb-8.1* Hct-23.9*
MCV-90 MCH-30.6 MCHC-33.9 RDW-16.8* RDWSD-56.3* Plt Ct-35*#
___ 06:50PM BLOOD Neuts-55 Bands-0 ___ Monos-3* Eos-0
Baso-0 ___ Myelos-0 AbsNeut-1.98 AbsLymp-1.51
AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00*
___ 06:50PM BLOOD Glucose-116* UreaN-24* Creat-1.0 Na-128*
K-3.4 Cl-88* HCO3-29 AnGap-14
___ 07:55AM BLOOD ALT-41* AST-28 LD(LDH)-217 AlkPhos-45
TotBili-0.7
___ 07:55AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
___ 10:03 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
___ 07:04AM BLOOD WBC-7.1 RBC-2.88* Hgb-8.5* Hct-25.7*
MCV-89 MCH-29.5 MCHC-33.1 RDW-17.1* RDWSD-55.1* Plt ___
___ 07:04AM BLOOD Neuts-48 Bands-0 ___ Monos-4* Eos-0
Baso-0 ___ Myelos-0 AbsNeut-3.41 AbsLymp-3.41
AbsMono-0.28 AbsEos-0.00* AbsBaso-0.00*
___ 07:04AM BLOOD Plt Smr-LOW Plt ___
___ 07:04AM BLOOD Glucose-120* UreaN-19 Creat-0.8 Na-131*
K-4.3 Cl-99 HCO3-26 AnGap-10
___ 07:04AM BLOOD ALT-16 AST-17 LD(LDH)-291* AlkPhos-48
TotBili-0.6
___ 07:04AM BLOOD Albumin-2.2* Calcium-8.2* Phos-2.7 Mg-1.9
UricAcd-3.3
IMAGIN:
CXR ___
FINDINGS:
The cardiomediastinal and hilar contours are within normal
limits. A
left-sided pacer and dual leads are in appropriate and unchanged
position. Sternotomy wires are unchanged. Subtle opacities at
the lung bases likely reflect atelectasis. Scarring noted at
the left lung apex. There is no consolidation or pleural
effusion. There is no pneumothorax. Compression deformity in
the lower thoracic spine is unchanged from prior CT.
IMPRESSION:
Subtle bibasilar opacities likely reflects subsegmental
atelectasis. No
consolidation or effusion.
Brief Hospital Course:
A ___ year old ___ speaking female w/ CAD s/p CABG, CVA, AVR,
AV block s/p PPM, and HTN, with complicated recent admit for
neutropenic fever and diagnosis of LPL, with DVTs on lovenox now
presents with dysuria/weakness.
#Fever: T max 100.5 on ___ @ ___, no reoccurrence since then.
Patient denies chills or rigors. No new symptoms besides as
stated in ROS/HPI. Repeat blood and urine cultures PND at
discharge.
#Recurrent UTI: Reported dysuria on admission, and UA w/ marked
pyuria, was on linezolid at rehab (per son 9 days of Zyvox);
does not cover GNs. f/u urine cx neg from ___ and ___ . Given
overall clinical improvement and no true infection found, we
discontinued cefepime (___). We repeated urine culture
___ in the
setting of low grade fever, see above. Urine culture pending at
discharge
#Hyponatremia: Improving. NA+ 128 on admission from 130 on
previous discharge. Possibly hypovolemic given history of poor
appetite but not improving w/ IVF hydration and urine lytes more
c/w SIADH so d/c'd IVF, remains on 1.5L fluid restriction and
NA+ 131 at discharge
#Malnutrition: During previous admission, c/o odynophagia;
initially was started on empiric Fluconazole. EGD on ___ was
relatively unremarkable, but she had more discomfort after EGD.
Fluconazole was switched to Micafungin on ___. For her sxs, she
received Lidocaine Viscous PRN and Magic mouth wash PRN. ENT was
consulted and performed serial throat exams. No longer having
pain. SLP consulted this admission to eval dysphagia, no acute
issues noted
#Thrombocytopenia: Now improving, worsening since last discharge
however would be unusual for LPL to cause rapid decline as is
typically more indolent. Had similar drop last admission while
on prophy lovenox and HIT ruled out inc PF4 & SRA both returned
negative. Etiology may be from sepsis and more recent linezolid
use. currently w/o bleeding. Holding therapeutic lovenox and
Plavix. Did not require transfusions this admission, plt count
103 at discharge
#LPL/Cytopenias: Recent admit w/ neutropenic fever, BM biopsy
showed LPL, also had M spike to > 4000 although this has since
decreased w/o intervention. Dr ___ therapy w/
patient and family, systemic chemotherapy not recommended but
may consider oral agents. She has f/u on ___ and this will be
discussed further.
-cont PO B12 repletion (low last admission) although not primary
cause
#RUE/LLE DVT: Patient was diagnosed with new DVTs on ___. She
was initially treated with Argatroban when team was concerned
for HITT. This was transitioned to a Heparin to Warfarin bridge
w/ Lovenox on discharge however at rehab had supratherapeutic
INR thus was only lovenox (warfarin stopped ___. INR 1.7;
holding anticoagulation given thrombocytopenia as above,
consider restarting with improvement in counts
#H/O CVA: hold Plavix for now given TCPY
#Code status: Do not resuscitate (DNR/DNI) confirmed w/ HCP
#CONTACT: ___ (son, HCP) ___ ___
(daughter) ___
#Dispo: Discharged to ___ on ___ with
follow up appointment on ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Docusate Sodium 200 mg PO BID
3. Senna 17.2 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Calcium Acetate 1334 mg PO TID W/MEALS
8. Cyanocobalamin 1000 mcg PO DAILY
9. TraZODone 50 mg PO QHS
10. Enoxaparin Sodium 60 mg SC Q24H
11. Furosemide 40 mg PO DAILY
12. LORazepam 0.5 mg PO TID:PRN anxiety
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 200 mg PO BID:PRN constipation
hold w/ diarrhea
7. Polyethylene Glycol 17 g PO DAILY
hold w/ diarrhea
8. Senna 17.2 mg PO BID
hold w/ diarrhea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
LPL/Waldenstroms
Dysuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted due to urinary burning, fatigue, weakness. We
thought this may be related to a urinary tract infection;
however, your work up did not reveal this. We repeated the test
and the result is still pending. If it is positive for an
infection, we will notify your providers at ___
center. We supported you with IV fluids and electrolytes and
your symptoms greatly improved. You will follow up in clinic as
stated below with Dr. ___. It was a pleasure taking care of
you. Please call with any questions or concerns.
Followup Instructions:
___
|
10594962-DS-20 | 10,594,962 | 24,340,966 | DS | 20 | 2174-10-10 00:00:00 | 2174-10-11 10:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
Cardiac catheterization - ___.
History of Present Illness:
___ with a past medical history of HTN and HLD who complains of
chest pain x5-6 days. Patient was in the ___ 6
days ago when he started to experience chest pain. He went to a
local hospital, had a stress test, and was told that he "had a
blocked atery" and recommended a cardiac catheterization at that
time. He wanted to get a second opinion and decided to come home
to the ___ for his medical care. Today he presented to ___ ED
due to worsening chest pain. Pain is described as a pressure
sensation and located throughout his entire chest. He denies
radiation to back, neck, or arms. Associated with diaphoresis
and shortness of breath. Episodes last approximately ___ minutes
in duration. Exacerbated by exercise and relieved with rest.
Also experiences chest pain at rest, but less severe.
In the ED, initial vitals were 98.3 73 181/84 16 99%. Labs WNL,
trop <0.01. EKG unavailable for viewing. Patient refused aspirin
325 mg given history of PUD. Patient was admitted to the
cardiology service for chest pain management.
On arrival to the floor, BP 187/84, Right 178/88, HR 68, RR 18,
98% RA. Patient was without chest pain, shortness of breath,
nausea or vomiting. Endorsed a mild headache. Admission EKG
notable for NSR HR 64, axis normal, no Q waves, 1mm ST elevation
in V3, <1mm ST elevation in V2, normal intervals.
Of note, patient has been taking clopidogrel for a few months.
It is unclear why patient has been on clopidogrel for this
duration. Family member states that he went to an emergency room
a few months ago with similar symptoms and was prescribed this
medication. Also of note, patient has not been taking aspirin
because of his history of peptic ulcers. He has never had a
catastrophic bleed from his PUD.
Past Medical History:
HTN
HLD
Peptic ulcer disease (no history of bleeding)
BPH s/p prostate surgery
Hearing loss
Elevated uric acid
peripheral neuropathy
Seasonal allergies
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. + history of HTN. + history of HLD.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: BP 187/84, Right 178/88, HR 68, RR 18, 98% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVP 12
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, nontender, no HSM, no ascites, +BS, +distention
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM
========================
VS: 98.0 98.2 105/60 (105-201/60-86) 55 18 96% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: Supple, JVP 10
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: Soft, nontender, no HSM, no ascites, +BS, +distention
Ext: WWP, no c/c/e, R groin dressing c/d/i, mild-TTP, no
hematoma, ecchymosis, bruits, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS
================
___ 10:10AM BLOOD WBC-6.0 RBC-5.11 Hgb-16.2 Hct-48.6 MCV-95
MCH-31.7 MCHC-33.3 RDW-12.7 Plt ___
___ 10:10AM BLOOD Neuts-51.0 ___ Monos-5.3 Eos-1.5
Baso-4.1*
___ 10:10AM BLOOD Glucose-108* UreaN-29* Creat-1.2 Na-137
K-4.4 Cl-101 HCO3-24 AnGap-16
___ 10:10AM BLOOD Calcium-9.6 Phos-2.8 Mg-2.1 Cholest-233*
___ 10:10AM BLOOD ___ PTT-33.5 ___
CARDIAC LABS
=============
___ 10:10AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:50PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD cTropnT-0.02*
___ 10:10AM BLOOD Triglyc-292* HDL-37 CHOL/HD-6.3
LDLcalc-138*
___ 10:10AM BLOOD %HbA1c-5.8 eAG-120
DISCHARGE LABS
===============
___ 06:10AM BLOOD WBC-7.6 RBC-4.44* Hgb-14.0 Hct-42.5
MCV-96 MCH-31.4 MCHC-32.8 RDW-13.1 Plt ___
___ 06:10AM BLOOD Glucose-118* UreaN-30* Creat-1.3* Na-137
K-4.1 Cl-101 HCO3-27 AnGap-13
___ 06:10AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
STUDIES
========
ETT (OSH in ___: Resting HR 66, Max HR 111 (78%). Max METS 6.9.
Nonspecific EKG changes after exercise.
TTE ___:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. Mild mitral regurgitation.
CARDIAC CATH ___:
Findings
ESTIMATED blood loss: 50-100cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No significant CAD
LAD: 90% proximal before large septal followed by TO proximal
before D1. Moderate collaterals from RCA.
LCX: No significant angiographic CAD.
RCA: No significant CAD;
Interventional details
Change for 6 ___ XB LAD guide. The proximal total occlusion
was crossed with a Pilot ___ wire after failed ___ XT and
with Corsair support. We then exchanged for Prowater and
Whisper
wire but were directed into a mid diagonal. Subsequent
angiography showed second total occlusion and we were not able
to
direct a wire into the LAD. The proximal lesions were dilated
with 1.5 balloon at ___ ATM restoring antegrade flow into the
mid
vessel and moderate diagonal. Subsequent attempts to probe for
a
LAD stump resulted in proximal dissection with preserved flow.
WE opted to abort further efforts due to difficulty crossing
distal occlusion. Final angiography showed improved flow into
the large septal branch and TIMI 2 fast flow to the mid
diagonal.
There is a grade C proximal dissection.
Assessment & Recommendations
1. Severe single vessel CAD with LAD chronic total occlusion
2. Successful PTCA of proximal LAD but persistent distal
occlusion
3. Medical therapy for angina. If symptoms not controlled then
retry to cross CTO using CART or retrograde techniques.
Brief Hospital Course:
___ with a past medical history of HTN and HLD who presents with
chest pain concerning for ACS.
# Chest Pain: History is suggestive of cardiac chest pain and
unstable angina, as symptoms are new and worse with exertion and
relieved by rest. EKG findings on ETT from OSH in ___ ___
___. Patient with history of PUD, but history not
suggestive of gastritis or worsening PUD. On admission here,
patient without chest pain. Troponins < 0.01 x 3. No new EKG
changes. Given stress test results and exertional CP, there was
high suspicion for ACS. As such, patient underwent cardiac
catheterization. Cath showed chronic LAD occlusion. He underwent
POBA to LAD, but distal portion was not able to be opened. Plan
was for medical management for now with possible repeat cath at
a later date if the patient continues to have anginal pain.
Patient was started on ASA 81 mg PO QD, atorvastatin 80 mg PO
QD, and carvedilol 12.5 mg PO BID. His plavix was stopped, given
that he has no prior stent and had single-vessel CAD. Of note,
prior to discharge ___ evlauated the patient and felt that he
would benefit from outpatient cardiac rehab. Please refer him to
cardiac rehab at his follow-up outpatient Cardiology
appointment.
# Hypertension: Patient with history of hypertension. On HCTZ
and valsartan at home, which were continued. Given elevated BPs
on admisison, patient started on carvedilol 12.5 mg PO BID as
well.
CHRONIC ISSUES
# HLD: Lipid panel with LDL 138, HDL 37, chol 233, trig 292.
Stopped ciprofibrate at home and started atorvastatin 80 mg PO
QD.
# PUD: On omeprazole at home, which was continued here. Patient
has not been on aspirin at home due to concern for bleeding, but
has never experienced GIB. Started ASA and will monitor as an
outpatient.
# BPH: Stable. Continued home tamsulosin. Held home dutasteride
in-house, but restarted at discharged.
TRANSITIONAL ISSUES
- Medications added: ASA 81 mg PO QD, atorvastatin 80 mg PO QD,
carvedilol 12.5 mg PO BID, nitro SL PRN CP
- Medications stopped: clopidogrel 75 mg PO QD
- ___ evlauated the patient and felt that he would benefit from
outpatient cardiac rehab. Please refer him at his follow-up
Cardiology appointment.
- Code: Full
- Contact: Wife, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO HS
2. dutasteride 0.5 mg oral qHS BPH
3. Valsartan 160 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Omeprazole Dose is Unknown PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Valsartan 160 mg PO DAILY
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth once a day Disp
#*30 Tablet Refills:*0
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
RX *nitroglycerin 0.4 mg 1 tab sublingually Q5MIN Disp #*30
Tablet Refills:*0
9. dutasteride 0.5 mg oral qHS BPH
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. CAD
2. HTN
Secondary:
1. HLD
2. PUD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital with chest pain. We were
concerned that this pain could be due to heart disease given
your abnormal stress test from the ___.
Therefore, you underwent a cardiac catheterization, which showed
a blockage in one of your arteries. Part of your artery was
opened with a balloon, but there is another part that is still
blocked off. If you continue to have more chest pain, please
notify your doctor. There is the possibility of undergoing
another procdure to retry to open up your blocked artery.
Please continue to take your medications as prescribed below.
Please follow-up at the appointments listed below.
Followup Instructions:
___
|
10594962-DS-22 | 10,594,962 | 24,555,952 | DS | 22 | 2175-01-13 00:00:00 | 2175-01-15 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ ___ speaking only hx BPH and prostate surgery, CAD p/w
fever, dysuria. States Two days of dysuria, urinary frequency,
urinary dribbling and fever. Denies flank/back pain. Also
endorses cough productive of white sputum for 3 weeks. Denies
any chest pain or dyspnea.
In clinic today urine dip with positive leukocytes, nitrates,
likely UTI. Was febrile to 102.7 at ___ with reported
chills/shakes by family and sent to ER for assessment and
consideration of IV antibiotics.
In the ED, initial VS were 101.4 68 148/68 16 98% ra. Labs
significant for WBC 13.4 82%PMN, 118 plts (baseline 160+), Cr
1.4 (baseline). UA grossly positive for UTI. CXR performed that
showed bibasilar atelectasis. Received IV ceftriaxone, 500 cc
IVF, 1000 mg tylenol. Transfer VS were 99.4 60 130/72 18 96% RA
On arrival to the floor, patient reports continued dysuria, has
to make multiple trips to the bathroom due to urinary dribbling.
REVIEW OF SYSTEMS: As above.
PAST MEDICAL AND SURGICAL HISTORY:
1. CAD RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ PTCA ___ LAD
with residual mid LAD chronic total occlusion
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Peptic ulcer disease (no history of bleeding)
BPH s/p prostate surgery
Hearing loss
Elevated uric acid
Peripheral neuropathy
Seasonal allergies
CKD
He does not know his medications, but tells me they are in the
computer. He tells me they have not changed since last
discharge.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Omeprazole 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. dutasteride 0.5 mg oral qHS BPH
10. Acetaminophen 650 mg PO Q6H:PRN headache
ALLERGIES: NKDA
SOCIAL HISTORY: ___
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. + family history of hypertension and
hyperlipidemia.
ADMISSION PHYSICAL EXAM:
VS - 99.2 158/72 61 18 97%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no suprapubic
tenderness
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: gait normal
SKIN: warm and well perfused
LABS: See attached
MICRO: blood and urine cultures pending
CXR: Bibasilar opacities likely atelectasis given the low lung
volumes noting that infection cannot be entirely excluded.
Past Medical History:
1. CAD RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ PTCA ___ LAD
with residual mid LAD chronic total occlusion
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Peptic ulcer disease (no history of bleeding)
BPH s/p prostate surgery
Hearing loss
Elevated uric acid
Peripheral neuropathy
Seasonal allergies
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. + family history of hypertension and
hyperlipidemia.
Physical Exam:
ADMISSION PHYSICAL EXAM
============================
VS - 99.2 158/72 61 18 97%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no suprapubic
tenderness
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: gait normal
DISCHARGE PHYSICAL EXAM
===========================
VS Tm 93.3, afebrile for > 24 hrs
BP ___ P 60-62 O2sat 99 %RA
General: up and walking, smiling
HEENT: anicteric, PERLL
Neck: No lymphadenopathy
CV: RRR, no murmurs appreciated
Lungs: CTAB, no wheezes
Abdomen: +BS, non-distended, non-tender, no hepatosplenomegaly
GU: No CVA tenderness, no suprapubic tenderness
Ext: warm, well perfused, no edema
Neuro: grossly intact
Skin: no rashes
Pertinent Results:
ADMISSION LABS
===============
___ 05:30PM BLOOD WBC-13.4*# RBC-4.10* Hgb-13.2* Hct-39.6*
MCV-97 MCH-32.2* MCHC-33.4 RDW-12.4 Plt ___
___ 05:30PM BLOOD Neuts-82.0* Lymphs-11.3* Monos-5.9
Eos-0.7 Baso-0.1
___ 05:30PM BLOOD Plt ___
___ 05:30PM BLOOD Glucose-102* UreaN-25* Creat-1.4* Na-135
K-3.8 Cl-96 HCO3-28 AnGap-15
___ 07:40PM BLOOD Lactate-1.7
DISCHARGE LABS
=================
___ 06:25AM BLOOD WBC-6.8 RBC-3.95* Hgb-12.7* Hct-38.3*
MCV-97 MCH-32.3* MCHC-33.3 RDW-12.3 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-113* UreaN-23* Creat-1.1 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
___ 06:25AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1
PERTINENT LABS
================
WBC ___
WBC ___
Creat ___
Creat ___
IMAGING:
==========
CHEST (PA & LAT) Study Date of ___
IMPRESSION: Bibasilar opacities likely atelectasis given the
low lung volumes noting that infection cannot be entirely
excluded.
RENAL U.S. Study Date of ___
IMPRESSION:
No evidence of hydronephrosis, nephrolithiasis, or fluid
collection concerning for renal abscess. No perinephric fluid
identified. Simple cysts in both kidneys.
Brief Hospital Course:
Mr. ___ is a ___ year old hx of BPH (s/p prostate surgery),
HTN, and HLD with 2 days of dysuria and rigors, who presented to
the ED and was found to be febrile with a WBC of 13.4, HD
stable, and a UA grossly positive for UTI. He was started on
ceftriaxone. Renal ultrasound showed no evidence of
obstruction/abscess. Urine culture with E. Coli, susceptable to
ceftriaxone and cipro. He was transitioned to cipro PO and
discharged to home, with an 8 day course of cipro to complete a
total 10 day course.
#Transitional issues:
-platelets of 120 on discharge, likely in the setting of
infection, but please recheck and consider work-up for liver
disease if they remain low
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Omeprazole 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. dutasteride 0.5 mg oral qHS BPH
10. Acetaminophen 650 mg PO Q6H:PRN headache
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. dutasteride 0.5 mg oral qHS BPH
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
9. Omeprazole 40 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Ciprofloxacin HCl 500 mg PO Q12H UTI Duration: 8 Days
Please finish all of your medication.
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis from a urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your recent hospital
stay. You were admitted because you had a urinary tract
infection. We gave you antibiotics, monitored your temperature
and blood pressure, and imaged your kidneys to make sure the
infection hadn't spread. Your symptoms resolved and you were
able to go home on oral antibiotics. You will need to complete
a 8 day course of Ciprofloxacin 500mg twice daily as an
outpatient.
Please follow up with your doctor as outlined below, and take
your medications as directed. It is very important that you
finish all of your antibiotics, even if you feel better, so that
the infection does not return.
Followup Instructions:
___
|
10594962-DS-24 | 10,594,962 | 20,852,777 | DS | 24 | 2175-11-09 00:00:00 | 2175-11-10 19:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dysuria
Major Surgical or Invasive Procedure:
___ PICC line insertion
___ PICC line removal
History of Present Illness:
Mr. ___ is a ___ with PMH significant for CAD s/p cardiac
cath, BPH s/p TURP/prostate resection ___ ago in ___ ___
orchiectomy complicated by urosepsis (in the ___
a few months ago) with a recent admission to ___ for
epididymitis/ complex UTI, retention and a foley presenting with
dysuria and scrotal pain.
Patient was discharged on ___ with a foley and PO
ciprofloxacin. On ___ he called the Urology office due to foley
issues and pain. They noted that his urine culture from the
previous admission was growing E coli sensitive to only zosyn,
ceftazidime and meropenem. He was advised to present to the ED
for further evaluation and managment.
In the ED, initial vitals: 98.6, 72, 134/66, 16, 98%RA
Labs were significant for Cr 1.3, Hct 38.7. UA showed moderate
bacteria, >182 WBC, large leuks and negative nitrites. BCx and
UCx was sent and patient was started on empiric abx. He was held
overnight in the ED for PICC placement.
No imaging was done.
Patient was given Zosyn and his home medications. PICC line
could not be placed in the ED. Case management confirmed that he
would be able to get home infusion services. He was admitted for
PICC placement and set up of his home infusion services.
Vitals prior to transfer: 97.7, 58, 122/77, 18, 100% RA.
On the floor, patient is reporting ongoing ___ scrotal pain
and 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 nausea or vomiting. No diarrhea or
constipation. No hematuria. No hematochezia, no melena. No
numbness or weakness, no focal deficits.
Past Medical History:
CAD: ___ Cardiac cath with ___ LAD with residual mid LAD
chronic total occlusion
Hypertension
Hyperlipidemia
Peptic ulcer disease (no history of bleeding)
BPH s/p prostate surgery ___ ago in ___
Episode of urosepsis in ___
Hearing loss
Elevated uric acid
Peripheral neuropathy
Seasonal allergies
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. + family history of hypertension and
hyperlipidemia.
Physical Exam:
ADMISSION EXAM:
===============
VS: 97.9, 163/80, 61, 18, 98% RA wt: 62.3kg
GEN: Alert, lying in bed, no acute distress
HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, no JVP
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended. Bowel sounds present. No
rebound or guarding.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE EXAM:
===============
VS: 98.5, 151/64, 58, 20, 99% RA
GEN: Alert, lying in bed, no acute distress
NECK: Supple without LAD
CV: RRR, no murmurs
PULM: CTAB
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema. PICC line C/D/I
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 08:30PM BLOOD WBC-10.0 RBC-4.26* Hgb-13.5* Hct-38.7*
MCV-91 MCH-31.7 MCHC-34.8 RDW-13.6 Plt ___
___ 08:30PM BLOOD Neuts-74.0* ___ Monos-4.8 Eos-1.2
Baso-0.3
___ 08:30PM BLOOD Glucose-118* UreaN-20 Creat-1.3* Na-134
K-3.9 Cl-99 HCO3-25 AnGap-14
___ 08:30PM BLOOD Calcium-8.6 Phos-2.7 Mg-1.9
PERTINENT LABS:
===============
___ 06:28AM BLOOD Glucose-110* UreaN-33* Creat-1.8* Na-136
K-4.2 Cl-101 HCO3-23 AnGap-16
___ 03:02PM BLOOD UreaN-31* Creat-1.4*
___ 06:41AM BLOOD Glucose-87 UreaN-26* Creat-1.3* Na-136
K-4.5 Cl-103 HCO3-23 AnGap-15
___ 07:40AM BLOOD Glucose-94 UreaN-24* Creat-1.2 Na-136
K-4.6 Cl-102 HCO3-23 AnGap-16
___ 05:02AM BLOOD Glucose-94 UreaN-34* Creat-1.1 Na-137
K-4.3 Cl-102 HCO3-25 AnGap-14
___ 06:41AM BLOOD GGT-183*
___ 03:00PM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD cTropnT-<0.01
___ 06:41AM BLOOD PSA-8.3*
DISCHARGE LABS:
===============
NONE DRAWN ON THE DAY OF DISCHARGE
MICRO:
======
___ BLOOD CULTURE -- NO GROWTH
___ URINE CULTURE -- NO GROWTH
IMAGING:
========
___ CHEST PORT. LINE PLACEMENT
IMPRESSION: PICC line in appropriate position.
Brief Hospital Course:
Mr. ___ is a ___ with PMH significant for CAD s/p cardiac
cath, BPH s/p TURP/prostate resection ___ ago in ___ ___
orchiectomy complicated by urosepsis (in the ___
a few months ago) with a recent admission to ___ for
epididymitis/ complex UTI, retention and a foley presenting with
dysuria and scrotal pain.
# Epididymoorchitis and UTI: s/p recent admission and initially
treated with ciprofloxacin but urine culture grew out e coli
resistant to cipro. He had a foley catheter from his previous
admission which was placed for urinary retention. He was
empirically started on Zosyn then transitioned to cefepime. A
PICC line was placed for administration. He was unable to get
home infusion services as this was not covered by his insurance.
He remained in house to complete his 10 day antibiotic regimen
which ended on ___. His pain and dysuria improved
significantly within 48hrs of starting antibiotic treatment. His
PICC line was discontinued prior to discharge without issue. He
underwent a voiding trial in house with < 30cc in post void
residuals on multiple checks. He will follow up with urology as
an outpatient.
# Rectal pain: Likely mucuosal irrtation related to reported
instrumentation in ___. ___ not consistent with
prostatitis. Started bowel regimen to aid with passing of stool
and advised outpatient follow up if does not resolve.
# ___ on CKD: Cr 1.8 from baseline of 1.1. Improved with
treatment of UTI and IV/PO hydration. Cr returned to baseline
prior to discharge.
# Urine retention: Present since last admission. Likely
complicated by if not directly related to TURP in ___ ___ years
ago. Managed with foley and completed a voiding trial in house
with < 30cc in post void residuals on multiple checks. He will
follow up with Urology as an outpatient. He was continued on his
home tamsulosin and finasteride.
# HTN: Stable, he was continued on his home lisinopril and
carvedilol.
# CAD: s/p cardiac catheterization in ___ which showed chronic
mLAD total occlusion with more recent pLAD disease. He was
continued on his home ASA 81mg, atorvastatin 80mg, lisinopril,
carvedilol.
# PUD: Continued home PPI.
TRANSITIONAL ISSUES:
[] will need follow up with urology as an outpatient, please
arrange for appointment with Dr. ___
[] consider outpatient RUQUS given elevated ALP and GGT in house
CODE STATUS: FULL CODE
CONTACT: Wife- ___ Daughter ___ is
emergency contact: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Omeprazole 40 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation INHALATION Q6H:PRN cough
11. dutasteride 0.5 mg oral QHS
12. Fexofenadine 180 mg PO DAILY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
16. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Fexofenadine 180 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
10. Omeprazole 40 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. albuterol sulfate 90 mcg/actuation INHALATION Q6H:PRN cough
15. dutasteride 0.5 mg oral QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Complicated UTI
Epididymitis
SECONDARY DIAGNOSES:
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with a urinary tract
infection. Your urine culture grew a resistant form of bacteria
which required treatment with IV antibiotics. A PICC line was
placed in your arm to allow you to get these antibiotics. You
improved with the antibiotics. You were discharged home with
outpatient follow up after completion of your antibiotic course.
Please take all your medications as prescribed. You will find a
list of your outpatient follow up appointments below. It is
important that you go to your appointments. You will be
contacted by the ___ clinic with a follow up appointment
with Dr. ___. If you have not heard from the office in the
next ___ weeks, please contact the office and ask if the
appointment has been made.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10595049-DS-17 | 10,595,049 | 26,161,694 | DS | 17 | 2184-11-24 00:00:00 | 2184-11-25 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Left IJ placement
History of Present Illness:
Ms. ___ is a ___ history of HTN, HLD, DMII, with recently
diagnosed GYN malignancy possible endometrial vs ovarian primary
in setting of new abdominal ascites and elevated CA-125,
presenting with tachycardia and shortness of breath.
Patient initially presented to ___ on ___ with new
onset chest pain. EKG there notable for sinus tachycardia per
report without ischemic changes and cardiac work-up there was
negative including stress test. CTA there was negative for PE,
showed a large amount of malignant ascites with omental caking
and peritoneal stranding. Also with intdeterminate 4mm lesion in
spleen. CA-125 on ___, prelim path pending however concerning
for either ovarian vs. endometrial primary.
This morning while she was walking upon getting up from bed
noticed sudden onset and worsening shortness of breath. It was
difficult for her to catch her breath with minimal exertion.
Denied any chest pain, no fevers, chills, nausea, vomiting. She
presented to the ___ ___.
On arrival to the ___, initial VS T 97.5 HR 133 BP 144/68 RR 15
O2 94%RA.
Labs notable for:
- WBC 7.0, Hb 12.4, HCT 38.5, PLT 653
- Na 136, K 5.1, BUn 22, Cr 1.2, glucose 141, AG 20
- LFTs within normal limits
- Lactate 3.0
- Troponin 0.16
On imaging:
Bedside US: No pericardial effusion, normal squeeze, mild to
moderate ascites without easily tappable pocket.
CXR: Linear left base atelectasis without definite focal
consolidation.
CTA Chest:
1. Extensive pulmonary emboli which extends throughout all 3
lobes
bilaterally. Proximal extent of the pulmonary emboli extends
into both the right and left main pulmonary arteries. There is
resultant right heart strain with significant compression of the
left ventricle.
2. Bibasilar atelectasis with question of left lung base
scarring without concerning parenchymal nodularity or
opacification.
CT Head WO Contrast: No intracranial hemorrhage.
Patient was administered:
___ 19:49 IVF NS ( 1000 mL ordered)
___ 21:44 IV Heparin 5000 UNIT
___ 21:44 IV Heparin
EKG: Sinus tachycardia HR 139, 2mm STD leads II, V4-V6, 2mm STE
in V1-V2, Q wave in lead III with TWI
Consults:
- OB/GYN: Per OB/GYN will likely need neoadjuvant chemotherapy,
will follow during admission.
___ Course: Some worsening hypotension initially SBP 144 on
arrival, down-trended to 97/60 also with worsening hypoxemia
initially on RA however subsequently requiring 4L O2. BPs
improved with IVF to 110s systolic.
On arrival to the MICU, patient confirmed the above history,
adding that she had decreased PO intake due to poor appetite for
the past ___ weeks.
REVIEW OF SYSTEMS:
10-point ROS negative except as noted in HPI.
Past Medical History:
- T2DM
- HTN
- HLD
- GERD
Social History:
___
Family History:
- half sister with uterine "carcinoma in situ" (?) in her ___
- denies history of breast or ovarian cancers
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: T 98.2, HR 126, BP 129/84, RR 25, O2 98% on 4L NC.
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rate, no murmurs, rubs, gallops
ABD: Soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ pulses, or edema
SKIN: No rashes or bruises
NEURO: AOx3
========================
DISCHARGE PHYSICAL EXAM
========================
VS: Temp: 99.2 PO BP: 120/77 HR: 93 RR: 18 O2 sat: 98% O2
delivery: Ra
Gen: NAD, sitting in bed eating breakfaset, alert and oriented
HEENT: NC/AT, EOMI, PERRL, neck supple nontender no cLAD
CV: RRR S1 S2 normal no m/r/g
Resp: CTA-B, no wheezing, good air movement, no crackles
Abd: Soft, non-distended, normoactive BS, mildly tender to
palpation diffusely in areas of SC heparin injection
Ext: 2+ pitting edema to mid shins
Skin: warm well perfused, no bruising/petechiae
Neuro: CN ___ grossly intact; no focal neurologic deficits
Pertinent Results:
Admission
=========
___ 05:12PM BLOOD WBC-7.0 RBC-4.72 Hgb-12.4 Hct-38.5 MCV-82
MCH-26.3 MCHC-32.2 RDW-14.0 RDWSD-41.2 Plt ___
___ 05:12PM BLOOD Neuts-83.8* Lymphs-9.7* Monos-5.4
Eos-0.1* Baso-0.4 NRBC-0.7* Im ___ AbsNeut-5.87
AbsLymp-0.68* AbsMono-0.38 AbsEos-0.01* AbsBaso-0.03
___ 01:25AM BLOOD ___ PTT-28.7 ___
___ 05:12PM BLOOD Glucose-141* UreaN-22* Creat-1.2* Na-136
K-5.1 Cl-96 HCO3-20* AnGap-20*
___ 05:12PM BLOOD ALT-13 AST-26 AlkPhos-86 TotBili-0.3
___ 05:12PM BLOOD cTropnT-0.18* proBNP-8549*
___ 05:12PM BLOOD Albumin-3.7 Calcium-9.8 Phos-3.9 Mg-2.1
___ 05:12PM BLOOD TSH-1.3
___ 01:30AM BLOOD ___ Temp-36.8 O2 Flow-4 pO2-32*
pCO2-38 pH-7.37 calTCO2-23 Base XS--3 Intubat-NOT INTUBA
___ 05:20PM BLOOD Lactate-3.0*
Micro
=====
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
Imaging
=======
___ CTA Chest
IMPRESSION:
1. Extensive pulmonary emboli which extends throughout all 3
lobes
bilaterally. Proximal extent of the pulmonary emboli extends
into both the
right and left main pulmonary arteries. Resultant right heart
strain with
significant compression of the left ventricle. Dilated main
pulmonary artery.
