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10598185-DS-30 | 10,598,185 | 26,947,434 | DS | 30 | 2193-06-07 00:00:00 | 2193-06-08 06:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bee Sting
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with ___ significant for metastatic rectosigmoid cancer
now s/p ostomy, chemotherapy, and radiation, HCV cirrhosis
complicated by hepatic encephalopathy and grade II esophageal
varices, and substance abuse who is here with throbbing
substernal chest pain. Patient reports pain started this morning
while sitting. He reports associated bilateral shoulder, neck,
and posterior head pain. Associated with belching. Pain was
___ but it is now only ___. Denies palpitations, SOB,
diaphoresis, light headedness, dizziness, abdominal pain, and
nausea/vomiting.
Notably, patient was recently admitted at ___ with fevers. He
was discharged 3 days ago on ciprofloxacin and Flagyl. Prior to
that he had been admitted at ___ for alcohol withdrawal. He
was monitored on CIWA scale while inpatient and discharged on
___. Patient has not had a drink since prior to last admission
at ___.
In the ED, initial vitals signs were 98.9, 74, 153/85, 16, 99%
RA. EKG was stable. Cardiac enzymes were sent and returned
negative. Labs were otherwise unremarkable. CXR and CT head were
unremarkable. CTA chest was negative for pulmonary embolism but
did show multiple pulmonary nodules consistent with metastases.
Patient was treated with Zofran and morphine with improvement in
symptoms.
Past Medical History:
- HCV genotype 1
- Alcoholic cirrhosis with grade II varices
- Metastatic rectosigmoid cancer
- Hypertension
- Mild aortic stenosis with valvular area 1.8 cm on ___ TTE
- GERD
- Insomnia
- Current alcohol abuse
- History of IV drug abuse
- History of SMV thrombosis
Social History:
___
Family History:
No history of liver disease or malignancy.
Physical Exam:
ADMISSION EXAM
Vitals: 98.9, 74, 153/85, 16, 99% RA
General: AAOx3, NAD, chronically ___ male
HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, positive bowel sounds, ___ colostomy
GU: No Foley
Ext: Warm, ___, no cyanosis, clubbing, edema
Neuro: CN ___ grossly intact, no asterixis
Skin: No concerning lesions
DISCHARGE EXAM
Vitals: 99.6, 59, 117/67, 18, 96% RA.
General: AAOx3, NAD, chronically ___ male
HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, positive bowel sounds, ___ colostomy
producing bilious fluid
GU: No Foley
Ext: Warm, ___, no cyanosis, clubbing, edema
Neuro: CN ___ grossly intact, no asterixis
Skin: No concerning lesions
Pertinent Results:
ADMISSION LABS
___ 12:25AM BLOOD ___
___ Plt ___
___ 12:25AM BLOOD ___
___
___ 02:38AM BLOOD ___ ___
___ 12:25AM BLOOD ___
___
___ 12:25AM BLOOD ___
___ 12:25AM BLOOD cTropnT-<0.01
___ 12:25AM BLOOD ___
___ 12:25AM BLOOD ___
___
___ 07:01AM URINE ___ Sp ___
___ 07:01AM URINE ___
___
DISCHARGE LABS
___ 06:00AM BLOOD ___
___ Plt ___
___ 06:00AM BLOOD ___
___
___ 06:00AM BLOOD ___
IMAGING
CT head (___): No acute intracranial process. Please note MRI
is more sensitive in the evaluation for intracranial metastatic
disease.
CTA chest (___): No pulmonary embolism or acute aortic
pathology. Numerous peripheral solid and cavitated pulmonary
nodules consistent with metastases are new or enlarged from
___. Prior imaging if available over the interval would
be helpful to determine the rate of progression. Cirrhosis with
splenomegaly and esophageal varices. Hazy ground glass changes
in the posterior segment of the right upper lobe could reflect
an inflammatory or infectious process.
___: No acute intrathoracic process.
Brief Hospital Course:
___ yo M with PMH significant for metastatic rectosigmoid cancer
now s/p ostomy, chemotherapy, and radiation, HCV cirrhosis
complicated by hepatic encephalopathy, grade II esophageal
varices, and substance abuse here with chest pain.
ACTIVE ISSUES
# Chest pain: Unclear etiology. Patient was ruled out for ACS
and PE in the ED but CTA chest was remarkable for multiple
pulmonary nodules that were suggestive of metastatic disease.
Given his widely metastatic rectosigmoid cancer, a malignant
etiology of pain was thought most likely. In the ED patient
received morphine with near resolution in chest pain. On the
floor patient was continued on his home narcotics regimen
including methadone 10 mg daily and oxycodone 75 mg daily PRN
left hip pain. He did not require further supplemental
narcotics. Consulted Palliative Care regarding pain control
regimen. They recommended against discharging patient with
prescriptions for narcotics. Patient was scheduled for
outpatient ___ with ___ Palliative Care. He was
instructed to bring his records from ___ to his appointment.
CHRONIC ISSUES
# HCV cirrhosis: Complicated by hepatic encephalopathy and grade
II esophageal varices. No ascites. MELD of 14. Childs class B.
Patient was continued on home rifaximin, nadolol, and
spironolactone.
# Rectosigmoid cancer: Metastatic. Patient expressed desire to
transfer his care from ___ to ___. For this reason Palliative
Care was consulted and patient was scheduled for outpatient
___ with them. As above, he was instructed to bring all of
his ___ records to his appointment.
# Chronic pain: Patient has a history of chronic abdominal pain.
Continued methadone given that it is for pain rather than for
narcotic addiction. Continued home gabapentin. Continued
oxycodone for left hip pain secondary to metastasis. Consulted
Palliative Care for pain control recs.
# Substance abuse: Patient recently admitted at ___ for detox.
During that admission he was monitored on CIWA scale and managed
with lorazepam. Patient has not had a drink since being
discharged on ___.
# Hypertension: Continued home nadolol and spironolactone.
# BPH: Stable. Continued home tamsulosin.
# Insomnia: Continued home Seroquel and Ambien as needed.
# GERD: Continued home omeprazole.
# Smoking: Currently smoking 2 PPD. Nicotine patch as needed.
TRANSITIONAL ISSUES
- ___ with PCP scheduled
- ___ with Palliative Care scheduled
- Patient to get ___ records
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO QAM
4. Gabapentin 600 mg PO QPM
5. Gabapentin 1200 mg PO HS
6. Methadone 10 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. Nadolol 40 mg PO QAM
9. Nadolol 40 mg PO QPM
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 75 mg PO DAILY:PRN hip pain
12. QUEtiapine Fumarate 350 mg PO QHS
13. Rifaximin 550 mg PO BID
14. Simethicone 120 mg PO DAILY
15. Spironolactone 50 mg PO DAILY
16. Tamsulosin 0.4 mg PO HS
17. Zolpidem Tartrate 10 mg PO HS insomnia
18. FoLIC Acid 1 mg PO DAILY
19. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 600 mg PO QAM
5. Gabapentin 600 mg PO QPM
6. Gabapentin 1200 mg PO HS
7. Methadone 10 mg PO QPM
8. Nadolol 40 mg PO QAM
9. Nadolol 40 mg PO QPM
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 75 mg PO DAILY:PRN hip pain
12. QUEtiapine Fumarate 350 mg PO QHS
13. Rifaximin 550 mg PO BID
14. Simethicone 120 mg PO DAILY
15. Spironolactone 50 mg PO DAILY
16. Tamsulosin 0.4 mg PO HS
17. Thiamine 100 mg PO DAILY
18. Zolpidem Tartrate 10 mg PO HS insomnia
19. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain likely due to metastatic cancer
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 while you were a patient at
___. You were admitted because
of chest pain. You were ruled out for heart and lung causes of
this. The pain is most likely due to your cancer.
Please take all of your medications as listed below. Please be
sure to keep all of your ___ appointments. Also, please
get your palliative care records from ___. The palliative care
physicians here will need them.
Followup Instructions:
___
|
10598267-DS-8 | 10,598,267 | 28,584,593 | DS | 8 | 2135-11-05 00:00:00 | 2135-11-08 00:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lactose
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
Mr. ___ is a ___ year old male with Hodgkin's lymphoma
(neck and groin) in remission s/p chemoradiation in 1980s
complicated by thyroid cancer s/p radioiodine in ___, chronic
pain ___ peripheral neuropathy and severe aortic stenosis (mean
of 26 mm Hg and sCHF (EF ___ in ___ who presented to his
PCP's office with worse than usual shortness of breath with
minimal exertion along with worse than usual productive cough
though no fever, chills, sick contacts, pleuritic chest pain,
nausea, vomiting, palpatations or syncope.
At PCP's office CXR and later CT scan showed new bilateral (R>L)
pleural effusion with hypoxia to 90% on room air and thus he was
transferred to ___ ED for further evaluation.
In the ED, 98.3 80 108/65 20 99%2L NC. Labs notable for normal
CBC and Chem7. ECG was normal. He was given vancomycin/levaquin
and transferred to medicine service for furhter evaluation.
On the floor, he does not report any other complaints.
Past Medical History:
Hodgkin's lymphoma in 1980s, in remission
Thyroid cancer
Asthma
Coronary artery disease s/p CABG
systolic congestive heart failure (EF ___
Moderate aortic stenosis
HTN
HLD
DM2
OA
Major depression
anemia
peripheral neuropathy
Left Lumbar Radiculopathy
Chronic pain on narcotics contract
Erectile dysfunction
lactose intolerance
h/o Subarachnoid hemorrhage following injury
h/o Colonic adenoma
BPH
Social History:
___
Family History:
No family history of CAD
Physical Exam:
Admission:
98.6 117/72 82 16 100%2LNC Wt: 76.5 kg
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP ~ 9 cm, no carotid bruits
LUNGS - Decrease breath sound at the bases (R > L) with crackles
right above it.
HEART - mid peaking crescendo decrescendo murmur best heart RUSB
with normal A2 and radiation to carotids.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Discharge:
VS: 98.4 110/69 84 20 99%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP ~ 9 cm, no carotid bruits
LUNGS - Decrease breath sound at the bases (R > L) with crackles
right above it.
HEART - mid peaking crescendo decrescendo murmur best heart RUSB
with normal A2 and radiation to carotids.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
Pertinent Results:
___ 08:00PM BLOOD WBC-11.8* RBC-4.02* Hgb-11.6* Hct-35.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-14.2 Plt ___
___ 06:01AM BLOOD WBC-9.0 RBC-3.86* Hgb-11.1* Hct-33.3*
MCV-86 MCH-28.8 MCHC-33.4 RDW-13.8 Plt ___
___ 08:00PM BLOOD Neuts-68.4 ___ Monos-6.7 Eos-6.1*
Baso-0.8
___ 06:01AM BLOOD Neuts-67 Bands-0 ___ Monos-7 Eos-4
Baso-0 ___ Myelos-0
___ 08:00PM BLOOD Glucose-82 UreaN-18 Creat-1.2 Na-142
K-5.2* Cl-102 HCO3-22 AnGap-23*
___ 06:01AM BLOOD Glucose-106* UreaN-20 Creat-1.0 Na-138
K-3.6 Cl-100 HCO3-29 AnGap-13
___ 08:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-6057*
___ 07:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:10AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
___ 06:01AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3
Pleural Fluid
___ 12:42PM PLEURAL WBC-24* RBC-469* Polys-21* Lymphs-65*
Monos-0 Eos-1* Meso-1* Macro-12*
___ 12:42PM PLEURAL TotProt-1.4 Glucose-105 LD(LDH)-48
Albumin-1.0 Cholest-13 Triglyc-6
___ 03:04PM OTHER BODY FLUID Misc-BNP=4473 P
___ 12:42 pm 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.
___ 8:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:13 pm BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___
Pathology Examination
Name ___ Age ___ # ___ MRN#
___ ___ ___
___
Report to: ___. ___ by: ___. ___
SPECIMEN SUBMITTED: IMMUNOPHENOTYPING - PLEURAL FLUID
Procedure date Tissue received Report Date Diagnosed
by
___. ___. ___
Previous biopsies: ___ GI BIOPSIES (11 JARS).
88-10414N (Not on file)
88-09424N (Not on file)
88-03036N (Not on file)
(and more)
Pleural Fluid FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 19, and 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. B cells are scant in numbers
precluding evaluation of clonality.
INTERPRETATION
Non-diagnostic study. Clonality could not be assessed in this
case due to insufficient numbers of B cells. Cell marker
analysis was attempted, but was non-diagnostic in this case due
to insufficient number of cells for analysis.
Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, lymphocytes, histiocytes, and
neutrophils.
___ ECG:
Normal sinus rhythm. Intraventricular conduction delay of left
bundle-branch block pattern. Abnormal Q wave in lead III
associated with ST segment elevation suggests an old inferior
myocardial infarction. Left atrial abnormality is present as is
left ventricular hypertrophy. Since the previous tracing of
___ the intra-atrial conduction defect and intraventricular
conduction defect are new.
___ CXR:
FINDINGS: Comparison is made to previous study from ___.
There are no pneumothoraces identified. There is a small
right-sided pleural effusion which is layering partially along
the right chest wall. The pleural fluid in the right minor
fissure has resolved. There is increase opacification in the
right lung apex corresponding to known loculated pleural fluid
best seen on the prior CT scan from outside hospital from
___ There are no signs for overt pulmonary edema.
There is cardiomegaly.
___ TTE:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is mild to moderate regional left
ventricular systolic dysfunction with thinning/akinesis of the
basal half of the inferolateral wall and severe hypokinesis of
the basal half of the inferior and anterolateral walls. There is
mild hypokinesis of the remaining basal segments. Systolic
function of apical segments is relatively preserved. (LVEF =
40-45 %)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 arch is mildly
dilated. The aortic valve leaflets are moderately
thickened.There is severe aortic valve stenosis (valve area
0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Left ventricular cavity dilation with regional
systolic dysfunction c/w CAD (PDA distribution). Severe aortic
valve stenosis. Mild mitral regurgitation. Pulmonary artery
hypertension. Increased PCWP.
Is the patient a candidate for aortic valve surgery?
Brief Hospital Course:
___ year old male with Hodgkin's lymphoma (neck and groin) in
remission s/p chemoradiation in ___ complicated by thyroid
cancer s/p radioiodine in ___, chronic pain ___ peripheral
neuropathy and severe aortic stenosis (mean of 26 mm Hg and sCHF
(EF ___ in ___ who presented to his PCP's office with
worse than usual shortness of breath and was noted to have
loculated pleural effusion, found to be transudative.
# Pleural effusion: Pt presented to ___ with worsening DOE, and
CT chest showed new loculated pleural effusion (since ___,
worse on the R side. IP was consulted and did a thoracentesis
with 130cc of serous drainage. Studies were indicative of a
transudative process, and cytology was negative, with flow
showing insufficient cells. Given transudative fluid, a TTE was
done to evaluate for worsening cardiac status. LVEF was improved
to 40-45%, with persistent severe aortic valve stenosis (valve
area 0.8cm2). The pt was discharged on lasix 40mg daily (he had
previously only been taking it intermittently) with plans to
follow-up with cardiology as an outpatient. At the time of
discharge the pt felt improvement in his dyspnea and was stable
on RA at rest and with ambulation.