2. Bibasilar atelectasis with question of left lung base
scarring without
concerning parenchymal nodularity or opacification.
___ B/L ___ Duplex
IMPRESSION:
Acute deep venous thrombosis of the left posterior tibial veins.
No evidence of acute deep venous thrombosis within the right
lower extremity.
___
TTE
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a small cavity. Overall left
ventricular systolic function is hyperdynamic. The visually
estimated left ventricular
ejection fraction is 75%. There is no resting left ventricular
outflow tract gradient. Moderately dilated right ventricular
cavity with focal hypokinesis of the basal free wall
___ sign). Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is abnormal
interventricular septal motion c/w right ventricular pressure
and volume overload. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral regurgitation. The
tricuspid valve leaflets are mildly thickened. There is moderate
to severe [3+] tricuspid regurgitation. There is moderate to
severe pulmonary artery systolic hypertension. In the setting of
at least moderate to severe tricuspid regurgitation, the
pulmonary artery systolic pressure may be UNDERestimated. There
is no pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis and at least moderate pulmonary artery hypertension
c/w acute or acute on chronic pulmonary process (e.g. pulmonary
embolism).
___ RUQ U/S LIMITED
IMPRESSION:
Low volume ascites.
Discharge
=========
___ 04:15AM BLOOD WBC-10.4* RBC-3.86* Hgb-9.9* Hct-32.2*
MCV-83 MCH-25.6* MCHC-30.7* RDW-14.9 RDWSD-43.9 Plt ___
___ 04:15AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-140
K-4.0 Cl-101 HCO3-26 AnGap-13
___ 04:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
Brief Hospital Course:
SUMMARY:
===========
___ with PMHx notable for HTN, DM2 with a recent diagnosis of
ovarian carcinosarcoma and who was admitted on ___ with dyspnea
found to have high risk submassive PE initially admitted to MICU
and treated with heparin gtt, eventually stepped down and
transferred to ___ on ___ for initiation of chemotherapy C1
carboplatin on ___.
# High risk submassive PE
# Pulmonary HTN
Admitted on ___ with dyspnea found to have extensive pulmonary
emboli with proximal extension into right and left main
pulmonary arteries. Lower extremity venous ultrasound
demonstrated DVT of left posterior tibial veins. Initially on
heparin gtt now on lovenox and doing well. TTE with mod-severe
pulmonary HTN. Vascular medicine consulted while in hospital and
recommended continuing lovenox for 1 month and consideration of
DOAC as an outpatient. Patient will follow up for pulmonary
hypertension with ___ MD and for her PE with Dr.
___.
# Ovarian carcinosarcoma
Initiation of chemotherapy with single-agent carboplatin with
plan to add taxane with subsequent cycles. Will follow-up with
Dr. ___ for further management as outpatient.
- C1 carboplatin ___
# Ascites
Concern for malignant ascites given imaging with omental caking
and peritoneal stranding. Abdominal ultrasound with low volume
ascites. Per abdominal ultrasound and discussion with
radiologists, the amount of ascites is <1L at this time, which
would be enough to get basic studies (protein, albumin) but not
enough volume to get oncologic studies such as flow cytometery
and cytology. This was discussed with patient, and the decision
was made to defer paracentesis at this time and possibly pursue
this procedure as an outpatient if it is determined necessary by
primary oncologist.
# HTN
Anti-hypertensives initially held in the setting of submassive
PE and soft BPs, but restarted after BPs recovered and patient
was noted to have ___ edema. Restarted and discharged on home
Lisinopril and HCTZ.
# Elevated Blood glucose
While on steroids, glucose levels were elevated. Off steroids
she did not require any insulin.
# GERD: Continued home PPI.
TRANSITIONAL ISSUES:
=======================
[ ] diagnosed with pulmonary HTN, will follow up with
___ MD.
[ ] new cancer dx of ovarian carcinosarcoma and is being set up
with new Oncologist Dr. ___ with ___ Heme/Onc
[ ] Ascites seen on imaging but on ultrasound was small volume,
decision was made with patient and medical team to defer
paracentesis at this time. ___ need future paracentesis if
ascites continues to accumulate.
[ ] Regarding anticoagulation, continue lovenox (___) for 1
month and consideration of DOAC as an outpatient. If for some
reason patient prefers to be on a DOAC sooner, favor starting
rivaroxaban or edoxaban. Patient will follow up with Dr. ___
in cardiology for her submassive PE.
[ ] Received C1D1 Carboplatin ___.
[ ] Patient with elevated sugars while on steroids. Did not
require insulin while off steroids. ___ benefit from following
HA1c as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Omeprazole 20 mg PO BID gerd
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
RX *enoxaparin 100 mg/mL 90 mg SC twice daily Disp #*60 Syringe
Refills:*0
2. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 8
hours Disp #*30 Tablet Refills:*0
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Omeprazole 20 mg PO BID gerd
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Dx:
-------------
high risk submassive pulmonary embolism
pulmonary hypertension
Ovarian carcinosarcoma
Secondary Dx:
-----------------
hypertension
diabetes mellitus
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had shorness of breath and were found to have a large
pulmonary embolism.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated in the ICU for your pulmonary embolism, which
improved with time.
- You were started on blood thinners to prevent future blood
clots and pulmonary embolisms.
- Heart pictures showed showed pulmonary hypertension, or
elevated blood pressures in the arteries of your lungs. This may
be because of your blood clot (Pulmonary emboli)
- You received a dose of chemotherapy, and were set up with
continuity of care with outpatient oncology.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- If you develop pain you can take up to 1000 mg of Tylenol up
to 3 times in a day
- Appointments are listed below (including follow up for your
newly diagnosed pulmonary hypertension).
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10595049-DS-18 | 10,595,049 | 21,653,622 | DS | 18 | 2185-01-14 00:00:00 | 2185-01-14 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
Port placement
Venting g tube
TPN with PICC
History of Present Illness:
___ h/o hypertension, T2DM, PE/DVT and metastatic carcinoma
of uterine origin s/p carboplatin presents to the ED with
constipation, nausea and vomiting.
She reports constipation starting 4 days ago. She tried Colace
and miralax once to twice a day with no relief. Yesterday she
started experiencing worsening nausea with subsequent emesis.
She
had ___ episodes of brown colored emesis, no blood noted. She
last had a solid bowel movement with normal stool caliber 7 days
ago. She passed small pellets ___ days ago and has not passed
gas
for 5 days.
Given her worsening symptoms she called her medical oncologist
who advised her to present to the ED for further management. In
the ED, she has received 1 dose of Zofran with good relief. She
She otherwise denies fevers, chills, abdominal pain, shortness
of
breath, chest pain, cough.
She is planning to have a port placed ___ with next cycle of
chemo on ___.
Past Medical History:
- T2DM
- HTN
- HLD
- GERD
Social History:
___
Family History:
- half sister with uterine "carcinoma in situ" (?) in her ___
- denies history of breast or ovarian cancers
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
98.4, HR119, BP 149/54, RR 19 98% RA
Gen: NAD
CV: RRR
Lungs: CTAB
Abd: soft, nontender, mildly distended, faint to absent bowel
sounds throughout
Ext: +1 swelling bilaterally
DISCHARGE PHYSICAL EXAM
============================
Vitals: 97.8 116/77 120 18 98 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: tachycardic, regular rhythm, S1/S2, no murmurs, gallops, or
rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: abdomen soft, nondistended, minimally TTP. g tube dressed
with no surrounding erythema or drainage
EXT: 2+ bilateral lower extremity pitting edema
NEURO: Alert, CN2-12 intact, MAE, oriented to person, self, and
date
Pertinent Results:
ADMISSION LABS
=======================
___ 02:14PM BLOOD WBC-10.8* RBC-4.33 Hgb-11.1* Hct-35.2
MCV-81* MCH-25.6* MCHC-31.5* RDW-16.8* RDWSD-47.8* Plt ___
___ 02:14PM BLOOD Neuts-84.0* Lymphs-10.0* Monos-5.5
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.06* AbsLymp-1.08*
AbsMono-0.59 AbsEos-0.00* AbsBaso-0.01
___ 02:14PM BLOOD Plt ___
___ 02:14PM BLOOD Glucose-124* UreaN-54* Creat-2.4*#
Na-134* K-4.9 Cl-90* HCO3-18* AnGap-26*
___ 02:14PM BLOOD Albumin-4.3 Calcium-10.9* Phos-5.0*
Mg-2.1
___ 02:24PM BLOOD Lactate-1.9
MICRO LABS
=======================
___ 9:12 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
IMAGINGS
=====================================
CT ABDOMEN AND PELVIS ___. Mildly dilated fluid distended small bowel loops with no
abrupt transition
point identified. Findings likely represent a partial small
bowel obstruction
likely due to malignant obstruction in this patient with
peritoneal and
omental carcinomatosis. Trace ascites is present. No free air.
2. Right lower lobe consolidation concerning for pneumonia.
Trace right
pleural effusion.
PORT PLACEMENT ___
Successful placement of a single lumen chest power Port-a-cath
via the right
internal jugular venous approach. The tip of the catheter
terminates in the
right atrium. The catheter is ready for use.
G TUBE PLACEMENT ___. Successful placement of a 16 ___ MIC gastrostomy tube.
RENAL ULTRASDOUND ___. No hydronephrosis.
2. Incompletely characterized hyperechoic focus in the inferior
aspect of the
liver may represent a conglomerate of peritoneal implants
therefore could
represent worsening of disease. Finding can be reassessed on
routine CT
oncology exams.
CTHNC ___. No acute intracranial abnormality.
2. Periventricular and subcortical white matter hypodensities
that are
nonspecific but most likely related to chronic small vessel
ischemia.
CT ABD/PELVIS ___. Omental caking and peritoneal thickening appears overall
similar to prior
CT from ___.
2. Small volume abdominopelvic ascites is mildly increased.
3. Mildly dilated proximal small bowel loops are similar to
prior, without
abrupt transition point to suggest high-grade obstruction.
4. Please refer to the separate report of CT chest performed on
the same day
for description of the thoracic findings.
CT CHEST ___. New small to moderate left pleural effusion with adjacent
smooth left
basilar consolidation. Findings favor atelectasis over
pneumonia given smooth
border and lack of adjacent inflammatory changes. Overall,
determination
between these 2 entities via imaging is difficult given lack of
intravenous
contrast.
2. 3 mm nodule in the right upper lobe is unchanged since
___.
Nodule can be followed on routine oncologic exams.
3. Unchanged anterior diaphragmatic lymph nodes, measuring up to
8 mm in short
axis.
4. Please see report from CT abdomen/pelvis from same day for
full description
of subdiaphragmatic findings.
DISCHARGE LABS
=======================
___ 04:59AM BLOOD WBC-10.1* RBC-2.69* Hgb-7.1* Hct-24.3*
MCV-90 MCH-26.4 MCHC-29.2* RDW-23.1* RDWSD-74.7* Plt ___
___ 04:59AM BLOOD Glucose-151* UreaN-24* Creat-0.7 Na-140
K-3.6 Cl-100 HCO3-27 AnGap-13
___ 04:59AM BLOOD ALT-11 AST-14 LD(LDH)-349* AlkPhos-106*
TotBili-<0.2
___ 04:59AM BLOOD Albumin-2.4* Calcium-8.6 Phos-3.7 Mg-1.8
___ 04:59AM BLOOD Triglyc-121
___ 06:13AM BLOOD freeCa-1.20
Brief Hospital Course:
Ms. ___ is a ___ yo woman with h/o DM2, HTN, submassive PE (on
lovenox), and recent diagnosis of metastatic endometrial
carcinosarcoma (___), admitted for malignant SBO.
#Malignant partial SBO
Presented with multiple days constipation and worsening nausea.
CT study demonstrated likely SBO. An NG tube was placed for
decompression. Cycle 2 of carboplatin (D1: ___ was initiated
in the hopes that shrinking her cancer burden would provide
symptom relief. Unfortunately, Ms. ___ continued to have emesis
multiple times a day and could not reliably tolerate PO intake.
TPN was initiated and she underwent venting G tube placement on
___. Her venting G tube was left intermittently to suction but
high output led to contraction alkalosis and electrolyte
abnormalities. Restricting her venting G tube to a 1L goal was
not well tolerated and associated with significant nausea.
Ultimately, Ms. ___ did well with her venting G tube left to
suction throughout the day, with 2L of daily maintenance IVF.
Her nausea was managed with nightly olanzapine and PRN zofran
and compazine. She was also started on octreotide 200 mg SC q8h
though she has been refusing this the day of discharge due to
lack of improvement in symptoms. She still had intermittent
nausea with emesis on discharge, but this was tolerable for the
patient.
#Advanaced metastatic endometrial carcinosarcoma
Diagnosed ___, complicated by peritoneal spread and malignant
ascites. She completed cycle 2 and 3 of carboplatin in house(D1:
___. She will follow-up with Dr. ___ further
management.
#UTI (resolved)
Completed IV ceftriaxone course x2 ___ and ___.
___ (resolved)
Presented with elevated creatinine to 2.4 in the setting of por
PO intake. Her kidney function normalized with fluids. She
sustained a subsequent ___ in the setting of high venting G
output which improved with maintenance fluids. Her home
lisinopril and hydrochlorothiazide medications were held as she
was normotensive. Her creatinine was at baseline on discharge.
#HTN
Ms. ___ home lisinopril and hydrochlorothiazide medications
were initially held in the setting of ___, but were ultimately
not resumed given she remained normotensive.
#Thrush
Appeared to have oral candidiasis. She was started on nystatin
swish and spit x7 days (___), but she refused this
medication so it was not continued on discharge.
#PE/DVT
Diagnosed with submassive PE on ___ in a previous
hospitalization. Lovenox 80mg BID dosing was assessed by
pharmacy to be the appropriate dosing.
#Sinus tachycardia: persistent throughout hospitalization.
Likely secondary to PE, pain, nausea and being overall
deconditioned.
#Lower extremity edema and weight gain: in the setting of
hypoalbuminemia and increased mIVF. No pulmonary symptoms.
Received 1 dose of 20mg IV Lasix on ___. mIVF discontinued on
___.
#DM2
No changes were made. Kept on ISSI in house.
Transitional Issues:
============================
Code status: full code, presumed
Contact: ___, Daughter (pediatrician),
___
___ weight: 88 kg
- Nausea plan: octreotide 200 mg SC q8h standing (though pt is
refusing this starting on day of discharge), Zofran 8 mg IV q8h
standing + prn nausea first line, Compazine 10 mg IV q6h prn
nausea second line though first line/second line should be
determined by patient
- If nausea is persistent/severe, can trial Haldol 0.5 mg IV;
can also consider dexamethasone
- PO medications have been stopped as patient will not absorb
these medications due to venting G-tube
- Please obtain a CBC with differential on ___ and fax to Dr.
___ at ___.
- If creatinine starts to increase, consider restarting mIVF.
This was discontinued the day of discharge due to increasing
lower extremity edema.
- Please obtain once weekly EKGs for QTc monitoring
- Closely monitor her blood pressure. If persistently > 140,
consider restarting her home antihypertensives
- PE/DVT: at next onc appointment, please consider changing
lovenox from BID to once daily (1.5mg/kg) vs transitioning to an
oral agent at follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 90 mg SC Q12H
2. Omeprazole 20 mg PO BID gerd
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick q12hr
Insulin SC Sliding Scale using HUM Insulin
2. Octreotide Acetate 200 mcg SC Q8H
3. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
4. Ondansetron 8 mg IV Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
5. Ondansetron 8 mg IV Q8H
6. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - Second
Line
7. Enoxaparin Sodium 80 mg SC Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Endometrial carcinosarcoma
Malignant small bowel obstruction
Secondary diagnosis:
Urinary tract infection
Pulmonary embolism/deep vein thrombosis
Type II diabetes
Hypertension
Sinus tachycardia
Thrush
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED?
- You were admitted for nausea, vomiting, constipation found to
have a malignant bowel obstruction.
WHAT WAS DONE WHILE I WAS HERE?
-Imaging here demonstrated a partial small bowel obstruction
related to your cancer. You were initially decompressed with an
NG tube to help with your nausea and vomiting . TPN (IV
nutrition) was started after a considerable period of food
intolerance. A venting G tube was ultimately placed to help with
persistent vomiting.
-You completed cycle 2 and 3 of chemotherapy with carboplatin.
WHAT SHOULD I DO NOW?
- You should take your medications as instructed
- You should stay in close contact with your oncology team
We wish you the best!
- Your ___ Care Team
Followup Instructions:
___
|
10595107-DS-18 | 10,595,107 | 29,816,916 | DS | 18 | 2147-04-25 00:00:00 | 2147-04-25 10:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
elbow pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a pleasant ___ year old male with hx of HIV who
presents with L elbow pain following fall
5 days ago. He reports redness, warmth and swelling as well as
purulent drainage over past few days as well as fever of 100.5
last night. Although he has had pain for the last 5 days, he
comes ___ today because the lesion started draining pus. ___
regards to the fall, pt thinks he may have slipped on ice after
drinking ___ drinks. No LOC, did not hit head. No weakness, CP,
SOB, seizure-like activity prior to the fall.
___ the ED, initial vitals were: 98.5 107 140/94 18 99% RA
Labs were notable for a CRP of 63.3. Pt was given 2L NS and
vancomycin. Wrist and elbow films showed no fracture or
dislocation. He was evaluated by ortho who did not think that
his presentation was consistent with septic joint, more likely a
superficial bursitis, recommended admission to medicine for IV
abx.
On the floor, he has no complaints other than arm pain. He is
reluctant to give me a full history stating that he has several
family members who have worked her and he is worried about
violations of confidentiality.
Review of systems:
(+) Per HPI
(-) Denies 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 ___ bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias other
than L elbow.
Past Medical History:
-HIV
Social History:
___
Family History:
No known medical problems
Physical Exam:
Vitals: 98.9 144/93 107 18 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, L elbow mildly tender to palpation,
mild surrounding errythema, small opening ___ skin draining pus.
No pain with passive or active movement of the L arm at the
elbow.
Neuro: CNII-XII and strength grossly intact,
On discharge
Only scant swelling and warmth over left elbow, no effusion, no
fluctuance, small excoriation at site of drainage.
Pertinent Results:
___ 05:12PM LACTATE-1.4
___ 04:58PM GLUCOSE-79 UREA N-15 CREAT-0.9 SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-29 ANION GAP-13
___ 04:58PM estGFR-Using this
___ 04:58PM CRP-63.3*
___ 04:58PM WBC-4.0 RBC-4.47* HGB-14.0 HCT-42.0 MCV-94
MCH-31.3 MCHC-33.3 RDW-12.9 RDWSD-44.1
___ 04:58PM NEUTS-44.1 ___ MONOS-10.4 EOS-1.8
BASOS-0.5 IM ___ AbsNeut-1.75 AbsLymp-1.69 AbsMono-0.41
AbsEos-0.07 AbsBaso-0.02
___ 04:58PM PLT COUNT-216
___ 04:58PM ___ PTT-30.2 ___
___ 04:50PM URINE HOURS-RANDOM
___ 04:50PM URINE HOURS-RANDOM
___ 04:50PM URINE UHOLD-HOLD
___ 04:50PM URINE GR HOLD-HOLD
___ 04:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 04:50PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:50PM URINE MUCOUS-RARE
___ 06:02AM BLOOD WBC-3.6* RBC-4.16* Hgb-13.1* Hct-39.1*
MCV-94 MCH-31.5 MCHC-33.5 RDW-12.7 RDWSD-43.5 Plt ___
xray wrist/elbow
No acute fracture or dislocation is seen. No concerning
osteoblastic or lytic lesion is seen. There is minimal spurring
at the lateral distal scaphoid and proximal triquetrum.
IMPRESSION:
No acute fracture or dislocation.
EKG: sinus tach with PVCs, no STE, TWI, mild L axis deviation
___ Blood culture no growth
Gram stain
___ 1:19 am SWAB Site: ELBOW Source: L elbow
lesion.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
Pleasant ___ yo M with hx HIV presenting with L arm pain
following fall, draining pus concerning for infectious bursitis.
# Infectious bursitis: Patient with dramatic improvement after
receiving IV vancomycin ___ ED; had "golf ball" size bursa, on
discharge has only scant swelling (no fluctuance) and scant
warmth over elbow. Fluid collection from bursitis appears to
have drained on its own. Will rx clindamycin for additional six
days to finish a one week course of antibiotics. Gram stain
done ___ ED but from a swab and not aspiration. Patient seen
by ortho ___ the ED who also felt
# HIV: Continued home atripla
# Fall: No concerning hx for cardiac or neurogenic etiology, ___
setting of EtOH use which likely contributed. Pt denies hx of
excessive EtOH use.
# Tachycardia: sinus. Asymptomatic. Pt taking hydroxicut at
home would could be contributing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
QHS
2. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Septic bursitis
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 septic bursitis, or
infection of the bursa. A bursa is a sac, and when you fell
last week, it got infected. You improved dramatically with
antibiotics, and the infection is nearly resolved. I am giving
you five additional days of antibiotics to take by mouth.
Please see your doctor this week so that we can be sure that
your infection completely improves. Please notify your doctors
___ have any diarrhea with antibiotics.
Followup Instructions:
___
|
10595153-DS-24 | 10,595,153 | 29,334,839 | DS | 24 | 2124-01-16 00:00:00 | 2124-01-16 21:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / Hibiclens / Ambien / methotrexate
Attending: ___.
Chief Complaint:
Vomiting, diarrhea, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a history of biopsy proven sarcoidosis
with lung involvement, HFrEF (EF 40% ___ with severe RV
dysfunction, inotrope-dependent on home milrinone (0.375
mcg/kg/min), currently UNOS status IB, who presents to the ED
with fevers. The patient reports that he took his iron this ___
and then an hour later began to have severe epigastric pain
associated with multiple episodes of loose watery stools and
vomiting. His abdominal pain improved but then he had a fever up
to 100.4 He called his cardiologist who recommended evaluation
in the ED.
Briefly, his history of Serratia bloodstream infection is
notable
in that he was admitted to ___ in late ___ with rigors, on ___ he became febrile to 38.5 and
developed leukocytosis to 16.9. ESR 50, CRP 124. CXR and
urinalysis were unremarkable, respiratory viral panel was
positive for human rhino/enterovirus. He was initially started
on
vancomycin/cefepime (___) which was transitioned to
ertapenem monotherapy (___-) when one set of blood cultures
(___)
came back positive for Serratia maracescens, but all subsequent
blood cultures were negative. His tunneled line (placed at
___
was removed during this admission as the likely source of
infection. He underwent TTE on ___ which revealed a mobile
echodensity near the septal leaflet of the tricuspid valve. He
then underwent TEE on ___ which showed possible small
vegetation on the
tricuspid valve. A new PICC line was placed on ___ for
home
milrinone and ertapenem therapy. It was decided to continue
ertapenem for a total of 6 weeks given the possibility of
endocarditis. He has a history of nausea vs. renal injury on
cipro in the past and in this setting was transitioned to
oral bactrim suppressive therapy after completion of the 6 weeks
of IV therapy. He overall is tolerating the antibiotics though
does note that he has some GI distress when taking it and finds
that the
combination of iron and bactrim cause significant GI distress.
He traveled to ___ a few weeks ago and while there, he had a
GI illness which rapidly resolved.
Past Medical History:
Symptoms began ___. Cardiac monitor showed 2:1 block.
Also
there was a report of complete heart block.
s/p PPM ___. Persistent fatigue, dyspnea and dizziness.
___ Cath - no CAD.
___ - admit A flutter- RVR. Unsuccessful chemical
cardioversion.
s/p ablation ___ - PVI, ___ line and mitral
isthmus
ablation.
___- cardiac arrest dx with sarcoidosis
___ CRT-D ___. LVEF ___
Mediastinoscopy - non-caseating granulomas
chronic renal insufficiency
OSA on CPAP
ulcerative colitis dx ___
squamous and basal cell skin cancer
Right Heart failure - listed for cardiac transplantation status
___.
*Sarcoidosis history
Cardiac PET at ___ highly suggestive for cardiac sarcoid
___ - prednisone - 6 months with methotrexate
Worsening creatinien - felt to be due to MTX.
Completed 6 months ___.
Pet repeat ___ - improvement in uptake and pulmonary nodules
___ severe systolic heart failure ___ advanced sarcoidosis
(sarcoid dx ___
AV block s/p pacemaker ___ and subsequent upgrade to
biventricular ICD ___ in setting fo prolonged VT
paroxysmal atrial fibrillation s/p ablation ___ at ___, placed
on amio ___
Treated again in ___ x 6 months with prednisone for sarcoidosis
Social History:
___
Family History:
F: died from lymphoma
M: AD, stroke
sister: stroke
No coronary artery disease or sudden cardiac death.
Physical Exam:
Admission Physical Exam:
___ 0257 Temp: 98.7 PO BP: 127/76 R Sitting HR: 62 RR: 18
O2
sat: 96% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
========================
PHYSICAL EXAM:
___ 0724 Temp: 98.3 PO BP: 103/68 HR: 62 RR: 20 O2 sat: 93%
O2 delivery: RA
GENERAL: NAD
HEENT:anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB, no wheezes,
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: no cyanosis, clubbing, or edema
Pertinent Results:
Admission Labs:
===============
___ 11:13PM BLOOD WBC-11.5* RBC-5.04 Hgb-15.6 Hct-46.4
MCV-92 MCH-31.0 MCHC-33.6 RDW-14.5 RDWSD-48.4* Plt ___
___ 11:13PM BLOOD Neuts-92.7* Lymphs-1.4* Monos-4.9*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.68* AbsLymp-0.16*
AbsMono-0.57 AbsEos-0.02* AbsBaso-0.03
___ 11:43PM BLOOD ___ PTT-37.4* ___
___ 11:13PM BLOOD Glucose-128* UreaN-33* Creat-1.6* Na-133*
K-4.9 Cl-95* HCO3-21* AnGap-17
___ 11:13PM BLOOD ALT-18 AST-24 AlkPhos-64 TotBili-0.5
___ 07:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
___ 11:13PM BLOOD cTropnT-<0.01 proBNP-415*
___ 11:20PM BLOOD Lactate-1.9
=============
Microbiology:
==============
___ 11:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH
___: Blood Cultures X4- pending at discharge
========
Imaging:
========
CXR ___:
IMPRESSION:
1. No acute cardiopulmonary abnormality, specifically despite
indwelling
pacemaker defibrillator leads and chronic mild cardiomegaly,
there is no
evidence of acute cardiac decompensation.
CXR ___:
IMPRESSION:
Left PICC ends at the cavoatrial junction. No significant
interval change.
================
Discharge Labs:
===============
___ 04:58AM BLOOD WBC-8.1 RBC-4.96 Hgb-15.4 Hct-45.8 MCV-92
MCH-31.0 MCHC-33.6 RDW-14.5 RDWSD-48.6* Plt ___
___ 04:58AM BLOOD Plt ___
___ 04:58AM BLOOD Glucose-104* UreaN-32* Creat-1.7* Na-136
K-3.9 Cl-95* HCO3-23 AnGap-18
___ 04:58AM BLOOD ALT-24 AST-32 AlkPhos-65 TotBili-0.5
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of biopsy
proven sarcoidosis with lung involvement, HFrEF (EF 40% ___
with severe RV dysfunction, inotrope-dependent on home milrinone
(0.375 mcg/kg/min), currently UNOS status IB, who presents to
the ED with fevers, concerning for repeat bacteremia, blood
cultures were no growth after 48 hours. He was discharged with
follow-up with heart failure clinic in 1 week. Infectious
disease will continue to follow.
ACUTE ISSUES:
==============
#Fever:
#History of Endocarditis (tricuspid valve)-- serratia on blood
cultures from ___:
Patient presented with fever to 100.8 ___s abdominal pain
and one episode of vomiting. He has a known history of
bacteremia and endocarditis without removal of ICD leads for
source control. Blood cultures were obtained and he received 1
dose of ertapenem in the ED. Infectious disease was consulted
and recommended a second set of blood cultures be taken from his
picc. The patient was continued on home 1 single strength
Bactrim BID. The patient was observed for 48 hours without
fever. Blood cultures from ___ and ___ with now growth at the
time of discharge (cultures were 36hrs and 24hrs old,
respectively). Stool cultures were ordered, but pt was unable to
move his bowels while admitted. He had no further GI symptoms.
He will follow up with ___ clinic in 1 week after discharge.
Infectious disease will follow up on his cultures if they do
grow anything after discharge.
Chronic Issues:
===============
#HFpEF with RV dysfunction ___ to Cardiac Sarcoidosis:
Patient with a history of HFpEF. He was maintained on his home
medications without changes. Appeared clinically euvolemic.
#Atrial Fibrillation:
Patient is on warfarin atrial fibrillation. He was continued on
home warfarin and amiodarone dosing.
TRANSITIONAL ISSUES
===================
Discharge weight: 98.9kg / 218.03lbs
Discharge Cr: 1.7
[] Please follow up blood cultures as an outpatient (ID (Dr
___ at ___ will be watching them for any growth and will
call him if they turn positive.
[] Will check INR on ___ at home and send it to Dr ___
review.
Full Code
Name of ___ care proxy: ___
Relationship: wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine (Rectal) ___AILY
2. Allopurinol ___ mg PO DAILY
3. LORazepam 1 mg PO QHS:PRN sleep
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Milrinone 0.375 mcg/kg/min IV DRIP INFUSION
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Amiodarone 200 mg PO DAILY
9. Triamcinolone Acetonide(Inhal) 1 spray inhalation qHS PRN
10. Warfarin 3 mg PO 5X/WEEK (___)
11. Warfarin 3.5 mg PO 2X/WEEK (___)
12. Pravastatin 40 mg PO QPM
13. Ferrous Sulfate 325 mg PO BID
14. Torsemide 40 mg PO DAILY
15. Spironolactone 50 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. sildenafil 25 mg oral PRN
18. Calcium Carbonate 500 mg PO DAILY
19. Potassium Chloride 40 mEq PO DAILY
20. Aspirin 81 mg PO DAILY
21. Sulfameth/Trimethoprim SS 2 TAB PO BID
22. Levothyroxine Sodium 100 mcg PO DAILY
23. Oxymetazoline 1 SPRY NU QHS before cpap
24. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Digoxin 0.125 mg PO EVERY OTHER DAY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Ferrous Sulfate 325 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. LORazepam 1 mg PO QHS:PRN sleep
10. Mesalamine (Rectal) ___AILY
11. Milrinone 0.375 mcg/kg/min IV DRIP INFUSION
12. Multivitamins 1 TAB PO DAILY
13. Oxymetazoline 1 SPRY NU QHS before cpap
14. Potassium Chloride 40 mEq PO DAILY
Hold for K >
15. Pravastatin 40 mg PO QPM
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. sildenafil 25 mg oral PRN
18. Spironolactone 50 mg PO DAILY
19. Sulfameth/Trimethoprim SS 1 TAB PO BID
20. Torsemide 40 mg PO DAILY
21. Triamcinolone Acetonide(Inhal) 1 spray inhalation qHS PRN
22. Vitamin D 4000 UNIT PO DAILY
23. Warfarin 3.5 mg PO 2X/WEEK (___)
24. Warfarin 3 mg PO 5X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Fever
Secondary Diagnosis:
====================
Atrial fibrillation
Heart Failure with Preserved Ejection Fraction
h/o serratia tricuspid valve endocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had a fever and
was not feeling well.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We took blood samples from you and observed you in the
hospital.
- Infectious disease saw you and will follow up your blood
cultures as an outpatient.
- You did not show any signs of infection
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, call your cardiologist (Dr
___ ___ if your weight goes up more than 3 lbs.
- Please check your INR on ___ ___ to
review.
We wish you the best.
Your ___ Team
Followup Instructions:
___
|
10595263-DS-20 | 10,595,263 | 24,863,581 | DS | 20 | 2188-08-17 00:00:00 | 2188-08-19 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / shellfish derived / oxycodone / Vicodin / Percocet
Attending: ___.
Chief Complaint:
elective admission
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Patient called to report a fever of ___ yesterday. He last
received gemcitabine/abraxane chemotherapy on ___ with an ___
at that time of about ___. He awoke on ___ feeling hot and
measured a temp of 100.7. He took some tylenol and went out to
breakfast. Later in afternoon he felt feverish again, and his
temp was about 102 states it went as high as 104. He also
describes having shaking chills. He has some redness at his
J-tube site but states it is not painful, no pustular drainage
and redness has been coming and going for the past month. He is
planned to have JT removed as he has gained 40lb w/ tube feeds
and is now eating well after his resection.