# Eosinophilia: pt with abs eos >1000 for two days, which was
concerning given his hx of hodgkins lymphoma. In reviewing
Atrius records over the past year, has been (%)
6.8-->8-->4.9-->6.5-->7. Transient eosinophilia was of unclear
significance but Dr. ___ (the pt's oncologist) was
notified. At the time of dc the pt's eosinophilia had resolved.
# CAD/sHF: Pt was continued on home aspirin, plavix, statin, BB,
ACE-I. He was given lasix 40mg PO daily. CE were neg on
admission. TTE as above.
# Radiation lung disease/reactive airway disease: Continued home
advair and albuterol.
# Hypothyroidism: Continued home levoxyl
# Chronic pain: Continued home hydrocodone
# BPH: Continued home tamsulosin
Transitional issues:
# Pt with follow-up with cardiology to further manage chronic
heart disease.
# Pt with follow-up with PCP to address issues of chronic
weakness and pain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
3. Nitroglycerin SL 0.4 mg SL PRN chest pain
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
5. Clopidogrel 75 mg PO DAILY
6. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
7. Albuterol Inhaler 2 PUFF IH Q6H
8. Aspirin 81 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Famotidine 40 mg PO BID
12. Atenolol 50 mg PO DAILY
13. Lisinopril 5 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Famotidine 40 mg PO BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Simvastatin 40 mg PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Albuterol Inhaler 2 PUFF IH Q6H
13. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
15. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pleural effusion
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 participating in your care. You were
admitted for worsening shortness of breath and oxygen
requirement and found to have a new pleural effusion. The fluid
was removed by interventional pulmonology and your symptoms
improved. The studies appear preliminarily to be due to your
heart disease, however there are still a number of studies
pending at the time of your discharge. We will follow up with
these studies and notify you once the results are available. In
the mean time, you should continue to take your lasix daily, and
follow-up with your PCP and cardiologist as below.
Followup Instructions:
___
|
10598277-DS-9 | 10,598,277 | 20,126,553 | DS | 9 | 2160-11-16 00:00:00 | 2160-11-17 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with no significant chronic medical problems, recent
campylobacter infection in setting of travel to ___, who
presents for dysphagia, among other issues.
Starting from the beginning, she was in ___ ___
for a recreational trip. He had a bike crash on ___ where she
hit her head (was wearing helmet). She was given a pain med (a
COX-2 inhibitor that is not FDA approved in USA per pt) and also
took Ibuprofen. She then subsequently developed an episode of
throat swelling on ___. She was given Benadryl "on the street"
and initially improved, then later had another episode the same
day for which she was brought to a hospital. She was given
steroids and more Benadryl. Apparently she was diagnosed with
"altitude sickness." She also might have had a UTI based on
___ UA.
On ___, a bartender had to give her the Heimlich x3 for a pill
that was stuck while swallowing. Apparently this was
unsuccessful in dislodging the pill. Just prior to leaving on
her flight back to the ___ ___ ___, she required 3 "shots" of
"something," given at the airport, prior to boarding the plane.
It is entirely unclear what this shot was. Her flight landed in
___ for a layover, and she was apparently seen at an ER there,
and diagnosed with a panic attack.
Of note, she started having diarrhea while in ___ around
___. On return to ___, she continued having diarrhea which
was bloody, and also had an episode of passing out. She was
diagnosed with Campylobacter in the ___ ED on ___, where stool
culture showed 1+ Campylobcter Jejuni. She was treated with
Cipro x3 days. She had stool cultures done elsewhere on ___,
___, which were positive again for Campylobacter, and she
continued to have postprandial non-bloody diarrhea. Her ___
PCP thus reached out to ___ ID, who recommended that 3 days of
Azithromycin be the first line Rx for this, so this was
prescribed to her. Her diarrhea has been improving since. She
only had one episode of loose stools ___.
Regarding her dysphagia, she notes a feeling of food and pills
getting "stuck" at approximately the level of her neck. It has
been going on for about 3 weeks, and was not present prior to
her ___ trip. She reports she attempted to eat soup
today, and feels like the chicken is caught in her throat, thus
presenting to ED. She has lost 25 pounds since ___, and has
decreased appetite and decreased PO intake due to these
symptoms. She is drinking liquids, not solids, due to the
symptoms. She takes Ativan prior to eating but it does not help.
She also has post-prandial epigastric pain. She also has a sore
throat, but just on the left side. She feels the left side of
her neck is "hard."
She reports she had a similar problem at Age ___, with spaghetti
squash that she swallowed "going up instead of down," and coming
out of her nose.
She is supposed to see ENT and allergist on ___. Reports no
GI visit is scheduled at this time. She has ongoing trouble with
anxiety, though did not have these troubles prior to the last
month or so. She also reports a cough with post nasal drip.
Reports insomnia, and has been reliant on Ativan for sleep. She
denies fever, chills, chest pain.
Of note, multiple recent outpatient visits for multiple
problems.
- Neuro visit ___: Felt her symptoms were post-concussive from
the head trauma, scheduled an outpatient MRI brain
- HCA epi visit ___: Seen for dysphagia, ordered a CT neck
which was normal
- HCA epi visit ___: Seen for sinusitis and anxiety, no
antibiotics, recommended Flonase, azelastine nasal spray,
oxymetalozine nasal spray, Neti Pot, and ENT follow up.
- HCA epi visit ___: Seen for similar complaints
- HCA establish care ___
- Orthopedics visit ___: ordered XR and MRI of shoulder joints
Also of note, had a court hearing on ___ for a reckless
driving charge.
She presented to the ED today because her symptoms had continued
to worsen and not improved.
In the ED, initial vitals were:
97.1, HR 77, 142/81, 16, 99% RA
Labs showed BUN 3
Received 1L NS
Decision was made to admit to medicine for further management of
weight loss and dysphagia.
Review of systems:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Anxiety
Recent campylobacter infection
ACL surgery ___ yrs ago
Social History:
___
Family History:
mom - NHL
Sister/Aunt - ___
Aunt - ___ cancer
Physical Exam:
ADMISSION EXAM:
Vital Signs: 97.6, 113/72, HR 54, RR 20, 100% RA
General: NAD, Alert
HEENT: Sclerae anicteric, Oropharynx clear, MM slightly dry. No
sinus tenderness.
NECK: Supple, no LAD
CV: RRR no murmur
Lungs: Normal resp effort, no distress, CTAB
Abdomen: Soft, non-tender, non-distended, BS+
Ext: Warm, well perfused, no edema
Neuro: CNII-XII intact
DISCHARGE EXAM:
VS: 97.4 107/67 60 18 99RA
GEN: NAD, Alert
HEENT: Sclerae anicteric, Oropharynx clear, MM slightly dry. No
sinus tenderness; no posterior pharyngeal erythema
NECK: Supple, no LAD
CV: RRR no murmur
LUNGS: Normal resp effort, no distress, CTAB
ABD: Soft, non-tender, non-distended, BS+
EXT: Warm, well perfused, no edema
NEURO: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
___ 08:45PM BLOOD WBC-7.4 RBC-4.14 Hgb-12.2 Hct-37.1 MCV-90
MCH-29.5 MCHC-32.9 RDW-12.3 RDWSD-40.2 Plt ___
___ 08:45PM BLOOD Neuts-53.2 ___ Monos-7.1 Eos-1.5
Baso-0.5 Im ___ AbsNeut-3.91 AbsLymp-2.76 AbsMono-0.52
AbsEos-0.11 AbsBaso-0.04
___ 08:45PM BLOOD ___ PTT-30.4 ___
___ 08:45PM BLOOD Glucose-91 UreaN-3* Creat-0.6 Na-137
K-4.6 Cl-99 HCO3-24 AnGap-19
___ 05:50AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
DISCHARGE LABS:
None
IMAGING/STUDIES:
___ EGD:
Normal mucosa in the esophagus (biopsy)
Normal mucosa in the stomach
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
___ UGI+SBFT:
Normal esophagram
___ Video Swallow:
Normal oropharyngeal swallowing videofluoroscopy.
Brief Hospital Course:
___ with no pertinent PMH presenting with 3 weeks of dysphagia
and weight loss following a bike accident during travel in
___ for initiation of dysphagia workup as inpatient.
# Dysphagia: The patient reported symptoms of dysphagia with
some sensation of swelling as her chief complaint on admission.
There is a lengthy history of her travel and misadventure while
in ___ which began with administration of COX2 inhibitors
not approved for use in USA inhibitors for shoulder/neck pain
from her bike accident. She may have experienced allergy
symptoms with this medication w/ complaints of throat swelling,
and was seen at a clinic where she was treated for a UTI as well
as given antihistamines and a dose of IM hydrocortisone. She was
taking an antibiotic pill at a bar when she first experienced
dysphagia which required the Heimlich maneuver to be performed
by a bartender. Since then these sensations of dysphagia with
solids have worsened, and she has been in contact with her PCP
about this. She was admitted for both worsening dysphagia to
solids as well as ~25lbs. weight loss. While inpatient she was
seen by several consulting services and had speech/swallow
evalution with video swallow which ruled out penetration or
aspiration. GI was consulted and recommened UGI+SBFT and EGD
which both showed no obstruction and no anatomic abnormalities;
biopsies were taken and patient will follow up with
multi-disciplinary team (GI, ENT, allergy, neurology, and PCP)
as outpatient. The patient receives some relief from lorazepam
suggesting contribution of anxiety/panic attacks to her
symptoms. She was amenable to starting a low-dose SSRI, and was
discharged with new sertraline 25mg PO QHS as a trial as well as
omeprazole 20mg PO daily.
# weight loss: Likely due to poor PO in setting of above
dysphagia/globus sensations. Albumin reassuring at 3.8. BUN low
at 3. Standing weight 135.6 on admission, down from reports of
~160. No clear etiology discovered during this admission,
however data-acquisition process initiated and patient will have
close follow-up with multiple disciplines as outpatient and
encouraged to increase PO intake as tolerated.
# anxiety: No longstanding history of this but has been
prescribed Ativan recently by PCP. Her PO Lorazepam PRN was
continued while inpatient. Started on low dose SSRI at time of
discharge after discussion with PCP.
# sinus symptoms: No sinus tenderness on exam, but the patient
states she had been taking several allergy medications for this
problem. Review of CT neck shows no overt or acute sinus
pathology. Her home regimen including Loratadine, Nasal Flonase,
Nasal Oxymetazoline was continued during admission.
# Campylobacter infection: Previously treated as outpatient with
first ciprofloxacin then azithromycin. Ordered stool culture to
verify clearance as inpatient, but will need outpatient f/u
regarding results as still pending.
TRANSITIONAL ISSUES:
- new medications: sertraline 25mg PO QHS, omeprazole 20mg PO
daily
- f/u stool campylobacter culture, pending at time of d/c
- f/u EGD biopsies by GI, pending at time of d/c
- f/u appts with GI, allergy, PCP, ___, ENT as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO BID:PRN anxiety
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. azelastine 137 mcg (0.1 %) nasal BID:PRN
4. Loratadine 10 mg PO DAILY
5. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*14
Capsule Refills:*0
2. Sertraline 25 mg PO QHS
RX *sertraline 25 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
3. azelastine 137 mcg (0.1 %) nasal BID:PRN
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Loratadine 10 mg PO DAILY
6. LORazepam 0.5 mg PO BID:PRN anxiety
7. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- dysphagia
Secondary diagnosis:
- weight loss
- anxiety
- campylobacter infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted for difficulty swallowing and significant
weight loss over the past month. Multiple studies were performed
by several teams as an inpatient, including exams of both your
mouth/nose/throat, as well as esophagus and stomach. Your
swallowing was assessed as well and ___ were not having problems
with aspiration of food into your lungs. In all, much data was
collected without a clear diagnosis yet and ___ will have close
follow-up as an outpatient.
Best regards,
Your ___ Care Team
Followup Instructions:
___
|
10598395-DS-7 | 10,598,395 | 21,552,039 | DS | 7 | 2137-01-26 00:00:00 | 2137-01-26 17:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Losartan
Attending: ___.
Chief Complaint:
Weakness, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with history of EtOH dependence and abuse
for years (since age ___), presumed cirrhosis, HTN, and
depression, thrombocytopenia, who presented with dizziness,
tremulousness, and anxiety in the setting of heavy drinking as
well as recurrent mechanical falls, the last of which was on the
day of admission.
He reported daily EtOH use since he was a teenager. He drinks
approximately a pint of alcohol per day, and last drink was the
day prior to admission. Family stated he has been more confused
recently.
He reported he stepped on a rock on the day of admission and
fell. His family reported he fell in ___ last month and broke a
glass coffee table with head strike.
#In the ED, initial vital signs were: 97.7 60 106/60 18 100% RA
- Exam notable for: A&Ox2, horizontal nystagmus and tongue
fasciculation, lungs CTA, left chest wall tenderness, abdomen
soft/NT/ND
- Labs were notable for H/H 9.4/28.9, platelets 119,
electrolytes within normal limits, ALT: 17 AP: 307 Tbili: 2.2
Alb: 3.2 AST: 144, Trop-T: <0.01
- Studies performed include CXR, CT head w/o contrast,
- Patient was given 1000 mL NS 1000 mL, Diazepam 10 mg, IV
Thiamine 100 mg, IV FoLIC Acid 1 mg
- Vitals on transfer: 98.3 65 122/67 16 100% RA
#Upon arrival to the floor, the patient was comfortable in bed.
He answered all questions appropriately. His main complaint was
pain on the left side of his chest. He confirmed the history
detailed above.
ROS (+)intermittent abdominal discomfort, non-bloody diarrhea
for several weeks, weight loss, night sweats, tremors, and
palpitations especially when anxious.
He denied any history of GI bleeding, melena, hematemesis, or
bright red blood per rectum. He denied any known fluid
retention, ascites or lower extremity edema. Otherwise, review
of systems is negative for fevers, chills, change in vision,
headaches, shortness of breath, chest pain, cough, abdominal
distension, diarrhea, melena, joint pain, or pruritus.
Past Medical History:
Alcohol dependence/abuse, h/o EtoH hepatitis
Cirrhosis, presumed based on imaging
Depression
HTN
Anemia of chronic disease
Thrombocytopenia
Gout
Pulmonary nodules: stable per recent CT chest ___
R peroneal nerve injury ___
Social History:
___
Family History:
Reviewed in detail, no significant family history
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
Vitals- 97.9 136/70 67 16 97%RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Normal bowels sounds, distended, tender to deep
palpation in left upper quadrant. Tympanic to percussion.
Hepato-splenomegaly noted.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: Scattered bloody lesions in hands and knees, likely
related to injuries from falls.
NEUROLOGIC: CN2-12 intact. ___ strength lower extremity, ___
upper extremity. Normal sensation. Could not assess dysmetria
and disdiadochokinesia because patient was unable to do
finger-to-nose exam. Truncal ataxia. Intact proprioception.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Vitals- Tc 97.4 Tm 99.4 100s-120s/40s-70's 60-70s 18 96% RA
GENERAL: Sitting at the edge of the bed and eating breakfast,
A&Ox3, NAD
HEENT: PERRL, no nystagmus appreciated.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: CTAB. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, mildly distended, tender to deep
palpation in left upper quadrant. Hepato-splenomegaly noted.
EXTREMITIES: WWP no edema.