In the ED, obtained full infectious workup including LFT's,
influenza, ua, urine culture, eval of J-tube site. S/p Cefepime
2g IV x1 in the ED and continued this am.
No fevers since admission. he denies any cough, SOB, sore
throat,
runny nose, congestion, sinus pressure, ab pain, diarrhea,
vomiting, dysuria.
REVIEW OF SYSTEMS: No HA, vision changes, numbness, focal
weakness, mleena, hematocheiza bruising, or any other bleeding.
remainder 10 pt ROS negative other than HPI above
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___: Presented to ED with above symptoms as well as ___ lb
weight loss. He was anemia and had guaiac-positive stools.
EGD/Colonoscopy showed a stricture in the second portion of the
duodenum.
-___: MRI Abdomen showed 3.7 cm pancreatic head mass causing
duodenal obstruction and gastric distention.
-___: C1D1 neoadjuvant FOLFIRINOX.
-___: Initiated tube feeds to improve nutritional status in
anticipation for resection.
-___: Pylorus-preserving pancreaticoduodenectomy (Whipple)
and open cholecystectomy, uncomplicated. Pathology showed pT3N0,
moderately differentiated, ___ lymph nodes involved, margins
negative to 6 mm, positive large vessel/angiolymphatic invasion,
positive perineural invasion.
-___: C1D1 gemcitabine 1000 mg/m2/abraxane
--hepatic mets discovered
- ___ - C2D15 Gem/Abraxane
PAST MEDICAL HISTORY:
1. GERD
2. PUD c/b UGIB
3. Pancreatic cancer (s/p chemo, has bile duct stent)
4. R cerebral aneurysm (at junction of R ACA and common carotid)
Social History:
___
Family History:
HTN, mother with lung CA, grandmother with COPD
Physical Exam:
DISCHARGE PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.2 106/62 88 20 97%RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB nonlabored
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, J-tube
site with 1cm surrounding erythema and induration no pustular
drainage or fluctuance very slightly tender
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown, port c/d/I/
NEURO: ___, EOMI, face symmetric, moves all ext against
resistance, sensation intact to light touch
Pertinent Results:
ADMISSION LABS:
___ 06:33PM BLOOD WBC-2.4* RBC-2.82* Hgb-8.0* Hct-25.7*
MCV-91 MCH-28.4 MCHC-31.1* RDW-17.8* RDWSD-58.1* Plt ___
___ 06:33PM BLOOD Neuts-78.6* Lymphs-12.4* Monos-7.0
Eos-0.8* Baso-0.8 Im ___ AbsNeut-1.90 AbsLymp-0.30*
AbsMono-0.17* AbsEos-0.02* AbsBaso-0.02
___ 06:33PM BLOOD Glucose-105* UreaN-14 Creat-0.9 Na-135
K-3.7 Cl-102 HCO3-25 AnGap-12
___ 06:33PM BLOOD ALT-60* AST-37 AlkPhos-175* TotBili-0.5
DISCHARGE LABS:
___ 04:41AM BLOOD Neuts-48 Bands-0 ___ Monos-9 Eos-1
Baso-1 ___ Myelos-0 AbsNeut-0.96* AbsLymp-0.82*
AbsMono-0.18* AbsEos-0.02* AbsBaso-0.02
___ 04:41AM BLOOD Glucose-103* UreaN-17 Creat-0.8 Na-141
K-3.8
IMAGING:
CT chest:
Aorta and pulmonary arteries are unremarkable. Heart size is
normal. Several mediastinal lymph nodes are not pathologically
enlarged and unchanged. No pericardial pleural effusion is
seen.
Minimal gynecomastia is present.
Central venous line tip terminates in right atrium.
Airways are patent to the subsegmental level bilaterally.
Several focal areas of ground-glass opacity and left upper lobe
most likely represent infectious process. No discrete nodules
masses or consolidations demonstrated.
No lytic or sclerotic lesions worrisome for infection or
neoplasm
demonstrated.
IMPRESSION:
No intrathoracic findings that would be concerning for
metastatic
disease.
Potential infectious process in the left upper lobe.
CT abdomen:
IMPRESSION:
1. Numerous hepatic metastases, many of which now demonstrate
increased
non-specific peripheral attenuation which could suggest
treatment response.
2. Persistent moderate attenuation of the portal vein-SMV
confluence from soft tissue encasement but the vessels remain
patent, similar to the prior exam.
Soft tissue density near the Whipple site continues to encase
the proximal
common hepatic artery, overall similar to the prior exam.
Persistent atrophy of the pancreatic body and tail.
3. J-tube in appropriate position without evidence of soft
tissue abscess.
4. Persistent migrated pancreaticojejunostomy stent without
evidence of
obstruction.
5. The fluid-filled appendix is borderline in diameter (up to
6-7 mm) without
adjacent significant fat stranding. Correlate with clinical
assessment. No
definite evidence to suggest acute appendicitis.
Brief Hospital Course:
Mr. ___ is a ___ man with pancreatic adenocarcinoma s/p
pylorus-preserving Whipple and open cholecystectomy,
uncomplicated, now on Gem/Abraxane presenting with fever
#Neutropenic Fever/Pneumonia - ANC ~1000 during admission, had
high fever w/ possible rigors, fevers here thru ___ now
improved. CXR clear but CT suggestive of pneumonia in LUL.
- treated with empiric cefepime/vanco, blood cultures NGTD, flu
PCR negative
- CT ab w/o evidence of infection around JT site
- did not require neupogen, WBC now uptrending on discharge
- transitioned to levaquin on discharge to complete addnl 5 days
#Pancreatic Adenocarcinoma: s/p Pylorus-preserving Whipple and
open cholecystectomy, currently undergoing treatment with
gemcitabine/abraxane on ___, C2 D15 was ___. cont prn Zofran
cont creon
#Anemia: likely marrow suppression from chemotherapy, prev had
iron deficiency but ferritin had normalized in ___. transfuse
Hgb
<7 or symptomatic
#Hx malnutrition - has been on tube feeds since prior to his
surgical resection, gained 40lb and now eating well. surgery
planning to remove after 2 weeks if weight remains stable off TF
(last ___ unless imaging suggestive of infection
#Hx anxiety - cont prn ativan
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Pantoprazole 40 mg PO Q24H
5. LORazepam 0.5-1 mg PO Q12H:PRN anxiety
6. Creon 12 2 CAP PO TID W/MEALS
Discharge Medications:
1. Creon 12 2 CAP PO TID W/MEALS
2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety
3. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q24H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth QID prn Refills:*0
8. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenic fever
Pneumonia
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 stay
at ___. You were admitted with fever and you had very low
white blood cell count. Fevers improved with antibiotics. You
were found to have a small pneumonia on chest CT. There was no
infection at the Jtube site on CT abdomen. You were seen by
surgery and they are planning for removal of the Jtube within
two weeks if you are able to maintain your weight off tube
feeds.
Followup Instructions:
___
|
10595263-DS-21 | 10,595,263 | 28,576,919 | DS | 21 | 2188-09-14 00:00:00 | 2188-09-14 10:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / shellfish derived / oxycodone / Vicodin / Percocet
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ male with pancreatic cancer
metastatic to liver s/p partial pancratectomy and neoadjuvant
FOLFIRINOX x2, currently on gem/abraxane last dose ___ presents
for fever and generalized malaise that began approximately 1
week
ago. Over past week has noted low grade fevers which had been
controlled with Tylenol until today he spiked temp to 102.7 and
came to ED. also has slight cough. Reported that he felt winded
at home but primary complaint generalized malaise. Patient feels
similar to his last experience with pneumonia. No chest pain,
hemoptysis. Also endorsing left lower extremity pitting edema
just been progressively worsening over the last 2 weeks.
Extremities are nonpainful
Vitals:102.7 102 145/88 18 96% RA
CXR showed new infiltrate
___ negative for DVT
in ED received 1L NS, cefepime 2g, Tylenol 1g and levofloxacin
750mg
on arrival to floor reports feeling better. no recurrence fever
thus far. currently denies any SOB. did have sick contact 2 days
ago with a cold.
Past Medical History:
-___: Presented to ED with above symptoms as well as ___ lb
weight loss. He was anemia and had guaiac-positive stools.
EGD/Colonoscopy showed a stricture in the second portion of the
duodenum.
-___: MRI Abdomen showed 3.7 cm pancreatic head mass causing
duodenal obstruction and gastric distention.
-___: C1D1 neoadjuvant FOLFIRINOX.
-___: Initiated tube feeds to improve nutritional status in
anticipation for resection.
-___: Pylorus-preserving pancreaticoduodenectomy (Whipple)
and open cholecystectomy, uncomplicated. Pathology showed pT3N0,
moderately differentiated, ___ lymph nodes involved, margins
negative to 6 mm, positive large vessel/angiolymphatic invasion,
positive perineural invasion.
-___: C1D1 gemcitabine 1000 mg/m2/abraxane
--hepatic mets discovered
- ___ - C2D1 Gem/Abraxane
- ___ - C3D1 Gem/Abraxane
PAST MEDICAL HISTORY:
1. GERD
2. PUD c/b UGIB
3. Pancreatic cancer (s/p chemo, has bile duct stent)
4. R cerebral aneurysm (at junction of R ACA and common carotid)
Social History:
___
Family History:
HTN, mother with lung CA, grandmother with COPD
Physical Exam:
General: NAD
VITAL SIGNS: 98.2 129/86 85 18 98%RA
HEENT: OMM
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB nonlabored
ABD: BS+, soft, NTND, no masses, prior tube feed site well
healed
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, face symmetric, moves all ext
against resistance bilateral, sensation intact to light touch
Pertinent Results:
___ 05:18AM BLOOD WBC-4.7 RBC-3.06* Hgb-8.1* Hct-27.2*
MCV-89 MCH-26.5 MCHC-29.8* RDW-18.2* RDWSD-59.3* Plt ___
___ 05:18AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-135
K-4.4 Cl-101 HCO3-26 AnGap-12
___ 09:20PM BLOOD ALT-16 AST-23 AlkPhos-177* TotBili-0.4
___ 05:18AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
___ 09:42PM BLOOD Lactate-1.3
Brief Hospital Course:
Mr ___ is a ___ w/ pancreatic cancer mets to liver s/p
pancreatectomy and adjuvant FOLFIRINOX currently C3D22
Gemcitabine/Abraxane who is admitted with fevers and cough. CXR
confirmed PNA. Due to exposure to sick contacts, and his rapid
improvement on admission, his PNA is most likely viral process.
Since he defervesced quickly, he was treated with 2gm
Ceftriaxone. His cultures were NGTD and since he improved so
quickly, was discharged home on oral cefpodoxime. He was
discharged to complete a 10 day course with vancomycin BID
dosing to extend 7 days afterwards for c.diff prophylaxis. He
was encouraged to continue protein supplementation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 2 CAP PO TID W/MEALS
2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety
3. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q24H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Discharge Medications:
1. Creon 12 2 CAP PO TID W/MEALS
2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety
3. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q24H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
8. Vancomycin Oral Liquid ___ mg PO BID c.diff prevention
RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp
#*31 Capsule Refills:*0
9. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Health Care Associated Pneumonia
Pancreatic Cancer
History of Severe Clostridium Dificile Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with pneumonia. You improved quickly. You
likely had a viral process but will continue antibiotics. Please
follow up with your oncologist. If you start having worsening
fevers or cough, let your oncologist know.
Your ___ Oncology Team
Followup Instructions:
___
|
10595263-DS-22 | 10,595,263 | 27,154,013 | DS | 22 | 2188-10-06 00:00:00 | 2188-10-06 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / shellfish derived / oxycodone / Vicodin / Percocet
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
PTBD tube placement
History of Present Illness:
___ w/ pancreatic cancer metastatic to liver s/p partial
pancratectomy and neoadjuvant FOLFIRINOX x2, currently on C4D14
palliative nab-paclitaxel/gemcitabine last dose ___ p/w fever.
He has had multiple admissions for neutropenic fever, most
recently for viral URI in ___, and he completed a course of
cepodoxime for presumptive PNA out of overabundance of
precaution
and oral vancomycine for c.diff prophylaxis.
Of note, patient had restaging CT scan yesterday PTA which
revealed progressive hepatic metastatic disease with increased
number and size of multifocal hepatic metastases and new
dilation
of the left biliary tree likely on the basis of obstruction
from
hepatic perihilar metastases.
On ___, developed temp to 103, dizziness, went to the ED.
Denies
cp, cough. Mildly sob. Denies abd pain/n/v/d or urinary sxs but
has decreased appetite. Has had some mild thrush which he
usually
gets after chemo but took fluconazole and this has improved.
States he otherwise feels improved from earlier today.
In the ED, found to have WBC of 3.2 (71% neut), CXR with no e/o
pneumonia, RUQ U/S report pending, s/p Vanc/Cef/Flagyl, 1L NS.
Past Medical History:
-___: Presented to ED with above symptoms as well as ___ lb
weight loss. He was anemia and had guaiac-positive stools.
EGD/Colonoscopy showed a stricture in the second portion of the
duodenum.
-___: MRI Abdomen showed 3.7 cm pancreatic head mass causing
duodenal obstruction and gastric distention.
-___: C1D1 neoadjuvant FOLFIRINOX.
-___: Initiated tube feeds to improve nutritional status in
anticipation for resection.
-___: Pylorus-preserving pancreaticoduodenectomy (Whipple)
and open cholecystectomy, uncomplicated. Pathology showed pT3N0,
moderately differentiated, ___ lymph nodes involved, margins
negative to 6 mm, positive large vessel/angiolymphatic invasion,
positive perineural invasion.
-___: C1D1 gemcitabine 1000 mg/m2/abraxane
--hepatic mets discovered
- ___ - C2D1 Gem/Abraxane
- ___ - C3D1 Gem/Abraxane
PAST MEDICAL HISTORY:
1. GERD
2. PUD c/b UGIB
3. Pancreatic cancer (s/p chemo, has bile duct stent)
4. R cerebral aneurysm (at junction of R ACA and common carotid)
Social History:
___
Family History:
HTN, mother with lung CA, grandmother with COPD
Physical Exam:
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
Pertinent Results:
PTBD placement ___
FINDINGS:
1. Mild to moderate left hepatic biliary dilation.
2. High-grade central left hepatic biliary duct obstruction,
consistent with
known metastatic disease.
3. Placement of a left PTBD with sideholes above and below area
of
obstruction.
CT A/P with contrast ___
1. Progressive hepatic metastatic disease with increased
number and size of
multifocal hepatic metastases as detailed above.
2. New dilation of the left biliary tree likely on the basis of
obstruction
from hepatic perihilar metastases, as above.
3. Remainder as detailed in the body of the report.
Brief Hospital Course:
___ w/ pancreatic cancer metastatic to liver s/p partial
pancratectomy and neoadjuvant FOLFIRINOX x2, currently on C4D14
palliative nab-paclitaxel/gemcitabine last dose ___ p/w fever.
# Fever Likely cholangitis based on the biliary obstruction seen
on CT yesterday. Per ___, received PTBD tube drain with no
complications. Started on Vanc/Cefipime/Flagyl, febrile for one
evening, transitioned to Cefipime/Flagyl and discharged on
Cipro/Flagyl for a total of a ten day course, as LFT's
improving.
# Pancreatic Cancer - Currently on C4 Paclitaxel and
gemcitabine. He is due for D15
dose on ___ which ___ need to be on hold for now. ___ with
Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Acetaminophen 650 mg PO Q6H:PRN headache
3. Creon 12 2 CAP PO TID W/MEALS
4. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache
2. Creon 12 2 CAP PO TID W/MEALS
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Pantoprazole 40 mg PO Q24H
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*15 Tablet Refills:*0
6. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*23 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please continue to follow with your oncologist and
interventional radiology team
Followup Instructions:
___
|
10595263-DS-23 | 10,595,263 | 24,575,403 | DS | 23 | 2188-10-11 00:00:00 | 2188-10-11 12:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / shellfish derived / oxycodone / Vicodin / Percocet
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
cholangiogram ___
History of Present Illness:
___ w/ pancreatic cancer metastatic to liver s/p partial
pancratectomy and neoadjuvant FOLFIRINOX x2, currently on C4D20
palliative nab-paclitaxel/gemcitabine last dose ___ p/w fever.
He has had multiple admissions for neutropenic fever, most
recently for viral URI in ___, and he completed a course of
cepodoxime for presumptive PNA out of overabundance of
precaution
and oral vancomycin for c.diff prophylaxis, as well as ___
for left ___ Fr int/ext PTBD placement on ___ for presumed
cholangitis and was discharged on a 10 day course of
Cipro/Flagyl. He kept his drain capped and it has not been
leaking.
Over the past day, he notes fevers to 101.1F but denied any
cough, CP, SOB, and otherwise feels well. Due to the fever, he
presented to the ED where he was found to have T of 101.1. CXR
with no e/o pneumonia, RUQ U/S report pending, s/p Cef, 1L NS.
On arrival to OMED, pt notes he has been having loose stools the
past few days. Normally his stool is formed and moves ~1.5x/day,
now moving loose stools BID. He denied abdominal pain but he
does
have intermittent nausea for which he takes compazine BID
(zofran
doesn't work for him). He does c/o of abnormal sensation in the
RUQ that is intermittent and feels like a "muscle strain." That
is not provoked w/ meals.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___: Presented to ED with above symptoms as well as ___ lb
weight loss. He was anemia and had guaiac-positive stools.
EGD/Colonoscopy showed a stricture in the second portion of the
duodenum.
-___: MRI Abdomen showed 3.7 cm pancreatic head mass causing
duodenal obstruction and gastric distention.
-___: C1D1 neoadjuvant FOLFIRINOX.
-___: Initiated tube feeds to improve nutritional status in
anticipation for resection.
-___: Pylorus-preserving pancreaticoduodenectomy (Whipple)
and open cholecystectomy, uncomplicated. Pathology showed pT3N0,
moderately differentiated, ___ lymph nodes involved, margins
negative to 6 mm, positive large vessel/angiolymphatic invasion,
positive perineural invasion.
-___: C1D1 gemcitabine 1000 mg/m2/abraxane
--hepatic mets discovered
hospitalized ___ with fever and diagnosed with
pneumonia. He completed a course of cefpodoxime for this as
well
as prophylactic po vancomycin to prevent recurrent c-diff
infection.
PAST MEDICAL HISTORY: Pancreatic adenocarcinoma as above.
Social History:
___
Family History:
HTN, mother with lung CA, grandmother with COPD
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 97.8 126/84 68 18 96%RA
General: NAD, Resting in bed comfortably
HEENT: MMM, + mild thrush in OP
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM, PTBD capped w/
dressing c/d/I no drainage
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: ___ strength throughout no tremors/asterixis
Pertinent Results:
___:26PM BLOOD WBC-5.5 RBC-3.13* Hgb-8.0* Hct-26.8*
MCV-86 MCH-25.6* MCHC-29.9* RDW-19.7* RDWSD-60.7* Plt ___
___ 05:36AM BLOOD WBC-6.7# RBC-3.15* Hgb-8.0* Hct-26.8*
MCV-85 MCH-25.4* MCHC-29.9* RDW-19.6* RDWSD-59.2* Plt ___
___ 07:26PM BLOOD Neuts-79* Bands-0 Lymphs-5* Monos-15*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-4.35 AbsLymp-0.28*
AbsMono-0.83* AbsEos-0.06 AbsBaso-0.00*
___ 05:36AM BLOOD Neuts-67.7 Lymphs-10.8* Monos-19.7*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.53 AbsLymp-0.72*
AbsMono-1.32* AbsEos-0.00* AbsBaso-0.00*
___ 04:24AM BLOOD ___ PTT-32.8 ___
___ 07:26PM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-133
K-3.8 Cl-98 HCO3-25 AnGap-14
___ 05:36AM BLOOD UreaN-22* Creat-0.7 Na-133 K-4.6 Cl-101
HCO3-24 AnGap-13
___ 07:26PM BLOOD ALT-29 AST-30 LD(LDH)-186 AlkPhos-559*
TotBili-0.5
___ 05:36AM BLOOD ALT-18 AST-15 AlkPhos-462* TotBili-0.3
___ 07:36PM BLOOD Lactate-1.2
Cholangiogram ___ with tube working
MRCP per verbal discussion w/ radiologist no obstruction or new
concerning findings (redemonstration of known hepatic mets)
Brief Hospital Course:
___ w/ pancreatic cancer metastatic to liver s/p partial
pancreatectomy and neoadjuvant FOLFIRINOX x2, currently on C4D14
palliative nab-paclitaxel/gemcitabine last dose ___ p/w fever.
# Fever - presented the week prior with cholangitis/biliary
obstruction and PTBD placed ___, pt discharged with 10d total
course of cipro/flagyl on ___ but had fever at home
and re-presented for fever. Otherwise clinically no symptoms and
felt quite well. Did report mild allergic type watering of the
eys and maybe some rhinorrhea in this context at home which
resolved. No cough, dysuria, significant diarrhea,
nausea,vomiting, abd pain, headache. WBC was not elevated and he
was not neutropenic. LFTs reassuring. Underwent cholangiogram
for PTBD check on ___ and tube was completely patent; given
significant hepatic met burden ___ suggested MRCP in case the
right side of the liver now with obstruction. MRCP read pending
at discharge but per verbal report w/ radiologist extremely
reassuring no e/o abscess, cholangitis, infection, but simply
redemonstration of known hepatic mets. Pt felt extremely well,
CXR and urine reassuring, C.diff testing neg (had some loose
stool likely abx related). Initially was placed on
cefepime/flagyl but remained afebrile and well after transition
to cipro/flagyl so will go home to complete the original 10d
course through ___ for the prior episode of cholangitis
requiring PTBD in his recent prior admission. Unclear source of
fever but suspect pt had a viral illness prior to admit that
self-resolved, which he had though was simply allergies.
# Loose stools
# History of Severe C.Diff - pt with some loose stool at home on
abx, c.diff was negative here and loose stools had resolved on
discharge. was likely antibiotic effect.
# Pancreatic Cancer
Currently on C4 Paclitaxel and gemcitabine, s/p ___. He was
due for D15 dose on ___ which has been on hold for now.
Unfortunately recent imaging revealed disease progression and
due to meet w/ Dr ___ ___ to discuss plan and ? C4D15 dose.
Discharged ___ and has f/u with oncology ___ to discuss
further. Cont creon, prn Ativan/compazin/Zofran. Contd PPI (h/o
PUD with UGIB, but that was prior to resection)
Greater than 30 minutes were spent in planning and execution of
this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN headache
2. Creon ___ CAP PO TID W/MEALS
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Pantoprazole 40 mg PO Q12H
5. Ciprofloxacin HCl 500 mg PO Q12H
6. MetroNIDAZOLE 500 mg PO Q8H
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. LORazepam 0.5-1 mg PO BID:PRN anxiety, insomnia, nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Creon ___ CAP PO TID W/MEALS
4. LORazepam 0.5-1 mg PO BID:PRN anxiety, insomnia, nausea
5. MetroNIDAZOLE 500 mg PO Q8H
6. Pantoprazole 40 mg PO Q12H
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic cancer
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fever. We did not find evidence of a
concerning infection. it's possible you had a virus.
Please continue your cipro and flagyl pills through ___ as you
had originally been planning.
Please follow up with your oncologist (you have an appointment
___
Followup Instructions:
___
|
10595263-DS-24 | 10,595,263 | 27,867,097 | DS | 24 | 2188-10-29 00:00:00 | 2188-10-30 14:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / shellfish derived / oxycodone / Vicodin / Percocet
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
PTBD ___
History of Present Illness:
___ with metastatic pancreatic cancer to liver with recent
disease progression through gemcitabine/Abraxane and started on
FOLFOX (today is C1D10). Recently has had multiple admissions
for fevers, some thought to be related to cholangitis (now s/p
PTBD), others of unclear etiology, potentially related to
hepatic lesions.
He developed a fever to 102 on the evening of ___. He took a
dose of Tylenol, but repeat temperature was 102.9 at 10:30PM. He
also had rigors and some chills. He has had no energy all day.
He denies cough, diarrhea, abdominal pain. His PTBD is stable
without erythema or drainage. He had some pain with urination 2
days ago, but states that this self-resolved. He denies rash. He
has had poor PO intake over the past week and reports losing
about 10 lbs.
In the ED, initial VS were: 101.8 137 ___ 97% RA
Labs were notable for: WBC 8.9 w/ 7% bands, alk phos 821, t-bili
2.4 (baseline 0.3-0.6), Na 130 (baseline 130-133), lactate 1.8,
normal UA. Rectal w/ brown guaiac negative stool
Imaging included: CXR unchanged from prior, RUQ US w/o biliary
dilation
Consults called: ERCP but no recs yet
Treatments received:
___ 01:14 PO Ibuprofen 600 mg
___ 01:50 IVF 1000 mL NS 1000 mL
___ 01:50 IV CefePIME 2 g
___ 02:45 IV Vancomycin 1000 mg
Vitals on transfer: 97.3 87 101/65 16 100% RA
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___: Presented to ED with above symptoms as well as ___ lb
weight loss. He was anemia and had guaiac-positive stools.
EGD/Colonoscopy showed a stricture in the second portion of the
duodenum.
-___: MRI Abdomen showed 3.7 cm pancreatic head mass causing
duodenal obstruction and gastric distention.
-___: C1D1 neoadjuvant FOLFIRINOX.
-___: Initiated tube feeds to improve nutritional status in
anticipation for resection.
-___: Pylorus-preserving pancreaticoduodenectomy (Whipple)
and open cholecystectomy, uncomplicated. Pathology showed pT3N0,
moderately differentiated, ___ lymph nodes involved, margins
negative to 6 mm, positive large vessel/angiolymphatic invasion,
positive perineural invasion.
-___: C1D1 gemcitabine 1000 mg/m2/abraxane
--hepatic mets discovered
hospitalized ___ with fever and diagnosed with
pneumonia. He completed a course of cefpodoxime for this as
well
as prophylactic po vancomycin to prevent recurrent c-diff
infection.
PAST MEDICAL HISTORY: Pancreatic adenocarcinoma as above.
Social History:
___
Family History:
The patient's mother died of tobacco-associated lung cancer at
___ years. His father is living in his ___. His one brother and
five children are without health concerns.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: T97.4 HR90 BP98/61 RR20 SAT 98% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: sclera anicteric, MMM, no thrush
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, PTBD
tube at epigastrium w/ site c/d/i
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, moving all extremities equally
SKIN: No significant rashes\
DISCHARGE PHYSICAL EXAM:
============================
VS: T 97.3 BP 100-116/76-86 HR ___ 100 % RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: sclera anicteric, MMM, no thrush or mucositis
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, PTBD
tube at epigastrium w/ site c/d/i
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, moving all extremities equally
SKIN: No significant rashes
Pertinent Results:
labs:
===========
___ 03:18PM URINE HOURS-RANDOM SODIUM-<20
___ 03:18PM URINE OSMOLAL-745
___ 08:51AM GLUCOSE-118* UREA N-13 CREAT-0.7 SODIUM-135
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
___ 08:51AM estGFR-Using this
___ 08:51AM ALT(SGPT)-23 AST(SGOT)-27 LD(LDH)-172 ALK
PHOS-711* TOT BILI-2.4*
___ 08:51AM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.1
___ 08:51AM HAPTOGLOB-204*
___ 08:51AM OSMOLAL-282
___:51AM WBC-5.7 RBC-3.15* HGB-8.0* HCT-26.8* MCV-85
MCH-25.4* MCHC-29.9* RDW-20.4* RDWSD-62.6*
___ 08:51AM PLT COUNT-221
___ 03:15AM URINE HOURS-RANDOM
___ 03:15AM URINE UHOLD-HOLD
___ 03:15AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:39AM ___
___ 01:39AM LACTATE-1.8
___ 01:26AM GLUCOSE-141* UREA N-13 CREAT-0.8 SODIUM-130*
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-26 ANION GAP-14
___ 01:26AM estGFR-Using this
___ 01:26AM ALT(SGPT)-29 AST(SGOT)-34 ALK PHOS-821* TOT
BILI-2.4* DIR BILI-1.4* INDIR BIL-1.0
___ 01:26AM LIPASE-9
___ 01:26AM ALBUMIN-3.2*
___ 01:26AM WBC-8.9 RBC-3.03* HGB-7.7* HCT-25.6* MCV-85
MCH-25.4* MCHC-30.1* RDW-20.1* RDWSD-61.2*
___ 01:26AM NEUTS-75* BANDS-7* LYMPHS-5* MONOS-13 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-7.30* AbsLymp-0.45*
AbsMono-1.16* AbsEos-0.00* AbsBaso-0.00*
___ 01:26AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-1+
___ 01:26AM PLT SMR-NORMAL PLT COUNT-265
___ 01:26AM ___ PTT-31.1 ___
imaging:
=============
IMAGING:
#RUQ US ___: (wet read) IMPRESSION:
1. No evidence of intrahepatic biliary dilatation.
2. Known pneumobilia.
3. Innumerable hepatic metastases.
4. Trace fluid adjacent to the inferior margin of the liver.
#CXR ___: (wet read) IMPRESSION:
Right lung base atelectasis or developing pneumonia.
___ Imaging BILIARY CATH CHECK/REPO:
Successful exchange of existing percutaneous transhepatic
biliary drainage
catheters with new ___ F PTBD catheter.
RECOMMENDATION(S): ___ will follow up. Please leave connected
to bag and
continue monitoring total bilirubin.
Brief Hospital Course:
This is a ___ with history of pancreatic adenocarcinoma s/p
whipple procedure with recurrence now on FOLFOX. He present to
the hospital with fever in the setting of leaving the PTBD drain
capped. His admission labs were notable for an increase in
T.bili to 2.4 with ALP to 580. However he did not have a
elevation in WBC. He was diagnosed with cholangitis and was
started on IV flagyl, MDZ, and vancomycin. on the ___, he underwent replacement of his PTBD by the ___ team
without complications. His PTBD was allowed to drain. his T.Bili
came down to 0.8 on discharge. His fever improved and he was
switched to oral metronidazole and ciprofloxacin. On day 2 after
the replacement of the PTBD, we caped the catheter. The patient
and his wife were given instructions on proper care of the
catheter prior to discharge.
We also noted chronic anemia which was stable during this
admission. no transfusions given.
TRANSITIONAL ISSUES:
=================================
- The patient was started on flagyl and ciprofloxacin (last day
of receiving there will be ___.
- follow up blood and bile cultures and sensitivities.
-___ will call patient next week for F/U appointment for
check/change as outpatient
-Planned for ___ services for ___; however family declined. Gave
extensive teaching.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN headache
2. Creon ___ CAP PO TID W/MEALS
3. LORazepam 0.5-1 mg PO BID:PRN anxiety, insomnia, nausea
4. Pantoprazole 40 mg PO Q12H
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Creon ___ CAP PO TID W/MEALS
2. LORazepam 0.5-1 mg PO BID:PRN anxiety, insomnia, nausea
RX *lorazepam [Ativan] 0.5 mg ___ tablets by mouth twice a day
Disp #*8 Tablet Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Pantoprazole 40 mg PO Q12H
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*15 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN headache
8. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hrs (3X a day) Disp #*22 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary
acute cholangitis
hyponetremia
secondary:
chronic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
admitted because of fever. Early in your admission you underwent
blood and imaging tests which showed that the fever is likely
from infection of your liver and biliary system. Therefore, you
were started on IV antibiotics and underwent replacement of you
bile drainage (also known as the percutaneous biliary drain).
You symptoms improved with the antibiotics which were switched
to an oral form. Please continue to take your antibiotics as
prescribed below.
Also please make sure to follow the proper care for your drain
to prevent infection from reaching you bile. Please make sure to
keep your appointment which are listed below.
Our interventional radiology team should call you next week with
a follow up appointment concerning your drain. You will follow
up with our oncologists later this week.
Again it was a pleasure taking care of you. We wish you all the
best.
Your ___ team
Followup Instructions:
___
|
10595448-DS-11 | 10,595,448 | 21,678,164 | DS | 11 | 2172-03-12 00:00:00 | 2172-03-13 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of obstructive nephropathy ___ to BPH now on
HD since ___ who is presenting with persistent hematuria.
He has a history of BPH leading to obstructive nephropathy which
progressed over the course of ___ years to ESRD. He used to
straight cath. He reports having what sounds like a TUMT
procedure for his BPH about 5 months ago, which was complicated
by urethral injury that required a suprapubic catheter to be
placed for 5 months. He had the suprapubic catheter removed
about
2 weeks ago days ago, and then after ___ straight caths at home
developed significant penile and rectal pain, went to ___.
At ___ he was diagnosed with a UTI, reportedly with "white
urine", and he was treated with ceftriaxone and then Bactrim for
a total of 10 days. Early in hospitalization he also developed
hematuria and some clots, Foley was placed and he was
subsequently discharged. He states that he was referred to
urology here and he himself came to the ED for evaluation. He
denies fevers, chills, abdominal pain, or back pain. He has had
hematuria in the past that he reports resolved with Bactrim.
Hemoglobin initially 8.2 in ED, today down to 7.5. Patient's
last
hemoglobin at ___ was 8.5 on ___ and 8.5 on ___. Patient
also reports that his baseline since he started dialysis has
been
about ___, requiring some EPO. Patient also had an ultrasound of
the kidney which showed severe left hydronephrosis on the left
and moderate right sided hydronephrosis.
In the ED, initial VS were 99.1, 124, 122/78, 18, 100% RA
Exam notable for
Gen: Patient lying down in bed in no apparent distress.
Pleasant.
Cardiovascular: Regular rate and rhythm no murmurs rubs or
gallop
Lungs: Clear to auscultation bilaterally
Abdomen: Soft nontender nondistended. No CVA tenderness. Site of
previous suprapubic catheter. No erythema or discharge.