NEURO: Mild tremulousness noted. CN grossly intact. Sensation,
motor strength, and coordination within normal limits
throughout. No ataxia was noted.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 05:28PM BLOOD WBC-5.7 RBC-2.86* Hgb-9.4* Hct-28.9*
MCV-101* MCH-32.9* MCHC-32.5 RDW-17.5* RDWSD-64.9* Plt ___
___ 05:28PM BLOOD Neuts-69.2 Lymphs-15.1* Monos-14.1*
Eos-0.5* Baso-0.4 Im ___ AbsNeut-3.94# AbsLymp-0.86*
AbsMono-0.80 AbsEos-0.03* AbsBaso-0.02
___ 05:28PM BLOOD Plt ___
___ 05:28PM BLOOD Glucose-87 UreaN-16 Creat-0.8 Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
___ 05:28PM BLOOD ALT-17 AST-144* AlkPhos-307* TotBili-2.2*
___ 05:28PM BLOOD Lipase-30
___ 05:28PM BLOOD cTropnT-<0.01
___ 05:28PM BLOOD Albumin-3.2*
___ 05:28PM BLOOD VitB12-___
LABS ON DISCHARGE:
==================
___ 07:30AM BLOOD WBC-5.9 RBC-2.94* Hgb-9.7* Hct-29.5*
MCV-100* MCH-33.0* MCHC-32.9 RDW-17.2* RDWSD-63.5* Plt ___
___ 07:20AM BLOOD ___
___ 07:30AM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-133
K-4.6 Cl-97 HCO3-27 AnGap-14
___ 07:20AM BLOOD ALT-39 AST-206* AlkPhos-339* TotBili-2.5*
___ 07:30AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.3*
IMAGING:
========
___ CT HEAD W/O CONTRAST:
Images are limited by motion artifact. Within this limitation,
no evidence of acute intracranial hemorrhage.
___ CXR:
No acute intrathoracic process. Mediastinal prominence due to
unfolded thoracic aorta.
___ MRI HEAD W/O CONTRAST:
1. Minimal abnormalities in the vicinity of the mammillary
bodies and
periaqueductal gray. These are of uncertain significance in a
patient with suspected Wernicke's encephalopathy.
2. Minimal white matter hyperintensities on FLAIR images of
doubtful
significance.
Brief Hospital Course:
___ yo M with history of EtOH dependence and abuse, presumed
cirrhosis, HTN, and depression, thrombocytopenia, who presented
with dizziness, tremulousness, and anxiety in the setting of
heavy drinking as well multiple mechanical falls the last of
which was on the day of admission.
#WERNICKE'S ENCEPHALOPATHY: He was found to have truncal and
gait ataxia with intact proprioception, and also with nystagmus
and encephalopathy with indifference and inattentiveness in
setting of chronic alcoholism. MRI head without contrast showed
minimal abnormalities in the vicinity of the mammillary bodies
and periaqueductal gray. There was no evidence of stroke on MRI.
His symptoms were thought to be secondary to Wernicke's
encephalopathy and he was treated with IV thiamine.
# ACUTE ALCOHOL DEPENDENCE WITH WITHDRAWAL: Longstanding
significant alcohol dependence, who unfortunately is not able to
stay sober and has failed multiple attempts of detoxification.
He has no prior history of withdrawal seizures. In terms of his
alcohol intoxication, he was initially placed on CIWA score with
diazepam PRN.
#RECURRENT FALLS: CT head was negative for any intracranial
process and rib series showed left rib fracture. Recurrent falls
were attributed to his alcohol intoxication and Wernicke's. As
discussed above, he was found to have truncal and gait ataxia
with intact proprioception. The ataxia was improving at time of
discharge and patient was discharged to rehab. The expected
length of stay at rehab is not more than 30 days.
# THROMBOCYTOPENIA: This is a chronic issue. During his prior
admission, blood smear was reviewed with hematology, and
thrombocytopenia was thought to be likely related to cirrhosis,
splenomegaly, and alcohol abuse.
# LOWER EXTREMITY WEAKNESS:
Patient has chronic lower extremity weakness, most likely
related to deconditioning and excessive alcohol intake. He was
noted to have right foot drop during prior admission, possibly
related to prior injury to alcoholic neuropathy. At that time,
he was seen by physical therapy, who recommended that patient be
discharged with a walker, as well as with ___ physical therapy.
Vitamin B12 was within normal limits. ___ was consulted and
recommended acute rehab.
CHRONIC ISSUES:
# CIRRHOSIS: Presumed EtOH related, and based on recent
ultrasound though has not had formal biopsy. Followed at the
___ at ___. Has varices grade II on endoscopy in
___. We continued nadolol and PPI 40 daily.
# ESOPHAGITIS: Noted on recent EGD. Patient was supposed to take
nystatin for 10 days, and it was unclear whether he completed
the course. He was treated with nystatin as in-patient.
# HTN, ESSENTIAL: We continued amlodipine.
***TRANSITIONAL ISSUES:***
- Continue to encourage alcohol cessation
- Monitor platelets
- Follow up with ___ as scheduled
- Continue Nystatin for esophagitis for a total duration of 10
days (day 1= ___, last day= ___
- Patient should have high-calorie diet
#CODE STATUS: Full
#EMERGENCY CONTACT: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO BID
6. TraZODone 150 mg PO QHS:PRN insomnia
7. Cyclobenzaprine 10 mg PO TID:PRN spasm
8. Lorazepam 1 mg PO BID anxiety
9. Sildenafil 20 mg PO DAILY:PRN erection
10. Nadolol 20 mg PO DAILY
11. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. TraZODone 150 mg PO QHS:PRN insomnia
6. Cyclobenzaprine 10 mg PO TID:PRN spasm
7. Lorazepam 1 mg PO BID anxiety
RX *lorazepam 1 mg 1 mg by mouth twice a day Disp #*10 Tablet
Refills:*0
8. Sildenafil 20 mg PO DAILY:PRN erection
9. Nadolol 20 mg PO DAILY
10. Sertraline 50 mg PO DAILY
11. ___ ___ UNIT PO Q8H
Last day is ___. Omeprazole 40 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Wernicke's encephalopathy
Alcohol intoxication
Recurrent falls
Lower extremity weakness
SECONDARY DIAGNOSES:
Cirrhosis
Thrombocytopenia
Megaloblastic 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 ___
___. You came to the hospital because of recurrent
falls and excessive alcohol drinking. You were found to be
unsteady and confused, a condition called "Wernicke", which is
due to vitamin deficiency secondary to excessive alcohol
drinking. We treated you with intravenous vitamins and gave you
some medications to treat your alcohol withdrawal symptoms.
We did imaging for your head and any fractures or bleeding. You
were found to have a rib fracture, which only required some pain
control.
We strongly encourage you to stop drinking alcohol due to the
negative effects on your health. Please make sure to take all
your medications on time and follow up with your doctors as
___.
Best regards,
Your ___ team
Followup Instructions:
___
|
10598407-DS-9 | 10,598,407 | 21,914,018 | DS | 9 | 2143-04-10 00:00:00 | 2143-04-10 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Diabetis ketoacidosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o DM1, hypothyroidism p/w with 2 days N/V and
diarrhea.
.
She was playing with child with similar symptoms 3 days ago. The
next day developed N/V/D and crampy abd pain. Unable to tolerate
PO intake x 2 days. Took reduced dose of insulin as not
tolerating PO (normally takes 35 units lantus qhs, was takign
10U lantus, and checking fingersticks q2 hrs. Getting values
from 200-300. Called PCP office and was told to come into ED.
Denies dietary changes, recent travel.
.
In ___ ED initial VS were WNL. Labs significant for anion gap
acidosis (gap 25, bicarb 9) and U/A demonstrated ketonuria. She
was given insulin 10U IV and started on an insulin infusion.
She was also given 2L NS and 40 mEq of K IV. VS on transfer 98
107 138/63 20 99/ra.
On arrival to the MICU she appeared comfortable and attempting
to study her homework. No complaints.
.
Past Medical History:
DMI--on insulin at home
Hypothyroidism--taking levothyroxine
Social History:
___
Family History:
father with HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 96.7 93 111/64 22 99/ra
HEENT: NCAT Dry mucus membranes, PERRL, EOMI
NECK Supple without LAD
CV mild tachycardia RR no MRG
ABD: Soft miniaml tenderness diffusely + BS
EXt no CCE
.
DISCHARGE PHYSICAL EXAM:
afebrile, vital signs stable
HEENT: no signs of infection, PERRLA
CV: rrr, no m/r/g
Pulm: clear bilaterally, no w/r/r
Abd: soft, NT, ND
EXT: no c/c/e
Pertinent Results:
ADMISSION LABS:
___ 09:30AM BLOOD WBC-6.2 RBC-5.10 Hgb-14.7 Hct-44.0 MCV-86
MCH-28.9 MCHC-33.5 RDW-12.4 Plt ___
___ 09:30AM BLOOD Neuts-80.7* Lymphs-14.9* Monos-3.8
Eos-0.3 Baso-0.4
___ 09:38AM BLOOD ___ PTT-26.4 ___
___ 09:30AM BLOOD Glucose-389* UreaN-19 Creat-0.9 Na-131*
K-4.7 Cl-98 HCO3-9* AnGap-29*
___ 09:30AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9
___ 12:45PM URINE Color-Straw Appear-Clear Sp ___
___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:45PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
.
DISCHARGE LABS:
___ 02:18AM BLOOD WBC-5.4 RBC-4.25 Hgb-12.4 Hct-35.8*
MCV-84 MCH-29.1 MCHC-34.5 RDW-12.5 Plt ___
___ 01:42PM BLOOD Glucose-220* UreaN-11 Creat-0.6 Na-133
K-3.9 Cl-104 HCO3-26 AnGap-7*
___ 01:42PM BLOOD Calcium-8.8 Phos-1.2* Mg-1.8
.
___ CXR FINDINGS: Single AP portable chest radiograph is
obtained. The image provided excludes the bilateral lung apices
and the lateral right hemithorax which considerably limits
evaluation. The imaged portions of the lungs appear clear.
Cardiomediastinal silhouette appears normal. Bony structures
appear intact.
IMPRESSION: Limited study given exclusion of the lung apices and
right
lateral hemithorax, though no definite signs of pneumonia.
Repeat study may be performed to fully assess.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of type 1
diabetes mellitus and hypothyroidism, who presented with
gastroenteritis and diabetic ketoacidosis (DKA).
.
ACTIVE ISSUES BY PROBLEM:
# DKA: She was originally admitted with blood sugars in the
300-400 range and ketones in her urine. Likely caused by
gastroenteritis, as urinalysis was negative for infection, chest
xray was normal, and she did not have symptoms of ischemia. She
was placed on an insulin drip until her glucose and bicarbonate
normalized. She was also maintained on IV fluids, originally
normal saline and then ___ normal until her bicarb
normalized. Electrolytes were repleted as needed. After about
24 hours, she was able to transition to subcutaneous insulin on
her home regimen plus a sliding scale. ___ was consulted and
they gave her diabetic education about what to do if she gets
sick again and proper diet. They would like to follow-up with
her in about 2 weeks.
.
# Gastroenteritis: Likely viral, symptoms have resolved with
treatment of DKA. Supported with IV fluids as above and
antiemetics. She was tolerating oral diet before discharge.
.
CHRONIC ISSUES BY PROBLEM:
# Hypothyroidism: continued Levothyroxine
.
TRANSITIONAL ISSUES:
- Please ensure that she has a follow-up appointment with ___
in about 2 weeks.
- We did not order a hemoglobin A1c, ___ will do this if she
keeps her follow-up appointment
Medications on Admission:
Lantus 34U qhs
Humalog 8U with meals (often only ___ for dinner)
Levothyroxine 100 mcg PO daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. insulin glargine 100 unit/mL Solution Sig: ___ (34)
units Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
three times a day: With meals.
4. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous three times a day: FBS =
101-150=2U
151-200=4U
201-250=6U
251-300=8U
> 300=call MD.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Gastroenteritis, virally mediated
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Ms. ___,
.
You were admitted to the hospital because you were having high
blood glucose levels. This was because you had a viral
gasteroenteritis which was affecting your body's electrolytes
and glucose balance. This condition is called diabetic
ketoacidosis. You were treated with IV insulin and fluids and
your electrolytes were replaced.
.
When you get sick in the future, this will likely happen again.
It will be important that you stay ahead of your blood sugars
and call your doctors when ___ are sick. They will advise you
about taking more insulin during that time period.
.
No changes were made to your medications while you were in the
hospital. You should always take your insulin as prescribed.
.
It is also very important that you keep all of the follow-up
appointments listed below.
.
It was a pleasure taking care of you in the hospital!!
Followup Instructions:
___
|
10598816-DS-4 | 10,598,816 | 22,886,008 | DS | 4 | 2176-10-09 00:00:00 | 2176-10-09 18:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with Colon CA currently undergoing Chemotherapy who
was on his way to his appointment when he missed a step and fell
striking his head. Patient denies LOC.
Past Medical History:
PMH: HTN, DMII (diet controlled per PCP), metastatic colon Ca,
MGUS, Normocytic anemia, factor 7 deficiency, Bladder CA in
___, gastritis, gout, Nephrolithiasis.
PSH: Cataract
Social History:
___
Family History:
Lives at home with wife and children
Physical Exam:
Upon admission:
O: T:97.6 BP: 177 /81 HR:80 R 18 O2Sats100
Gen: Frail and emaciated ___ male
HEENT: Multiple facial abrasians
Neck:
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Upon discharge:
Farsi speaking, frail, PERRL, No drift, face symmetric with some
lacerations, full strength
Pertinent Results:
___ CT cspine
1. No acute fracture or vertebral malalignment. Moderate
degenerative
changes.
2. Right thyroid lobe nodule measuring 17 x 15 mm, with
possible additional smaller nodules. Recommend follow-up
ultrasound on a non-emergent basis.
___ CT head
1. Acute subdural hematoma layering along the left cranial
convexity, with a maximum thickness of 19 mm. Hematoma
demonstrates mixed density, concerning for a possible
coagulopathy or ongoing bleeding.
2. Subfalcine herniation with rightward midline shift of 7 mm
and mild
effacement of the left lateral ventricle.
3. Early uncal herniation with mild protrusion of the left
uncus into the
supracellar cistern. Pons and midbrain shifted to the right,
abutting the
tentorium on the right.
___ CXR
Vague suspected opacity in the right lower lung, probably
compatible with atelectasis; other possibilities that could be
considered in the appropriate setting are slight contusion or
even developing pneumonia or aspiration.
___ CT head
1. Acute subdural hematoma, slightly redistributed from prior
exam, but
appears to be slightly increased in size from the prior exam 4
hr prior.
Hematoma continues to demonstrate mixed density, concerning for
possible
coagulopathy or ongoing bleeding.
2. Subfalcine herniation rightward midline shift of 5 mm with
mild effacement of the right lateral ventricle, slightly reduced
since the prior exam.
3. Early uncal herniation with mild protrusion of the left
uncus in the
suprasellar cistern and rightward shift of the pons which is
abutting the
tentorium, similar prior exam.
Brief Hospital Course:
___ y/o with Colon CA and hx of bladder CA who was on his way to
chemo today when he fell on a step and hit his head. Patient has
7mm of midline shift and an INR of 1.4 He was admitted to the
ICU for close monitoring. He was started on Keppra. Repeat CT
scan revealed acute subdural hematoma, slightly redistributed
from prior exam, but
appears to be slightly increased in size from the prior exam 4
hr prior.
Hematoma continues to demonstrate mixed density, concerning for
possible
coagulopathy or ongoing bleeding.
On ___ the patient remained neurologically stable. A Factor VII
level was drawn and remained pending throughout the day.
On ___, the patient remained neurologically stable. His INR was
1.3 and a Factor VII level was 30. ___ and OT were consulted for
dispo planning but the patient refused ___ evaluation and he
was discharged home with follow up in four weeks with a head CT.
Medications on Admission:
PrevPac
Lidocaine Viscous 2% ___ mL PO QID:PRN mouth pain
Mirtazapine 7.5 mg PO/NG HS
Ondansetron 4 mg PO/NG QHS nausea
Prochlorperazine ___ mg PO Q6H:PRN nausea
Potassium Chloride 20 mEq / 50 mL SW IV ONCE Duration: 1 Dose
Xeloda 500mg 2 tabs by mouth 2x/day
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN fever/pain
2. Amoxicillin 1000 mg PO DAILY
3. Clarithromycin 500 mg PO DAILY
4. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
5. Lidocaine Viscous 2% ___ mL PO QID:PRN mouth pain
6. Mirtazapine 7.5 mg PO HS
7. Ondansetron 4 mg PO QHS nausea
8. Prochlorperazine ___ mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Left holohemespheric SDH with 7mm MLS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
**You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCPs
office, but please have the results faxed to ___.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not relieved
by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10598816-DS-7 | 10,598,816 | 25,397,511 | DS | 7 | 2176-12-28 00:00:00 | 2176-12-28 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an ___ male with metastatic colon cancer,
chronic SDH, and a recent diagnosis of pneumonia who is here for
the evaluation of respiratory distress. Per nursing home notes
the patient started complaining of abdominal pain this morning
was given 10mg of oxycodone and became somnolent, and was found
to be hypoxic in the mid ___ respiratory rate of 34 and was
subsequently brought here for further management of his care. On
arrival pt was in mild respiratory ditress, satting in ___ on
NRB. He is unable to provide an elaborate hx but his son states
that prior to this episode there has been no report chest pain,
n/v/d, changes in mental status prior to today. He does state he
aspirates chronically and has been coughing for some time now.
___ was recently admitted here for PNA.
He was given vancomycin and cefepime in the ED and admitted to
the floor on nasal canula. Shortly after arriving on the floor,
he was noted to be hypoxic to the low ___. He was placed on a
non-rebreather, and O2 sats rose to the mid ___. He was
tachypneic w/ RR in the ___ and using accessory muscles of
respiration. ABG showed a PaO2 59 on non-rebreather. He was
transferred to the MICU for hypoxic respiratory failure. Upon
arrival in the unit, CXR showed new left lower lobe collapse. He
was suctioned w/ return of copious thick secretions. Shortly
thereafter, his tachypnea improved, as did his oxygenation. He
was able to be weaned back to nasal canula.
After suctioning, he states that his breathing is much better.
He continues to have a productive cough. He denies any pain or
other acute symptoms.
Past Medical History:
Past Medical History:
- HTN
- DMII, diet controlled
- advanced metastatic colon adenocarcinoma
- MGUS
- Normocytic anemia
- factor 7 deficiency
- Bladder CA in ___
- gastritis / H. pylori +
- gout
- nephrolithiasis
- subdural hematoma following mechanical fall ___, managed
non-operatively
Social History:
Social History:
-retired, ___ in ___, moved to ___ ___ yrs ago
-three children who live in ___ area
-former smoker
denies ETOH
-married
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress. Cachectic,
chronically ill-appearing elderly man
HEENT: Sclera anicteric, dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds at left base. Good air movement.
Breathing comfortably on nasal canula
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, 1+ lower extremity edema
Discharge: Mr. ___ is lying in bed and is alert but unable to
engage in meaningful discussion with translation. He is
occasionally able to follow basic commands. He is mildly
tachypneic but in no apparent respiratory distress. He does not
appear to be in pain.
Pertinent Results:
___ 03:00PM BLOOD WBC-11.5* RBC-3.82* Hgb-12.7* Hct-40.8
MCV-107* MCH-33.3* MCHC-31.2 RDW-15.1 Plt ___
___ 04:14AM BLOOD WBC-11.0 RBC-3.49* Hgb-11.5* Hct-37.3*
MCV-107* MCH-32.9* MCHC-30.8* RDW-15.0 Plt Ct-78*
___ 03:00PM BLOOD Neuts-93.5* Lymphs-2.5* Monos-3.7 Eos-0.1
Baso-0.1
___ 04:14AM BLOOD Glucose-67* UreaN-22* Creat-0.7 Na-142
K-4.5 Cl-110* HCO3-22 AnGap-15
___:00PM BLOOD ALT-104* AST-125* AlkPhos-656*
TotBili-2.5*
___ 08:41PM BLOOD Lactate-2.2*
Images:
CXR: Bilateral pleural effusions and increased interstitial
markings suggesting edema as on prior. Increased bibasilar
opacities with more dense retrocardiac opacity silhouetting the
hemidiaphragm may represent superimposed infection versus
atelectasis. Consider PA and lateral views for better
characterization.
Brief Hospital Course:
By Dr. ___ ___:
___, Farsi speaking w/h/o HTN, DMII, MGUS, Normocytic anemia,
Factor 7 deficiency, Bladder CA in ___, gout, nephrolithiasis,
gastritis / H. pylori +, ___ post ___, end-stage
metastatic colon CA (off of chemo) poor functional status and
recurrent aspirations admitted from nursing home through the
floor to the ICU with hypoxia, resp distress and CXR showing bil
multifocal opacities, atelectasis and left pleural effusion.
Resp status reportedly improved markedly after suctioning.
Vanco/Cefep were started to cover HCAP + a pos UA. Also found to
have elevated liver enzymes w/o RUQ pain suggestive of
cholestasis slightly uptrending from previous. RUQ US showed
nodular liver with multiple lesions compatible with metastatic
disease as well as sludge/stone in gall bladder w/o signs of
cholecystits. Mr. ___ was transffered to the medical floor
where he remained stable but mostly confused and unable to
engage in decision making. I met with patient's son and HCP
___. We discussed patient's prognosis and goals of care.
___ thought his father looked comfortable. He expressed his
wish that his father continues to live as long as possible "even
if he is in a coma". At the same time he would like to avoid any
measures that would cause his father any pain or discomfort
without significant long term benefit. I explained that due to
Mr. ___ advanced wide-spread malignancy it is my opinion
that focusing on treating intercurrent complications such as
infections, laboratory and vital signs abnormalities would
likely lead at this point to discomfort with little chance of
significant benefit or life prolongation. I explained that his
father will eventually likely succumb to a combination of
infection and organ failure but that there is little we can do
to prevent or delay this inevitability. At the same time
focusing his care on his comfort will assure that he will spend
the time he has left in as much general wellbeing as possible. I
recommended that given the family's goal of ensuring patient
lives as long as possible without discomfort we change the goals
of his care to comfort focused care. I explained that this would
entail discontinuing IV fluids, vital sign, lab checks,
antibiotics and any medication that does not directly contribute
to his father's ___. Code status will be changed to DNR/DNI.
___ expressed his understanding and full support for this
plan.
Mr. ___ was discharged for hospice care at ___,
___ with the following plan:
- allow liberal oral hydration and nutrition with dysphagia diet
to the degree that patient seems interested.
- focus medical interventions on treating any symptoms that
arise such as respiratory distress, nausea, hypersecrition or
agitation.
- Code status is DNR/DNI
- Comfort Measures Only
BY ___. ___ ___
I met patient this early AM. He was obtunded and
non-responsive. Patient expired peacefully on CMO at 12:46pm.
Family, PCP and admitting were notified. Death report
completed. Condolences given to the family.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Dexamethasone 4 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Mirtazapine 7.5 mg PO HS
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
9. Senna 8.6 mg PO DAILY
10. Lactulose 15 mL PO Q8H:PRN constipation
Discharge Medications:
None - patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Colon Cancer
Discharge Condition:
expired
Discharge Instructions:
Mr. ___ was admitted due to difficulty breathing as a
consequence of complications of his advance cancer. Given his
condition and the feeling that nothing further could be done to
improve his state of health and in accordance with the wishes
expressed by his health care proxy to assist him to live as long
as possible in comfort and free from uneasiness and pain it was
decided to focus further care on treating his symptoms and
making sure that he is comfortable while avoiding any
interventions that may cause him discomfort. He passed away on
comfort measures. Family and PCP ___.
Followup Instructions:
___
|
10598818-DS-11 | 10,598,818 | 20,256,389 | DS | 11 | 2124-05-25 00:00:00 | 2124-05-25 12:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall over bicycle handles
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ y/o M with history of asthma presents s/p fall over
bicycle handlebars today after driving his bicycle into a ditch.
Patient states that he was helmeted, but helmet was not secured.
He fell striking the R side of his head and R shoulder. Head CT
shows R superior orbital wall fracture with associated
pneumocephalus. Neurosurgery was consulted for further
evaluation.
He reports headache, orbital pain, nausea and pain with ocular
movements, but denies any dizziness, vomiting or changes in
vision.
Past Medical History:
Asthma
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: R frontal hematoma with abrasion, periorbital ecchymosis
and edema
Pupils: 4-3mm bilaterally EOMs: intact, pain with movement
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Handedness Left or Right
EXAM ON DISCHARGE:
Neurologically intact
Echymosis over right eye.
Pertinent Results:
___ CT:
Fracture of the right superior orbital wall, with associated
small volume pneumocephalus, better characterized on concurrent
sinus CT.
In addition, there is a small 4 x 6 mm hyperdensity along the
floor of the anterior cranial fossa on the right adjacent to the
fracture (602b: 25), potentially a contusion or extra-axial
hematoma.
___ CT head:
Preliminary ReportRe- demonstration of a right superior orbital
wall fracture with minimal
Preliminary Reportpneumocephalus, and adjacent contusion of the
anterior inferior right frontal
Preliminary Reportlobe. No evidence of intraparenchymal
hemorrhage. Right supraorbital soft
Preliminary Reporttissue swelling has minimally increased.
___ CT C-Spine:
There is no acute fracture or vertebral malalignment. There is
no prevertebral
soft tissue swelling. Vertebral body and disc space heights are
maintained. CT
is not able to provide intrathecal detail comparable to MRI, but
the
visualized outline of the thecal sac appears unremarkable.
No lymphadenopathy is present by CT size criteria. The
visualized lung apices
are clear. The thyroid is unremarkable.
Brief Hospital Course:
Mr. ___ was admitted to the neurosurgery service after
evaluation in the emergency room. Plastic surgery was consulted
for his orbial wall fracture. No surgical intervention was
indicated. He had repeat imaging which was stable.
He is being discharged home with antibiotics and follow up
instructions.
Medications on Admission:
Albuterol
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 10 Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth q
8h Disp #*30 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
R orbital superior wall fx/pneumo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have sustained a superior orbital was fracture.
You are on Sinus precautions until you are cleared by plastic
surgery.
Call our office if you develop headaches that are not relieved
by pain meds, neck stiffness, nausea, vomiting or fevers.
The number for Dr. ___ office is ___.
Refrain from contact sports and strenuous excercise until you
are seen in follow up.
You should take a stool softer or laxative while you are on
narcotic pain meds.
-Sinus precautions: No nose blowing, no straws, sneeze with your
mouth open.
-Continue on Augmentin fo 10 days after discharge.
Followup Instructions:
___
|
10598868-DS-13 | 10,598,868 | 27,299,106 | DS | 13 | 2120-02-27 00:00:00 | 2120-02-27 19:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / oxycodone
Attending: ___.
Chief Complaint:
Polytrauma s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Ms. ___ is an ___ year old female who fell down
approximately 13 stairs on ___ while carrying a heavy
heater. She denies loss of conciousness or head strike. She
initially sought care on ___ in the ___ where she
received a CT scan of her head, chest, abdomen, and pelvis.
These studies revealed a potential right-sided non-displaced
nasal bone fracture, left ___ lateral and ___ anteior
rib fractures, L2-4 transverse fractures, suspected acute L1
compression fracture, possible acute (versus chronic) T8
compression fracture, and a left comminuted scapular fracture.
She was given intravenous hydromorphone and transferred to ___
for further evaluation.
She had repeat reads of these same films done in the ___ ___
(had only arrived with preliminary reads) in addition to a plain
film of her left shoulder. This film appeared normal. She was
seen by the plastics consult service who recommended a dedicated
maxillofacial CT of the head to further assess this potential
nasal fracture. A serum toxicology panel was negative. The
remainder of her objective studies were largely unremarkable.
She was transferred to the ___ on the morning of ___ for
further evaluation, particularly with respect to her left-sided
rib fractures.
Past Medical History:
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
Temp 98.3 P 72 BP 118/53 RR18 ___ 97RA
GEN: NAD, pleasant
HEENT: bilateral facial ecchymosis, EOMI
CV: RRR, in TLSO brace
PULM: CTAB,mild bibasilar crackles, unchanged from previous.
ABD: Soft, NTTP, ND
Pertinent Results:
___ CBC on admission
WBC-9.8 RBC-4.21 Hgb-12.1 Hct-35.5* MCV-84 MCH-28.8 MCHC-34.2
RDW-14.9 Plt ___
___ CBC on discharge
WBC-8.4 RBC-3.85* Hgb-11.0* Hct-32.5* MCV-84 MCH-28.6 MCHC-33.9
RDW-14.9 Plt ___
MRI ___
IMPRESSION:
1. Acute anterior wedge compression fractures of T4 and L1 is
noted with
minimal loss of vertebral body height.
2. Acute transverse fracture of the T8 vertebral body is also
noted, which
extends to the right pedicle.
3. No new rib fractures and spinous process fractures seen on CT
examination
from outside hospital is not well evaluated on current MRI exam.
4. Severe cervical spondylosis is noted with moderate spinal
canal narrowing
at C4-5 and C5-6. No definitive cord signal changes noted.
5. Extensive right much greater than left paraspinal muscle
edema is seen
spanning the neck to the thorax. Subcutaneous hematoma of the
left paraspinal
lumbar region is also seen.
6. No definitive ligamentous injury is identified.
7. Vertebral alignment is anatomic.
8. Cholelithiasis is noted. Clinical correlation is recommended.
CT SINUS ___
Minimally displaced bilateral nasal bone fractures. No
additional facial bone fracture identified.
Brief Hospital Course:
The patient presented to the Emergency Department on the evening
of ___. Pt was evaluated by ACS and Ortho Trauma. Given
findings of poly trauma and multiple rib fractures, she was
transferred to the TICU for observation. Her injuries did not
require surgical intervention, she was put in a TLSO brace for
comfort, she was started on her home medications and pain
regimen after Acute pain service was consulted but did not
require an epidural. Over the course of 2 days, she proved to
not require ICU level of care and was transferred to the floor
for continuation of pain management.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a Fentanyl PCA,
but was transitioned to Tramadol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint despite serious injuries to her thorax; vital signs
were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirometry were encouraged throughout
hospitalization. She was able to tolerate IS manuevers.