GU: Foley in place, 300 cc of frank blood in Foley bag. No clot
seen
Labs showed Hb 8.2->7.1->7.5, WBC 12.0, K+ 5.4, HCO2 22, AG 17,
UA >182 RBC, 9WBC, Sm leuks, neg nitrites.
Imaging showed:
Renal US
Moderate to severe right hydronephrosis. The bladder is
decompressed by a Foley and cannot be adequately evaluated on
this examination.
Received 1UPRBC, calcium acetate and sevelamer carbonate
renal and urology consulted, urology recommends continued
bladder
irrigation with triple foley.
Past Medical History:
- ESRD since ___ MWF via left radiocephalic AVF
- BPH
- H/o DM that was controlled with weight loss
- H/o HTN that resolved with weight loss
Social History:
___
Family History:
No CKD/ESRD.
Physical Exam:
VS: 98.0 132 / 81 98 19 98 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Lower lobe crackles bilaterally that seemed to have
cleared with a few deep breaths. No wheezing or rhonchi. No use
of accessory muscles.
ABDOMEN: Large pannus. nondistended, nontender in all quadrants.
suprapubic catheter scar lower midline appears well healed, no
evidence of infection.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
GU: Penis with foley in place, no evidence of discharge or
bleeding at the urethral opening, no pain to palpation.
Pertinent Results:
LABS
=======================
___ 05:00PM BLOOD WBC-13.7* RBC-2.61* Hgb-8.2* Hct-25.5*
MCV-98 MCH-31.4 MCHC-32.2 RDW-15.3 RDWSD-53.8* Plt ___
___ 04:48AM BLOOD WBC-12.2* RBC-2.24* Hgb-7.1* Hct-22.5*
MCV-100* MCH-31.7 MCHC-31.6* RDW-15.6* RDWSD-55.8* Plt ___
___ 08:58AM BLOOD WBC-13.0* RBC-2.43* Hgb-7.6* Hct-24.5*
MCV-101* MCH-31.3 MCHC-31.0* RDW-17.0* RDWSD-60.6* Plt ___
___ 08:58AM BLOOD Glucose-84 UreaN-76* Creat-10.3* Na-138
K-5.7* Cl-97 HCO3-21* AnGap-20*
___ 08:58AM BLOOD Calcium-8.7 Phos-6.8* Mg-3.0*
___ 08:58AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 08:58AM BLOOD HCV Ab-NEG
___ 07:15PM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM*
___ 07:15PM URINE RBC->182* WBC-9* Bacteri-NONE Yeast-NONE
Epi-0
MICROBIOLOGY
======================
Urine culture - negative
REPORTS
======================
Renal US ___
Moderate to severe right hydronephrosis. The cause of the
obstruction is not identified on this examination. The bladder
is decompressed by a Foley and cannot be adequately evaluated on
this examination.
Brief Hospital Course:
___ year-old man with a history of BPH c/b obstructive uropathy
leading to ESRD and HD, s/p TUMT
procedure c/b uretheral injury requiring suprapubic catheter
placement. His suprapubic catheter was removed ~2 weeks ago and
he resumed self catheterization. Soon after, he developed pelvic
pain, foul smelling urine, and bloody urine. He was admitted at
___ at treated with ceftriaxone and TMP-SMX for a UTI for a
total of 10 days. He did have a foley in place at that time.
Three days ago, he again started to pass blood clots in his
urine, and he came to ___, as he seeks to transfer Urologic
care here. He denied fevers and chills. No pelvic or back pain.
No diarrhea.
He was seen by Urology in the ED who placed a Foley catheter for
continuous bladder irrigation. He received 1U PRBC and was
admitted to medicine.
While in the hospital, his urine cleared up, and was a pink
lemonade color following continuous bladder irrigation. His
anemia appears to be long-standing, and related to ESRD rather
than hematuria. His Hemoglobin was stable on day of discharge.
He was not placed on antibiotics, and his urine culture was
negative. The plan was discussed with ___, and given that
his hematuria was clearing up, the plan was established for
outpatient Urology follow up for consideration of cystoscopy.
Per Urology, no Foley needed on discharge, he will continue to
do intermittent straight cath.
CHRONIC PROBLEMS
=============================
#ESRD: Received HD on ___, and will continue his MWF schedule
after discharge
#DM: Diet controlled
#HTN: Diet controlled
TRANSITIONAL ISSUES
=============================
- Outpatient Urology follow up for cystoscopy and further workup
for hematuria
- Continue intermittent self catheterization at home
- No changes to his chronic medications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Acetate 1334 mg PO TID W/MEALS
2. sevelamer CARBONATE 1600 mg PO TID W/MEALS
3. Vitamin D 3000 UNIT PO DAILY
Discharge Medications:
1. Calcium Acetate 1334 mg PO TID W/MEALS
2. sevelamer CARBONATE 1600 mg PO TID W/MEALS
3. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria
End Stage Renal Disease
BPH
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
our hospital following hematuria (red urine). You were seen by
Urology and you had a Foley placed for continuous irrigation.
Because your red urine cleared up and your hemoglobin is normal,
the Urologists do not need or want to do any urgent procedure.
They would like to see you in clinic for consideration of a
cystoscopy.
In the meantime, continue to do straight catheterization as you
have been. If you are unable to catheterize yourself due to
clots or any other issues, please seek medical attention.
Additionally, if you develop fever, chills, or worsening bloody
urine (pink color is OK), seek medical attention as well.
Follow up with your PCP within the next week. Follow up with
___ Urology using the phone number and information below.
We wish you all the best!
___ Medicine Team
Followup Instructions:
___
|
10595567-DS-6 | 10,595,567 | 23,044,954 | DS | 6 | 2166-09-26 00:00:00 | 2166-09-26 18:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Iodine / Bactrim / naproxen / Shellfish
Attending: ___.
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
___ Diagnostic cerebral angiogram
History of Present Illness:
___ M had sudden onset severe headache in context of
receiving treatment for anaphylaxis to shrimp at another
hospital
(23:30 on ___. He was subsequently discharged. He returned
home and had a second sudden onset severe headache during
intercourse at 15:30 on ___ and a second time at 18:00 on ___.
Presented to OSH where CT head was interpreted as normal and LP
(19:30) demonstrated 60,000 RBC and 115 WBC. Patient referred
for further workup. Pt has no feves, chills, or persistent neck
pain. Had some neck pain during headache episodes. Headache
resolved at present time.
Pt has some paresthesias in riht hand which are new since this
episode. He has classical migranies, and also seizure d/o,
neither of which have presented with headaches or neurologic
symptoms similar to those he has experienced over the past 2
days. He has not taken his antiepileptics in two days.
Past Medical History:
Classical migraines
Seizure d/o
EtOH abuse
Polysubstance abuse (used crack cocaine on ___
Tobacco use
Social History:
___
Family History:
No brain aneurysms
Physical Exam:
T:97.2 BP:103/42 HR:69 R:18 O2Sats:96
Gen: comfortable, NAD.
Awake and alert, cooperative with exam, normal affect
Orientation: Oriented to person, place, and date
Speech fluent with good comprehension and repetition
Naming intact
Pupils equally round and reactive to light
Visual fields are full to confrontation
Extraocular movements intact bilaterally
Facial strength and sensation intact and symmetric
Hearing intact to voice
Palatal elevation symmetrical
Sternocleidomastoid and trapezius normal bilaterally
Tongue midline without fasciculations
Normal bulk and tone bilaterally
No abnormal movements, tremors
Strength full power ___ throughout
No pronator drift
Intact to light touch.
Toes downgoing bilaterally
Coordination normal on finger-nose-finger
No meningismus
Pertinent Results:
___ CT HEAD: There is no acute intracranial hemorrhage,
vascular territorial infarction, edema, or mass effect seen.
There is no hydrocephalus or midline shift. There is slight
asymmetry of the lateral ventricles, which is likely a normal
variant. No fractures identified. Visualized orbits, paranasal
sinuses, and mastoid air cells are unremarkable.
___ CTA HEAD: 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. There is an effective ___ termination of the right
vertebral artery. Left posterior communicating artery is
hypoplastic.
___ Cerebral angiogram: cerebral vasculitis
Brief Hospital Course:
Mr. ___ was admitted to the Neuro-ICU for work up to rule out
to aneurysm or vascular abnormality. He underwent a diagnostic
cerebral angiogram that was negative for aneurysm but
demonstrated diffuse cerebral vasculitis. Post-Procedure he
remained flat x2 hours for hemostasis. Pulses remained bounding
and intact and the groin was without hematoma. There was a mild
ooze from groin that did not extend the boundaries of the
dressing. Stroke neurology was consulted and felt that it was
cocaine induced vasculitis. The patient remained neurologically
intact throughout his hospital stay and his headache improved.
Neurology felt that since his headache improved there was no
need to start a new agent for headache control. They recommend
follow up in 3 months in outpatient clinic or sooner if his
headaches increase in frequency. The patient was counselled on
stopping all cocaine use.
At the time of discharge the patient was tolerating a regular
diet, ambulating without difficulty, afebrile with stable vital
signs.
Medications on Admission:
Topamax 75 mg po bid
Ativan 1 mg PO prn aura
Fioricet
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Topiramate (Topamax) 75 mg PO BID
3. Nicotine Patch 14 mg TD DAILY
RX *Nicoderm CQ 14 mg/24 hour Daily Disp #*1 Box Refills:*1
4. Lorazepam 1 mg PO Q12H:PRN Seizure activity
RX *Ativan 1 mg Every 12 hours as needed Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral Vasculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving for 24 hours.
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
Followup Instructions:
___
|
10595724-DS-10 | 10,595,724 | 28,045,404 | DS | 10 | 2163-11-25 00:00:00 | 2163-11-26 08:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
pain with lying flat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p oocyte retrieval on ___ with hCG trigger 10K Novarel
on ___ presents with pain lying flat. She had her egg retrieval
in the morning, where 10 oocytes were retrieved. When she got
home, she was walking up stairs, was dizzy and had LOC. Husband
caught her on way down so she did not sustain any
trauma, she woke up very shortly after LOC and over the course
of the day was able to eat bfast and lunch and felt better.
However she has developed chest discomfort radiating up to
shoulders, more in front in the epigastric area and RUQ. The
chest discomfort does move all over, not cardiac in description.
She
says that it feels like it is hard to catch breath as expanding
lungs hurts.
Slight heartburn this time but less than last time. Slight
increase in abdominal girth this time but nothing compared to
last time where she actually did develop mild OHSS.
Received Lupron/Gonal F for stimulation protocol.
No vaginal bleeding or vaginal discharge. Last cycle had more
vag bleeding.
Past Medical History:
GYN Hx: PCOS, no abnl paps. S/p Clomid x 2 cycles, then IUI
converted to IVF cycle ~1 month ago due to large number of
developing follicles. She had a premature P4 rise prior to hCG
trigger, and her E2 peaked at 3710. She developed mild OHSS with
this cycle. None of the embryos developed enough for transfer.
OB Hx: G0
PMHx: None
PSHx: Hip arthroscopy for labrum tear in ___
Social History:
___
Family History:
non-contributory
Physical Exam:
T 98.9 HR 86 BP 133/92 RR 14 O2 100% RA
NAD appears well. Uncomfortable lying flat but able to breathe
normally on RA
RRR, no m/r/g
CTAB
Abd soft, mildly tender to palpation throughout without rebound.
+ BS.
___
Pelvic: done by ED staff, reportedly normal with minimal
bleeding.
Pertinent Results:
___ 09:40AM BLOOD WBC-9.0 RBC-2.82* Hgb-8.6* Hct-25.4*
MCV-90 MCH-30.5 MCHC-33.8 RDW-13.1 Plt ___
___ 05:30AM BLOOD Hct-26.7*
___ 12:25AM BLOOD WBC-15.1* RBC-3.59* Hgb-11.1* Hct-32.5*
MCV-91 MCH-30.8 MCHC-34.0 RDW-12.2 Plt ___
___ 12:25AM BLOOD Neuts-81.9* Lymphs-14.8* Monos-2.4
Eos-0.3 Baso-0.5
___ 12:25AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-138
K-4.8 Cl-102 HCO3-26 AnGap-15
___ 12:25AM BLOOD ALT-11 AST-18 AlkPhos-32* TotBili-0.4
___ 12:25AM BLOOD Lipase-18
___ 12:25AM BLOOD Albumin-4.3
___ 12:25AM BLOOD D-Dimer-859*
___ 12:25AM BLOOD HCG-207
___ 02:58AM URINE Color-Straw Appear-Clear Sp ___
___ 02:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 02:58AM URINE UCG-POSITIVE
CTA ___:
IMPRESSION: 1. No PE detected to the subsegmental levels. No
dissection. 2. Moderate amount of complex, possibly
hemorrhagic, intra-abdominal ascites.
CXR ___: IMPRESSION: No acute intrathoracic process.
Pelvic US ___:
IMPRESSION:
1. Moderate free fluid within the pelvis.
2. Left ovary measuring up to 8 cm, which could represent
changes related to hyperstimulation. Lack of follicles may be
due to recent harvesting. Correlate with any recent outside US
examinations or reports for stability.
Brief Hospital Course:
Ms. ___ presented to the emergency department with pain,
dizziness, and loss of consciousness one day s/p oocyte
retrieval. She was found to have post-procedure intrapelvic
bleeding and anemia with a hematocrit drop from 39 to 26.7.
Patient was clinically stable with no further evidence of
bleeding and repeat hematocrit was stable. She was discharged on
hospital day 0 in good condition with pain well-controlled,
ambulatory, tolerating a regular diet, and voiding on her own.
She was instructed to follow up with her doctor the following
day for repeat hematocrit.
Medications on Admission:
MVI, Ca
Discharge Medications:
1. oxycodone-acetaminophen ___ mg tablet Sig: One (1) tablet
PO every ___ hours as needed for pain: Do not take more than
4000mg acetaminophen in 24 hours.
Disp:*5 tablet(s)* Refills:*0*
2. Colace 100 mg capsule Sig: One (1) capsule PO twice a day.
Disp:*60 capsule(s)* Refills:*2*
3. Iron (ferrous sulfate) 325 mg (65 mg iron) tablet Sig: One
(1) tablet PO twice a day.
Disp:*60 tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute bleed following oocyte retrieval
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Bedrest until follow up appointment tomorrow
Followup Instructions:
___
|
10595746-DS-21 | 10,595,746 | 26,482,485 | DS | 21 | 2130-12-20 00:00:00 | 2130-12-22 11:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lisinopril / Demerol / Motrin / Diovan
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with PMH of hypertension, hypercholesterolemia, coronary
artery disease (prior MI ___ with DES to proximal and mid-LAD,
40% OM1,100% acute marginal and in-stent mid-LAD stenosis
treated with ___ 2 in ___ and unchanged 70% mid-LCX and
total occlusion of the distal RCA), ischemic cardiomyopathy, and
atypical chest pain who presents for evaluation of chest pain.
Pt states CP started this AM, described as an elephant sitting
on his chest. Pain w/o radiation, w/o associated sx of
diaphoresis or vomiting. He feels this CP is similar in
character to chest pain when he required a stent. Tx'ed with
full dose ASA by EMS on arrival to his home.
ED COURSE
In the ED intial vitals were: VS 98.3, HR 112, BP 121/73, RR 20,
Pox 94% on RA
EKG: NSR, normal axis, nl intervals, ?TWI in V1, LAE
Labs/studies notable for: CK 648, MB 8, Trop < 0.01, CXR
Increased bibasilar opacities are likely consistent with
atelectasis, however pneumonia or aspiration could be considered
in the appropriate clinical setting.
On evaluation by cards fellow, patient reported chest pain ___
with no administration of nitro or beta blocker. Due to concern
for ACS (UA vs. NSTEMI), the patient was started on IV heparin
gtt w/bolus, also beta blocker and NTG gtt. Bedside echo showed
LVEF ___ with anterior, septal and apical hypo/akinesis
unchaged from prior
Vitals on transfer: 98.2, 100, 112/63, RR 14, 99% on RA
On the floor, the patient reports feeling well. Chest pain now
___ with no residual shortness of breath or diarhoresis. Pt
denies abdominal pain, NVD, constipation, dysuria, hematuria.
REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative
Past Medical History:
Hypertension
Obesity
Stage I colon cancer s/p resection
Superior mesenteric vein thrombosis
Coronary artery disease ___ 2 to LAD ___ mid-LAD infarction
___ cath ___ with 90% instent mid LAD restenosis treated
with ___ 2, diffuse distal disease; 70% midLCX; 100% distal
RCA with L-to-R collaterals.
Left knee injury/meniscial surgery
Hematuria/nephrolithiasis
Hypercholesterolemia
Atypical left chest pain
Left arm paresthesias
Diabetes mellitus
Left wrist arthritis
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4, 121/68, 95, 12, 96% on RA
GENERAL: well appearing, no acute distress
HEENT: sclera anicteric
NECK: no JVD
CARDIAC: RRR, nl S1 S2, systolic murmurs RUSB/LUSB
LUNGS: clear to ausculation
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP, no edema
SKIN: ___ b/l
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1, 135/80, 82, 20, 99% on RA
General: well appearing, no acute distress
HEENT: JVP not visualized ___ body habits
Lungs: clear to auscultation b/l
CV: RRR, nl S1 S2, systolic murmur RUSB/LUSB
Abdomen: obese, soft, NT, ND
Ext: WWP, 1+ non-piting edema
Pertinent Results:
ADMISSION LABS:
___ 08:50AM BLOOD WBC-6.6 RBC-4.18* Hgb-13.9 Hct-41.7
MCV-100* MCH-33.3* MCHC-33.3 RDW-12.9 RDWSD-47.3* Plt ___
___ 08:50AM BLOOD Neuts-63.9 ___ Monos-7.0 Eos-2.0
Baso-0.2 Im ___ AbsNeut-4.20 AbsLymp-1.75 AbsMono-0.46
AbsEos-0.13 AbsBaso-0.01
___ 08:50AM BLOOD ___ PTT-29.5 ___
___ 08:50AM BLOOD Glucose-190* UreaN-18 Creat-0.9 Na-142
K-3.7 Cl-102 HCO3-17* AnGap-27*
___ 08:50AM BLOOD CK(CPK)-648*
___ 08:50AM BLOOD CK-MB-8
___ 08:50AM BLOOD cTropnT-<0.01
___ 03:25PM BLOOD CK-MB-6 cTropnT-<0.01
DISCHARGE LABS:
___ 08:35AM BLOOD WBC-5.3 RBC-4.17* Hgb-13.7 Hct-41.9
MCV-101* MCH-32.9* MCHC-32.7 RDW-12.9 RDWSD-47.8* Plt ___
___ 08:35AM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 08:35AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
IMAGING/STUDIES:
CXR ___
1. Increased bibasilar opacities are likely consistent with
atelectasis, however pneumonia or aspiration could be considered
in the appropriate clinical setting.
2. Engorged pulmonary vasculature.
STRESS ___
This ___ year old ___ man with a PMH of MIs, PCIs
and CHF was referred to the lab for evaluation of chest
discomfort. Due
to knee injury, the patient was infused with 0.142 mg/kg/min of
dipyridamole over 4 minutes. No arm, neck, back or chest
discomfort was
reported by the patient throughout the study. There were no
significant
ST segment changes during the infusion or in recovery. The
rhythm was
sinus with rare isolated apbs and vpbs. Appropriate hemodynamic
response to the infusion and recovery. The dipyridamole was
reversed
with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
1. Moderate partially reversible defect involving the
anteroseptal
wall and apex with akinetic apex and hypo kinetic anteroseptal
wall which is
new since ___. 2. Decrease in left ventricular
ejection fraction to
30%. 3. Severe LV dilatation.
MICROBIOLOGY N/A
Brief Hospital Course:
___ with PMH of hypertension, hypercholesterolemia, coronary
artery disease (prior MI ___ with DES to proximal and mid-LAD,
40% OM1, 100% acute marginal and in-stent mid-LAD stenosis
treated with ___ 2 in ___ and unchanged 70% mid-LCX and
total occlusion of the distal RCA), and ischemic cardiomyopathy
who presents for evaluation of chest pain.
# Chest pain: The patient presented with chest pain, brought on
with movement, similar in character to previous chest pain when
patient had MI in the past, possibly relieved with rest vs. SL
nitro though unclear based on history. The patient was evaluated
with ECG, which showed no changes. The patient was initially
started on heparin gtt, which was discontinued when troponins
were found to be negative x2. The patient was evaluated with
persantine MIBI stress test which per radiology evaluation
showed moderate partially reversible defect involving the
___ wall and apex with akinetic apex and hypo kinetic
anteroseptal wall which is
new since ___. On Dr. ___ of
these images, these defects were thought to be irreversible,
consistent with the patient's prior history of CAD. The patient
was instructed to f/u with his cardiologist for further
evaluation. He was continued on his home metoprolol, ASA,
clopidogrel and statin.
# Chronic Systolic Heart Failure: The patient appeared euvolemic
on admission. He was continued on his home metoprolol and
losartan.
# DM: The patient was maintained on ISS while in house. He was
restarted on his home metformin at discharge.
# HTN: continued home losartan
# Macrocytosis: The patient was found to have MCV 101, without
anemia on H/H. The patient should f/u with PCP for consideration
of B12, folate and TSH testing for further evaluation if
persistent.
Transitional Issues
- f/u with cardiology for further management of CAD and ischemic
cardiomyopathy, consider addition of anti anginal medications if
needed
- f/u with PCP for further management of other medical
conditions
- Consider testing B12, folate, and TSH to further evaluate
macrocytosis noted on CBC in the hospital
# CODE: Full Code (confirmed with patient, ok with
resuscitation/intubation in short term, but does not want life
prolonging therapy if no chance of meaningful recovery)
# CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Losartan Potassium 25 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Losartan Potassium 25 mg PO BID
5. Metoprolol Tartrate 50 mg PO BID
6. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: coronary artery disease, atypical angina
Secondary: Diabetes Mellitus Type 2, Hypertension, Ischemic
Cardiomyopathy, Chronic Systolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of chest pain. We did
not find any evidence of injury to your heart muscle in your
blood. We evaluated you with a stress test which showed mostly
unchanged coronary artery disease.
After discharge, please continue to take all of your medications
as prescribed. Please weigh yourself every morning, and call
your doctor if your weight goes up more than 3 lbs. Please
follow up with your cardiologist, Dr. ___ further
evaluation.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10595935-DS-10 | 10,595,935 | 28,189,240 | DS | 10 | 2166-07-25 00:00:00 | 2166-07-25 19:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / hydrocodone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female (deaf, knows ASL, limited literacy), with
poorly controlled diabetes (last a1c 14.2), on insulin, htn,
obesity, recurrent yeast infection, uterine fibroids, who
presented to ___ ___ for f/u of abdominal pain and was now
referred to the ED for CT AP.
The patient had been seen in ED at ___ for left sided
back pain and abdominal pain. She told her PCP her BG 700 there,
they gave her fluids and tramadol. Tramadol caused vomiting. She
was d/ced and on ___ c/o of ongoing severe left sided back
and abd pain.
Of note, was treated for a UTI Ecoli a few months ago but did
not finish meds, did have some urinary frequency, dysuria. Ucx
on ___ grew E Coli again, abx prescribed today for possible
infection, ?pyelo but not filled. Her PCP attempted to obtain CT
abd both days to rule out pyelo, stone, other intraabdominal
process but was unable to obtain through radiology.
On day of presentation, she was feeling worse and ibuprofen had
not been helpful. Exam at PCP's with VSS, diffuse tenderness,
left sided back tendernss. Unclear if intraabdominal vs. msk,
but given poorly controlled diabetes and difficult history,
referring to ED for repeat labs, CT abd/pelvis.
She states that the pain set on spontaneously, without preceding
trauma or injury. She reports she presented to an OSH ED several
days ago for eval of the pain and was dc'd with no diagnostics.
She presented to PCP office earlier in the week and had urine
culture sent ___ that has grown E. Coli UTI. Unclear if she was
treated at that time. Per PCP note, patient was unable to give
urine during that visit so source of the sample not totally
clear. She does not think that she has been taking medication
for a urinary tract infection during the past week. No fevers,
no nausea, no emesis, no diarrhea. She complains of vaginal
itching (has a history of vulvar candidiasis, using nystatin
powder).
In the ED, initial VS were 4 97.6 ___ 18 100% RA 496
Exam notable for:
___, able to ambulate comfortably
abdomen: soft, obese. no guarding, no rebound. Umbilicus is
enlarged and soft, easily palpated and pushed. left cva with
tenderness to palpation. also demonstrates pain to left side,
but without particular tenderness to palpation there pelvic:
inguinal folds with mild symmetric erythema. vaginal mucosa with
scant white discharge. no cervical friability. no CMT, no
adnexal tenderness ext: no swelling, no tenderness to palpation
bilaterally
Labs showed: Glucose 604, Plt 148, UA with 60 WBC,
Imaging showed:
1. No acute findings in the abdomen or pelvis to account for the
patient's symptoms. Specifically, no urolithiasis or CT evidence
for pyelonephritis.
2. Small midline infraumbilical ventral hernia below the
anterior abdominal mesh containing a single loop of bowel
without evidence of complication.
3. Cholelithiasis.
4. Fibroid uterus.
Received NS, regular insulin 6 + 10, morphine, CTX
Transfer VS were 98.8 89 104/61 16 99% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports endorses the above
story. Patient reports RLQ abdominal pain with R flank pain, no
N/V for a few days. No hematuria. Also with 1 week of increased
urinary frequency and thirst. She states that she has been
complaint with her insulin.
Past Medical History:
1. Diabetes type 2, insulin dependent
2. hypertension
3. chronic candidiasis
4. allergic rhinitis
5. stress incontinence
6. obesity
7. asthma
Social History:
___
Family History:
Lives with her 2 children. Unemployed. Deaf. No tob/ETOH/IVDA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 103 / 69 96 18 97
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild TTP in LLQ, no rebound/guarding
EXTREMITIES: L CVAT, no cyanosis, clubbing or edema, moving all
4 extremities with purpose
NEURO: CN ___ grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.4 127/75 82 18 97 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild TTP in LLQ, no rebound/guarding
EXTREMITIES: L CVAT, no cyanosis, clubbing or edema, moving all
4 extremities with purpose
NEURO: No gross motor/coordination abnormalities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 11:15AM URINE ___
___
___ 11:15AM URINE ___
___
___
___ 11:32AM ___
___ IM ___
___
___ 11:32AM ___
___
___ 11:32AM ___
___ 11:32AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 11:38AM ___
___ 11:38AM ___ TOTAL ___
BASE XS--2 ___ INTUBA
___ 09:28PM ___
___ 09:28PM ___
___ 09:28PM ___
___ 09:28PM ALT(SGPT)-18 AST(SGOT)-15 ALK ___ TOT
BILI-<0.2
___ 09:28PM ___ UREA ___
___ TOTAL ___ ANION ___ CTAP:
1. No acute findings in the abdomen or pelvis to account for the
patient's symptoms. Specifically, no urolithiasis or CT evidence
for pyelonephritis.
2. Small midline infraumbilical ventral hernia below the
anterior abdominal mesh containing a single loop of bowel
without evidence of complication.
3. Cholelithiasis.
4. Fibroid uterus.
Discharge labs:
___ 05:45AM BLOOD ___
___ Plt ___ TO
___ 05:45AM BLOOD ___
___ 09:28PM BLOOD ___
Brief Hospital Course:
___ year old female (deaf, knows ASL, limited literacy), with
poorly controlled diabetes (last a1c 14.2), on insulin, HTN,
obesity, recurrent yeast infection, uterine fibroids, who
presented to ___ ___ for abdominal pain, found to have UTI and
hyperglycemia.
#Urinary Tract Infection: Urine culture growing pansensitive E
coli and CT showed no evidence of pyelonephritis. Had borderline
hypotension on presentation as well as tachycardia, but has been
afebrile and has no leukocytosis. She was given IVF and started
on a 7d course of CTX/ciprofloxacin (___) given complicated
nature of infection in setting of diabetes.
#LL flank pain: No radiographic signs of pyelonephritis. Likely
musculoskeletal given that it worsens with movement and has no
association with food. Differential also includes chronic pelvic
pain from uterine fibroids but has not been able to get
hysterectomy due to uncontrolled DM. Also noted to have
cholelithiasis on CT but clinically pain does not resemble
biliary colic and LFTs normal. Also has infraumbilical ventral
hernia below the anterior abdominal mesh containing a single
loop of bowel however without evidence of complication on CT.
Lastly, likely component of constipation leading to colicky
pain. She was discharged with increased bowel regimen and pain
was controlled with Tylenol.
#Hyperglycemia/ T2DM: Poorly controlled. Last A1C 14.2%
___. Repeat A1c 14.3. BG on presentation 604. No gap,
positive ketones on UA on admission. Received 16U insulin in the
ED, 12U insulin on admission, and blood sugars downtrended to
200s. She was continued on home glargine 88U + ISS. Held home
liraglutide (GLP1 Agonist). Diabetes counseling in house. Pt
does acknowledge missing her basal insulin ___ times per week,
which she attributes to forgetting, or being busy. She expresses
an understanding of the potential consequences of poorly
controlled diabetes, and affirms her commitment to achieving
improved BS control.
#HTN: BP on presentation 99/63, improved with fluids, from
baseline ___ per ___ clinic records. She was continued on
home lisinopril.
Transitional issues:
=====================
- Discharge abx: Ciprofloxacin 500mg PO q12H for 7 day course
with last day on ___
- Insulin regimen on disharge: 88U lantus in AM and 4u Humalog
with meals
- Patient would benefit from continued education about diabetes
and insulin compliance, which she would like to have done with
primary care physician
- ___ assist patient to set up new glucometer as outpatient
- Full Code
- Contact: ___ (sister) ___
Medications on Admission:
WeThe Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DINNER
3. Vitamin D ___ UNIT PO DAILY
4. Glargine 80 Units Breakfast
We
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Please do not take more than 3g per day
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN severe constipation
RX *bisacodyl [Biscolax] 10 mg 1 suppository(s) rectally once a
day Disp #*12 Suppository Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
Total 7 day course with last dose on ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Glargine 88 Units Breakfast
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Needed
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
88 Units before BKFT; Disp #*30 Syringe Refills:*0
RX ___ meter [FreeStyle Lite Meter] Please use as
directed four times a day Disp #*1 Kit Refills:*0
8. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DINNER
9. Lisinopril 20 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Urinary Tract Infection
-Hyperglycemia
-Type 2 Diabetes Mellitus
-Abdominal pain
-Constipation
SECONDARY DIAGNOSIS/ES:
-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 caring for you at ___. You were admitted
because you had abdominal pain. You were found to have a urinary
tract infection and treated with antibiotics. Your blood sugars
were also very high. We adjusted your insulin regimen. Please
take your insulin as prescribed at home, and follow up with your
PCP as scheduled. Lastly, your abdominal pain was most likely
related to strain of your back muscles as well as constipation.
You were given some medication to help with this pain and to
help you move your bowels.
Your ___ team
Followup Instructions:
___
|
10595935-DS-11 | 10,595,935 | 29,172,726 | DS | 11 | 2166-11-05 00:00:00 | 2166-11-05 18:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / hydrocodone
Attending: ___.
Chief Complaint:
Abd Pain, Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH of deafness (knows ASL), IDDM, HTN, uterine
fibroids, recent admission to ___ for pyelonephritis and spinal
cord lesion who presents with abdominal pain and constipation.
Interview somewhat limited as there was no sign language
interpreter present overnight. Per report the patient had a
recent admission to ___ where she was noted to have a lesion
involving her spine. She was scheduled to have MRI on ___.
Discharged from ___ on ___ with IV abx (apparently for
pyelonephritis though no records available), methadone,
dilaudid, senna (per nursing note). Patient continued to have
back pain but it worsened ___ days ago and is now unbearable.
She has also been constipated for the last couple of days but is
afraid to try to have a bowel movement because bearing down
brings on more pain. No fever, diarrhea, dysuria, vaginal
discharge, numbness, focal weakness. She has chronic stress
urinary incontinence--this is not worse today.
In the ED, initial VS were: ___ 86 138/80 15 99% RA
Labs showed:
1) CBC: 6.7 WBC, Hb 9.5, plt 139
2) LFT: lipase 18
3) BMP: Na 137, K 4.3, Cl 96, HCO3 26, BUN 14, Cr 0.5
4) U/A: 1 WBC, 1 RBC, few bacteria, + protein, + glucose,
negative ketones. UCG Negative
Imaging showed:
1) CT A/P:
1. Trace pleural effusions, small pericardial effusion.
2. Mild perivertebral soft tissue thickening at the level of
T10, please correlate clinically. Consider MRI of the thoracic
spine to further assess. Stable prominent retrocrural lymph node
at this level.
3. Small focus of extra-axial hyperdensity within the central
spinal canal at T7 level, similar to multiple prior exams, this
lesion can also be further assessed on thoracic spine MRI.
4. Uterine lesion, may represent a fibroid. As stated
previously, an MRI may be performed to further assess given
unclear margins raising potential concern for malignancy.
5. Hepatomegaly, unchanged.
6. Stable left adrenal nodule, likely an adenoma.
2) CXR: no acute abnormalities
Received:
___ 17:27 IV HYDROmorphone (Dilaudid) 1 mg
___ 18:58 IV Ondansetron 4 mg
Transfer VS were: 98.2 86 142/87 16 98% RA
On arrival to the floor, patient is very uncomfortable and
typed "I hate pain" on her phone. She has been unable to sleep
for a couple of days because of this pain. She also reports n/v
and had an episode of retching while in the room that she thinks
is ___ pain. She would like to talk to the team in the morning
in the presence of an ASL interpreter.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
Diabetes type 2, insulin dependent
Hypertension
Chronic candidiasis
Allergic rhinitis
Stress incontinence
Obesity
Asthma
Fibroid Uterus
Social History:
___
Family History:
GM- DM
Aunt- HTN
Aunt- ___ Ca
Mother- her mother had chemotherapy, but she is not sure why.