GI/GU/FEN: The patient tolerated regular diet, Input and output
were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril Dose is Unknown PO DAILY
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
3. Ranitidine 75 mg PO DAILY
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*100
Tablet Refills:*0
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
3. Docusate Sodium 100 mg PO BID
Please take as needed for constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*1
4. Senna 8.6 mg PO BID
Take as needed for constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth twice a day
Disp #*30 Tablet Refills:*1
5. Ranitidine 75 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Please take as needed for pain.
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*60 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN pain
Please do not take more than 3000mg in a single day.
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth Every ___ hours Disp #*60 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma, scapular fracture, Left rib ___ fractures,
Transverse process fractures at L2-4, Spinous fractures at T5-7,
Compression fracture at L1, Right nasal bone fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* Your injury caused multiple left sided rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10599327-DS-20 | 10,599,327 | 26,804,768 | DS | 20 | 2135-12-30 00:00:00 | 2135-12-30 14:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Decreased responsiveness
Major Surgical or Invasive Procedure:
Femoral central line
History of Present Illness:
___ with PMHx of CVA (nonverbal and does not move his arms or
legs at baseline), Afib on coumadin, multiple pneumonias (s/p
trach/PEG ___, multiple UTI/urosepsis with Proteus sensitive
to Cefepime/ceftriaxone/meropenem, ESBL Klebsiella sensitive to
cipro/meropenem/zosyn, C diff s/p colectomy, type 2 diabetes
mellitus, peripheral vascular disease. Patient presents from
SNF found today with sats ___ and not responding to commands,
not nodding. Baseline non-verbal, but will nod to questions.
___ ED, BPs dipped to high ___, low ___. Patient with a trach,
seems to have a cuff ___ need to be changed out. UA
positive. Given cefepime and vanco. Trop may be demand. Given 2L
NS.
On transfer, VS: 85 95/52 16 100% trach mask.
On arrival to the ICU, HR 73, BP 87/53, RR 11, 93% trach mask.
Patient unresponsive, not moving extremities.
Review of systems: unable to obtain, patient unresponsive
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no ___ records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration (___) -
Portex Bivono, Size 6.0
* C.diff colitis ___ ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin ___
(outside facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
Admission exam:
Vitals: HR 73, BP 87/53, RR 11, 93% trach mask
General: Unresponsive, no respiratory distress. No facial
expression, not moving extremities
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchi from anterior lung fields. No crackles.
CV: RRR, ___ systolic ejection murmur. No rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: Foley draining purulent urine
Ext: cold, not well perfused, slow cap refill. b/l hands and
feet contracted. no cyanosis or edema
Discharge exam:
Vitals: HR 84 BP 128/72 97% trach mask
Gen: Nodding to questions
GU: foley draining clear urine
Ext: warm and well perfused
Exam otherwise unchanged
Pertinent Results:
___ 07:45PM BLOOD WBC-21.5*# RBC-6.16 Hgb-13.5* Hct-43.8
MCV-71* MCH-21.9* MCHC-30.8* RDW-16.8* Plt ___
___ 07:45PM BLOOD Neuts-86.9* Lymphs-7.5* Monos-4.4 Eos-1.0
Baso-0.1
___ 07:45PM BLOOD ___ PTT-30.1 ___
___ 07:45PM BLOOD Glucose-171* UreaN-47* Creat-2.0*# Na-137
K-6.4* Cl-97 HCO3-27 AnGap-19
___:45PM BLOOD ALT-33 AST-62* AlkPhos-88 TotBili-0.8
___ 07:45PM BLOOD Lipase-32
___ 07:45PM BLOOD cTropnT-0.13*
___ 07:50PM BLOOD Glucose-160* Lactate-3.5* Na-142 K-5.3*
Cl-98 calHCO3-29
MICROBIOLOGY:
Blood culture x2 (___)- pending, NGTD
Urine culture (___)- preliminary, pending final
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Sputum culture (___)-
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Stool culture (___)- negative for c.difficule toxin
IMAGING:
CT head ___:
FINDINGS: No hemorrhage, evidence of acute major vasculaR
territorial
infarction, edema, or shift of normally midline structures is
present.
Ventricles and sulci remain mildly prominent. Large arachnoid
cyst ___ the
left middle cranial fossa is stable. ICA, vertebral and basilar
calcifications are stable. Periventricular hypodensities are
consistent with small vessel ischemic changes. Retained
secretions are seen ___ the
oropharynx. The visualized mastoid air cells and paranasal
sinuses are well aerated. Minimal thickening is seen ___ the
anterior left ethmoid air cells.
IMPRESSION: No acute intracranial process.
CXR ___:
FINDINGS: Portable AP upright chest radiograph is obtained. Hazy
opacities
are new ___ the mid and lower lungs, which is concerning for
pneumonia. No
large effusion or pneumothorax is seen. Cardiomediastinal
silhouette appears grossly stable.
IMPRESSION: New hazy opacities involving the mid and lower lungs
could
reflect pneumonia.
CXR ___: PICC tip projecting over mid SVC
Brief Hospital Course:
___ with PMHx of CVA, h/o multiple pneumonias (s/p trach/PEG
___ with Pneudomonas, multiple UTI/urosepsis with Proteus
and ESBL Klebsiella, presents from SNF with sats ___ and
decreased responsiveness.
# Hypotension: Patient initially hypotensive with SBP ___ and
MAP ___. Hypotension due to septic shock as lactate elevated to
3.5 on presentation. Given grossly dirty UA, UTI was thought to
be most likely source. However, with hypoxia, pneumonia and
pulmonary source were also considered. Patient has an extensive
history of UTI and pneumonia with ESBL Kleibsiella, and
Pseudomonas sensitive to cipro and gentamicin. Hypovolemic
hypotension possible, but patient only minimally responsive to
fluid boluses. No obvious source of bleeding. Hct well-above
baseline, likely hemoconcentrated. ___ the FICU, femoral CVL
placed, and patient responded to some fluid boluses. He briefly
required levophed. He was off of pressure support and not
requiring fluid boluses for greater than 24 hours on the day of
discharge. Blood cultures showed no growth to date and urine
cultures grew proteus and gram negative rods ___ sputum. Patient
was broadly covered with meropenem, cipro and vancomycin. Cipro
was discontinued and patient was discharged on vancomycin and
meropenem with planned 8 day course (day 3 on day of discharge).
A PICC line was placed on ___ for antibiotic
administration.
# Hypoxia: O2 sat ___ ___ at nursing home. Improved to mid ___
on trach mask. Patient was treated with antibiotics as above
and improved.
# ___- Patient with history ___ with septic episodes. Given
elevation BUN/Cr ratio, likely pre-renal etiology ___ the setting
hypotension and hypoperfusion. Cr trended down to baseline
(1.0) with fluid resuscitation.
# Goals of care: Discussed at length with family. Decided to
make patient DNR but ok to ventilate via trach if needed.
# Atrial Fibrillation - EKG was consistent with Sinus rhythm.
Coumadin initially held and INR was 3.8 on the day of discharge
so was held.
# Sacral decubitus ulcer: Granulation tissue with no exudate.
Two Stage 2 ulcers.
# Hypothyroidism: stable. T4 ___ ___ 10.0 (wnl). Continued on
home Levothyroxine.
# Type 2 Diabetes: Stable. ___ Glucose, HISS.
# Peripheral Neuropathy: Continued home Gabapentin and Fentanyl
Patch
# Depression: Switched duoloxetine to Paxil for NG tube.
Continued mirtazapine.
# GERD: Continued lansoprazole.
.
TRANSITIONAL ISSUES:
- held warfarin at the time of discharge as INR 3.8
- meropenem and vancomycin x 8 days (final day = ___
- code status: CHANGED to DNR, ok to ventilate via trach if
necessary
- pending labs/studies: blood cultures x 2, final urine culture
- follow-up: vancomycin trough on ___ prior to AM dose needs to
be drawn
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) nebs q6H
2. ipratropium bromide 0.02 % nebs q6H
3. baclofen 15mg ___ QID
4. duloxetine 30 mg Capsule, Delayed Release(E.C.) ___ BID
5. fentanyl 100 mcg/hr Patch q72hr
6. gabapentin 300 mg q8H
7. levothyroxine 25 mcg ___
8. mirtazapine 15 mg ___ qHS
9. acetaminophen 650 mg/20.3 mL Solution ___ Q6H prn pain
10. ascorbic acid ___ mg ___
11. miconazole nitrate 2 % Powder Appl Topical BID prn skin
irritation
12. senna 8.6 mg ___ BID prn constipation.
13. lansoprazole 30 mg Tablet,Rapid Dissolve ___ ___
14. bisacodyl 10 mg Tablet ___ prn constipation.
15. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution ___
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) nebs q2H prn SOB
17. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension
___ ___ QID prn stomach upset.
18. meropenem 500 mg Recon Soln IV Q6H for 11 days (last day
___
19. docusate sodium 50 mg/5 mL Liquid 10ml ___ qHS
20. enoxaparin 80 mg/0.8 mL Subcutaneous BID until INR is
therapeuic
21. Lantus 100 unit/mL Solution 34 units qHS
22. Insulin Sliding Scale
23. warfarin 4 mg ___
24. acetylcysteine 20% (200 mg/mL) 1 QID
25. ipratropium bromide 0.02 % nebs q2h prn SOB
26. Milk of Magnesia 400 mg/5 mL 30 ml ___ prn constipation
27. Glucerna Liquid Sig: One (1) app ___ once a day: 1.2 via
feeding pump at 75 mL/hr. Up at 2pm down at 10am.
28. multivitamin ___
29. Novolin R 100 unit/mL Solution Sig: per sliding scale
Injection QAC.
Discharge Medications:
1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___
(___).
2. therapeutic multivitamin Liquid Sig: Five (5) milliliters
___: Gtube at 9AM.
3. Novolin R 100 unit/mL Solution Sig: per sliding scale
Injection four times a day: 6:30, aA:00, 16:00, 21:0O ___.
Sliding Scale: ___ = 0 units, 201-250 = 2 units, 251-300 4
units, 301-350 = 6 units, 351-400 = 8 units, 401 - 450 = 10
units, 451-500 = 12 units, >500 units = ___ MD/NP.
4. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime): 9 ___.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet ___ four times
a day as needed for pain: or temperature > 100.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation q2hrs as needed for
shortness of breath or wheezing.
7. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
8. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol: PRn glycometer check < 70 special insrtuctions: if BS
< 70 and resident unresponsive give glucagon 1 mg sub-q, recheck
___ ___ 10 minutes, notify MD/NP.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
milli-liters ___ once a day as needed for constipation.
10. Mylanta 200-200-20 mg/5 mL Suspension Sig: Thirty (30) ___
four times a day as needed for heartburn.
11. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
0.25 milliliters ___ every twelve (12) hours as needed for pain.
12. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for constipation.
13. miconazole nitrate 2 % Powder Sig: One (1) Topical twice a
day as needed for groin.
14. nystatin 100,000 unit/g Powder Sig: One (1) Topical twice a
day as needed for hand (right).
15. zinc oxide Ointment Sig: One (1) Topical twice a day as
needed for buttocks.
16. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day): g tube.
17. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ___ once a
day as needed for constipation.
18. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) ___ twice a day.
19. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal
once a day: change q72 hours.
20. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution Sig: Five
(5) mL ___ once a day.
21. gabapentin 250 mg/5 mL Solution Sig: One (1) ___ every eight
(8) hours.
22. Glucerna Liquid Sig: One (1) ___ qshift.
23. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) ___ once a day.
24. insulin glargine 100 unit/mL Solution Sig: ___ (34)
Subcutaneous at bedtime.
25. meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 5 days: ending ___.
26. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 5 days: ending ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urosepsis v pneumonia
Discharge Condition:
Mental status: nonverbal, nods to questioning
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Patient was admitted with hypotension concerning for septic
shock. He was treated with meropenem and vancomycin and a ___
line was placed for ongoing IV antibiotics. Antibiotics should
be continued through ___. Patient will need vancomycin
trough level checked tomorrow morning prior to 4th dose
(___).
Warfarin was held as INR supratherapeutic at 3.8.
MEDICATION CHANGES:
START vancomycin 1000mg IV q12h ending ___
START meropenem 500mg IV q8h ending ___
HOLD warfarin until INR therapeutic
Followup Instructions:
___
|
10599327-DS-22 | 10,599,327 | 25,430,648 | DS | 22 | 2136-02-13 00:00:00 | 2136-02-14 11:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
___ PICC line placement
___ PICC line replacement
History of Present Illness:
Mr. ___ is a ___ gentleman with a complicated PMH
including CVA (nonverbal and does not move arms/legs at
baseline), afib on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG ___, multiple prior episodes of
UTI/urosepsis with drug-resistant organisms, C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presents now with fever to 101, leukocytosis to
27.7, one episode of vomiting earlier today, and question of
aspiration. He was given a dose of tylenol ___ his nursing home
prior to transfer. He was brought to ED by ambulance from his
nursing home.
.
___ the ED, initial vitals were 97.6 67 101/64 18 99% 2L.
Patient reported left chest pain as he is able to nod yes or no.
Labs notable for WBC 23.7 with 87% N. UA showed mod leuk, tr
bld, neg nitr, 7 RBC, 101 WBC, mod bacteria, no epis. EKG was
sinus at 69, LAD, RBBB, c/w prior per report. CXR revealed
infiltrates concerning for pneumonia. He received broad
spectrum antibiotics including levaquin, vancomycin 1 gram, and
cefepime 2 grams. He was initially assigned a floor bed, but
his BP dropped to mid 80's systolic. A 18G was placed on the
right with a 20G on the left. He was bolused with IVF for a
total of 3L. Was admitted for treatment of PNA and UTI. Most
recent vitals prior to transfer were 64 101/64.
.
Of note, patient has had several recent admissions, including
admission to ___ ___ ___ with urosepsis treated with
vancomycin and meropenem, and Medicine ___ with
UTI/sepsis treated with ceftriaxone and a right cold foot felt
to be secondary to vasospasm, that did not require surgical
intervention. Patient received pain control, was seen by
Vascular surgery, and had return of palpable pulses during the
admission.
.
Upon arrival to the MICU, his vital signs were T 36.1, p 72, bp
116/67, r 11, 94% trach mask. On interview, he acknowledged that
he was ___ some discomfort but indicated that it was not ___ his
chest, abdomen, extremities, or genital area. Interview was
limited by his inability to respond beyond nodding yes/no, and
he was only responsive to very simple questions.
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no ___ records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration (___) -
Portex Bivono, Size 6.0
* C.diff colitis ___ ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin ___
(outside facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
GENERAL: well-appearing ___ NAD, comfortable, appropriate
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no cervical LAD, no JVD, no carotid bruits
LUNGS: CTAB, no wheezing/rales/rhonchi, good air movement,
respirations unlabored, no accessory muscle use
HEART: RRR, nl S1-S2, no r/m/g
ABDOMEN: normoactive bowel sounds, soft, NT, ND, no
organomegaly, no guarding or rebound tenderness
EXTREMITIES: warm, well-perfused, no edema, 2+ peripheral pulses
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
On discharge:
VSS, HR ___ mid ___, pressures 110-120/60s
Complains of right leg pain when asked, but pulses strong and no
open lesions. Otherwise as above.
Pertinent Results:
Admission Labs:
___ 06:10PM LACTATE-1.0 K+-4.7
___ 06:00PM GLUCOSE-140* UREA N-33* CREAT-0.7 SODIUM-145
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-30 ANION GAP-15
___ 06:00PM estGFR-Using this
___ 06:00PM WBC-23.7*# RBC-5.62 HGB-12.5* HCT-40.2
MCV-72* MCH-22.3* MCHC-31.2 RDW-16.1*
___ 06:00PM NEUTS-87.0* LYMPHS-8.9* MONOS-3.1 EOS-0.8
BASOS-0.2
___ 06:00PM PLT COUNT-212
___ 06:00PM ___ PTT-32.6 ___
___ 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:00PM URINE HYALINE-4*
___ 06:00PM URINE HYALINE-4*
.
Other relevant labs:
___ 03:33AM BLOOD WBC-12.1* RBC-4.32* Hgb-9.8* Hct-31.4*
MCV-73* MCH-22.7* MCHC-31.1 RDW-16.2* Plt ___
___ 07:55AM BLOOD WBC-7.9 RBC-4.38* Hgb-9.6* Hct-32.8*
MCV-75* MCH-22.0* MCHC-29.4* RDW-16.3* Plt ___
___ 07:55AM BLOOD ___ PTT-31.2 ___
___ 07:55AM BLOOD Vanco-18.3
___ 05:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 05:00PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
CXR ___:
New bibasilar opacities, with low lung volumes. Considerations
include pneumonia ___ the appropriate clinical setting, but
atelectasis or even aspiration could be considered depending on
clinical circumstances.
.
___ CXR:
FINDINGS: Tip of right PICC terminates ___ the lower superior
vena cava. The tip of the catheter is about 3.3 cm below the
level of the radiodense
guidewire, which terminates ___ the mid superior vena cava.
Tracheostomy tube remains ___ standard position. Stable
cardiomegaly, and improving pleural effusion and left basilar
atelectasis.
.
MICROBIO:
___ Blood cult1ure x 2: Negative to date
___ Urine: URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ and ___ Sputum: GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
Unable to definitively determine the presence or absence
of commensal
respiratory flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
___ Legionella: Negative
Studies pending at Discharge:
___ Urine Cx
Brief Hospital Course:
___ gentleman, nonverbal status post a prior stroke with
residual paraplegia status post trach/PEG, atrial fibrillation
on warfarin, history of chronic aspiration and multiple
pneumonias, urinary tract infections and sepsis with
drug-resistant organisms admitted with pneumonia, sepsis, and
possible urinary tract infection
.
#Septic Shock/Pneumonia/Urinary tract infection:
Patient was initially admitted to the MICU with fluid responsive
hypotension. He had a dirty UA and chest X-ray consistent with
pneumonia. He was empirically treated with Vancomycin and
Cefepime with improvement ___ his hypotension and leukocytosis
(initially 27 but normal on discharge). A PICC line was placed
to complete an 8 day course of Vancomycin/Cefepime for health
care associated pneumonia which was felt to cover urinary
pathogens as well. Sputum grew Proteus. Although urine culture
was pending at time of discharge, the overall clinical
improvement suggested that any urinary pathogens would be
sensitive to Vancomycin and Cefepime. Urine culture however
should be followed at rehab. Given chronic Foley catheter if
urine culture is positive would consider treating for two weeks
with antibiotics to cover urinary sources and Foley should be
changed at next Urology appointment.
..
#Diabetes mellitus: Continued on home glargine and ISS
.
# Depression: Continued on Duloxetine and Mirtazapine
.
# Atrial fibrillation: Continued on Warfarin. INRs were mildly
subtherapeutic at 1.8
.
# Pain, probably neuropathic: Pt complained of right leg pain.
Pulses were strong and there was no wound. Pt continued on
Fentanyl, Morphine, Tylenol, Gabapentin, and Cymbalta.
.
# Hypothyroidism: Continued Levothyroxine
.
# Sacral decubitus ulcer: Healing. Would continued wound care
with frequent repositionings and dressings ___ as needed.
.
.
Code status: DNR/DNI.
.
TRANSITIONAL:
1) Complete antibiotics-Last day: ___ if urine culture
negative, ___ if urine culture positive.
2) Follow up with urology for consideration of suprapubic
catheter placement given recurrent urinary tract infections and
sepsis
3) Follow up sensitivities for proteus positive sputum culture
and enteroccocus urinary tract infection with adjustment of
antibiotic course as dictated by urine culture
Medications on Admission:
MEDICATIONS (per ___ d/c summary):
1. fentanyl 75 mcg/hr Patch 72 hr Sig: One Patch 72 hr
Transdermal Q72H (every 72 hours).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
3. insulin glargine 100 unit/mL Solution Sig: ___ (32)
units Subcutaneous at bedtime.
4. insulin sliding scale, continue insulin sliding scale as
prior to admission
5. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for constipattion.
6. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One
capsule, Delayed Release(E.C.) ___ once a day: g/j tube.
7. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
8. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day).
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) ___ HS (at
bedtime).
10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___.
11. coumadin 4mg coumadin ___
12. gabapentin 300 mg Capsule Sig: One (1) Capsule ___ every 8
hours.
13. ascorbic acid ___ mg/5 mL Syrup Sig: One (1) ___ BID
14. therapeutic multivitamin Liquid Sig: One (1) Tablet ___
15. zinc sulfate 220 mg Capsule Sig: One (1) Capsule ___
16. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
18. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML ___ as needed for constipation.
19. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
20. furosemide 20 mg Tablet Sig: One (1) Tablet ___
21. ceftriaxone ___ dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 7 days.
22. morphine 10 mg/5 mL Solution Sig: Ten (10) mg ___ Q6H (every
6 hours) as needed for pain.
23. acetaminophen 325 mg Tablet Sig: One (1) Tablet ___ Q6H
(every 6 hours) as needed for fever, pain.
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
2. insulin glargine 100 unit/mL Solution Sig: ___ (32)
units Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
QACHS: Continue insulin sliding scale.
4. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for Constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) ___.
6. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) inh Inhalation every ___ hours as
needed for shortness of breath or wheezing.
7. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day).
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL ___ BID (2
times a day).
9. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___
(___).
10. warfarin 4 mg Tablet Sig: One (1) Tablet ___ once a day.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule ___ Q8H (every
8 hours).
12. ascorbic acid ___ mg/5 mL Syrup Sig: Five (5) mL ___ twice a
day.
13. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q12H
(every 12 hours): Completed after ___.
14. vancomycin ___ D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours): Finished after ___.
15. multivitamin Liquid Sig: One (1) dose ___ once a day.
16. zinc sulfate 220 (50) mg Capsule Sig: One (1) Capsule ___
once a day.
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above ___ and PRN
per lumen. .
18. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___ a day.
19. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
mL ___ once a day as needed for constipation.
20. bisacodyl 10 mg Suppository Sig: One (1) Rectal at bedtime
as needed for constipation.
21. furosemide 20 mg Tablet Sig: One (1) Tablet ___
(___).
22. morphine 10 mg/5 mL Solution Sig: 10mg ___ Q6H (every 6
hours) as needed for pain.
23. acetaminophen 325 mg Tablet Sig: ___ Tablets ___ Q6H (every 6
hours) as needed for pain.
24. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every ___ (72) hours.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Sepsis from UTI and possibly Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive, non-verbal, but
able to answer questions with nods and shakes and follows
commands.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for sepsis that was found to be most likely from your
urine and possibly from your lungs. You were given fluids and
IV antibiotics which improved your infection. A PICC line was
placed so that you may take these antibiotics at your extended
care facility.
You should follow up with urology regarding evaluation for
suprapubic catheter placement as this may decrease your episodes
of urinary tract infection and sepsis.
Changes to your medications:
STARTED Vancomycin
STARTED Cefepime
STOPPED Ceftriaxone
Followup Instructions:
___
|
10599327-DS-23 | 10,599,327 | 24,503,635 | DS | 23 | 2136-03-24 00:00:00 | 2136-03-24 16:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cracked PEG-tube requiring replacement
Major Surgical or Invasive Procedure:
PEG tube replacement by ___
History of Present Illness:
Mr. ___ is a ___ ___ with complicated
PMH including CVA (nonverbal and does not move arms/legs at
baseline), AF on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG ___, multiple prior episodes of
UTI/urosepsis with drug-resistant organisms, C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presents for PEG tube replacement.
.
The patient was in his usual state of health until ___
afternoon when his PEG-tube was found to be cracked near the
colored distal ending. Because of this, he did not receive his
tube feeds for the remainder of the day. He was sent to ___
for replacement of PEG tube.
.
In the ED, initial VS: T- 98, HR- 94, BP- 144/90, RR- 18, SaO2
95% 5L trach mask. Besides being mildy diaphoretic, the patient
has no other active issues/symptoms. Lab work pertinent for WBC
14.5, INR 1.9, normal renal function. UA showed lg leuk, mod
bld, pos nitr, 35 RBC, 109 WBC, few bacteria, no epis. CXR did
not demonstrate an acute process and the patient remained
afebrile and comfortable in the ED. Vital signs on transfer T-
98.2, HR- 77, RR- 18, BP- 148/81, SaO2- 94% on trach mask
.
On arrival to the floor, vital signs were T- 98.1, HR- 80, RR-
20, SaO2- 96% on RA. On ___, pt endorses pain in his upper
legs, but denies CP, HA, SOB, abdom pain.
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
* Type 2 Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no ___ records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration (___)-
Portex Bivono, Size 6.0
* C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin ___
(outside facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T- 98.1, HR- 61, BP- upon my recheck SBP 110s/70-80s (BP
lower on R arm), RR- 12, SaO2- 98% on RA.
GENERAL: NAD, comfortable, non-verbal but can nod/shake head in
response to ?'s
HEENT: Persistent mouth smacking, EOMI and making good eye
contact
NECK: supple, trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use
HEART: distant heart sounds but RRR, nl S1-S2, no r/m/g
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. Ostomy in place, PEG in place (cracked near
distal end). Midline scar. no guarding or rebound tenderness
or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema
NEURO: awake, non-verbal. Cannot move legs or feet/toes; can
move both arms slightly (contracted hands b/l).
.
DISCHARGE PHYSICAL EXAM:
VS - T- 97.5, HR- 57, BP- 118/50, RR- 12, SaO2- 100% on trach
GENERAL: NAD, comfortable, non-verbal but can nod/shake head in
response to ?'s
HEENT: Persistent mouth smacking, EOMI and making good eye
contact
NECK: supple, trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use
HEART: distant heart sounds but RRR, nl S1-S2, no r/m/g
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. Ostomy in place, PEG in place (cracked near
distal end). Midline scar. no guarding or rebound tenderness
or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly (contracted hands b/l).
Pertinent Results:
ADMISSION LABS:
___ 11:20PM BLOOD WBC-14.4*# RBC-5.90# Hgb-13.4*# Hct-41.5#
MCV-70* MCH-22.8* MCHC-32.4 RDW-15.5 Plt ___
___ 11:20PM BLOOD Neuts-78.7* Lymphs-14.6* Monos-5.7
Eos-0.4 Baso-0.5
___ 11:36PM BLOOD ___
___ 11:20PM BLOOD Glucose-135* UreaN-25* Creat-0.6 Na-143
K-4.1 Cl-102 HCO3-34* AnGap-11
___ 05:15AM BLOOD Calcium-9.3 Phos-4.1# Mg-2.2
___ 05:15AM BLOOD TSH-3.4
___ 11:36PM BLOOD Lactate-1.2
___ 02:01AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:01AM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 02:01AM URINE RBC-35* WBC-109* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
___ 02:01AM URINE WBC Clm-FEW Mucous-RARE
.
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-10.2 RBC-4.70 Hgb-10.6* Hct-33.2*
MCV-71* MCH-22.5* MCHC-31.8 RDW-15.5 Plt ___
___ 05:50AM BLOOD ___ PTT-37.1* ___
___ 05:50AM BLOOD Glucose-144* UreaN-17 Creat-0.4* Na-145
K-3.3 Cl-108 HCO3-30 AnGap-10
.
MICROBIOLOGY:
-___ 4:16 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
__________________________________________________________
___ 11:35 pm BLOOD CULTURE # 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
.
IMAGING:
___ CXR:
IMPRESSION: Patchy left basilar opacity and retrocardiac
opacities likely
represent atelectasis although supervening infection must be
considered in the appropriate clinical setting.
Brief Hospital Course:
Mr. ___ is a ___ ___ with complicated PMH
including CVA (nonverbal and does not move arms/legs at
baseline), AF on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG ___, multiple prior episodes of
UTI/urosepsis with drug-resistant organisms, C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presents for PEG tube replacement due to a
cracked PEG tube.
.
ACTIVE ISSUES:
.
# PEG tube replacement- damage to PEG tube was occured ___ at
nursing home. Patient did not received tube feeds on ___. ___
replaced his tube on ___. His tube feeds and meds were resumed
without difficulty.
.
# Leukocytosis - Initial WBC elevated to 14.5 ->17.3 on ___.
Blood cultures showed NGTD. Lactate was within normal limits
and pt remained afebrile throughout admission with stable
vitals. Pt likely has leukocytosis from UTI ___ chronic foley,
and he has an extensive Hx of multiply resistant organisms in
his urine; initial U-Cx came back with >100,000 Proteus, likely
colonizer given chronic foley. PNA was unlikely given clinical
picture and CXR. Pt remained stable, and his WBC decreased to 10
on ___, thus antibiosis was deferred. His foley catheter was
changed for a new one on ___.
.
CHRONIC ISSUES:
.
# Diabetes mellitus: ISS while admitted.
.
# Depression: Continued on duloxetine and mirtazapine.
.
# Atrial fibrillation: continued on home dose of warfarin 4mg
daily. Admission INR mildly subtherapeutic at 1.9 -> 1.8 on
___ improved to 2.3 on ___.
.
# Hypothyroidism: continued levothyroxine at home dose; TSH this
admission was 3.4.
.
# Tracheostomy- satting well on trach mask.
.
# Pain, probably neuropathic: On fentanyl, Morphine, Tylenol,
Gabapentin, and Cymbalta at home; we continued his home regimen
while in ___.
.
# Sacral decubitus ulcer: Healing. Wound care was consulted (see
their recs below).
.
TRANSITIONAL ISSUES:
.
-Pt's code status was DNR/DNI prior to admission and throughout
this admission.
.
-Pt's foley catheter was changed for a new one on ___
.
-Wound care recs:
sacral/coccyx skin breakdown:
Goals of care: prevention of increased skin breakdown
Suggest:
Pressure ulcer care per guidelines:
Turn and reposition off back q 2 hours and prn
Limit sit time to 1 hour at a time using a pressure
redistribution cushion.
Clease B/L gluteals with Commercial wound cleanser. Pat dry.
Apply Mepilex Sacral Border dressing
Change every 3 days
Medications on Admission:
(per ___ d/c summary):
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
2. insulin glargine 100 unit/mL Solution Sig: ___ (32)
units Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
QACHS: Continue insulin sliding scale.
4. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for Constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
capsule, Delayed Release(E.C.) ___ DAILY (Daily).
6. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) inh Inhalation every ___ hours as
needed for shortness of breath or wheezing.
7. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day).
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL ___ BID (2
times a day).
9. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___ DAILY
(Daily).