Physical Exam:
===================================
ADMISSION PHYSICAL EXAM:
===================================
VS: 98.2 148/82 92 18 97 RA
GENERAL: Uncomfortable appearing F
HEENT: NCAT, MMM
NECK: Neck veins flat sitting upright
HEART: RRR, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, diffuse TTP, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
BACK: Diffuse TTP most significant over spine but no gross
deformity noted
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
===================================
DISCHARGE PHYSICAL EXAM:
===================================
VS: T:98.1 BP:119 / 74 HR:87 RR:18 SaO2:96 Ra
GENERAL: Well appearing woman sitting up chair and sleeping
HEENT: Sclerae anicteric
LUNGS: Clear to auscultation bilaterally, normal respiratory
effort
HEART: S1/S2 regular, no murmurs or s3/s4
ABDOMEN: Soft abdomen, tender to palpation in upper quadrants
without rebound or guarding, and with less tenderness than in
previous exams.
EXTREMITIES: Warm, non-edematous extremities
NEURO: ___ strength in lower extremity and foot flexion and
extension bilaterally; normal gait
BACK: Tender to palpation diffusely, no clear point tenderness
at a particular spinal level
Pertinent Results:
===================================
ADMISSION LABS:
===================================
___ 04:05PM BLOOD WBC-6.7 RBC-3.21*# Hgb-9.5*# Hct-29.0*
MCV-90 MCH-29.6 MCHC-32.8 RDW-13.0 RDWSD-42.5 Plt ___
___ 04:05PM BLOOD Neuts-53.6 ___ Monos-13.2*
Eos-2.5 Baso-0.7 Im ___ AbsNeut-3.60 AbsLymp-1.97
AbsMono-0.89* AbsEos-0.17 AbsBaso-0.05
___ 04:05PM BLOOD Plt ___
___ 04:05PM BLOOD Glucose-234* UreaN-14 Creat-0.5 Na-137
K-4.3 Cl-96 HCO3-26 AnGap-15
___ 04:06PM URINE Color-Straw Appear-Clear Sp ___
___ 04:06PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:06PM URINE RBC-1 WBC-1 Bacteri-FEW* Yeast-NONE Epi-3
===================================
DISCHARGE LABS:
===================================
___ 02:35PM BLOOD WBC-7.6 RBC-3.11* Hgb-9.1* Hct-28.7*
MCV-92 MCH-29.3 MCHC-31.7* RDW-13.3 RDWSD-44.4 Plt ___
___ 02:35PM BLOOD Calcium-9.3 Phos-3.8 Mg-1.6
===================================
IMAGING:
===================================
___ MRI Pelvis with and without contrast
IMPRESSION:
1. Previously noted abnormality within the uterine corpus on CT
abdomen/pelvis from ___ corresponds to avidly
enhancing myometrium without evidence of malignancy. No
endometrial thickening.
2. 4.9 cm right subserosal fibroid likely representing a
degenerating myxoid fibroid, insidious ___ decreasing in size
from multiple priors.
3. No aggressive appearing osseous lesions.
RECOMMENDATION(S): Given the unusual T2 signal of the
subserosal fibroid,
recommend ___ year follow-up pelvic ultrasoundto ensure stability
or continued decrease in size of the uterine fibroid.
CXR ___: PA and lateral views of the chest provided.
Right upper extremity access PICC line is seen extending into
the region of the cavoatrial junction. Lung volumes are low
limiting assessment. There is bronchovascular crowding limiting
assessment through the lungs. Allowing for this, no gross signs
of pneumonia or overt edema. No large effusion or pneumothorax.
Overall cardiomediastinal silhouette appears grossly unchanged.
Bony structures are intact. No free air below the right
hemidiaphragm.
CT ABD/PELVIS WITH CONTRAST ___:
1. Trace pleural effusions, small pericardial effusion.
2. Mild perivertebral soft tissue thickening at the level of
T10, please
correlate clinically. Consider MRI of the thoracic spine to
further assess. Stable prominent retrocrural lymph node at this
level.
3. Small focus of extra-axial hyperdensity within the central
spinal canal at T7 level, similar to multiple prior exams, this
lesion can also be further assessed on thoracic spine MRI.
4. Uterine lesion, may represent a fibroid. As stated
previously, an MRI may be performed to further assess given
unclear margins raising potential concern for malignancy.
5. Hepatomegaly, unchanged.
6. Stable left adrenal nodule, likely an adenoma.
RECOMMENDATION(S): Nonemergent thoracic spine MRI Nonemergent
pelvic MRI.
===================================
MICROBIOLOGY:
===================================
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
___ with a PMH of deafness (knows ASL), IDDM, uterine fibroids,
and a recent admission to ___ with strep intermedius bacteremia
and spinal hemangiomas who presented with back pain, abdominal
pain, constipation.
====================
ACUTE MEDICAL ISSUES
====================
# Abdominal Pain: Likely multifactorial abdominal pain given
opioid induced constipation at presentation and known uterine
fibroids. She presented on a regimen of methadone, but was
interested in pursuing a non-opioid regimen. She was started on
Naproxen 500PO BID, acetaminophen 500 q6hr, gabapentin 300TID,
300QHS, lidocaine patch, started cyclopbenzaprine 10mg qhs with
oxycodone 5mg q8hrs. This provided some relief, and we counseled
her that total relief may take some time. A pelvic MRI was not
concerning for malignancy, and showed a uterine fibroid. A CT
abd/pelvis otherwised showed stable hepatomegaly. Finally, we
started an aggressive bowel regimen including Colace, senna and
miralax.
#Back pain with known spinal cord lesion and hemangiomas: There
is a L4/L5 facet cyst, with plan for follow up at ___ by ___
after completion of antibiotics for bacteremia for possible
decompression and steroid injection. She was also found on
PET-CT and MRI to have spinal hemangiomas, and will repeat
PET-CT/MRI in early to mid ___ at ___.
#Strep Bloodstream infection: At ___ febrile to 102, blood
culture grew
Step milleri anginosus (again repeat ___, TTE unremarkable, CT
without abscess. Two week course CTX 2g daily through ___
started on ___ and completed inpatient ___. No hemodynamic
instability while hospitalized at ___.
#Uncontrolled insulin dependent diabetes mellitus type 2: Last
A1C 14.4%, and patient generally unsure of what home dose should
___ consulted, and regimen simplified to mixed insulin in
AM and ___. 70/30 insulin 40 units in AM and 20 units in ___. She
should continue metformin 500 BID and victoza 1.2mg daily.
CHRONIC ISSUES:
===============
# HTN: Lisinopril 20 mg daily
TRANSITIONAL ISSUES:
- New Meds:
----Cyclobenzaprine 10mg QPM
----Gabapentin 300mg TID and 300mg QHS
----Naproxen 500mg Q12hr
----70/30 mix insulin 40units qAM; 20units QPM
- Stopped/Held Meds:
----Methadone 2.5mg PO BID
----Celebrex ___ daily
----Dilaudid 4mg PO Q6hr
----Insulin sliding scale
# CODE: Full, presumed
# CONTACT: ___, sister and HCP (___)
[] ___ need titration of her insulin regimen, given resolving
infection and resuming metformin and victoza
[]Pelvic ultrasound in ___ yr (___) to monitor uterine
mass
[]Follow up at ___ clinic for spinal hemangiomas
[]Follow up at ___ with ___ for facet cyst decompression and
steroid injection
[]Call ___ or ___ infectious disease to see if follow up
required for strep bacteremia now that treatment course
completed and ___ removed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DINNER
3. Acetaminophen 500 mg PO Q8H
4. Senna 8.6 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Bisacodyl 10 mg PR QHS:PRN severe constipation
8. Glargine 15 Units Breakfast
Glargine 15 Units Bedtime
Insulin aspart 5 Units Breakfast
Insulin aspart 5 Units Lunch
Insulin aspart 5 Units Dinner
Insulin SC Sliding Scale using UNK InsulinMax Dose Override
Reason: Home Medication
9. Omeprazole 40 mg PO DAILY
10. Celebrex ___ mg oral DAILY
11. Magnesium Citrate 300 mL PO ONCE
12. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate
13. Loratadine 10 mg PO DAILY
14. Methadone 2.5 mg PO BID
Discharge Medications:
1. Cyclobenzaprine 10 mg PO QPM
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth at bedtime Disp
#*7 Tablet Refills:*0
2. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
3. Gabapentin 300 mg PO QPM
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*7
Capsule Refills:*0
4. Naproxen 500 mg PO Q12H
RX *naproxen 500 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth Q8h:PRN Disp #*15
Capsule Refills:*0
6. Acetaminophen 500 mg PO Q6H
RX *acetaminophen 500 mg 1 capsule(s) by mouth every six (6)
hours Disp #*28 Capsule Refills:*0
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily:prn Disp #*14
Tablet Refills:*0
8. 70/30 40 Units Breakfast
70/30 20 Units Dinner
RX *insulin NPH and regular human [Humulin 70/30] 100 unit/mL
(70-30) AS DIR 40 Units before BKFT; 20 Units before DINR; Disp
#*1 Vial Refills:*3
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DINNER
RX *liraglutide [Victoza 2-Pak] 0.6 mg/0.1 mL (18 mg/3 mL) 0.2
mL Dinner Disp #*1 Syringe Refills:*0
11. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
12. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
Daily Refills:*0
14. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.8 mg/5 mL 1 by mouth twice a day
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Streptococcal bacteremia
Acute back pain
Acute abdominal pain
Opioid induced constipation
Anemia
Uterine fibroids
Uncontrolled insulin dependent diabetes mellitus type 2
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 WERE YOU ADMITTED?
- You were having back and abdominal pain
WHAT HAPPENED IN THE HOSPITAL?
- We treated your pain with new medications that don't make you
nauseous
- We finished treating you with antibiotics for an infection
that was found at ___
- We changed your insulin regimen to make your doses easier to
take
- We did an MRI of your uterus that showed it is unlikely you
have cancer there
WHAT SHOULD YOU DO AT HOME?
- Make sure you take your new insulin regimen every morning and
night
- Don't drive while taking gabapentin or oxycodone
- Keep eating a healthy diet and staying active
- Go to all of your doctors ___
Thank ___ for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10596508-DS-21 | 10,596,508 | 25,439,749 | DS | 21 | 2204-09-28 00:00:00 | 2204-09-30 09:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
abdominal distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo postmenopausal woman with stage IIA
cervical adenocarcinoma s/p chemo/radiation completed in ___ who presents with abdominal pain, distension, and N/V. Pt
reports onset of distention and nausea ___ followed by
increasing abdominal discomfort and vomiting on ___. Sxs have
been worsening. Pt reports daily small, hard bowel movements.
Denies fevers/chills. Reports pinkish vaginal discharge. Reports
taking meds to ___ for constipation, but is unsure what she has
been taking. Patient also has noted leakage of urine at night.
Urine is blood tinged. She denies dysuria.
Regarding her recent disease course, she was initially scheduled
for surgery on ___, but prior to that was admitted on ___
for L flank and LLQ pain. At that time she was found to have L
hydroureter and hydronephrosis concerning for tumor extension
vs. radiation scarring. She had a stent placed. She recovered
well. Given that her findings were of unclear etiology and not
necessarily tumor extension, plan was then for surgery on ___,
which was cancelled due to Hurricane ___. She was rescheduled
for surgery on ___. Plan was for laparoscopy, removal of the
left tube and ovary, obtaining biopsies of the cervix to further
understand the nature of her disease and the retroperitoneal
disease, with possible laparotomy.
Past Medical History:
PMH: Hyperlipidemia, upper extremity blood clots at age ___
treated with Coumadin without recurrence, concussions as a
child. Seizure disorder characterized by occasional loss of
motor control and consciousness without medication or symptoms
within the recent past.
PSH: Wisdom teeth surgery, inguinal hernia repairs in ___ and
___, myomectomy
OBSTETRIC/GYNECOLOGIC HISTORY: Menarche age ___, menopause age
___. G1P0, SAB x1. Abdominal myomectomy in ___ in ___
___. EBRT/vaginal brachytherapy with concomittant cisplatin
completed ___.
Social History:
___
Family History:
A paternal aunt had breast cancer.
Physical Exam:
Physical exam upon discharge:
Afebrile, vital signs stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, mildly distended, mildly tender to palpation
throughout, no rebound or guarding
Ext: nontender to palpation, no edema
Pertinent Results:
___ 05:00PM BLOOD WBC-7.6 RBC-3.95* Hgb-11.2* Hct-34.0*
MCV-86# MCH-28.4# MCHC-33.0 RDW-14.1 Plt ___
___ 05:00PM BLOOD Neuts-86.8* Lymphs-6.1* Monos-6.2 Eos-0.8
Baso-0.2
___ 06:25AM BLOOD WBC-2.7* RBC-3.43* Hgb-9.8* Hct-29.8*
MCV-87 MCH-28.5 MCHC-32.7 RDW-15.2 Plt ___
___ 05:15PM BLOOD WBC-2.6* RBC-3.30* Hgb-9.6* Hct-28.4*
MCV-86 MCH-29.0 MCHC-33.8 RDW-14.3 Plt ___
___ 05:15PM BLOOD Neuts-73.0* Lymphs-10.9* Monos-10.4
Eos-5.6* Baso-0.1
___ 06:20AM BLOOD WBC-5.6# RBC-3.64* Hgb-10.2* Hct-30.9*
MCV-85 MCH-28.0 MCHC-32.9 RDW-14.7 Plt ___
___ 06:20AM BLOOD Neuts-79.5* Lymphs-7.7* Monos-9.1 Eos-3.4
Baso-0.4
___ 06:15AM BLOOD WBC-6.6 RBC-3.33* Hgb-9.4* Hct-28.6*
MCV-86 MCH-28.2 MCHC-32.8 RDW-15.0 Plt ___
___ 06:15AM BLOOD Neuts-82.6* Lymphs-7.4* Monos-7.7 Eos-2.2
Baso-0.2
___ 06:10AM BLOOD WBC-5.8 RBC-3.18* Hgb-8.9* Hct-27.6*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.5 Plt ___
___ 06:10AM BLOOD Neuts-81.8* Lymphs-8.3* Monos-6.5 Eos-3.3
Baso-0.1
___ 06:10AM BLOOD WBC-6.1 RBC-3.13* Hgb-8.9* Hct-26.7*
MCV-86 MCH-28.5 MCHC-33.3 RDW-15.4 Plt ___
___ 06:10AM BLOOD Neuts-82.7* Lymphs-6.9* Monos-8.0 Eos-2.1
Baso-0.2
___ 07:05AM BLOOD WBC-7.5 RBC-3.57* Hgb-9.9* Hct-30.5*
MCV-85 MCH-27.6 MCHC-32.3 RDW-15.5 Plt ___
___ 07:05AM BLOOD Neuts-84.5* Lymphs-7.4* Monos-6.2 Eos-1.7
Baso-0.3
___ 05:23PM BLOOD Lactate-1.4
___ 05:00PM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-137
K-4.4 Cl-96 HCO3-27 AnGap-18
___ 07:05AM BLOOD Glucose-125* UreaN-3* Creat-0.9 Na-138
K-3.5 Cl-104
HCO3-23 AnGap-15
COAGULATION PROFILE:
___ 05:47PM BLOOD ___ PTT-35.3 ___
___ 12:30AM BLOOD ___ PTT-77.0* ___
___ 06:20AM BLOOD ___ PTT-61.0* ___
___ 06:15AM BLOOD ___ PTT-66.5* ___
___ 06:10AM BLOOD ___ PTT-66.3* ___
___ 06:10AM BLOOD ___ PTT-36.3 ___
___ 07:05AM BLOOD ___ PTT-37.7* ___
URINE:
___ 01:57AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:57AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 01:57AM URINE RBC-14* WBC-19* Bacteri-FEW Yeast-NONE
Epi-1
PERITONEAL FLUID:
___ 03:45PM ASCITES WBC-595* RBC-345* Polys-46* Lymphs-5*
Monos-0 Eos-2* Mesothe-2* Macroph-45*
___ 03:45PM ASCITES TotPro-4.1
MICROBIOLOGY:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
PERITONEAL FLUID:
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
PATHOLOGY:
SPECIMEN SUBMITTED: CELL BLOCK OF PERITONEAL FLUID
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ Slides referred for
consultation.
DIAGNOSIS:
Peritoneal fluid, cell block: Groups of atypical epithelial
cells with vacuolated cytoplasm consistent with metastatic
adenocarcinoma; see note.
IMAGING:
1) KUB, ___:
IMPRESSION:
Findings concerning for small bowel obstruction.
2) CT ABD/PEL, ___:
IMPRESSION:
1. Bilateral adnexal enhancing soft tissue masses with
peritoneal
nodularity/enhancement and new ascites is suggestive of local
extension of
malignancy with possible carcinomatosis. There is also
associated small bowel
obstruction with a transition point within the distal ileum.
2. Severe left and mild right-sided hydroureter.
3) CXR, ___:
IMPRESSION:
1. Small left pleural effusion and possibly a tiny right pleural
effusion.
2. NG tube terminates in the expected location of the stomach.
3. Moderate distention of small and large bowel.
4) CT ABD/PEL, ___:
IMPRESSION:
1. In this patient with history of advanced cervical cancer with
uterine
invasion, nodularity and peritoneal thickening more pronounced
in the lower abdomen/pelvis is worrisome for peritoneal
carcinomatosis.
2. Stable partial small-bowel obstruction with transition point
in the right lower quadrant of the abdomen where small bowel
loops are tethered.
3. Interval improvement of the left hydroureteronephrosis,
status post
placement of a new stent in appropriate position.
4. Multiple enlarged retroperitoneal lymph nodes, similar to the
recent prior study. Deep venous thrombosis involving the right
common iliac vein.
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecologic
oncology service from the ED for conservative management of a
partial small bowel obstruction; at time of presentation, it was
unclear whether the obstruction had evolved from progressive
disease or as a sequelae of her radiation therapy. She was
initially made NPO and managed with nasogastric tube, IV pain
medications and anti-emetics. CT abd/pelvis obtained on ___
demonstrated likely partial small bowel obstruction with a
transition point at the distal ileum, an enhancing mass at the
uterine fundus and new onset ascites. A diagnostic paracentesis
was performed on ___.
On ___, the patient developed fever to 102.9. Her WBC was
noted to trend down from 7.6 on admission to a nadir of 2.6; her
ANC was 3000. Chest x-ray was obatined and was significant for a
new small left pleural effusion that could represent a
parapneumonia, but no focal consolidation was noted, and lung
fields were otherwise clear. UA did not demonstrate signs of
infection, and urine culture showed no growth. Blood cultures
were also obtained, but these also demonstrated no growth. A C.
difficile assay returned negative. KUB was obtained which showed
worsening SBO with a diameter up to 6.7 cm, but without free air
or pneumatosis. The patient was started on broad spectrum
antibiotics with ciprofloxacin and flagyl.
Due to worsening abdominal distention in the setting of her
febrile illness without a clear source for infection, CT
abd/pelvis was obtained on ___ to evaluate for bowel
perforation, worsening obstruction and/or worsening disease. CT
abd/pelvis demonstrated stable partial SBO, mildly improved left
hydroureter and new right common iliac DVT. A heparin drip was
initiated. It was felt that her DVT was the most probable source
of her fever; she was continued on IV flagyl and ciprofloxacin
and did not have any additional fever for the remainder of her
hospitalization.
On ___, ___ medical oncology, colorectal surgery and
nutrition consults were also placed. Medical oncology
recommended no role for chemotherapy at present given the
presence of infection compounded by her SBO. Colorectal surgery
advised no role for surgical intervention for her SBO;
conservative management was recommended. Nutrition consult
advised that if patient was unable to tolerate po, given that
she had been without adequate nutrition for 5 days, enteral or
parenteral feeds should be initiated.
The patient was continued on a heparin drip until final
paracentesis cytology returned positive for adenocarcinoma on
___. On ___, the nasogastic tube fell out, but was not
replaced given that the patient had no nausea or emesis.
Nasogastric output prior to falling out had been ~250cc over a
12 hour period. On ___, she was transitioned from her heparin
drip to lovenox. On ___, her diet was advanced successfully
and she was transitioned from her dilaudid PCA to IV toradol and
morphine to po tylenol and oxycodone. Throughout her
hospitalization, she continued to pass flatus and have loose
bowel movements.
On ___, the patient was tolerating a regular diet and po
anti-emetics, her pain was well controlled on po pain
medication, and she was receiving lovenox injections. She
completed a seven day course of IV antibiotics; at time of
discharge, her leukocyte count had normalized, and all cultures
remained without growth. Although her primary medical
oncologist, Dr. ___, had requested a port-a-cath be
placed if possible prior to discharge, this in fact was not
possible at time of discharge. On ___, the patient was
discharged home with outpatient follow-up scheduled.
Medications on Admission:
lorazepam, oxybutynin, percocet
Discharge Medications:
1. Enoxaparin Sodium 50 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL inject 50 mg twice a day Disp #*60
Syringe Refills:*1
2. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
3. Lorazepam 0.5 mg PO Q4H:PRN anxiety, pain
RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp
#*20 Tablet Refills:*0
4. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Promethazine 25 mg PO Q6H:PRN nausea
RX *promethazine 25 mg 1 tablet by mouth every six (6) hours
Disp #*60 Tablet Refills:*1
7. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
right iliac deep vein thrombosis
advanced cervical cancer
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 gynecologic oncology service for
treatment of a small bowel obstruction. Your obstruction was
managed with a nasogastric tube and medications to manage your
nausea and pain. You also developed a fever while you were
admitted and received antibiotics. In addition, you were found
to have a blood clot for which you received anticoagulation. You
have made excellent progress and the team feels you are now
ready for discharge. Please follow the below instructions.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10596591-DS-14 | 10,596,591 | 21,257,325 | DS | 14 | 2161-01-07 00:00:00 | 2161-01-08 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Intubation
Sutures applied to head wound ___
History of Present Illness:
___ yo M w/ PMHx of PArkinsons, cognitive impairment, aflutter
who was found down then noted to be dyspnic and 02 sats on RA in
the ___, bilateral crackles and ___ edema oer EMS reports. He was
given nitro sprays. In the ED, the pt was tachycardic to 100 and
agitated. BNP was 1450, he had negative troponins and an ECG
showed aflutter at a rate of 80bpm. He was intubated and placed
on a nitro drip. He became hypotensive so the nitro drip was
stopped. He was extubated in the MICU. He has been
intermittently agitated with tachypnea but with adequate oxygen
saturations. He received one dose of IV lasix in the MICU. He
becomes anxious when multiple individuals walk in and out of his
room. He is also anxious that his home will be taken away from
him and that he will be unable to return to living
independently. On transfer, the pt had no complaints, no chest
pain, no shortness of breath. He states that he had been in his
USOH without palpitations or poor PO intake.
Past Medical History:
___ disease
Cognitive impairement
Psoriasis
Atrial flutter
Social History:
___
Family History:
No family history of neurologic disease.
Physical Exam:
admission:
Vitals- T: BP:134/93 P:61 R: 18 O2:97%
General- pt intubated and sedated
HEENT- PERRLA, head laceration covered with protective dressing
Neck- supple, cannot appreciated JVD given pt habitus and ETT
CV- RRR, normal S1/S2, no appreciable M/R/G
Lungs- scattered bilateral crackles, no wheezing, rhonchi
Abdomen- soft, NT/ND, +BS, no hepatomegaly or splenomegaly, no
rebound or guarding
GU- foley in place draining clear urine
Ext- WWP, pulses 2+ bilaterally, trace b/l ___ edema to shin
Neuro- pill-rolling tremor with stimulation R>L, otherwise pt
intubated and sedated
discharge:
VS: 98.4 148/64 99 18 96% RA
General: anxious, ___ speaking male
HEENT: EOMI, pupils equal and round, +tongue w/ EP movements,
right subconjunctival hemorrhage
Neck: non-elevated JVP
CV: irregularly irregular, nl S1&S2, no murmurs appreciated
Lungs: poor inspiratory effort, CTAB, no wheeze, rales, or
rhonchi
Abdomen: +BS, soft, NT/ND
GU: no foley
Ext: no peripheral edema, +2 pulses distally in UE and ___, warm
& well perfused
Neuro: + pill rolling tremors, +intention tremor + EPS signs w/
tongue rolling
Pertinent Results:
admission:
-------------
___ 08:00PM BLOOD WBC-8.7 RBC-5.07 Hgb-14.6 Hct-45.0 MCV-89
MCH-28.8 MCHC-32.4 RDW-13.7 Plt ___
___ 08:00PM BLOOD Neuts-65.1 ___ Monos-5.5 Eos-3.2
Baso-0.5
___ 05:31AM BLOOD ___ PTT-31.3 ___
___ 08:00PM BLOOD Glucose-126* UreaN-32* Creat-1.0 Na-141
K-4.5 Cl-103 HCO3-30 AnGap-13
___ 08:00PM BLOOD ALT-8 AST-22 LD(LDH)-175 AlkPhos-84
TotBili-0.3
___ 08:00PM BLOOD Albumin-4.3
___ 08:10PM BLOOD Lactate-1.7
pertinent:
------------
___ 08:00PM BLOOD proBNP-1452*
___ 08:00PM BLOOD cTropnT-<0.01
___ 05:31AM BLOOD CK-MB-5 cTropnT-<0.01
discharge:
------------
___ 06:10AM BLOOD WBC-10.4 RBC-4.94 Hgb-14.1 Hct-44.5
MCV-90 MCH-28.6 MCHC-31.7 RDW-13.9 Plt ___
___ 06:10AM BLOOD ___ PTT-34.4 ___
___ 06:10AM BLOOD Glucose-93 UreaN-24* Creat-0.8 Na-140
K-4.3 Cl-104 HCO3-28 AnGap-12
___ 06:10AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
imaging:
------------
___ ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with severe hypokinesis of
the basal to mid inferior and inferolateral segments. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild focal left ventricular systolic dysfunction
consistent with coronary artery disease. No significant valvular
abnormality.
___ CT HEAD:
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large
territorial infarction. Mildly prominent ventricles and sulci
are compatible with age-related volume loss. There is
prominence of the extra-axial CSF spaces bilaterally compatible
with chronic subdural hygromas. Prominent perivascular spaces
in the basal ganglia are similar to prior. The basal cisterns
appear patent and there is preservation of gray-white matter
differentiation.
No fracture is identified. Anterior ethmoid air cells are
partially
opacified. Opacification of the right middle ear and mastoid
air cells is similar to prior. The visualized paranasal
sinuses, left mastoid air cells, and left middle ear cavity are
otherwise clear. The globes are unremarkable.
IMPRESSION:
No intracranial hemorrhage or calvarial fracture.
___ CTA:
IMPRESSION:
1. No pulmonary embolism.
2. Endotracheal tube is low lying and terminates 1.8 cm above
the carina.
3. Mild bronchial wall thickening, consistent with airway
infection or
inflammation.
4. Mild bibasilar atelectasis.
___ CXR:
FINDINGS:
Single frontal view of the chest. New endotracheal tube
terminates 3.8 cm above the carina. NG tube passes below the
diaphragm and beyond the limits of the film. Heart size and
cardiomediastinal contours are stable. Calcification of the
aortic knob is unchanged. There is mild bibasilar atelectasis.
Lungs are otherwise clear without focal consolidation, pleural
effusion, or pneumothorax.
IMPRESSION:
New endotracheal tube terminates 3.8 cm above the carina. Mild
bibasilar
atelectasis.
Brief Hospital Course:
___ w/hx of ___ who presents s/p fall with dyspnea.
# Hypoxia: It is unclear why the patient was hypoxemic and
differential includes anxiety from falling. However, more likely
is that, due to his tremor from his ___, we were not
able to get an accurate pleth and oxygen saturation. His BNP was
elevated, and in the setting of his anxiety and hypertension, it
is possible that there was an element of pulmonary edema. In
that setting, while in the MICU, he was given IV Lasix and then
was extubated the morning after admission to the unit. His
oxygen saturations remained stable afterwards.
# Fall: It is unclear why the patient was found down on the
floor, but differential includes includes a syncopal event from
orthostatic hypotension vs. symptomatic bradycardia vs. ? of
seizure activity. Patient has documented variation in his BP
and was previously advised to increase salt intake and wear
compressions stockings and is unclear if he has been compliant
with that. He also has documented asymptomatic bradycardia.
EKG on admission ___ Aflutter with ventricular rate of 80BPM,
unchanged from prior, but certainly cardiogenic with high degree
heart-block should be considered. Pt not known to have seizure
activity, but this should also be considered. However, pt
relates a history of falling asleep in his chair prior to his
fall so it is likely that the pt fell asleep and fell out of his
chair, hitting his head on the way down.
# subconjunctival hemorrhage: Unfortunately, the day prior to
discharge, the pt was hit in his right eye with the bed lift
resulting in a subconjunctival hemorrhage. Ophthamology
evaluated the pt and recommended bacitracin ointment TID x 3
days with follow up as an outpatient at the ___. The pts family
was aware of this as they were visiting at that time. The
primary team apologized for this unfortunate event.
# head laceration - Sutures placed ___. To be removed in 7
days. Wound was without signs of infection.
# ___ disease: The patient was continued on his home
carbidopa-levodopa.
# Atrial Flutter: The patient was monitored on telemetry and
continued on his home ASA.
# Psoriasis: continued home skin care
# living situation: This has been an issue for the patient in
the past, as he has been living alone and there is concern for
his ability to take care of himself. For the pts safety,
physical therapy recommended home with ___ care. This was
arranged with the family and the pt was additionally sent home
with home ___ services and home physical therapy.
Transitional issues:
* f/u w/ ophthomologist at the ___ in ___ days
* needs ___ supervision to ensure home safety
* help with medication administration
* help with ADLs
* bacitracin ointment applied to right eye three times daily for
three days (last day ___.
* suture removal ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO TID
2. Aspirin 81 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 30 mg PO Frequency
is Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE TID Duration: 3
Days
RX *bacitracin 500 unit/gram 1 application eye three times a day
Disp #*1 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
1. fall
2. Parkinsons disease
3. atrial fibrillation
4. subconjunctival hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came into the hospital because you
had passed out. When you were in the hospital, you had a
breathing tube for a short period of time because the doctors
were concerned that you were not getting enough oxygen to your
body. You were able to come off of this breathing tube quickly.
We looked for reasons why you passed out but could not find any.
When you fell, you hit your head. You have stitches that were
placed on ___. You should have these removed ___. Please
make an appointment with your primary care doctor for removal.
To help your eye, please use bacitracin for a total of 3 days, 3
times daily. You will need to follow up with an ophthalmologist
in ___ days at ___ (see below for phone number).
Thank you for choosing ___
Followup Instructions:
___
|
10596759-DS-10 | 10,596,759 | 28,359,781 | DS | 10 | 2185-10-09 00:00:00 | 2185-10-09 21:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ gentleman with a history of HTN,
CAD, HL, and anemia who presents with four hours of altered
mental status.
Patient lives alone at baseline, but son and daughter check in
frequently. On the evenining before presentation, patient was
staying with his son for the holiday, who heard him wake up at
4am. Patient was more confused than usual with some word-finding
difficulty, looking for "something that plays music," and he
said to his son, "I don't feel right. I need to see the doctor."
He reportedly has some confusion at baseline, but this was worse
and included perseveration. Family stated that he has not been
looking well recently, but there is nothing specific that they
identify. No cough, fevers, chills, nausea, vomiting, diarrhea.
No recent falls. Daughter and son have noticed audible wheezing,
which was also present before an episode of pneumonia in
___. At that time, he was symptomatic with cough and was
treated with a 7-day course of levaquin.
In the ED, initial VS were HR 30, BP 142/78, RR 14, O2 sat 100%
ra. CT Head showed stable atrophy and small vessel ischemic
changes but no acute process. A CXR showed bilateral patchy
opacities in the lung bases, which were unchanged from most
recent CXR in ___. He received a dose of Levaquin and 2L NS
and mental status improved. EKG shows first degree heart block,
many PVC''s.
On transfer, vital signs were 97.8 63 20 153/88 20 100 3L.
Patient feels "like myself," and daughter and son agree that
mental status has improved since last night. ROS is positive
only for intermittent neck pain, which patient and children
attribute to his spinal stenosis.
Past Medical History:
1. Hypertensive
2. Coronary artery disease with angina pectoris: No history of
known MI or catheterization
3. Hyperlipidemia.
4. Abnormal blood sugar.
5. Anemia, probable myelodysplasia.
6. Osteoarthritis.
7. R scrotal hernia
Social History:
___
Family History:
Family history reviewed and not relevant to this
hospitalization.
Physical Exam:
ADMISSION EXAM:
VS - 97.8 63 20 153/88 20 100 3L.
GEN - Pleasant older gentleman, hard of hearing, no acute
distress, loud expiratory wheezing audible without stethoscope
HEENT - No upper teeth, missing many lower teeth, MMM, sclera
anicteric, posterior OP clear
NECK - supple, no JVD, no LAD
PULM - No wheezing is heard in anterior or posterior lung
fields, though an expiratory whistle is heard over trachea. Very
faint rales at bilateral bases.