10. warfarin 4 mg Tablet Sig: One (1) Tablet ___ once a day.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule ___ Q8H (every
8 hours).
12. ascorbic acid ___ mg/5 mL Syrup Sig: Five (5) mL ___ twice a
day.
13. multivitamin Liquid Sig: One (1) dose ___ once a day.
14. zinc sulfate 220 (50) mg Capsule Sig: One (1) Capsule ___
once a day.
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
untravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
18. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
tablet,Rapid Dissolve, ___ ___ a day.
19. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
mL ___ once a day as needed for constipation.
20. bisacodyl 10 mg Suppository Sig: One (1) Rectal at bedtime
as needed for constipation.
21. furosemide 20 mg Tablet Sig: One (1) Tablet ___ DAILY
22. morphine 10 mg/5 mL Solution Sig: 10mg ___ Q6H (every 6
hours) as needed for pain.
23. acetaminophen 325 mg Tablet Sig: ___ Tablets ___ Q6H (every 6
hours) as needed for pain.
24. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every ___ (72) hours.
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
2. insulin glargine 100 unit/mL Solution Sig: ___ (32)
Units Subcutaneous at bedtime.
3. insulin aspart 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
4. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day) as needed for constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) ___ DAILY (Daily).
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) Inhalation every ___ hours as
needed for shortness of breath or wheezing.
7. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day).
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL ___ BID (2
times a day) as needed for constipation.
9. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___ DAILY
(Daily).
10. warfarin 2 mg Tablet Sig: Two (2) Tablet ___ Once Daily at 4
___.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule ___ every
eight (8) hours.
12. ascorbic acid ___ mg/5 mL Syrup Sig: Five (5) mL ___ BID (2
times a day).
13. therapeutic multivitamin Liquid Sig: One (1) Tablet ___
DAILY (Daily).
14. zinc sulfate 220 mg Capsule Sig: One (1) Capsule ___ DAILY
(Daily).
15. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___ a day.
16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
mL ___ once a day.
17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
18. furosemide 20 mg Tablet Sig: One (1) Tablet ___ DAILY
(Daily).
19. morphine 10 mg/5 mL Solution Sig: Ten (10) mg ___ every six
(6) hours as needed for pain.
20. acetaminophen 650 mg/20.3 mL Solution Sig: ___ ___ Q6H
(every 6 hours) as needed for pain.
21. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Broken PEG Tube
Urinary tract infection
Secondary diagnoses:
- Hypertension
- Hypothyroidism
- History of stroke
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- Atrial fibrillation (on coumadin)
- Peripheral vascular disease
- Hyperlipidemia
- Anemia of chronic disease
- Tracheostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because your PEG
tube broke. You were also found to have a urinary tract
infection, which did not require any antibiotic treatment. Your
PEG tube was replaced, and your Foley catheter was also replaced
with a new one.
Your condition has improved and you can be discharged to your
rehab.
The following changes were made to your medications:
NEW: none
CHANGED: none
STOPPED: none
Please keep your follow-up appointments as scheduled below.
Followup Instructions:
___
|
10599327-DS-24 | 10,599,327 | 20,533,373 | DS | 24 | 2136-03-31 00:00:00 | 2136-04-01 12:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
Mr. ___ is a ___ ___ with complicated
PMH including CVA (nonverbal and does not move arms/legs at
baseline), AF on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG ___, multiple prior episodes of
UTI/urosepsis with drug-resistant organisms (VRE), C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presented to ED with blocked foley and elevated
WBC, and became hypotensive.
.
The patient was discharged on ___ after an admission for PEG
tube replacement. During this admission his foley catheter was
replaced and proteus not treated as this was felt to be due to
colonization.
.
In the ED, initial VS: T 97.6 HR 80 BP ___ RR 20 Sat 94% 4L
trach mask. WBC was 30, Na 146, Cr 1.6 from baseline of 0.4 and
UA was markedly positive. However, he dropped his SBPs to ___,
maps to ___, improved with IVF. MAP 65, HR 69, O2 95% trach on
4L breathing on his own at 16. has a 20g in EJ. DNR ok to vent.
.
In ICU, initial BP in 130/70 ___ecame hypotensive to 60-70s
again. Started on IVF and dopamine. Additional PIVs obtained.
Abx broadened to linezolid and cefepime.
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
* Type 2 Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no ___ records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Tracheostomy and GJ tube for chronic aspiration
___ Bivono, Size 6.0
* C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin
___ facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 97.7 (Axillary) BP: 125/64 P: 58 R: 17 O2: 97% on
trach 4L
General: awake, non-verbal, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear. Eyes looking
up, pupils R>L but reactive to light bilaterally
NECK: trach in place with thick white secretions
LUNGS: Coarse breath sounds bilaterally, +scattered wheezing
bilaterally, good air movement, respirations unlabored, no
accessory muscle use
HEART: distant heart sounds but RRR, nl S1-S2, no r/m/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, PEG and ostomy bags in place.
GU: foley draining cloudy urine.
Ext: cold, palpable pulse on L DP, dopplerable ___ on R, no
edema.
NEURO: awake, non-verbal. No spontaneous movement of
extremities. Contracted arms bilaterally.
.
DISCHARGE EXAM:
VS - T- Afebrile, HR- ___ , BP- 120-130s/70s-80s , RR-20 ,
SaO2- 96-99% RA
GENERAL: non-verbal but can nod/shake head in response to
questions
HEENT: EOMI and making good eye
contact, sclera anicteric
NECK: supple, trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use
HEART: distant heart sounds but Reg nl S1-S2,
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. PEG in place. Midline scar. no guarding or
rebound tenderness or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema, contractions. Some
mild bleeding at midline insertion site with pressure dressing
placed.
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly L>R (contracted hands b/l).
Pertinent Results:
ADMISSION LABS:
___ 06:10PM BLOOD WBC-30.2*# RBC-5.64 Hgb-13.4*# Hct-40.0
MCV-71* MCH-23.8* MCHC-33.5 RDW-16.0* Plt ___
___ 06:10PM BLOOD Neuts-84.7* Lymphs-10.9* Monos-3.6
Eos-0.2 Baso-0.4
___ 02:10AM BLOOD ___
___ 06:10PM BLOOD Glucose-134* UreaN-50* Creat-1.6*#
Na-146* K-4.9 Cl-107 HCO3-29 AnGap-15
.
___ 07:01PM BLOOD Lactate-2.3*
___ 10:47PM BLOOD Lactate-1.1
.
___ 06:10PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 06:10PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 06:10PM URINE RBC-28* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
.
Microbiology:
UCx ___: URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
BCx ___: no growth to date
Sputum cx:
___ 10:00 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
.
IMAGING STUDIES:
___ CHEST (PORTABLE AP) - In comparison with study of ___,
there may be some mild engorgement with poor definition of lower
lung vessels, suggesting some elevated pulmonary venous
pressure. The right hemidiaphragm is more sharply seen,
suggesting some improved aeration at the right base. Patchy
opacifications at the bases most likely reflect atelectasis,
though in the appropriate clinical setting, supervening
pneumonia would have to be considered.
Discharge Labs/Notable Studies:
___ 06:25AM BLOOD WBC-8.3 RBC-4.71 Hgb-10.1* Hct-32.3*
MCV-69* MCH-21.4* MCHC-31.3 RDW-16.1* Plt ___
___ 06:25AM BLOOD ___
___ 06:25AM BLOOD Glucose-157* UreaN-15 Creat-0.4* Na-140
K-3.3 Cl-104 HCO3-28 AnGap-11
Studies pending on discharge:
None
Brief Hospital Course:
___ yo M with history CVA c/b anoxic brain injury now nonverbal,
paraplegic, bedbound, able to shake head and move upper
extremities slightly, s/p trach/PEG admitted with septic shock
due to Proteus urinary tract infection.
#Urinary tract infection/Septic shock:
Patient was admitted with septic shock initially to the
Intensive Care Unit and was treated with broad spectrum abx
including Linezolid (for h/o VRE) and Cefepime and required
dopamine for vasopressor support along with IVF rescucitation.
His symptoms improved and he was transferred to the floor. His
urine cultures grew proteus sensitive to Ceftriaxone and his
antibiotics were narrowed to Ceftriaxone alone to be continued
for a 2 week course for complicated UTI.
# Trach/respiratory: Patient had some thick secretions but CXR
showed no pneumonia and he did not have hypoxia. Duonebs were
given prn.
#Acute renal failure: Patient found to have elevated creatinine
to 1.6 which improved to baseline 0.4-0.7 with treatment of
sepsis.
# Hypernatremia: mild, likely in setting of
hypovolemia/dehydration, improved with hydration/free water.
.
#Type 2 Diabetes mellitus: Patient on insulin as outpatient. his
blood blood glucose was monitored and he was continued on home
lantus and humalog SSI.
.
# Depression/Leg pain:
Duloxetine and mirtazapine were initially held due to concern of
interaction with Linezolid. Patient did experience increased leg
pain with these held. These were restarted when renal function
improved and linezolid was discontinued and pain symptoms
improved.
.
# Atrial fibrillation: Patient was continued on Coumadin. INR
was therapeutic except for day of discharge (1.7). This should
be followed by NH.
.
Chronic Issues:
# Hypothyroidism: continue levothyroxine 25 mcg ___ by NG tube
.
# Spasticity: continue baclofen 15 mg QID
.
# C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___
- colostomy care
.
# Peripheral neuropathy: continued gabapentin 300 mg q8hrs
.
# FEN: NPO. Tube feeds
# Prophylaxis: systemic anticoagulation with coumadin
# Access: midline Left upper extremity
# Communication: ___ ___ (cell);
___ (day); ___ (eve), son/HCP
# Code: DNR, ok to use trach (discussed with the HCP)
# Disposition: Patient was discharged to his NH to complete
treatment for proteus UTI to end ___. INR should be monitored
as INR was 1.7 on day of discharge.
Medications on Admission:
- acetaminophen 650 mg/20.3 mL Solution, ___ by mouth every six
(6) hours as needed for pain.
- ascorbic acid ___ mg/5 mL Syrup, Five (5) mL by mouth twice a
day.
- baclofen 10 mg Tablet 1.5 Tablets by mouth four times a day.
- bisacodyl 10 mg Suppository, One (1) Suppository Rectal HS (at
bedtime) as needed for constipation.
- docusate sodium 50 mg/5 mL Liquid, Ten (10) mL by mouth twice
a day as needed for constipation.
- duloxetine 30 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) by mouth ___.
- fentanyl 100 mcg/hr Patch 72 hr One (1) Patch 72 hr
Transdermal every ___ (72) hours.
- furosemide 20 mg Tablet One (1) Tablet by mouth ___.
- gabapentin 300 mg Capsule One (1) Capsule by mouth every eight
(8) hours.
- insulin aspart 100 unit/mL Solution sliding scale Subcutaneous
four times a day.
- insulin glargine 100 unit/mL Solution ___ (32) Units
Subcutaneous at bedtime.
- ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization One (1) Inhalation every ___ hours as needed
for shortness of breath or wheezing.
- lansoprazole 30 mg Tablet,Rapid Dissolve, ___ ___ (1)
Tablet,Rapid Dissolve, ___ ___ mouth once a day.
- levothyroxine 25 mcg Tablet One (1) Tablet by mouth ___
(___).
- magnesium hydroxide 400 mg/5 mL Suspension Thirty (30) mL by
mouth once a day.
- mirtazapine 15 mg Tablet One (1) Tablet by mouth HS (at
bedtime).
- morphine 10 mg/5 mL Solution Ten (10) mg by mouth every six
(6) hours as needed for pain.
- sennosides [senna] 8.6 mg Tablet One (1) Tablet by mouth twice
a day as needed for constipation.
- therapeutic multivitamin Liquid One (1) Tablet by mouth ___
(___).
- warfarin 2 mg Tablet Two (2) Tablet by mouth Once ___ at 4
___.
- zinc sulfate 220 mg Capsule One (1) Capsule by mouth ___
(___).
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) ___ Q6H
(every 6 hours) as needed for pain/fever.
2. ascorbic acid ___ mg/5 mL Syrup Sig: One (1) ___ BID (2 times
a day).
3. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day).
4. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
twice a day as needed for constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) ___: please give via
GT.
6. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule ___ TID (3
times a day).
8. insulin aspart 100 unit/mL Solution Sig: as directe
Subcutaneous every six (6) hours: according to sliding scale.
9. insulin glargine 100 unit/mL Solution Sig: ___ (32)
units Subcutaneous at bedtime.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as
needed for wheezing/shortness of breath.
11. ipratropium bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for wheezing/shortness
of breath.
12. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
13. furosemide 20 mg Tablet Sig: One (1) Tablet ___
(___).
14. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
15. morphine 10 mg/5 mL Solution Sig: Five (5) mL ___ Q6H (every
6 hours) as needed for pain.
16. warfarin 2 mg Tablet Sig: Two (2) Tablet ___ Once ___ at 4
___.
17. zinc sulfate 220 mg Capsule Sig: One (1) Capsule ___
(___): continue until ___.
18. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML ___ QID
(4 times a day) as needed for thrush.
19. levothyroxine 25 mcg Tablet Sig: One (1) Tablet ___
(___).
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
21. CeftriaXONE 1 gm IV Q24H Duration: 7 Days
To end ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Sepsis
Urinary tract infection
Secondary:
Prior stroke
Type 2 Diabetes Mellitus
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent. (nonverbal but understands
and able to communicate with head nodding)
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for sepsis due to a urinary tract infection.
You improved with antibiotics and are being discharged on a two
week total course of antibiotics to end ___.
Your pain medications were initially held, but were restarted
prior to discharge once your renal function and blood pressure
returned to normal.
Followup Instructions:
___
|
10599327-DS-25 | 10,599,327 | 26,477,106 | DS | 25 | 2136-06-13 00:00:00 | 2136-06-13 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GJ tube needing exchange, UTI, need for trach exchange
Major Surgical or Invasive Procedure:
Tracheostomy exchange
PICC placement
GJ tube unclogging X2
History of Present Illness:
Mr. ___ is a ___ ___ with complicated
PMH including CVA (nonverbal and does not move arms or legs at
baseline), AFib on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG ___, multiple prior episodes of
urosepsis with drug-resistant organisms (VRE), C diff s/p
colectomy, DM2, PVD, and multiple admissions (most recently
___ for GJ tube replacement presenting today from nursing
home with concern that GJ tube is not working. En route with
EMS, patient developed desaturations down to 80%s. BLS was
unable to suction.
In the ED, initial VS were 98.8F 80 130/70 98% on trach mask.
Repiratory therapy was able to succion with rapid improvement in
respiratory status. Labs in the ED were notable for WBC 16.1
78%N, lactate 1.8, Cr 0.5, Na 141, K 4.2. UA was notable 25
RBCs, 136 WBCs, nitrite postitive and many bacteria.
A cuff leak was noted and replacement was not possible in the
ED. CXR did not reveal evidence of PNA. Clearance of J tube was
attempted with coke that was unsuccessful and imaging of J tube
was not possible given obstruction. ___ was consulted for J tube
replacement and advised admission for replacement. Surgery was
also consulted for replacement of trach and J tube and advised
admission to MICU for trach replacement. The patient receive 4.5
g Zosyn for UTI and admitted to the MICU for further management.