CV - RRR, S1/S2, no m/r/g
ABD - Soft, NT/ND, normoactive bowel sounds, no guarding or
rebound, large R scrotal hernia is not reducible but is soft and
not markedly tender
EXT - WWP, venous stasis changes bilaterally are mild, 1+ edema,
1+ ___ pulses,
NEURO - CN II-XII intact, though with some lower facial
asymmetry due to missing teeth, strength ___ and symmetrical
bilaterally, A+O x 2 (name, place, but misses year), able to say
days of week backwards but not months of year.
SKIN - onychomycosis of bilateral toes
DISCHARGE EXAM:
VITAL SIGNS: 97.6 138/71 (120s-150/50-80) 20 95%RA
GEN - elderly gentleman lying comfortably in bed in NAD, hard of
hearing
HEENT - No upper teeth, missing many lower teeth, MMM, sclera
anicteric, posterior OP clear
NECK - JVP improved to approx 7-8cm
PULM - Improved mild rales at the bases bilaterally. No rhonchi
or wheezes.
CV - RRR, S1/S2, no m/r/g
ABD - Soft, NT/ND, normoactive bowel sounds, no guarding or
rebound, large R scrotal hernia is not reducible but is soft and
non-tender
EXT - WWP, venous stasis changes bilaterally are mild, 1+ edema,
1+ ___ pulses,
NEURO - CN II-XII intact with the exception of stable right
lower facial asymmetry due to missing teeth, A+O x 2 (name,
place, but misses year)
SKIN - Cutaneous horn lesion on left anterior scalp with minimal
surrounding erythema. stable onychomycosis of bilateral toes
Pertinent Results:
ADMISSION LABS
___ 08:30AM BLOOD WBC-7.6 RBC-3.30* Hgb-11.3* Hct-35.1*
MCV-106* MCH-34.3* MCHC-32.3 RDW-12.4 Plt ___
___ 08:30AM BLOOD Neuts-67 Bands-0 ___ Monos-8 Eos-4
Baso-0 ___ Myelos-0
___ 08:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 08:30AM BLOOD ___ PTT-31.2 ___
___ 08:30AM BLOOD Glucose-89 UreaN-25* Creat-1.1 Na-143
K-4.3 Cl-113* HCO3-19* AnGap-15
___ 08:30AM BLOOD cTropnT-<0.01
___ 08:30AM BLOOD proBNP-2844*
___ 08:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:15AM BLOOD Lactate-2.5*
MICROBIOLOGY
___ Blood Culture: PENDING
___ Blood Culture: PENDING
IMAGING
___ CT head
IMPRESSION: Stable atrophy and small vessel ischemic changes.
No acute intracranial process. Note that MRI is more sensitive
for acute ischemia
___ CXR
FINDINGS: AP and lateral views of the chest demonstrate
bilateral patchy opacities within the bases which are relatively
stable from ___ but markedly increased from ___ likely reflective of mild pulmonary edema. Cardiac size
remains mildly enlarged. No pleural effusion. Thoracic aorta
remains tortuous. Mediastinal and hilar contours are within
normal limits. Lungs appear hyperinflated with flattened
diaphragms. There is no
pneumothorax. IMPRESSION: Mild pulmonary edema.
___ ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (ejection
fraction 40 percent) secondary to severe hypokinesis/akinesis of
the inferior and posterior walls. A small inferobasal aneurysm
is present. 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
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, severe inferior posterior hypokinesis is now
present.
DISCHARGE LABS
___ 06:30AM BLOOD WBC-6.1 RBC-4.03* Hgb-11.8* Hct-37.4*
MCV-93# MCH-29.2# MCHC-31.5 RDW-13.7 Plt ___
___ 06:30AM BLOOD Glucose-109* UreaN-27* Creat-1.2 Na-142
K-3.8 Cl-107 HCO3-25 AnGap-14
___ 06:30AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.1
Brief Hospital Course:
Mr. ___ is an ___ gentlman with a history of CAD who
presented with encephalopathy and CHF exacerbation.
ACTIVE ISSUES:
# Encephalopathy: Improved. Likely delirium in the setting of
sleeping in a different environment of his son's home. Mild
pulmonary edema, as evidenced on ED CXR, also likely contributed
to his delirium, though it is unclear to what degree as fluid
resuscitation in the ED resulted in some improvement in
delirium. Neurological event less likely given non-focal exam
and negative CT head. Infectious work-up negative with notable
lack of any focal lung consolidation to suggest pneumonia. No
evidence for MI given negative troponins and non-ischemic EKG.
He received 1 dose of levofloxacin in the ED but was otherwise
managed with frequent re-orientation and subsequent treatment of
CHF exacerbation as below.
# Acute on Chronic systolic heart failure: Improved with
diuresis. Exacerbated by poorly controlled HTN and IV fluid
resuscitation. Evidenced by elevated JVP, pulmonary rales, ___
edema, and elevated BNP. CXR from ___ showed worsening pulmonary
congestion and pleural effusions. He did not had any cough,
fever, chills, or an elevated white count to suggest PNA. Echo
performed ___ showed severe inferior posterior wall
hypokinesis and EF of 40% compared to last EF > 55% in ___ with
mild diastolic dysfunction. He received a total of 3 doses of
10mg IV Lasix over his hospital course with significant clinical
improvement based on symptoms and exam.
Notable medication changes for his CHF include initiation of
lisinopril and furosemide, and replacing atenolol with
metoprolol. He will be seen by Dr. ___ on ___ for
further evaluation and management, including labs and possible
introduction of spironolactone. His HTN was managed as below.
# Hypertension: Improved on afterload reduction with
ACE-inhibitor. Likely contributed to acute on chronic CHF. Home
atenolol dose was initially reduced to 50mg daily (from 75mg
daily) due to bradycardia, though atenolol was subsequently
discontinued with plans to start metoprolol ___ for medical
optimization. His HTN improved on standing captopril 6.25mg po
TID and was transitioned to lisinopril 5mg po daily. He will
need labs drawn and likely further up-titration of this regimen.
# Bradycardia: Improved. Patient's HR was 30's in ED but we do
not have an EKG capturing rhythm at that time. This was likely
due to over-nodal blockade from atenolol. Telemetry monitoring
did not reveal ongoing bradyarrhythmia.
CHRONIC ISSUES:
# HTN: Lisinopril 5mg po daily and metoprolol 50mg XL daily as
above.
# Anemia: Stable. Patient has a history of anemia per records
possibly due to MDS.
# High Cholesterol: Continued simvastatin 10mg daily.
# CAD: Continued ASA, though decreased from 325mg to 81mg daily.
TRANSITIONAL ISSUES:
# Need chem-10 drawn on ___ after starting furosemide and BP
check for possible up-titration of anti-HTN meds
# Consider adding spironolactone to CHF medication regimen
# Ensure patient checking BP and weight daily for CHF
# Dermatology outpatient appointment to evaluate cutaneous horn
on scalp and rule out squamous cell carcinoma
# New Medications: metoprolol 50mg XL po daily; furosemide 20mg
po daily; lisinopril 5mg po daily
# Changed Medications: aspirin 81mg po daily from 325mg
# Stopped Medications: atenolol (replaced by metoprolol)
I have seen and examined the patient on ___ and agree with the
findings in Dr. ___. More than 30 minutes was spent in
this patient's discharge planning. Blood cultures from ___
show no growth to date as of ___ at 0800.
- ___, MD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atenolol 75 mg PO DAILY
3. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Simvastatin 10 mg PO HS
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis:
Encephalopathy
Congestive Heart Failure, systolic
Secondary Diagnosis:
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you during your hospitalization.
You were admitted to the hospital on ___ after having some
confusion. You underwent an extensive work-up including labs and
a CT scan of your head. The results of these studies were
reassuring. Your confusion was most likely related to being in a
different home setting, and it is important to have your family
help re-orient you frequently if this happens again.
While in the hospital, you were also noted to have too much
fluid on your body. You underwent lab tests and an echo study to
look at your heart - this revealed that your heart is not
pumping as well as it should be. We have changed several
medications to help your heart function.
It is very important that you follow-up with your doctor at the
appointment below. It is also very important that you take all
of your medications as prescribed below.
- Please be sure to check your weight every day and notify your
doctor if it goes up by a couple of pounds.
- Please check your blood pressure every day and notify your
doctor if the top number is higher than 150 or the bottom number
higher than 100.
- Please avoid foods that are high in salt.
Followup Instructions:
___
|
10596759-DS-9 | 10,596,759 | 26,819,503 | DS | 9 | 2185-07-07 00:00:00 | 2185-07-08 09:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old male with a pmh of HTN, CAD, HLD,
and anemia who presents with myalgias, and non-productive cough
over the past ___ days with increased pain and difficulty
breathing. He has had trouble sleeping at night secondary to a
wheezing cough and shortness of breath. He does not think he has
had any fevers, though he has not taken his temperature. He has
otherwise felt like his normal self. His cough has been dry and
not productive. He has not had any CP, palps, or abdominal pain,
nausea or vomiting.
In the ED, initial vitals: T 98.4, HR 71, BP 126/62, rr 24, O2
sat 88% on RA. He was given albuterol and ipratropium neb,
levofloxacin 750mg x1. His imaging showed an early RLL
infiltrate and a CT head was negative. Labs were remarkable for
plts in the 130s, MCV of 101, and anemia. Otherwise unremarkable
lab values. Vitals prior to transfer: T 98.4, hr 74, b/p ___,
rr 20, 02 sat 100 % on 2 liters.
Currently, he feels ok. His breathing was improved with the
nebulizer downstairs. He also has nasal cannula in place at 3
liters.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Hypertensive heart disease without heart failure.
2. Coronary artery disease with angina pectoris.
3. Hyperlipidemia.
4. Abnormal blood sugar.
5. Anemia, probably myelodysplasia.
6. Osteoarthritis.
Social History:
___
Family History:
Family history reviewed and not relevant to this
hospitalization.
Physical Exam:
ADMISSION EXAM
VS - Temp 98.0F, BP 184/96, HR 67, R 16, O2-sat 100% on 2L
GENERAL - NAD, comfortable, appropriate, hard of hearing
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, TTP over trapezius and paraspinals but full ROM
of neck without pain. no JVD.
HEART - PMI, normal rate, regular rhythm, II/VI SEM at USB
LUNGS - Wheezy throughout the right lung field with
focalcrackles at the right base, good air movement, resp
unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema bilaterally with erythematous
chronic venous stasis changes over bilateral shins
SKIN - venous stasis changes over bilateral shins without
warmth, or purulence
NEURO - awake, A&Ox3, CNs II-XII grossly intact with the
exception of his hearing difficulties, moving all extremities.
Answering questions appropriately.
.
DISCHARGE EXAM
VS - Temp 98.2 F, BP 118/64(118/64-170/84), HR 66, R 20, O2-sat
97% RA
GENERAL - NAD, comfortable, appropriate, hard of hearing
NECK - supple, no JVD.
HEART - PMI, normal rate, regular rhythm, II/VI SEM at USB
LUNGS - trace wheezes on R side with focal crackles at base good
air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - WWP, 1+ edema bilaterally with erythematous
chronic venous stasis changes over bilateral shins, cool to the
touch
Pertinent Results:
Admission Labs:
___ 09:00AM BLOOD WBC-5.0 RBC-3.38* Hgb-11.6* Hct-34.1*
MCV-101* MCH-34.2* MCHC-34.0 RDW-12.6 Plt ___
___ 09:00AM BLOOD ___ PTT-32.2 ___
___ 09:00AM BLOOD Glucose-99 UreaN-20 Creat-1.1 Na-139
K-4.0 Cl-106 HCO3-23 AnGap-14
___ 09:20AM BLOOD Lactate-1.8
DISCHARGE LABS
___ 06:05AM BLOOD WBC-5.2 RBC-3.47* Hgb-11.8* Hct-35.1*
MCV-101* MCH-34.0* MCHC-33.6 RDW-12.3 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-96 UreaN-24* Creat-1.2 Na-139
K-4.1 Cl-106 HCO3-22 AnGap-15
Studies:
CXR
IMPRESSION: Right basilar opacity may reflect early pneumonia
and/or
pulmonary vascular congestion.
CT Head
1. No acute intracranial process.
2. Mild mucosal sinus disease
.
EKG
Artifact is present. Sinus rhythm. The P-R interval is
prolonged.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___
ST-T wave changes are new.
.
MICROBIOLOGY
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
Blood culture
___- negative, final as of ___
Brief Hospital Course:
Mr. ___ is an ___ year old male with a pmh of HTN, CAD, HLD,
and anemia who presents with myalgias, and non-productive cough
over the past ___ days with increased pain and difficulty
breathing, found to have pneumonia.
1. Pneumonia: Mr ___ was admitted with shortness of breath and
evidence of pneumonia on chest xray. Influenza swab was negative
as was urine legionella antigen. He was started on levofloxacin
for a planned 7 day course. He was given nebulizer treatments
with improvement in wheezing and shortness of breath. At the
2. HTN: Patient was hypertensive on admission. However this
improved without changes to his medications. He was discharged
on his home atenolol
3. CAD: Patient was continued on his home beta blocker,
aspirin, statin.
4. Anemia: Myelodysplasia vs. toxic effect. EtOH possible. MCV
101. B12 was within normal limits. His HCT remained stable
throughout admission without evidence of bleeding.
Transitional issues
- Blood cultures were pending at the time of discharge
- Patient was full code throughout this admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atenolol 75 mg PO DAILY
3. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atenolol 75 mg PO DAILY
3. Simvastatin 10 mg PO DAILY
4. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 trouble breathing. You
were found to have a pneumonia on your chest xray. You were
given antibiotics for this infection which you will need to
continue for 5 more days.
Followup Instructions:
___
|
10596872-DS-21 | 10,596,872 | 28,948,403 | DS | 21 | 2134-10-11 00:00:00 | 2134-10-11 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
worsening symptoms of myasthenia
Major Surgical or Invasive Procedure:
Pheresis line placement
History of Present Illness:
Mr. ___ is a ___ right-handed man presenting with on a
background of obstructive sleep apnea (on CPAP), diabetes
(recently started insulin), hypertension, hypercholesterolemia,
renal calculi (complicated by sepsis), parathyroidectomy
(partial, ___, myasthenia ___.
In ___ he developed double vision. ___ years earlier he
had had a diabetic cranial neuropathy with diplopia. He went
for an ophthalmologic check up and given double vision,
myasthenia
antibodies (returning in ___. He then saw a neurologist at
___, where he had previously worked as a ___, who
then referred him to Drs. ___ on suspicion of
myasthenia ___. At that time he had also been tired, but
does not think that he was weak elsewhere, short of breath or
had
difficulty swallowing. A trip to ___ for a conference soon
after the diagnosis was complicated by great fatigue and staying
in the hotel, but he did not notice muscular weakness and his
eyes had not yet become droopy.
Eye lid drooping, mostly on the left, appeared next, perhaps
three or four months ago. He thinks that this was likely
intermittent at the beginning and worsened over the course of
the day. In ___ he was driving with his left eye closed.
He has not had any shortness of breath that is related.
Occasionally he
has some difficulty swallowing solids only that he attributes to
"glands being puffed up". Body weakness has clearly appeared,
but still fatigue predominates.
He notes bodily weakness over the last two weeks or so, and even
a short walk is troublesome. An eight minute jaunt to the bus
was exhausting recently. Fatigue sends him to bed early and he
has been sleeping more, perhaps for two hours in the afternoon,
then seven to eight hours at night, interupted by frequent
nocturia, perhaps two times, sometimes three times.
Mestinon had been his only treatment, was started in ___,
and has gradually been titrated up. He is now at 120 mg four
times per day. He has not had diarrhea, but his constipation is
gone, with a now regular, once per day bowel habit. About this
he is very happy. Chest CT has been done and no thymoma was
noted. Prendisone has been avoided given his diabetes. IVIG
and plasmapheresis have been discussed.
He notes recent sinus problems and is using sprays and inhalers,
including saline. ___ morning his was miserable with his
sinuses. He has not had any antibiotics recently, but had been
on some in ___ for his sinuses - myasthenia was worsening,
but it did not clear make things temporarily worse. He has had
some low neck or high back pain and notes that he has become a
little stooped. He has some numbness over his low neck. He has
a mild bifrontal intermittent headache without radiation to the
neck. He has recently stopped gliburide and has not taken
Provigil in a long time (months). Sleep apnea has recently
worsened, but he has been unable to get into clinic given Sleep
Health Clinics going out of business. Review of systems is
otherwise negative except as above.
Past Medical History:
-Myasthenia ___ (per above): +AChR, no thymoma, previously on
mestinon only
-Obstructive sleep apnea (on CPAP; presently worsened, waiting
for follow-up here)
-Diabetes (recently started insulin, continues metformin and has
stopped gliburide)
-Hypertension
-Hypercholesterolemia
-Renal calculi (complicated by sepsis)
-Parathyroidectomy (partial, ___
Social History:
___
Family History:
Father with myasthenia at ~ ___, on 'steroids', heart disease.
Mother with unclear cause of death in ___, in context of
diabetes. Daughter is well. No other known neurologic problems.
Brother with gastric carcinoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 60 160/73 16 95%
VC 2.8 L; NIF -40 cmH2O
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits. Reduced ROM and lordotic.
Lungs: CTA bilaterally. Good inspiratory efforts.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Trophic changes in lower legs and mild pedal edema ___.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect.
Orientation: Oriented to person, place, date and context.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors.
Registration of three words at one trial and recall of all at
five minutes without hints.
Fund of knowledge for recent events within normal limits.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: The left eye remains closed for much of the exam.
On holding open, then allowing to close the right lid pops
higher. On opening the left eye voluntarily, the brow contracts
and he then later voluntarily allows the right to close.
Diplopia is mostly vertical, with the left eye able to track
down
better than the right and vice versa for tracking upward. There
is greater abducens palsy on the right than the left. Diplopia
gradually worsens with sustained upgaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Counts to 43 on one breath with non-ideal posture in stretcher.
Apparently 52 this morning. The neck is strong.
Tone normal throughout. Normal bulk.
Power
D B T WE WF FE FAb | IP Q H AT G/S ___ TF
R 4+* ___ ___ | ___ ___ 5
L 4* ___ 5 4& 5 | ___ ___ 5
* Fatigues slightly after arm flapping. & Arthritis
Reflexes: B T Br Pa Ac
Right ___ 1 0
Left ___ 1 0
Toes upgoing bilaterally on lateral stimulation.
Vibration is mild to moderately reduced in feet. Joint position
slightly impaired. Romberg negative.
Normal finger nose, great toe finger, RAM's bilaterally.
Gait: Normal initiation, cessation, turn, armswing, base. Tandem
unsteady - difficulty with one single accurate step.
DISCHARGE PHYSICAL EXAM: ***
Pertinent Results:
LABS ON ADMISSION:
-WBC-7.7 RBC-4.16* HGB-12.6* HCT-38.1* MCV-92 MCH-30.3 MCHC-33.0
RDW-13.7 PLT COUNT-139*
-NEUTS-68.0 ___ MONOS-4.2 EOS-5.5* BASOS-0.5
-GLUCOSE-125* UREA N-24* CREAT-1.2 SODIUM-142 POTASSIUM-4.2
CHLORIDE-105 TOTAL CO2-27 ANION GAP-14
-CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-1.7
-IgA-145
-Lactate-0.9
-UA: COLOR-Straw APPEAR-Clear SP ___ BLOOD-NEG
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG
-ABG: BLOOD Type-ART pO2-32* pCO2-52* pH-7.39 calTCO2-33* Base
XS-4
PA/LAT CXR (___): Mild left base atelectasis. Otherwise, no
acute cardiopulmonary process.
TTE (___): The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with normal left ventricular
diastolic function. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function.
Brief Hospital Course:
___ with history of myasthenia ___, confirmed with Abs, now
with exacerbation.
# NEURO
Patient has had progression of diplopia, ptosis now with SOB on
minimal exertion and dysphagia, requiring hospitalization.
Patient was referred to the ED from clinic for admission and
treatment with plasmapheresis x5 cycles, as well as initiation
of Cellcept. On admission he was seen by speech and swallow and
did not require any restrictions. His mestinon dose was
decreased from 120mg qid to 60mg qid. Baseline VBG on HD#2
showed pvco2 of 52 (normal is 45), so he was placed on 2L O2 via
NC and started q6hr NIF/VC monitoring. On HD #2, VC was low at
<1 L and pt with respiratory distress so was transferred to the
ICU overnight for monitoring. There he received intermittent
positive pressure ventilation with CPAP and his symptoms
improved. On HD #5 he was transferred back to the stepdown unit
in stable and improved condition. Cellcept was uptitrated from
500mg BID to ___ BID. As mestinon was increasing his oral
secretions, it was decreased to 30mg QID (PRN for evening dose
if patient complaining of secretions). Steroid therapy with
prednisone 15mg PO BID (with famotidine + Ca/D prophylaxis) was
also initiated, to be continued until further addressed at
___ clinic follow-up. Patient completed his 5-day
course of plasmapheresis without complications, and then one
extra session of plasmapheresis after this given ongoing ptosis.
After the above interventions (particularly starting steroids)
his symptoms improved significantly. He was cleared by physical
therapy for discharge home, and will follow up in ___
clinic as an outpatient.
# ALLERGY: During hospitalization patient complained of
rhinorrhea and conjunctival irritation, likely combination of
his known seasonal allergies and the cholinergic effects of
mestinon. Home fexofenadine was restarted, as were afrin and
nasal saline. Mestinon was tapered per above.
# ENDO: patient has h/o NIDDM, on metformin and glargine at
home. During hospitalization metformin held and started ISS.
When prednisone were started for his myasthenia (per above), his
blood sugar became difficult to control ___ diabetes was
consulted. Per their recommendations, glargine was uptitrated
and NPH added with improvement in his blood sugars. On discharge
he will follow up in ___ Diabetes clinic in one week for
close blood sugar monitoring while on Prednisone.
# ID: no issues throughout hospitalization.
# Cardio: Pt was on Lisinopril 20mg qd on admission. He was
changed to Losartan 100mg qd while on plasmapheresis.
==================
TRANSITIONS OF CARE:
-CODE STATUS: Full, confirmed
-Health Care Proxy: Wife ___, home phone ___
Medications on Admission:
AZELASTINE - Dosage uncertain - (Prescribed by Other Provider)
FLUTICASONE PROPIONATE (BULK) - Dosage uncertain - (Prescribed
by Other Provider)
INSULIN GLARGINE [LANTUS] - Dosage uncertain - (Prescribed by
Other Provider)
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth daily
- (Prescribed by Other Provider)
METFORMIN - metformin 1,000 mg tablet. 1 tablet(s) by mouth
twice
a day - (Prescribed by Other Provider)
PYRIDOSTIGMINE BROMIDE - pyridostigmine bromide 60 mg tablet. 2
tablet(s) by mouth four times a day as needed for myasthenia
symptom
Medications - OTC:
ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg
tablet,delayed release. 1 tablet(s) by mouth daily -
(Prescribed
by Other Provider)
CYANOCOBALAMIN (VITAMIN B-12) - Dosage uncertain - (Prescribed
by Other Provider)
MULTIVITAMIN - Dosage uncertain - (Prescribed by Other
Provider)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Pyridostigmine Bromide 60 mg PO QID
RX *pyridostigmine bromide 60 mg 1 tablet(s) by mouth four times
a day Disp #*120 Tablet Refills:*2
5. Lisinopril 20 mg PO DAILY
6. Cyanocobalamin 100 mcg PO DAILY
Home dose is unknown - please continue taking same dose as you
were prior to hospitalization.
7. Multivitamins 1 TAB PO DAILY
8. Atorvastatin 80 mg PO DAILY
9. azelastine *NF* 137 mcg NU unknown
10. Mycophenolate Mofetil 1000 mg PO BID
RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*2
11. Famotidine 20 mg PO BID
Please take this while you are on prednisone (to reduce risk of
developing stomach ulcers).
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
12. Calcium Carbonate 500 mg PO TID
Please take this medication while you are on prednisone to
prevent osteoporosis.
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*2
13. Vitamin D 400 UNIT PO DAILY
Please take this medication while you are on prednisone to
prevent osteoporosis.
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*2
14. Fexofenadine 60 mg PO BID
15. Glargine 15 Units Bedtime
RX *insulin glargine [Lantus] 100 unit/mL 15 units sub-q 15
Units before BED; Disp #*1 Vial Refills:*0
16. NPH insulin human recomb *NF* 25 units Subcutaneous daily
RX *NPH insulin human recomb [Humulin N] 100 unit/mL 25 units
sub-q daily Disp #*1 Vial Refills:*0
17. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous TID
per given sliding scale
RX *insulin lispro [Humalog] 100 unit/mL 1 unit sub-q three
times a day Disp #*1 Vial Refills:*0
18. PredniSONE 15 mg PO QAM
RX *prednisone 5 mg 3 tablet(s) by mouth qAM Disp #*90 Tablet
Refills:*0
19. PredniSONE 15 mg PO QNOON
RX *prednisone 5 mg 3 tablet(s) by mouth qnoon Disp #*90 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
myasthenia ___ exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with a myasthenia ___
exacerbation. We treated you with 6 cycles of plasmapheresis
and also started you on Cellcept. You were transiently in the
intensive care unit for closer monitoring of your respiratory
status. After starting steroids (prednisone) and making
adjustments to your mestinon dosing, your symptoms improved.
.
Due to starting steroids, your blood sugars have been more
difficult to control, so you will need to follow up with the
___ Diabetes Clinic as an outpatient to make sure your
insulin regimen is adequate.
.
Please attend the follow-up appointments listed below with
___ clinic (Drs. ___ and the ___
Diabetes Clinic.
.
We made the following changes to your medications:
We have made the following changes to your medications:
1. STARTED mycophenolate mofetil (Cellcept) 1000mg twice daily
2. STARTED prednisone 15 mg twice a day
3. DECREASED pyridostigmine (Mestinon) to 60mg four times daily.
Can take ___ bedtime dose or skip bedtime dose altogether if
having excess oral secretions.
4. STARTED famotidine 20mg twice daily (to prevent stomach
ulcers from developing while you are on steroids)
5. STARTED calcium + vitamin D (to prevent you from developing
osteoporosis while you are on steroids)
6. ****CHANGES TO INSULIN REGIMEN****
Followup Instructions:
___
|
10597014-DS-18 | 10,597,014 | 29,200,086 | DS | 18 | 2166-08-28 00:00:00 | 2166-08-28 21:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain, fever
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangeopancreatography
History of Present Illness:
___ s/p ccy 2 weeks ago complains of RUQ pain. Patient developed
nonradiating RUQ pain this afternoon. Also had fever to 101.
Denies N/V. Able to eat this am but now has no appetite. Seen at
OSH where his lipase was found to be 1100 and LFTs were
elevated. Underwent CT which was read as negative. Got Zosyn at
OSH.
In the ED inital VS were T98.8 °F (37.1 °C), Pulse: 75, RR: 16,
BP: 155/69, O2Sat: 97. Per report, pt. sent from OSH with fevers
to 101 and abdominal pain. Labs were significant for a
creatinine of 1.8, ALT of 295, AST of 479, AP of 375, and lipase
of 845. CBC was concerning for WBC of 14.5 with PMN of 84.5, HCT
of 32.1, and platelets of 174. Had CT that showed stranding
adjacent to the the pancreatic head c/w acute pancreatitis as
well as focal ectasia of the abdominal aorta to 2.3cm,
incompletely evaluated, with no radioopaque retained stone
identified after CCY. Started on IV Zosyn 3.75 GM, and received
morphine. Given lack of available beds on the ___,
patient was admitted to ___ for ERCP in the AM. VS prior to
admission was T 98.8, P 75, RR 16, BP 155/69, O2 of 97%.
On the floor pt is in NAD.
REVIEW OF SYSTEMS:
Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
DM type 2
CAD s/p CABG ___ ___
HTN
Hyperlipidemia
PVD s/p stents
Tobacco use
ETOH in remission
Depression and Anxiety
Social History:
___
Family History:
No history of GB or pancreatic disease.
Social History: Lives in ___. Used to be a ___.
No EtOH, Tobacco, or drugs.
Physical Exam:
ADMISSION EXAM:
VS: T 98| BP 140/60| HR 66| RR 18| satting 97% on RA
General: NAD.
HEENT: PERRL, EOMI
Neck: no carotid bruits, JVD
Lungs: CTAB
Heart: RRR, normal S1 S2, no MRG
Abdomen: Distended. NBS. Soft, NT, NABS, no organomegaly
Extremities: No c/c/e
Neurologic: A+OX3. Slurs words occassionally but no overta
dysarthria. No focal motor deficits. Gross touch in tact
throughout. Left lid lag baseline.
Skin: Tan with UE tatoos.
DISCHARGE EXAM:
VS: 98.4 154/58 62 20 98%RA
General: NAD, AAOx3
HEENT: PERRL, EOMI
Neck: supple, no carotid bruits
Lungs: CTAB
Heart: RRR, normal S1 S2, no MRG
Abdomen: Soft, NT, NABS, no organomegaly
Extremities: No c/c/e
Pertinent Results:
ADMISSION LABS:
___ 08:39PM LACTATE-1.6
___ 08:20PM GLUCOSE-143* UREA N-26* CREAT-1.8* SODIUM-137
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
___ 08:20PM estGFR-Using this
___ 08:20PM ALT(SGPT)-295* AST(SGOT)-479* ALK PHOS-375*
TOT BILI-1.3
___ 08:20PM LIPASE-845*
___ 08:20PM ALBUMIN-4.1
___ 08:20PM WBC-14.5*# RBC-3.48* HGB-10.7* HCT-32.1*
MCV-92 MCH-30.7# MCHC-33.3 RDW-14.9
___ 08:20PM NEUTS-84.5* LYMPHS-11.7* MONOS-2.8 EOS-0.5
BASOS-0.5
___ 08:20PM PLT COUNT-174#
OTHER PERTINENT LABS:
___ 12:40PM BLOOD Hct-29.3*
___ 12:40PM BLOOD UreaN-12 Creat-1.6*
___ 08:20PM BLOOD Lipase-845*
___ 07:00AM BLOOD Lipase-551*
___ 05:41AM BLOOD Lipase-335*
___ 05:45AM BLOOD Lipase-201*
___ 05:35AM BLOOD Lipase-159*
___ 06:30AM BLOOD Lipase-139*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-13.1* RBC-2.87* Hgb-8.6* Hct-26.5*
MCV-93 MCH-29.9 MCHC-32.3 RDW-15.0 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-180* UreaN-20 Creat-1.6* Na-136
K-4.4 Cl-101 HCO3-26 AnGap-13
___ 07:00AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
MICRO:
C. difficile DNA amplification assay (Final ___:
Positive for toxigenic C. difficile by the Illumigene DNA
amplification.
Blood cultures: ___: no growth
IMAGING: ERCP
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: The common bile duct, common hepatic duct, right
and left hepatic ducts, biliary radicles and cystic duct were
filled with contrast and well visualized. The course and caliber
of the structures are normal and non-dilated. A tiny mobile
filling defect was noted in the distal CBD. There was no
evidence of bile leak on occlusion cholangiogram.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Balloon sweep was performed and a small amount of sludge was
extracted.
IMPRESSION: (cannulation)
Normal biliary tree(sphincterotomy, stone extraction). Otherwise
normal ercp to third part of the duodenum. Recommendations: NPO
overnight with aggressive IV hydration with LR at 200 cc/hr. If
no abdominal pain in the AM, advance diet to clear liquids and
then advance as tolerated.
CT abdomen ___:
CT ABD & PELVIS W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip #
___
Reason: evaluate for acute process, retained stone
UNDERLYING MEDICAL CONDITION:
___ year old man with RUQ pain, ccy 2 weeks ago, lipase 1100,
elevated LFTs, fever, elevated wbc
REASON FOR THIS EXAMINATION:
evaluate for acute process, retained stone
CONTRAINDICATIONS FOR IV CONTRAST:
Final Report
CLINICAL HISTORY: ___ man with right upper quadrant
pain,
cholecystectomy two weeks ago with lipase of 1100, elevated
LFTs, fever and
elevated leukocytosis. Evaluate for acute process or retained
stone.
This is a second read studies for a CT performed at ___
___ on
___ at 5:46 p.m. A report was provided by the outside
institution of no acute process. However, as this is discordant
with the patient's clinical picture, a second read was requested
by the ED physicians.
COMPARISON: No relevant comparisons available.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the
pubic
symphysis were displayed with 5-mm slice thickness with oral
contrast only.
No intravenous contrast was administered. Coronal reformatted
images are
provided for review.
CT ABDOMEN: The visualized lung bases are clear aside from mild
dependent
bibasilar atelectasis. There is no pleural or pericardial
effusion. There
are mild coronary artery calcifications.
Evaluation of the intra-abdominal organs is limited without
intravenous
contrast. The unenhanced liver is diffusely hypodense
compatible with fatty liver. No intra- or extrahepatic bile duct
dilation is noted. The gallbladder is surgically absent. The
spleen is normal. Mild stranding around the pancreatic head is
compatible with acute pancreatitis. The bilateral adrenal
glands are normal. No renal stones, hydronephrosis or contour
altering renal mass is identified.
The small and large bowel are normal in course and caliber
without
obstruction. There is a small duodenal diverticulum (2:34).
Diverticula are
seen throughout the large bowel without inflammatory changes.
The appendix is visualized and is normal. There is no free
fluid and no free air. There is focal ectasia of the abdominal
aorta with dense atherosclerotic calcifications to 2.3 cm,
incompletely evaluated on this unenhanced CT. A 15mm porta
hepatic lymph node is likely related to fatty liver. No other
pathologically enlarged mesenteric or retroperitoneal lymph
nodes are identified.
CT PELVIS: The rectum is normal. Diverticula are seen in the
sigmoid colon without inflammatory changes. The bladder and
prostate are normal. There is a small fat containing left
inguinal hernia. There is no free fluid and no pelvic or
inguinal lymphadenopathy. Dense atherosclerotic calcifications
are seen in the iliac vessels bilaterally.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen.
IMPRESSION:
1. Acute pancreatitis. No adjacent fluid collection identified
on this
noncontrast CT.
2. Status post cholecystectomy. No radiopaque retained stone
identified. No bile duct dilation.
3. Focal ectasia of the abdominal aorta to 2.3 cm, incompletely
evaluated on this non-contrast CT.
Brief Hospital Course:
___ y/o male s/p ERCP presents with abdominal pain consistent
with pancreatitis and concerning for cholangitis.
# Pancreatitis/cholangitis: Patient presented with RUQ pain and
fever. Clinical symptoms, labs and imaging consistent with
pancreatitis. ERCP performed on ___ with sludge extraction and
sphincterotomy. Patient treated with 5-day course of Zosyn and
diet was advanced slowly to regular. Initially switched to
Cipro 500mg BID after 5 days of Zosyn, which was stopped when
patient developed diarrhea and C. diff PCR was positive. Patient
transitioned to normal diet and no further complications.
Omeprazole frequency was increased to BID, however on d/c pt was
switched to ranitidine to decrease the risk of recurrent C.
diff. Please discuss on PCP follow up the need for PPI.
# C. difficile colitis: Patient developed loose stools in the
setting of receiving antibiotics- Zosyn, then Cipro. Started on
PO Flagyl and had normal stools prior to discharge. WBC
initially rose from 10K to 14K, then decreased to 13K on the day
of discharge. Plan to continue 2 week course of PO Flagyl (last
day ___
# Chronic kidney Disease: Per PCP office records, baseline Cr
appears to be 1.7-1.8. At ___, Cr was as low as 1.2. On the
days prior to discharge, Cr stable at 1.6.
# HTN: Initially held home BP meds in the setting of infection.
All home BP meds restarted by the time of discharge.
# CAD: no active chest pain or other cardiac symptoms. Home
cardiac medication continued.
# Depression: Continued citalopram.
# Transitional issues:
- Code status: full code
- HCP: Daughter ___ ___
- ___ labs: none
- Medication change: started Flagyl and ranitidine
- Follow up with: PCP ___ on ___ at 9:45
- Additional abdominal imaging to evaluate incidental finding of
abdominal aortic ectasia (see related letter) as deemed
appropriate by primary MD
Medications on Admission:
MEDICATION ON ADMISSION:
1. GlipiZIDE 10 mg PO BID
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Ferrous Gluconate 325 mg PO DAILY
9. lisinopril-hydrochlorothiazide *NF* ___ mg Oral daily
10. hydrALAZINE *NF* 50 mg Oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. hydrALAZINE *NF* 50 mg Oral BID
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
day 1= ___
8. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. GlipiZIDE 10 mg PO BID
11. Ferrous Gluconate 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Pancreatitis
HTN
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for pain and fever that developed after your operation two weeks
ago. We were concerned about infection and put you on
antibiotics and gave you medicine for pain control.
While you were here, we advanced your diet to include clear
liquids and you were able to tolerate them with no pain, so you
should be ready to go home. Please follow up with your primary
care doctor.
We made the following changes to your medication:
STARTED: Flagyl
STOPPED: Omeprazole
STARTED: Ranitidine
Followup Instructions:
___
|
10597404-DS-2 | 10,597,404 | 29,352,870 | DS | 2 | 2142-12-31 00:00:00 | 2143-01-04 16:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Near-Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year-old woman with depression, OCD, asthma
and recent near-syncopal episodes presenting with chest pain .
Patient using toilet and had a bowel movement. She then began to
feel chest tightness, non radiating, central. The tightness
continued and she felt as though she had to lay down. Her
husband called EMS. She then felt nausea and had some dry
heaving without vomiting. The chest pain resolved by the time
EMS arrived. She did not feel lightheaded or as if she was going
to pass out. She did not have any visual changes, palpitations,
or shortness of breath. She had no diarrhea. No vomiting. She
does describe night sweats occuring 2 out of the past three
nights, and a feeling of being "unwell" in ___ evening with some
"shakiness". She thought it may be flu like, however she denies
any myalgias, fatigue, or decreased appetite. She did have an
episode of syncope approximately 3 months in ___ as well.
This was thought to be vasovagal. Patient reports good exercise
tolerance; she is able to bike 6 miles plus per day without any
chest pain or palpitations.
Initial vitals in the ED were 96.6 70 114/68 15 100% RA. Labs in
the ED were notable for Na 139, K 4.1, BUN 21, Cr 0.7, WBC 5.8,
HCT 35.2 and PLTs 219 and TropT < 0.01. CXR revealed no acute
process. She was give 324 mg ASA and admitted to the general
medicine service for further evaluation. Vitals on transfer were
98.2 102/58 59 16 97%RA.
On arrival to the general medical floor, vitals 98, 107/69, 66,
16, 99% RA. Patient currently denies any chest pain, dyspnea,
palpitations, fever, sweats, chills, N/V/D. She feels well and
would like to go home.
REVIEW OF SYSTEMS:
Denies chills, headache, vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
OCD, picks at skin
Depression
Asthma
Osteoporosis
Social History:
___
Family History:
GM with RA
Father and Mother s/p valve surgery in their ___
Father with CVA in his ___
No DM or CA history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98, 107/69, 66, 16, 99% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, trace edema, small marks
on skin of R foot consistent with history of picking at skin,
non-tender, non erythematous, not warm to touch
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Labs:
___ 05:55AM ___ PTT-29.1 ___
___ 05:55AM PLT COUNT-219
___ 05:55AM WBC-5.8 RBC-3.96* HGB-11.4* HCT-35.2* MCV-89
MCH-28.8 MCHC-32.3 RDW-13.5
___ 05:55AM D-DIMER-238
___ 05:55AM GLUCOSE-140* UREA N-21* CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-31 ANION GAP-11
___ 01:45PM cTropnT-<0.01
CHEST (PA & LAT) Study Date of ___
FINDINGS: The heart size is within normal limits. The
mediastinal contours again demonstrate a large hiatal hernia.
The lungs are hyperinflated but clear. There is no pleural
effusion or pneumothorax.
IMPRESSION: Hiatal hernia and hyperexpanded lungs with no acute
cardiopulmonary process.
EKGs:
-Sinus rhythm. Without diagnostic abnormality. No previous
tracing available for comparison.
-Sinus rhythm. PR segment depression seen in the lateral leads,
may be normal variant but cannot exclude acute pericardial
disease.
Brief Hospital Course:
___ year-old woman with depression, OCD, asthma and recent
near-syncopal episodes admitted for chest pain.
# Chest pain: Patient describes self limited episode of chest
pain that was non-radiating and occured in setting of bowel
movement, associated with episode of nausea and wretching.
Suspicion of cardiac etiology low given atypical description
with EKG without any evidence of ischemia, troponin <0.01,
<0.01. Exercise tolerance test ___ normal. ___ be secondary to
increased vagal tone causing drop in blood pressure, although
patient does not describe feeling light-headed and did not pass
out. She did have an episode of syncope several months ago that
was consistent with vaso-vagal episode. Suspicion of arrhythmia
low given description of event. Patietn monitored on telemetry
while here, without any arrhythmias. Differential also includes
GI source such as GERD or gastritis and pulmonary cause such as
PE. D-dimer 238 (<400), making PE highly unlikely. Patient
also does not have oxygen requirement and chest painr resolved.
The patient will follow up with her primary care doctor as noted
below. GERD is possible given description, patient given
prescription for one month of omeprazole.
Chronic Issues:
# Asthma: Appears clinically stable. Continue inhaler PRN.
# Depression: Appears clinically stable. Continue Bupropion and
Vilazodone.
# Osteoporosis: Continue alendronate.
Transitional Issues:
-follow up with primary care doctor
-___ hernia seen on CXR
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea, wheezing
2. Alendronate Sodium 70 mg PO QTHUR
3. BuPROPion 150 mg PO BID
4. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
5. estradiol *NF* 10 mcg Vaginal twice weekly
6. vilazodone *NF* 30 mg Oral daily
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea, wheezing
2. Alendronate Sodium 70 mg PO QTHUR
3. BuPROPion 150 mg PO BID
4. vilazodone *NF* 30 mg Oral daily
5. estradiol *NF* 10 mcg Vaginal twice weekly
6. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
7. Omeprazole 20 mg PO DAILY Duration: 4 Weeks
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*28
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Chest tightness
Secondary: Depression, GERD, OCD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you at ___
___. You were admitted for chest tightness. A
cardiac workup did not reveal any abnormalities.
You may follow up with your primary care doctor as described
below.
Medication changes:
Omeprazole 20mg per day for 4 weeks to treat GERD
(gastroesophageal reflux disease)
Followup Instructions:
___
|
10597434-DS-14 | 10,597,434 | 21,939,404 | DS | 14 | 2122-04-20 00:00:00 | 2122-04-22 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Fosamax
Attending: ___.
Chief Complaint:
Wrist pain and swelling
Major Surgical or Invasive Procedure:
___ Direct thrombin injection to radial artery pseudoaneurysm
History of Present Illness:
Ms. ___ is a an ___ w/ CAD w/ prior stenting and
recent cardiac catheterization, atrial fibrillation, HTN, HLD,
hypothyroidism, cutaneous Lupus, basal cell carcinoma, & RLS who
presents with right wrist pain.
The patient has had progressive shortness of breath for which
she underwent cardiac catheterization via the right radial
artery ___ at ___ (which was negative).
Post-catheterization, she developed swelling of the right wrist,
and was admitted for what was thought to be a hematoma related
to access. She was observed overnight and was discharged the
next day (no imaging obtained at that time). However, over the
following week, she developed increasing swelling and pain of
the right wrist, so she re-presented to ___ ___.
Cardiology recommended arterial duplex studies and Vascular
Surgery consultation, which is not available at ___, so
she was transferred to ___.
In the ___ ED, she had an US which showed normal color flow
and spectral Doppler waveforms in the right radial artery, w/ a
2.8 x 2.6 x 3.___rtery pseudoaneurysm. There
were no other fluid collections or hematomas are noted.
Interventional radiology was consulted and felt that she was a
good candidate for thrombin injection, so she was admitted.
In summary in the ED:
- Initial vitals:
T 96.9 HR 78 BP 150/80 RR 16 O297% RA
- Exam notable for:
"General- NAD
HEENT- PERRL, EOMI, normal oropharynx
Lungs- Non-labored breathing, CTAB
CV- RRR, no murmurs, normal S1, S2, no S3/S4, radial artery
pulses intact distal to puncture site
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Msk- No spine tenderness
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal coordination and gait. Normal
neurovascular function of the right hand
Ext- No edema, cyanosis, or clubbing. 3 cm x 5 cm tender mass at
the radial artery puncture site, no audible bruit, no
pulsatility"
- Labs notable for:
WBC 6.6
HGB 12.9
platelets 171
INR 1.1
Na 142
K 4.7
Cl 108
HCO3 21
BUN 20
Cr 0.8
- Imaging notable for:
US:
Large pseudoaneurysm of the radial artery measuring up to 3.4
cm.
- Patient given:
PO Acetaminophen 1000 mg
PO Pantoprazole 40 mg
PO/NG Simvastatin 20 mg
IV Morphine Sulfate 2 mg
PO Acetaminophen 650 mg
On the floor, she confirms the above story. She is sleeping and
feels relatively well. She is hoping that the procedure can be
done early tomorrow. She is currently chest pain-free with no
shortness of breath.
REVIEW OF SYSTEMS:
===================
A full ROS was performed and negative except noted in HPI.
Past Medical History:
CAD w/ prior stentin
atrial fibrillation
HTN
HLD
hypothyroidism
cutaneous Lupus
basal cell carcinoma
RLS
Social History:
___
Family History:
Reviewed, non-contributory to this admission
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
97.5 145/82 80 18 96 Ra
GENERAL: WN/WD, NAD.
HEAD: NC/AT, conjunctiva clear, EOMI, pupils reactive, sclera
anicteric, oral mucosa w/o lesions
NECK: Supple, no LAD, no thyromegaly. JVP is 5 cm.
CARDIAC: Precordium is quiet, PMI non-displaced, RRR, S1S2 w/o
m/r/g.
RESPIRATORY: Speaking in full sentences, CTABL.
ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable
organomegaly.
EXTREMITIES: Warm, large slightly pulsatile mass in the right
wrist with edema of the forearm and hand, peripheral pulses are
strong and full, no ___ edema.
NEUROLOGIC: Grossly intact, face symmetric, speech fluent.
PSYCHIATRIC: Pleasant and cooperative.
========================
DISCHARGE PHYSICAL EXAM
========================
VITALS: ___ 0714 Temp: 97.6 PO BP: 135/82 L Lying HR: 68
RR:
16 O2 sat: 96% O2 delivery: Ra
GENERAL: Elderly woman, appears frustrated
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Nontender, nondistended
EXT: Hematoma over the right wrist, purple discoloration,
raised.
Right radial pulse is intact. Full ROM of right upper extremity.
Sensation intact.
NEURO: Alert and oriented, moving all extremities
Pertinent Results:
====================
ADMISSION LABS
====================
___ 04:41PM BLOOD WBC-6.6 RBC-4.27 Hgb-12.9 Hct-40.5 MCV-95
MCH-30.2 MCHC-31.9* RDW-13.5 RDWSD-46.7* Plt ___
___ 04:41PM BLOOD Neuts-61.0 ___ Monos-9.4 Eos-3.5
Baso-0.6 Im ___ AbsNeut-4.05 AbsLymp-1.67 AbsMono-0.62
AbsEos-0.23 AbsBaso-0.04
___ 04:41PM BLOOD ___ PTT-34.5 ___
___ 04:41PM BLOOD Glucose-86 UreaN-20 Creat-0.8 Na-142
K-4.7 Cl-108 HCO3-21* AnGap-13
==================
DISCHARGE LABS
==================
___ 12:20PM BLOOD WBC-6.3 RBC-4.05 Hgb-12.5 Hct-38.1 MCV-94
MCH-30.9 MCHC-32.8 RDW-13.4 RDWSD-46.3 Plt ___
___ 12:20PM BLOOD ___ PTT-31.3 ___
___ 12:20PM BLOOD Glucose-171* UreaN-21* Creat-0.9 Na-141
K-4.3 Cl-107 HCO3-24 AnGap-10
___ 12:20PM BLOOD Calcium-9.0 Phos-2.8 Mg-1.6
=================
IMAGING/REPORTS
=================
___ UPPER EXTREMITY ULTRASOUND
FINDINGS:
Normal color flow and spectral Doppler waveforms are present in
the right
radial artery. A 2.8 x 2.6 x 3.___rtery
pseudoaneurysm is
noted along the distal forearm with a narrow neck measuring 1
mm. No other fluid collections or hematomas are noted.
IMPRESSION:
Radial artery pseudoaneurysm measuring up to 3.4 cm at the
distal forearm.
Brief Hospital Course:
Ms. ___ is a ___ w/ CAD w/ prior stenting and
recent cardiac catheterization, atrial fibrillation, HTN, HLD,
hypothyroidism, cutaneous Lupus, basal cell carcinoma, & RLS who
presents with right wrist pain, found to have right radial
artery pseudoaneurysm.
# Pseudoaneurysm
Patient was found to have evidence on ultrasound exam of
pseudoaneurysm after cardiac cath one week ago. She complained
of significant pain radiating up her arm, but did not have
numbness, weakness, or limitation of mobility. She was seen by
interventional radiology, who performed thrombin injection to
the area on ___.
# CAD with history of stents
Unclear when/where the stenting occured, but patient stated that
it was several years ago. Her most recent cardiac cath was
without any suspicious lesions. Her home aspirin was initially
held but restarted post-procedure with ___. She was continued on
home atenolol and simvastatin.
# Atrial fibrillation
Continue beta blocker for rate control. Her home apixaban was
initially held prior to ___ procedure, but subsequently
restarted. She takes 5 mg once daily, which is not a typical
dose but this is her true prescription per her recent fill
history.
# HTN:
Continued BB, isosorbide mononitrate ER 30 mg daily.
# HLD:
Continued statin as above.
# Hypothyroidism:
Continued levothyroxine 88 mcg daily.
# Cutaneous Lupus:
Continue triamcinolone & azelaic acid
# RLS:
Continue rotigotine 3 mg/24
# Asthma:
Continued fluticasone-salmeterol.
CODE: DNR/DNI
CONTACT: daughter (___) ___
=======================
TRANSITIONAL ISSUES
=======================
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. rotigotine 3 mg/24 hour transdermal QHS
2. Simvastatin 20 mg PO QPM
3. Atenolol 25 mg PO DAILY
4. ALPRAZolam 1 mg PO QHS
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN cutaneous
lupus
8. Pantoprazole 40 mg PO Q24H
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Apixaban 5 mg PO DAILY
11. azelaic acid 15 % topical PRN
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 1 mg PO QHS
2. Apixaban 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. azelaic acid 15 % topical PRN
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. rotigotine 3 mg/24 hour transdermal QHS
11. Simvastatin 20 mg PO QPM
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN cutaneous
lupus
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Radial artery pseudoaneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were admitted to the hospital because of pain and swelling
in your wrist.
What did you receive in the hospital?
- You received medication to relieve your wrist pain
- An ultrasound showed that you had an injury to your blood
vessel (pseudoaneurysm)
- The interventional radiologists injected a medication into
the area to help it heal.
What should you do once you leave the hospital?
- Continue to take all of your medications as prescribed
- Return to the emergency room if you develop pain, numbness or
weakness in your hand.
- Follow up with your cardiologist as previously scheduled.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10597762-DS-28 | 10,597,762 | 29,522,703 | DS | 28 | 2144-07-17 00:00:00 | 2144-07-18 10:35:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Morphine / Femara / Amoxicillin /
HCTZ
Attending: ___.
Chief Complaint:
Dyspnea, Cough, Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with PMHx CKD, DM, HTN, asthma, breast cancer,
multiple SBO, presents with several weeks of right lower back
pain, and dyspnea worsening over the past one week.
Since ___, the patient has had somewhat of a decline.
She fell around that time, and has had persistent right lower
back pain. The pain is sharp, located at her right flank,
occasionally radiates around to the front, worse with movement.
She has been evaluated with CXR which showed pleural effusion,
and lumbar spine xray and CT, significant for dextroscoliosis
with multilevel spondylosis but no other acute pathology. She
has been having home ___ sessions, which per family have not made
the pain any better and seem to have in fact made her pain
worse.
She was seen in early ___ by her PCP for changes in mental
status, specifically episodes of unnresponsiveness in which the
patient was breathing but not arrousable. ___
monitoring did not reveal a cardiogenic cause. Her carvidolol
was reduced and her sitagliptin was stopped. Per PCP notes the
episodes resolved by ___. Per the family, those episodes have
stopped, but the patient is still quite sleepy most days. Per
the patient she is feeling excessively fatigued over the past
few weeks.
She denies any fever, CP, abd pain, N/V/D, constipation. She has
not had any dysuria. She is incontinent of urine at baseline.
She has had a dry cough, and also endorses some subjective
chills.
In the ED, initial VS were 97.8 70 138/61 20 93%. Labs
significant for WBC 7.8 Hbg/Hct 10.4/34.8 Plt 232. Chem-7 wnl.
BNP 823. D-dimer 401. U/A with moderate leuks, 10 WBCs, neg
blood, neg nitrite, few bacteria. CXR showing small right
pleural effusion, but no infiltrate. She was given a dose of IV
cipro for potential UTI.
Transfer VS were 97.6 78 176/88 18 96% RA.
On arrival to the floor, patient reports no specific complaints.
Her back pain is not bothering her, except when she moves.
REVIEW OF SYSTEMS:
Denies fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
CHRONIC KIDNEY DISEASE STAGE III
ADRENAL ADENOMA
ALLERGIC RHINITIS
ANEMIA
ASTHMA
B12 DEFICIENCY ANEMIA
BACK PAIN
BREAST CANCER
CYST/PSEUDOCYST, PANCREAS
DIABETES MELLITUS
PSHx:
Appendectomy
Cholecystectomy
Hysterectomy
Multiple abdominal surgeries for SBOs
HEARING LOSS
HYPONATREMIA
INTERNAL KNEE DERANGEMENT
BOWEL ADHESIONS
OSTEOARTHRITIS
OSTEOPENIA
SARCOMA
SCOLIOSIS
SMALL BOWEL OBSTRUCTION
SUPRAVENTRICULAR TACHYCARDIA
URINARY INCONTINENCE
Social History:
___
Family History:
- Two sisters died of breast cancer.
- Mother had stroke in her ___
- Father had DM, multiple MIs
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
========================================
VS: 97.7 168/67 81 16 96%RA
General: Awake, alert, pleasant. Oriented to person, place,
time. Able to say days of week forward and backward.
HEENT: PERRL. MMM, no oral lesions.
Neck: Supple. No cervical or supraclavicular LAD.
CV: RRR. No murmur appreciated.
Lungs: CTA b/l. Faint crackles at bases b/l.
Abdomen: BS present. Soft, nondistended, mild tenderness over
epigastric region. No rebound or guarding. No HSM appreciated.
GU: Deferred. No foley.
Ext: Warm. DP pulses intact. No ___ edema.
Neuro: AOx3. CN2-12 grossly intact with the exception of
impaired shoulder shrug on left (patient with previous shoulder
surgery). ___ strength in UEs and LEs with the exception of
inability to abduct her left shoulder (previous surgery).
Finger-to-nose intact.
Back: Marked scoliosis. No spinal tenderness. Tender over right
CVA. No muscle spasm appreciated.
PHYSICAL EXAM ON DISCHARGE:
========================================
VS: 98.7 167/70 82 16 97%RA
General: Awake, alert, pleasant. Oriented to person, place,
time.
HEENT: PERRL. MMM, no oral lesions.
Neck: Supple. No cervical or supraclavicular LAD.
CV: RRR. No murmur appreciated.
Lungs: CTA b/l, with overall decreased BS. Faint crackles at
bases b/l.
Abdomen: BS present. Soft, nondistended, nontender. No rebound
or guarding. No HSM appreciated.
GU: Deferred. No foley.
Ext: Warm. DP pulses intact. No ___ edema.
Neuro: AOx3. CN2-12 grossly intact with the exception of
impaired shoulder shrug on left (patient with previous shoulder
surgery). ___ strength in UEs and LEs with the exception of
inability to abduct her left shoulder (previous surgery).
Back: Marked scoliosis. No spinal tenderness. Tender over right
CVA as well as right SI joint. No muscle spasm appreciated. Able
to ambulate with assistance.
Pertinent Results:
LABS:
=====================================
___ 12:40PM BLOOD WBC-7.8 RBC-3.66* Hgb-10.4* Hct-34.8*
MCV-95 MCH-28.5 MCHC-30.0* RDW-14.6 Plt ___
___ 12:40PM BLOOD Neuts-69.4 ___ Monos-5.2 Eos-2.4
Baso-0.5
___ 12:50PM BLOOD ___ PTT-28.5 ___
___ 12:40PM BLOOD Glucose-205* UreaN-23* Creat-1.0 Na-137
K-4.6 Cl-104 HCO3-26 AnGap-12
___ 12:40PM BLOOD ALT-17 AST-22 AlkPhos-67 TotBili-0.2
___ 12:40PM BLOOD Albumin-3.8
___ 12:40PM BLOOD proBNP-823*
___ 02:33PM BLOOD D-Dimer-401
___ 12:52PM BLOOD Lactate-1.4
___ 06:15AM BLOOD WBC-7.4 RBC-3.48* Hgb-10.0* Hct-32.5*
MCV-93 MCH-28.7 MCHC-30.7* RDW-14.6 Plt ___
___ 06:15AM BLOOD Glucose-104* UreaN-17 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-29 AnGap-12
___ 06:15AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.6
IMAGING:
=====================================
-CHEST (PA & LAT) Study Date of ___:
IMPRESSION: Blunting of the right costophrenic angle is
unchanged and may
reflect a small pleural effusion. Otherwise, no acute
cardiopulmonary process.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
===============================================
___ y/o female with PMHx significant for CKD, DM, HTN who
presents with several weeks of dyspnea and right lower back
pain, with acute worsening in her dyspnea over the last several
days.
ACTIVE ISSUES:
===============================================
# Back pain: Patient presented with right lower back pain that
had been present for several weeks and began after a mechanical
fall. Pain was sharp, nonradiating, worse with movement
(especially walking). Prior to admission she had CT lumbar spine
significant for significant for dextroscoliosis with multilevel
spondylosis but no other acute pathology. She also had hip plain
films significant for demineralization, but no fracture. On exam
she had point tenderness at the right SI joint. She was seen by
___ who agreed with SI pathology. She was started on 1000mg q8hr
standing Tylenol, as well as 400mg q8hr standing ibuprofen (for
a 10 day course). She was discharged with home ___ services and
an appointment to be seen in the Pain Management Clinic.
# Dyspnea: Patient also endorsed dyspnea with exertion and cold
air, though it was unclear if this was really any worse than her
baseline. She is followed as an outpatient by Pulmonology, who
feel her dyspnea is due to adult-onset asthma and her
significant kyphoscoliosis. Upon admission she had a negative
d-dimer (ruling out PE), her BNP was slightly elevated at 823,
however she displayed no physical exam findings of heart failure
or volume overload. CXR was significant only for trace right
pleural effusion. She was placed on her home asthma medications.
During hospitalization she saturated 97-98% on room air at rest;
she saturated 93-95% on room air with ambulation.
# Urinary tract infection: In the ED, urinalysis showed few
bacteria and WBCs on urinalysis; culture grew mixed flora
consistent with contamination. She had been afebrile, with no
leukocytosis. She is incontinent of urine at baseline, but had
no other urinary symptoms. She did receive 400mg IV cipro in the
ED, however her ABx were discontinued on the floor as it was
felt she did not have a UTI.
# DM: her most recent last HbA1c 7.1% (___). Her home
metformin (875mg BID) was hled while she was hospitalized and
she was placed on HISS.
# HTN: she was continued on her home carvedilol (12.5mg BID).
However, during her hospitalization her SBPs were 160-170, thus
she was discharged on 25mg BID.
# Breast cancer: Carcinoma of the right breast ___, s/p
right partial mastectomy on ___. Carcinoma of the left
breast ___, s/p left total mastectomy ___ with radiation and
chemo. While hospitalized she was continued on tamoxifen 20mg
daily.
# Depression: She was continued on home escitalopram 10mg daily.
# Overactive bladder: Her home home Enablex ___ daily was not
given while hospitalized as this was not on formualary.
TRANSITIONAL ISSUES:
===============================================
# Hypertension: She was hypertensive to the 150s-170s
consistently in the hospital. She was recently decreased from
25mg to 12.5 mg of carvediol and so she was increased back to
25mg. She should have her blood pressure checked in the
outpatient setting.
# Back Pain: Felt to be MSK, likely SI joint pathology. Seen by
___ who recommended home ___. Started on NSAID and scheduled for
pain clinic follow-up.
#Dyspnea: Ruled out for PE. Continued on her home medications.
Sats in the mid to high 90%s on ambulation without signs of DOE.
Felt to be stable with outpatient pulmonary follow-up in about 1
month.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. darifenacin 15 mg oral daily
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6hrs shortness of breath
3. Alendronate Sodium 70 mg PO QSAT
4. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
5. Carvedilol 12.5 mg PO BID
6. Escitalopram Oxalate 10 mg PO DAILY
7. MetFORMIN (Glucophage) 850 mg PO BID
8. Montelukast Sodium 10 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Pravastatin 10 mg PO DAILY
11. Tamoxifen Citrate 20 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Torsemide 5 mg PO DAILY
14. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
15. ZyrTEC (cetirizine) 10 mg oral daily
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
2. darifenacin 15 mg oral daily
3. Escitalopram Oxalate 10 mg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Pravastatin 10 mg PO DAILY
8. Tamoxifen Citrate 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Torsemide 5 mg PO DAILY
11. Acetaminophen 1000 mg PO Q8H
12. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
13. Alendronate Sodium 70 mg PO QSAT
14. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
15. MetFORMIN (Glucophage) 850 mg PO BID
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6hrs shortness of breath
17. ZyrTEC (cetirizine) 10 mg oral daily
18. Ibuprofen 400 mg PO Q8H Duration: 10 Days
RX *ibuprofen 400 mg 1 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
19. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Please take only for severe breakthough pain. ___ cause
confusion.
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Every ___
hours Disp #*10 Tablet Refills:*0
20. Lidocaine 5% Patch 1 PTCH TD QAM
12 hours on and 12 hours off.
RX *lidocaine 5 % (700 mg/patch) 1 Patch, 12 hours on and 12
hours off Daily Disp #*15 Transdermal Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Back Pain, possible Sacroiliac pathology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with back pain and concern for your
breathing. You were worked up for a cause you and you were felt
to have pain in your sacroiliac (SI) joint. You were seen by the
physical therapists in the hospital who agreed that the pain was
likely coming from there. They felt that you should continue
with home physical therapy. We also feel that she will do well
with an anti-inflammatory medication, ibuprofen, which should
help with the pain. We are also setting you up with an
appointment for the pain clinic as well to see if it would be
beneficial for an injection if you do not continue to improve.
Your breathing was also evaluated and you had a number of tests
to rule out several causes. Your oxygenation level was stable
when you walked and you did quite well. This may be a component
of deconditioning associated with this and should improve as you
are more active.
You were given several medications for your pain and you should
take them as directed. Please keep the appointments below.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10597762-DS-29 | 10,597,762 | 23,838,403 | DS | 29 | 2144-12-05 00:00:00 | 2144-12-05 13:39:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Morphine / Femara / Amoxicillin
Attending: ___.
Chief Complaint:
dyspnea, s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of HTN, DM, breast cancer,,CKD stage III, asthma and
significant kyphoscoliosis (followed by ___ Dr. ___ who
originally presented with rib fractures s/p fall and now being
transferred from ACS to medicine due to hypoxemia in the setting
of acute ___ and ___ right rib fractures.
On ___, she was at the movie theater, and when getting up from
a very low seat she lost her balance and fell backward onto the
arm rest. She had no associated lightheadedness, chest pain,
dizziness, or LOC with this episode. No head strike. She
initially presented to an OSH ED, where she was discharged home.
She was unable to tolerate the pain and became progressively
dyspneic at home, so she presented to ___ yesterday at the
urging of her PCP. Here, she was admitted to the ___ service
with aggressive pulmonary toilet. Her O2 saturation has
improved, and she is now at mid-90s on room air. CT chest
showed known rib fractures, mildly displaced, as well as a small
hemorrhagic effusion and small apical PNX. Repeat CXR today
demonstrated low lung volumes with persistence of the
pneumothorax. There appears to be worsening of the effusion on
the right side (she does have a chronic right sided pleural
effusion) as well as some associated atelectasis vs
consolidation. She denies productive cough or fevers. Her
torsemide has been held and she was given ~1L of IVF on
admission.
Currently, she denies any dyspnea, breathing comfortably on room
air, sitting up in the chair. She states that she does feel
tired and sleepy and finds it hard to stay awake. She is not
sure if this is a result of the pain medication. She continues
to have ___ right rib pain and pain with inspiration. This is
better than yesterday, when she had ___ rib pain. Denies
N/V/abdominal pain, diarrhea, dysuria, chest pain, cough, URI
symptoms. Prior to her rib fractures she states that she does
tend to be dyspneic with exertion but that her dyspnea became
notably worse after her fall.
Past Medical History:
CHRONIC KIDNEY DISEASE STAGE III
ADRENAL ADENOMA
ALLERGIC RHINITIS
ANEMIA
ASTHMA
B12 DEFICIENCY ANEMIA
BACK PAIN
BREAST CANCER
CYST/PSEUDOCYST, PANCREAS
DIABETES MELLITUS
HEARING LOSS
HYPONATREMIA
INTERNAL KNEE DERANGEMENT
BOWEL ADHESIONS
OSTEOARTHRITIS
OSTEOPENIA
SARCOMA
SCOLIOSIS
SMALL BOWEL OBSTRUCTION
SUPRAVENTRICULAR TACHYCARDIA
URINARY INCONTINENCE
PSHx:
Appendectomy
Cholecystectomy
Hysterectomy
Multiple abdominal surgeries for SBOs
Social History:
___
Family History:
- Two sisters died of breast cancer.
- Mother had stroke in her ___
- Father had DM, multiple MIs
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7/98.4 111/54 71 18 99% 2L -> 94% on RA during my
exam
General: Alert, oriented, no acute distress, did seem sleepy but
easily arousable
HEENT: Pupils equal/round, EOMI, Sclera anicteric, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: No accessory muscle use, Very kyphotic. Decreased breath
sounds and crackles right base. Apices clear. No
wheezes/rhonchi.
Back: Has lidocaine patch over right upper back. Tender to
palpation at location of rib fractures. No crepitus.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Left shoulder: Chronically unable to abduct without help
Neuro: Alert, oriented, no facial asymmetry, Moving all
extremities well.
DISCHARGE PHYSICAL EXAM:
Vitals: 99.3/99.3 SBP 120s-150s, this AM 160/83, 77 18 96% RA
24h: 920 in / ___ out, BMx1
General: Alert, oriented, no acute distress, sitting up and
eating breakfast
HEENT: Pupils equal/round, EOMI, Sclera anicteric, MMM,
oropharynx clear
Neck: Supple, JVP not elevated
Lungs: No accessory muscle use, Very kyphotic. Decreased breath
sounds and crackles right base. Apices clear. No
wheezes/rhonchi.
Back: Tender to palpation at location of rib fractures. No
crepitus.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented, no facial asymmetry, Moving all
extremities well.
Pertinent Results:
ADMISSION LABS:
___ 02:00PM BLOOD WBC-7.6 RBC-3.41* Hgb-10.3* Hct-33.0*
MCV-97 MCH-30.3 MCHC-31.3 RDW-14.1 Plt ___
___ 02:00PM BLOOD Neuts-70.3* ___ Monos-7.2 Eos-1.6
Baso-0.5
___ 02:00PM BLOOD ___ PTT-27.4 ___
___ 02:00PM BLOOD Glucose-150* UreaN-29* Creat-1.3* Na-132*
K-6.1* Cl-98 HCO3-25 AnGap-15
___ 05:15AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.3* Hct-30.2*
MCV-97 MCH-29.7 MCHC-30.7* RDW-14.3 Plt ___
___ 05:40AM BLOOD Glucose-136* UreaN-23* Creat-1.2* Na-138
K-5.0 Cl-100 HCO3-31 AnGap-12
___ 05:40AM BLOOD Phos-2.7 Mg-2.0
MICRO:
___ URINE CULTURE-negative, grew mixed flora c/w skin
contamination, not speciated
IMAGING/STUDIES:
***** ___ EKG ****
Sinus rhythm. Prominent precordial QRS voltage suggestive of
left ventricular hypertrophy. No major change from previous
tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 162 92 448/462 72 56 78
***** ___ CT CHEST, ABDOMEN, PELVIS w/o contrast****
FINDINGS:
CT CHEST: There is no axillary, hilar or mediastinal
lymphadenopathy.
Extensive coronary calcifications are seen. The pericardium is
intact without
evidence of a pericardial effusion. The intrathoracic aorta is
tortuous due
to significant scoliosis; however, no aneurysmal dilatation is
identified.
The main pulmonary artery is normal in size and configuration.
The airways are patent. There is a small right hemorrhagic
pleural effusion
as well as a small anterior right pneumothorax. 4 mm
ground-glass nodule is
seen in the right middle lobe, series 2, image 28. The left
lung overall
appears to be clear. There may be a small 4 mm lung nodule at
the left lung
base, series 2, image 28.
CT ABDOMEN: Liver is unremarkable. The patient is status post
cholecystectomy. No focal hepatic lesions concerning for
malignancy are
identified. Spleen is normal. There appears to be a rounded
soft tissue
focus at the pancreatic tail as well as additional hypodensities
in the
pancreatic head and uncinate process. There is no evidence of
pancreatic duct
dilatation. There is a large left adrenal nodule measuring
approximately 2.3
cm x 2.2 cm, series 2, image 14. Additional hypodensities
within the kidneys
bilaterally are too small to characterize by CT.
The stomach, duodenum and small bowel are normal without
evidence of wall
thickening or obstruction. There is no retroperitoneal or
mesenteric
lymphadenopathy.
CT PELVIS: Urinary bladder is unremarkable. There is no pelvic
free fluid.
No pelvic wall or inguinal lymphadenopathy is identified.
OSSEOUS STRUCTURES: Patient is status post left-sided hip
replacement. Acute
rib fractures are seen involving the ninth and tenth right
posterior ribs
which are minimally displaced. Old left-sided rib fractures are
seen. No
definite lytic or sclerotic lesions concerning for malignancy
are identified.
There is severe scoliosis at the mid thoracic spine.
IMPRESSION:
1. Acute right ninth and tenth minimally displaced rib
fractures. There is a small right-sided hemorrhagic effusion as
well as small anterior right pneumothorax.
2. Soft tissue densities along the pancreatic head, uncinate
and tail is
incompletely evaluated by this exam. Although these may be
representative of IPMNs, an MRI is recommended for further
evaluation.
3. Large left adrenal nodule measures up to 2.3 cm, which can
be further
evaluated by MRI.
4. Unchanged bilateral pulmonary nodules.
***** ___ CXR ****
PORTABLE CHEST
Compared to previous radiograph of ___ and CT torso of
___.
FINDINGS: Lung volumes are low, accentuating the cardiac
silhouette and
bronchovascular structures. Moderate right pleural effusion has
increased in
size and is accompanied by adjacent atelectasis or consolidation
in the right
lung base. Known right rib fractures are more fully
characterized on recent
CT ___. Tiny right apical pneumothorax is present,
and is
probably unchanged since the recent CT.
***** ___ LEFT SHOULDER XRAY ****
THREE VIEWS OF THE LEFT SHOULDER: Demonstrate no evidence of
acute fracture
or dislocation. There are severe degenerative changes of the
glenohumeral and
acromioclavicular joint, with joint space narrowing, subchondral
sclerosis and
subchondral cyst formation. These findings have progressed
since ___.
There is soft tissue ossification adjacent to the proximal
diaphysis of the
left humerus, which has increased in degree since ___ exam and
may represent
myositis ossificans. Multiple surgical clips project over the
proximal
humerus. The humeral head is high riding, suggestive of rotator
cuff injury.
Partially visualized right lung demonstrates no pneumothorax.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Severe osteoarthritis of the glenohumeral and
acromioclavicular joints,
progressed since ___ exam.
3. High-riding left humeral head, suggestive of underlying
rotator cuff
injury.
The study and the report were reviewed by the staff radiologist.
***** ___ CXR PA and LAT ****
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old woman with right pleural effusion
(hemorrhagic per
CT) and right sided rib fractures presented with dyspnea. Please
evaluate for
change in size of effusion. // Evaluate for progression of
right pleural
effusion
COMPARISON: Chest radiographs ___ through ___
IMPRESSION:
Previous asymmetric pulmonary edema has cleared although
pulmonary vascular
engorgement and moderate cardiomegaly persist. There is probably
a substantial
hiatus hernia, projecting to the left of the midline just above
left
hemidiaphragm. . Small right pleural effusion is the residual.
Right basal
consolidation could be either atelectasis hila or concurrent
pneumonia.
Followup advised.
Brief Hospital Course:
Ms. ___ is an ___ year-old woman with hypertension, diabetes
mellitus type II, breast cancer, CKD stage III, asthma and
significant kyphoscoliosis who originally presented with rib
fractures s/p fall and was then transferred from ACS to medicine
due to hypoxemia in the setting of acute ___ and ___ right rib
fractures. Her respiratory status improved, as detailed below,
and she was discharged to rehab after evaluation by Physical
Therapy.
# HYPOXEMIA, DYSPNEA: The patient's dyspnea and hypoxemia (desat
to ___ on room air with ambulation) was likely secondary to pain
on inspiration due to rib fractures, in the setting of low lung
volumes and significant scoliosis. There may also be a small
contribution from enlarging right sided effusion, which looked
hemorrhagic on CT and may be secondary to trauma and rib
fractures. She was treated with incentive spirometry, pain
control with acetaminophen and oxycodone, and continued on home
inhalers. On repeat chest xrays, her right-sided effusion
appeared to improve. Her respiratory status improved and she had
O2 sat of mid-90s on room air. Her small right apical
pneumothorax did not progress on repeat chest xrays.
Additionally, her hct remained stable around 30, so there was no
concern for extension of her small possibly hemorrhagic right
pleural effusion. We discussed her case with Dr. ___
patient's outpatient pulmonologist, who will continue to follow
up with the patient after discharge.
# s/p FALL: Clinical history is most suggestive of mechanical
fall. UA showed pyuria suggesting possible contribution of a
UTI. She was empirically started on IV ceftriaxone on ___ and
narrowed to cefpodoxime 200mg Q12H on discharge. Last dose
should be on ___ for a 3 day course. Urine culture grew mixed
flora that was not speciated. She was seen by physical therapy,
who suggested discharge to rehab. She was placed on Fall
Precautions while in the hospital.
# LEFT SHOULDER PAIN: On presentation, the patient had
complained about left shoulder pain. Xray of the left shoulder
showed no acute fracture and possible rotator cuff injury. The
patient states that she has baseline trouble abducting her left
shoulder, and this has not changed since her fall; therefore,
rotator cuff injury most likely chronic. This issue should be
followed up by the patient's PCP as an outpatient.
CHRONIC ISSUES:
-----------------
# Diabetes mellitus: While inpatient, home metformin was held
and the patient was continued on home Januvia and insulin
sliding scale.
# HTN: Currently not hypertensive. She was continued on home
carvedilol and torsemide.
# Breast cancer: Carcinoma of the right breast ___, s/p
right partial mastectomy on ___. Carcinoma of the left
breast ___, s/p left total mastectomy ___ with radiation and
chemo. Continued on home tamoxifen 20mg daily.
# Depression: Continued home escitalopram 10mg daily.
# Overactive bladder: Continued home Enablex ___ daily and
tamsolusin.
TRANSITIONAL ISSUES
# Dyspnea, rib fractures: The patient had stable respiratory
status on discharge and pain was well-controlled. She should
continue to follow up with her pulmonologist Dr. ___ as
scheduled in 2 months.
# s/p fall: The patient is being discharged to rehab.
# Left rotator cuff injury, likely chronic: This can be further
evaluated as an outpatient with her PCP ___.
# Incidental pancreatic head lesion and adrenal mass: The
patient is noted to have known pancreatic mass and adrenal mass
on her past medical history. This incidental finding on CT
abdomen/pelvis was conveyed to the patient's PCP. The patient
and her PCP and decide as an outpatient what further follow up
is clinically indicated. If indicated, radiology has suggested
that MRI would be a good modality for further characterizing
these lesions.
# Possible UTI: Antibiotic course: cefpodoxime PO 500mg Q12H
through ___ for a total 3 day course
# Hypertension: The patient had mostly well-controlled SBPs but
had an SBP of 160s on discharge. Her outpatient records show SBP
120s-200s. She was asymptomatic so no changes were made to her
antihypertensives. This should be followed up as an outpatient.
# CODE: DNR/DNI
# CONTACT:
___ (daughter, ___) - ___ (cell)
___ (daughter, lives with patient) - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 10 mg PO DAILY
2. MetFORMIN (Glucophage) 850 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Pravastatin 10 mg PO DAILY
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheeze
6. Montelukast 10 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
8. Torsemide 5 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH QPM
11. Tamoxifen Citrate 20 mg PO QAM
12. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral TID
13. Carvedilol 25 mg PO BID
14. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg oral daily
15. Clarinex (desloratadine) 5 mg oral QAM
16. Enablex (darifenacin) 15 mg oral QPM
17. Alendronate Sodium 70 mg PO DAILY
18. Januvia (sitaGLIPtin) 50 mg oral QAM
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheeze
3. Carvedilol 25 mg PO BID
4. Clarinex (desloratadine) 5 mg oral QAM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Enablex (darifenacin) 15 mg oral QPM
7. Escitalopram Oxalate 10 mg PO DAILY
8. Januvia (sitaGLIPtin) 50 mg oral QAM
9. Montelukast 10 mg PO QPM
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 10 mg PO DAILY
12. Tamoxifen Citrate 20 mg PO QAM
13. Tiotropium Bromide 1 CAP IH DAILY
14. Torsemide 5 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Hold for sedation or respiratory rate < 12 per minute.
RX *oxycodone 5 mg half to 1 tablet(s) by mouth Up to every 4
hours Disp #*14 Tablet Refills:*0
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO HS
20. Simethicone 40-80 mg PO QID:PRN bloating, stomach upset
21. Alendronate Sodium 70 mg PO DAILY
22. Caltrate 600+D Plus Minerals (Ca-D3-mag
___ 600
mg-400 unit tablet oral BID
23. Centrum Silver
(
m
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l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg oral daily
24. MetFORMIN (Glucophage) 850 mg PO BID
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS IH BID
26. Cefpodoxime Proxetil 200 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Right ___ and 10th rib fractures
- Dyspnea secondary to splinting
- Right pleural effusion
- Small right apical pneumothorax
- s/p fall
SECONDARY DIAGNOSES:
- Kyphoscoliosis
- Reactive airways
- Left rotator cuff injury, likely chronic
- Incidental pancreatic head lesion on CT
- Incidental left adrenal mass on CT
- Pyuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you fell on broke some
ribs on the right side. This caused difficulty breathing. At
first, you required oxygen. We think this is from pain, lack of
deep breaths, and from some fluid in the right lung. Over your
hospital stay, your breathing improved and you no longer
required oxygen. Your pain was better controlled and the fluid
on the right side of your lung also looked improved on chest
xray. You are being discharged to rehab so that you can get
stronger and they can help prevent falls in the future.
The imaging studies during this hospitalization showed that you
also may have an old rotator cuff injury in your left shoulder.
This does not require any immediate intervention. However, you
should follow up with your PCP ___ this issue.
Imaging also showed that you have a mass inside your pancreas
and inside your left adrenal gland. We are not sure about the
significance of these findings, since according to your medical
record, these have been noted before. Please discuss these
findings with your PCP ___ whether or not you need
further imaging.
It was a pleasure to take care of you during this
hospitalization. We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10597796-DS-13 | 10,597,796 | 22,336,135 | DS | 13 | 2156-01-23 00:00:00 | 2156-01-27 11:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Appendectomy
History of Present Illness:
Mrs. ___ is a ___ G2P1 with history of c-section delivery
and current pregnancy at 16 weeks presenting from ___ with
RLQ pain. Pt reports being awoken from sleep with acute onset
RLQ
pain which was initially throughout her abdomen and subsequently
localized to the RLQ. She reports some nausea and denies
appetite. She had a regular BM this AM, and denies vomiting. She
presented to ___ this AM where labs were notable
for WBC 11.1, H/H 12.5/35.9, UA with trace blood, normal LFTs,
lipase 121, normal BMP. US abdomen demonstrated no evidence of
cholecystitis, however the appendix was unable to be identified.
She received tylenol, morphine, zofran and 2L NS. Pt was then
transferred to ___, where she gets her obstetric care, and an
MRI performed.
Pt reports fevers & chills last ___ and ___ and soft tan
stools ___ & ___. Anorexia during this time. Pt then
felt well ___ & ___. Then awoke, as above, today
(___)
w abdominal pain and return of nausea and anorexia.
Past Medical History:
none
Social History:
___
Family History:
Skin cancer, atypical moles
Physical Exam:
T 98.2 P 88 BP 124/74 RR 18 Sat 98% RA
GEN: NAD, Comfortable
CV: RRR
PULM: CTAB
ABD: Pregant, soft, mildly painful to palp, no rebound or
guarding
EX: No edema
Pertinent Results:
___ 05:00PM BLOOD WBC-12.4* RBC-4.11* Hgb-12.4 Hct-35.9*
MCV-87 MCH-30.2 MCHC-34.6 RDW-13.6 Plt ___
Abdomen MRI ___. Findings consistent with acute uncomplicated appendicitis.
2. Mild pregnancy-related right-sided hydronephrosis.
Pathology
Acute appendicitis and periappendicitis.
Brief Hospital Course:
Ms. ___ was admitted to the ACS service for appendectomy. She
tolerated the procedure well and was moved to the floor after an
uneventful PACU course. Fetal heart monitoring was performed
intra-op and post-op. Her diet was advanced as tolerated and
pain was controlled with PO regimen under the guidence of the
OB/Gyn service. She was uncomfortable for much of her post
operative course due to not wanting to take any medications in
fear of affecting the fetus. We contacted her OB who provided
reassurance. She remained afebrile and hemodynamically intact
during her hospitalization. She was OOB and ambulating without
assist. She tolerated regular diet well and was discharged in
good condition with plan to have close follow up with her OB and
our clinic.
Medications on Admission:
prenatal vitamins
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Do not take more than 3,000mg in a single day. Wean as tolerated
RX *acetaminophen 325 mg ___ tablet(s) by mouth Every ___ hours
Disp #*40 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Wean as tolerated, do not drive while taking
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Every ___
hours Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID Constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
a day Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10597796-DS-14 | 10,597,796 | 27,445,095 | DS | 14 | 2156-02-02 00:00:00 | 2156-02-03 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ woman now 17 weeks pregnant who
underwent laparoscopic appendectomy ___ for acute
appendicitis. Her initial postoperative course was uncomplicated
and she was discharged home the day after surgery. However,
approximately 4 days postop, she developed sharp, excruciating
RLQ abdominal pain that came in waves. The pain has been
associated with small volume diarrhea. She says she has had
nothing but loose stools since her operation. She went to a
hospital in ___ near where she lives. An ultrasound
was done, she was diagnosed with constipation, admitted for a
day
and treated with a bowel regimen and ultimately discharged home.
However, within 1 hr of returning home, she redeveloped crampy
RLQ pain, for which she tried milk of mag and enemas. The pain
became unbearable to the point where she was screaming and
writhing in her bed. She thus returned to the ___ ED
where
she required 2mg IV dilaudid in order to get relief. She
underwent MRI which ultimately revealed a RLQ phlegmon/abscess
(~2.0-2.5cm) near her cecum. She was thus started on zosyn and
transferred to ___ for further management.
Past Medical History:
none
Social History:
___
Family History:
Skin cancer, atypical moles
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 99.8 HR: 103 BP: 99/60 O(2)Sat: 100
Constitutional: Comfortable
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, gravid with clean incision site
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 04:30AM BLOOD WBC-5.8 RBC-3.15* Hgb-9.4* Hct-27.1*
MCV-86 MCH-29.7 MCHC-34.5 RDW-13.8 Plt ___
___ 04:30AM BLOOD WBC-7.6 RBC-3.14* Hgb-9.5* Hct-27.1*
MCV-86 MCH-30.1 MCHC-34.9 RDW-13.5 Plt ___
___ 01:11PM BLOOD WBC-8.7 RBC-3.25* Hgb-9.7* Hct-27.8*
MCV-86 MCH-29.8 MCHC-34.8 RDW-14.0 Plt ___
___ 01:11PM BLOOD Neuts-83.4* Lymphs-11.2* Monos-4.6
Eos-0.5 Baso-0.3
___ 04:30AM BLOOD Plt ___
___ 04:30AM BLOOD ___
___ 04:30AM BLOOD Glucose-115* UreaN-5* Creat-0.3* Na-132*
K-3.4 Cl-101 HCO3-25 AnGap-9
___ 04:30AM BLOOD Glucose-111* UreaN-5* Creat-0.4 Na-130*
K-3.2* Cl-99 HCO3-24 AnGap-10
___ 04:30AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.7
___ 01:33PM BLOOD Lactate-0.7
___: MRI:
Findings consistent with acute uncomplicated appendicitis.
Mild pregnancy-related right-sided hydronephrosis.
___: MRI abdomen:
Right lower quadrant intraperitoneal hematoma, without evidence
of an abscess.
Small amount of loculated ascites along the right side of the
uterus.
Brief Hospital Course:
___ at 17 weeks pregnant tranferred from OSH with RLQ pain
concerning for phlegmon after appy on ___. MRI was repeated and
showed ascites with phlegmon, no drainable collection. Patient
was initially on zosyn and transitioned to ceftriaxone/flagyl.
Patient's pain improved but had constipation, which was
aggressively treated. She was transitioned to augmentin at
discharge to complet 5 days of antibiotics total and will follow
up in clinic as scheduled.
Medications on Admission:
prenatal vitamins
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*5 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Phlegmon
Asymptomatic Bacteriuria of pregnancy
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 right lower quadrant
abdominal pain. You underwent an MRI and you were reported to
have a hematoma/collection of fluid related to your prior
surgery. No additonal imaging or surgical intervention was
indicated. You were started on a bowel regimen to help decrease
the bloating which you were experiencing as well as pain
medication. Your abdominal pain has decreased in severity and
your vital signs have been stable.
You are being discharged on medications to treat the pain.
These medications will make you drowsy and impair your ability
to drive a motor vehicle or operate machinery safely. You MUST
refrain from such activities while taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
10597987-DS-5 | 10,597,987 | 27,989,159 | DS | 5 | 2123-09-29 00:00:00 | 2123-09-29 19:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ year old woman with no known medical history
who
presents with 2 falls this afternoon and found at OSH to have a
small intraparenchymal hemmorhage. According to the patient's
sister, she was witnessed by neighbors to fall in her backyard.
EMS was called but patient refused to go to hospital. The
neighbors then called the sister, who subsequently went to the
patient's house, where the patient fell again, no headstrke or
LOC. She was subsequently taken to the ___ ED. There,
records state that the patient was combative, received 1 mg of
ativan. CT of the head called a 3x6mm IPH in the right parietal
lobe, and she was subsequently transferred here for further
management.
Initial VS in the ED: 98.0 70 150/76 18 100% RA. Labs in the ED
notable for a WBC 15, trop .04, AP 182. ECG showed TWI in
anterolateral leads with no prior for comparison. Repeat CT head
showed "A punctate hyperdensity in the parenchyma of the left
cerebellar lobe could represent a small hemorrhagic focus."
Neuro was consulted, recommended admission to medicine. CT C
spine negative. CXR, U/A largely unremarkable. VS prior to
transfer: 62 114/65 17 97% RA.
On the floor, patient cooperative, comfortable. Per the
patient's sister, she does not go to see a doctor. She has been
in a steady decline over the past year and she is concerned that
she can no longer live on her own.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
None- pt does not see doctors
Social History:
___
Family History:
2 brothers with "memory problems" and maybe Alzheimers. No other
FH of cognitive disorders.
Physical Exam:
Admission exam:
GENERAL - elderly female, disheveled appearance
HEENT - MMM, OP clear, right pupil 3 mm, reactiv, left fixed at
4 mm, nonreactive, EOM intact, no visual field deficits
NECK - supple, no thyromegaly, no JVD
LUNGS - CTAB, no wheezes or rhonchi
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Neuro: Alert, not oriented to place, thinks it is ___, no
asterixis, uncooperative for CN, strength, and sensory exam
Discharge exam: same as above except:
GENERAL: NAD
Neuro: Alert, oriented only to person, no other focal neuro
deficits
Pertinent Results:
___ 11:20PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:20PM WBC-15.0* RBC-4.46 HGB-12.6 HCT-38.0 MCV-85
MCH-28.2 MCHC-33.1 RDW-13.4
___ 11:20PM NEUTS-94.7* LYMPHS-3.2* MONOS-1.7* EOS-0.1
BASOS-0.2
___ 11:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:10AM WBC-11.0 RBC-3.79* HGB-10.6* HCT-32.5* MCV-86
MCH-27.9 MCHC-32.5 RDW-13.3
Chest Xray ___
IMPRESSION: Findings compatible with mild interstitial edema
and pulmonary vascular congestion in the setting of
cardiomegaly.
CT Head with contrast ___
IMPRESSION:
1. A punctate hyperdensity in the parenchyma of the left
cerebellar lobe could represent a small hemorrhagic focus but
would be consistent with a cavernoma given intermediate density.
Further assessment with MR is recommended if feasible.
2. Small hyperdensity in the right corona radiata without
surrounding edema may represent a granuloma or calcified vessel.
3. Chronic changes as described above.
CT C-spine without contrast
IMPRESSION: No evidence of fracture or malalignment. Moderate
degenerative changes as described above.
CT Head without contrast ___
IMPRESSION:
No evidence of acute hemorrhage or significant change since the
previous
study. The previously described subtle hyperdensity in the left
cerebellum is unchanged and not likely to be due to hemorrhage.
Calcific density in the right coronal radiata lagain seen. No
new hemorrhage mass effect or hydrocephalus.
Brief Hospital Course:
___ year old female with no known past medical history
transferred from OSH after several witnessed falls and CT with
concern for small right parietal lobe IPH at OSH, found to have
possible small left cerebellar lobe IPH on admission at ___.
ACTIVE ISSUES:
#Falls/ Possible Intraparenchymal hemorrhage:
Pt was witnessed to have multiple witnessed mechanical falls
prior to admission. Head CT on ___ showed a hyperdensity in
the left cerebellar lobe
that could represent a small hemorrhagic focus but would be
consistent with a
cavernoma given intermediate density; a small hyperdensity in
the right corona radiata without surrounding edema that may
represent a granuloma or calcified vessel; and chronic changes.
Neurology was consulted and recommended CT or MRI when tolerated
by the patient. Neurology consult advised that mental status
changes were not consistent with possible IPH seen on CT. CT
head without contrast on ___ showed stable hyperdensity in
the left cerebellum that was not likely to be hemorrhage and may
be due to congenital vascular abnormality. Otherwise, she had no
evidence of hemorrhage or focal neurologic abnormalities.
#Altered Mental Status
During her hospitalization, pt was oriented to self but not
place or time. She was unaware of the length of her stay, often
insisting that she had just arrived. Agitation on admission was
controlled with 5mg Zyprexa PO as needed and QHS. She was placed
on memantine for dementia, per psychiatry consult. Work up for
reversible causes of dementia yielded low vitamin B12 and normal
TSH, folate, neg RPR. She was supplemented with 2g Vitamin B12
PO QD because she declined IM. She had a dramatic improvement in
agitation with Zyprexa QHS, but did remain disoriented with poor
short term memory.
#Guardianship
Guardianship forms were completed with the help of social worker
Mr. ___. Her court date was ___pproved her
sister ___ as her guardian.
#Back Pain
Patient complained of back stiffness and pain, which improved
with scheduled tylenol and lidocaine patches.
INACTIVE ISSUES:
#Asymmetric pupils: Right pupil was 4mm and nonreactive and left
pupil was 2-3mm and reactive. This appears to be secondary to be
post-surgical.
TRANSITIONAL ISSUES:
- Cognitive Decline/ Dementia
- Back Pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H
2. Cyanocobalamin ___ mcg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Memantine 10 mg PO BID
5. OLANZapine 5 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dementia
Lumbago
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Dear Ms. ___,
You were hospitalized after you fell several times and you were
confused. A CT of your head at ___ was concerning
for a bleed in your brain, so they transferred you to ___.
Here, your head CT was concerning for a bleed in a different
location in your brain. We conducted a repeat head CT and this
showed both these locations to be stable, so we were no longer
concerned about a bleed in your brain.
When you first arrived, you were acutely confused and agitated,
consistent with delirium. You were given medication and over the
next few days, your agitation improved but you continued to be
confused. We also began a medication called memantine to help
with the confusion. This confusion is most likely due to
dementia that has been ongoing. You were not found to have a
reversible cause of dementia; although you did have low vitamin
B12, so you were given vitamin B12 supplementation.
Because your dementia impaired your ability to make decisions
and care for yourself, we underwent a process for your sister
___ to become your guardian.
Finally, you had back pain which we treated with tylenol and
lidocaine patches. These are good modalities to continue to
treat your back pain in the future.
Followup Instructions:
___
|
10598185-DS-28 | 10,598,185 | 26,059,416 | DS | 28 | 2192-10-16 00:00:00 | 2192-10-16 15:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bee Sting
Attending: ___
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ gentleman with a pmhx. significant for HCV
cirrhosis, active colorectal cancer (likely metastatic) treated
at ___ s/p diverting loop ileostomy, and HTN who is admitted
with abdominal pain and fever.
Patient was in his usual state of health until 2 days prior to
admission when he developed moderate abdominal discomfort and
low grade fevers. On day of admission, Mr. ___ noticed that
his urine was quite dark. He also felt feverish and checked his
temperature, which was 101.5. He therefore decided to come into
the ED for further evaluation.
In the ED, initial vitals were: 98.4 84 153/70 16 98. His labs
were significant for bili of 4.3 AST of 92 and ALT of 69. He
underwent a RUQ ultrasound and CT scan, both of which
preliminarily showed no obvious obstruction. Patient was given
cipro and flagyl. On admission, vitals were: 99.4 84 121/80 16
98%.
10 point ROS was otherwise negative
Past Medical History:
1. Hepatitis C genotype 1
2. Alcoholic cirrhosis with no grade 1 varices, on nadolol,
sober since ___.
3. Colorectal cancer treated by Dr. ___ subsequent
revisions by Dr. ___ in transplant surgery. Now with end
ostomyand mucous fistula.
4. Hypertension.
5. Mild aortic stenosis with an aortic valvular area of 1.8 cm
on ___ echo.
6. GERD.
7. Insomnia
8. Remote history of IV drug use.
9. History of SMV thrombosis.
Social History:
___
Family History:
No history of liver disease or malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.6, 114/62, 75, 20, 97% on RA
GENERAL: Chronically ill appearing, pale, no acute distress
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi, dullness
at basese bilaterally
CARDIAC: RRR, ___ systolic murmur
ABDOMEN: +BS, well-healed surgical scar, soft, non-tender,
non-distended, colostmy in place, bag with gas and stool
EXTREMITIES: No edema bilaterally
SKIN: Warm and dry
NEURO: Alert and oriented x3, left eye with ?slight ptosis
Discharge PE
?????????
Pertinent Results:
___ 03:10AM URINE HOURS-RANDOM
___ 03:10AM URINE GR HOLD-HOLD
___ 03:10AM URINE COLOR-ORANGE APPEAR-Clear SP ___
___ 03:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-8* PH-8.0
LEUK-NEG
___ 03:10AM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
___ 03:10AM URINE MUCOUS-RARE
___ 11:41PM LACTATE-2.1*
___ 11:25PM GLUCOSE-169* UREA N-19 CREAT-0.8 SODIUM-138
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 11:25PM estGFR-Using this
___ 11:25PM ALT(SGPT)-69* AST(SGOT)-92* LD(___)-129 ALK
PHOS-102 TOT BILI-4.3* DIR BILI-3.2* INDIR BIL-1.1
___ 11:25PM LIPASE-70*
___ 11:25PM ALBUMIN-4.2
___ 11:25PM WBC-3.7* RBC-3.78* HGB-13.5* HCT-40.5
MCV-107* MCH-35.8* MCHC-33.4 RDW-15.0
___ 11:25PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.6 EOS-0.5
BASOS-0
___ 11:25PM PLT COUNT-59*
___ 11:25PM ___ PTT-38.0* ___
RUQ ___: nondistended gallbaldder. known cholelithiasis.
mild GB wall thickening likely due to underlying chronic liver
disease. neg sonographic ___ sign. no evidence of acute
cholecystitis.
CT SCAN ___: rectal wall chickening/edema persists. adjacent
presecral soft tissue prominence/fluid slightly incrased since
prior (FGD avid on PET). no bowel obstruction. no abscess
formation. mild terminal ileum and cecal wall thickening more
conspicous since prior. no pericolic fat stranding. cirrhotic
liver. splenomegaly. portosystemic collaterals.
.
___ 1:10 pm IMMUNOLOGY
HCV VIRAL LOAD (Pending):
Brief Hospital Course:
This is a ___ gentleman with a history of HCV cirrhosis
and colorectal cancer who is admitted with abdominal pain, dark
urine and fever, found to have elevated t. bili and US with
cholelithasis
.
# hyperbilirubinemia
The patient presented with a symptoms complex of abdominal pain,
fevers and elevated t. bili that was suspious for a biliary
pathology. The patient got a RUQ US which did not show evidence
of acute cholecytitis but did show cholelithasis. The patient
was treated with cipro/flagyl empirically for biliary coverage.
The patients t. bili came down without intervention and ERCP and
MRCP were defered. The etiology of the patient pain and
elevated t. bili was likely due to a passed stone. Hepatology
and ERCP followed while in house.
.
# Severe Neutropenia
The patient has a history in the past of neutropenia. The
etiology of the patients neutropenia during this admission is
likely due to bone marrow suppression from prior XRT to the
abdomen and pelvis and superimposed viral infection, as well as
due to cirrhosis. The Hem/Onc service saw the patient in house
and reviewed his blood smear which showed toxic granulation c/w
infection. The patient was then given neupogen daily until his
ANC improved to >1000.
.
# FEVER:
Unclear etiology, though intially thougt to be due a GI
etiology. Cholangitis seemed less likely given improvement
without intervention other then abx. Stool cultures were sent
and negative for cdiff. Patient did not have any upper
respiratory symptosm consistent with influenza and got the
vaccine. Hepatology was consulted and felt as thought HCv
reactivation as a cause for fever was unlikely. HCV VL was
checked and was pending.
.
# Transtional Issues:
- Follow up with Oncology and Hepatology
- Follow up final stool studies
- CBC as outpatient (to be faxed to PCP and outpatient
oncologist)
- Follow up on HCV viral load
- Complete empiric cipro/flagyl total of 10 day course.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Gabapentin 1800 mg PO HS
3. Nadolol 20 mg PO DAILY
Please hold for SBP <100 or HR <55.
4. Omeprazole 20 mg PO DAILY
5. Quetiapine Fumarate 200 mg PO QHS
6. Spironolactone 50 mg PO DAILY
Please hold for SBP <100.
Discharge Medications:
1. Gabapentin 1800 mg PO HS
2. Nadolol 40 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
Please hold for SBP <100.
5. traZODONE 150 mg PO HS:PRN Insomnia
Please hold for oversedation or RR <12.
6. Quetiapine Fumarate 350 mg PO QHS
7. Ascorbic Acid ___ mg PO DAILY
8. EpiPen *NF* (EPINEPHrine) 0.3 units INJECTION PRN anaphylaxis
9. Finasteride 5 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
13. Outpatient Lab Work
CBC with differential.
Please fax to:
1) Attn: ___ Fax: ___
2) Attn: ___ Fax: ___
14. Zolpidem Tartrate 10 mg PO HS
RX *zolpidem 10 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
myelosupression due to viral infection
pancytopenia
hyperbilirubinemia
splenomegaly
chololithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were initially admitted to ___ for fevers, dark colored
urine and vague abdominal pain. You were found to have elevated
bilirubin and got an US of your gallbladder which showed
gallstones. You were treated conservatively and your t. bili
improved. You then devloped low blood counts. The
Hematology/Oncology team saw you in the hospital and advised
growth factors. You counts improved, but are not yet at your
baseline.
Please continue continue ciprofloxacin and flagyl for 5 more
days (the last day of antibiotics will be ___.
We checked HCV viral load which is pending.
You will need a blood count check ___ which will be faxed
to your PCP and oncologist to follow.
Followup Instructions:
___
|
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