Vitals on transfer were ___ 82 119/79 21 98% on trach mask.
On arrival to the MICU, the patient appeared comfortable and was
hemodynamically stable. Surgery evaluated Pt for trach exchange,
but part was apparently not availble. Pt remained very stable,
with O2 sat > 98% on trach mask and Pt was called out to the
medical floor for further management.
.
Past Medical History:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- h/o DVT (? - no ___ records)
- Atrial fibrillation (on coumadin)
- Peripheral vascular disease
- Hyperlipidemia
- Tracheostomy and GJ tube for chronic aspiration
___ Bivono, Size 6.0
- C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin
___ facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease
.
Physical Exam:
Initial physical exam:
VITALS: 98.8F 80 130/70 98% on trach mask
GENERAL: non-verbal but can nod/shake head in response to
questions, patient denies pain. Also denies cough.
HEENT: EOMI and making good eye contact, sclera anicteric
NECK: supple, trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use
HEART: distant heart sounds but Reg nl S1-S2,
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. PEG in place. Midline scar. no guarding or
rebound tenderness or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema, contractions. Some
mild bleeding at midline insertion site with pressure dressing
placed.
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly L>R (contracted hands b/l).
Discharge exam:
GENERAL: non-verbal but can nod/shake head in response to
questions in ___, patient reports pain in lower extremities.
Denies cough, denies respiratory problems.
VITALS: 98.1, 92-100/53-56, 63-79, 20, 98% on trach mask
HEENT: EOMI and making good eye contact, sclera anicteric
NECK: supple, trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use. Thick
but clear phlegm expectorated from trach.
HEART: distant heart sounds but regular rate and rhythm, nl
S1-S2, no m/r/g
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. PEG in place. Midline scar. no guarding or
rebound tenderness or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema, contractions. Legs
atrophied but no visible lesions, no erythema. Reports severe
pain in lower extremities, mostly calves and thigh, seems to
worsen with palpation.
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly L>R (contracted hands b/l).
Pertinent Results:
Admission labs:
___ 07:50PM BLOOD WBC-16.1* RBC-5.49 Hgb-11.7* Hct-39.4*
MCV-72* MCH-21.2* MCHC-29.6* RDW-16.1* Plt ___
___ 07:50PM BLOOD Neuts-78.0* Lymphs-15.7* Monos-4.8
Eos-1.1 Baso-0.4
___ 07:50PM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-141
K-4.2 Cl-99 HCO3-32 AnGap-14
___ 07:50PM BLOOD Lactate-1.8
___ 08:50PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 08:50PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 08:50PM URINE RBC-25* WBC-136* Bacteri-MANY Yeast-NONE
Epi-0
Discharge labs:
___ 07:00AM BLOOD WBC-11.2* RBC-4.48* Hgb-9.7* Hct-33.1*
MCV-74* MCH-21.7* MCHC-29.4* RDW-16.2* Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-12 Creat-0.5 Na-141
K-3.6 Cl-105 HCO3-27 AnGap-13
___ 07:00AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.7
CK: 506
Micro:
___ 8:50 pm URINE
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORKUP REQUESTED BY ___. ___ ___.
GRAM NEGATIVE ROD #1. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #3. UNKNOWN AMOUNT.
GRAM NEGATIVE ROD #4. UNKNOWN AMOUNT.
Imaging:
___:
FINDINGS: A single portable AP chest radiograph was obtained and
is limited by portable technique and patient rotation. Focal
opacity at the left base appears more conspicuous compared with
prior studies dating back to ___. No other distinct
consolidation is identified. There is no effusion or
pneumothorax. Mild cardiomegaly is unchanged. Tracheostomy tube
remains in unchanged position. Right upper quadrant surgical
clips and a percutaneous gastrostomy tube are in appropriate
positions. IMPRESSION: Increased conspicuity of left lower lobe
opacity could represent developing consolidation and/or
aspiration or atelectasis.
___ Radiology CHEST PORT. LINE PLACEM
FINDINGS: AP single view of the chest has been obtained with
patient in semi-upright position. Comparison is made with the
next preceding similar study obtained two and a half hours
earlier during the same day. The previously identified
right-sided PICC line has been withdrawn by a few centimeters
and terminates now in a location 3 cm below the carina. This is
compatible with the lower third of the SVC. No other significant
interval change can be identified. As identified on previous
examinations the patient has a tracheoscopy cannula in place.
Brief Hospital Course:
___ with history CVA c/b anoxic brain injury (non-verbal at
baseline), paraplegic, bedbound, able to shake head and move
upper extremities slightly, s/p trach/PEG admitted with UTI,
occluded GJ tube and trach leak.
#Urinary tract infection: Patient has a history of UTIs with
urosepsis notable for resistant organisms including proteus,
pseudomonas and VRE now presenting with elevated WBC and pyuria
on UA, concerning for UTI. Patient received zosyn in the ED for
possible UTI. Most recent UTI ___ grew proteus species that
intermittently sensitive to unasyn but sensitive to cefepime and
ceftazidime. Prior UTI in ___ grew pseudomonas and VRE. Pt's
urine culture grew > 3 different colonies suggestive of
contamination. Given history of urosepsis with resistant
organsims, Pt will need broad antibiotic coverage. Pt was thus
treated with cefepime 1g iv q12h and daptomycin 450mg iv q24,
and received a PICC line to continue antibiotics until ___. His blood culture remained without growth during this
admission, and his leukocytosis resolved from 16k to 11k on
discharge. Pt was not febrile. While taking daptomycin, Pt will
need weekly creatinine kinase (CK) checks; his baseline CK is
~500 on discharge.
# GJ tube obstruction: Patient has had multiple ED visits and
admissions for occlusion of GJ tube since placement, most recent
replaement was ___. Patient sent today from nursing home for
evaluation of occluded GJ tube that was not cleared using coke
in the ED. ___ was consulted and advised admission with inpatient
replacement. Pt was taken to ___ today but apparently, GJ tube
was reportedly working well and flushed both water and contrast
w/out issue. Pt was then returned to floor and tube feeds
restarted per nutrition recs. Pt's tube reclogged temporarily on
___, but was easily opened by flushing the J tube with a 5
cc syringe full of diet coke. A 5 CC SYRINGE MUST BE USED in
order to generate the force necessary to clear any blockages. Pt
was tolerating tube feeds well and may need to receive
supplementation with neutra-phos to keep phos between 2.7 - 4.5.
# Trach/respiratory: Patient was succioned by respirtory with
rapid improvement in respiratory status in the ED. Low suspicion
for PNA with patient has been afebrile and CXR did not show
evidence of PNA. Nursing home did not report worsening
respiratory status prior to presentation. Initial hypoxia
probably due to Pt having some mucus plug during transport,
which subsequently resolved w/ suctioning in ED. CXR suggests
probably L basilar atelectasis. Pt originally supposed to have
trach exchange, but part was initially not available. Pt had
trach part successfully replaced by respiratory therapist on
___. Pt w/ copious but clear sputum. Pt had a repeat CXR,
which showed a possible focal opacity in left lung base,
possibly developing consolidation, aspiration, or atelectasis
and bibasilar atelectasis. Since Pt was at baseline respiratory
status and did not have any additional respiratory complaints or
fever, Pt was felt not to have a pneumonia.
#Type 2 Diabetes mellitus: Patient is on lantus and SSI at home.
continued prior insulin scale after unclogging tube.
# Atrial fibrillation: Patient is on warfarin as an outpatient.
Pt's warfarin was held given elevated INR. Home dose 4mg ___
___, should be restarted on ___ and have INR recheck ___
until it stabilizes.
# Hypothyroidism: levothyroxine 25 mcg ___
# Spasticity: Continue baclofen 15 mg QID
# C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___. Received colostomy care.
# Peripheral neuropathy / Leg pain: doubled gabapentin to 600mg
___ tid, increased Pt's fentanyl to 200mcg/hr patch, q72hr, and
started Capsaicin 0.025% cream tid to lower extremities.
# Depression: Continued duloxetine and mirtazapine.
TRANSITIONAL ISSUES:
-recheck INR ___, restart warfarin 4mg ___ when INR is <
3.0, with goal 2.0-3.0
-A 5 CC SYRINGE MUST BE USED in order to generate the force
necessary to clear any J tube blockages. He may need a
prophylactic flush every day with diet coke.
-Pt will need to have CK checked weekly while on daptomycin.
Medications on Admission:
- Acetaminophen 650 mg Q6H
- Ascorbic acid ___ mg BID
- Baclofen 15 mg QID
- Bisacodyl 10 mg BID
- Duloxetine 30 mg ___
- Fentanyl 150 mcg Q72H
- Gabapentin 300 mg TID
- Insulin aspart sliding scale
- Insulin glargine 32 units at bedtime
- Albuterol sulfate 2.5 mg/3 mL Q6H:PRN SOB or wheezing
- Ipratropium bromide 0.02% Q6H:PRN SOB or wheezing
- Lansoprazole 30 mg ___
- Furosemide 20 mg ___
- Mirtazapine 15 mg ___ HS
- Morphine 10 mg Q6H:PRN pain
- Warfarin 4 mg ___
- Nystatin 5 ML ___ QID:PRN thrush
- Levothyroxine 25 mcg ___
Discharge Medications:
1. levothyroxine 25 mcg Capsule Sig: One (1) Capsule ___ once a
day.
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML ___ QID
(4 times a day) as needed for thrush.
3. Coumadin 4 mg Tablet Sig: One (1) Tablet ___ once a day:
Resume ___.
INR to be checked by Dr. ___ on ___.
4. baclofen 10 mg Tablet Sig: 1.5 Tablets ___ QID (4 times a
day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) ___ BID (2 times a day).
6. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) ___.
7. morphine 10 mg/5 mL Solution Sig: Five (5) mL ___ every six
(6) hours as needed for severe pain.
8. mirtazapine 15 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
9. fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule ___ Q8H (every
8 hours).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB or wheeze.
12. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB or wheezing.
13. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
14. capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day): Apply thin layer to bilateral lower extremities
(calves and thights).
15. daptomycin 500 mg Recon Soln Sig: Four Hundred Fifty (450)
mg Recon soln Intravenous Q24H (every 24 hours) for 14 days: To
end on ___.
16. cefepime 1 gram Recon Soln Sig: One (1) gram Recon Soln
Injection Q12H (every 12 hours) for 14 days: To end on ___.
17. insulin glargine 100 unit/mL Solution Sig: ___ (32)
units Subcutaneous at bedtime.
18. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale Injection qACHS.
19. ascorbic acid ___ mg Tablet Sig: One (1) Tablet ___ twice a
day.
20. Tylenol ___ mg Tablet Sig: Two (2) Tablet ___ every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
clogged J tube
urinary tract infection
tracheostomy leak
Secondary:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___, baseline averbal, paraplegic)
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- Atrial fibrillation
- Peripheral vascular disease
- Hyperlipidemia
Discharge Condition:
Mental Status: Averbal but responsive to questions in ___.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___,
You were sent to the hospital because your J tube was clogged.
During transport, your oxygen level was low, but they had
trouble providing suctioning. Your tracheostomy was leaking, and
you were admitted to the hospital. Your breathing improved
rapidly, your tracheostomy was exchanged successfully, your J
tube was unclogged, and you were treated for a urinary tract
infection. You will need to continue your antibiotics for 2
weeks to treat this infection, so you received a special
tunneled IV line (PICC) for this. You also had severe leg pain,
which we felt was neuropathic (related to your nervous system)
and we increased your pain medications.
We have made the following changes to your medications:
INCREASE Fentanyl patch to 200mcg/hr patch, 1 patch every 72
hours
INCREASE Gabapentin to 600mg by mouth three times ___
START Capsaicin 0.025% cream, apply to lower extremities three
times ___
START Daptomycin 450 mg IV every 24 hrs, stopping on ___.
START Cefepime 1g IV every 12 hrs, stopping on ___.
** Your J tube was flushed successfully with diet coke in a 5cc
syringe. (You MUST use a 5 cc syringe to generate the necessary
force,.)
We have not made any other changes to your medications. Please
continue to take them as previously prescribed.
Followup Instructions:
___
|
10599327-DS-27 | 10,599,327 | 23,077,556 | DS | 27 | 2136-09-11 00:00:00 | 2136-09-12 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, elevated WBC count
Major Surgical or Invasive Procedure:
GJ tube revision with angio
History of Present Illness:
___ quadrapelgic with trach, GJ tube, and chronic indwelling
foley presenting from ___ with fever. ___
had CXR as outpt which showed L basilar infiltrate concerning
for PNA with leukocytosis of 20.7. The patient was then started
on levofloxacin. Pt was sent to ED from ___ for fever,
persistent leukocytosis. Patient is nonverbal at baseline. He
doesn't appear in acute distress, following commands, and alert.
Recently hospitalized in ___ for difficulty with Foley
placement.
Has a history of recurrent UTIs with indwelling Foley. Last UTI
was positive for Proteus. Has a h/o VRE +Ucx which was only
sensitive to linezolid.
In the ED, initial vitals 99.6F 99 112/66 20 99%
Spiked 102.8 in ED. SBP 97-107.
Labs notable for Lactate 2.1, P1.6, WBC 17, INR 5.4, dirty UA
He received ceftaz and 1L of IVF.
Vitals prior to transfer: 97.5F P89 RR19 BP107/63 SpO294%
Currently, on 50% humidifier and HD stable.
ROS: unable to obtain
Past Medical History:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- h/o DVT (? - no ___ records)
- Atrial fibrillation (on coumadin)
- Peripheral vascular disease
- Hyperlipidemia
- Tracheostomy and GJ tube for chronic aspiration
___ Bivono, Size 6.0
- C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin
___ facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease
Physical Exam:
On admission:
VS - 98.1 80 104/60 18 94% humidified mask over trach 50% 10L
GENERAL - NAD, nonverbal, eyes track, follows commands
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly
LUNGS - rhonchorous throughout, bibasilar crackles, bronchial
breath sounds transmitted from upper airways
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - hypoactive BS, soft/NT/ND, no masses or HSM, no
rebound/guarding, ostomy beefy red draining succus
EXTREMITIES - hands clenched with contractures, 2+ peripheral
pulses
SKIN - unstageable R inferior buttock 3x3cm, 2 stage II sacral
decub ulcers
NEURO - awake, as above
On discharge:
VS 96.9 108/48 71 18 96% on 35% humidifier mask
GENERAL - NAD, nonverbal, eyes track, follows commands
HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly
LUNGS - rhonchorous throughout, bibasilar crackles
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - normoactive BS, soft/NT/ND, no masses or HSM, no
rebound/guarding, ostomy beefy red draining succus
EXTREMITIES - hands clenched with contractures, 2+ peripheral
pulses
SKIN - unstageable R inferior buttock 3x3cm, 2 stage II sacral
decub ulcers
NEURO - awake, as above
Pertinent Results:
On admission:
___ 03:30PM BLOOD WBC-17.0*# RBC-5.73 Hgb-12.0* Hct-40.0
MCV-70* MCH-20.9* MCHC-30.0* RDW-16.7* Plt ___
___ 03:30PM BLOOD Neuts-84.2* Lymphs-11.7* Monos-3.8
Eos-0.1 Baso-0.3
___ 03:30PM BLOOD ___ PTT-45.0* ___
___ 03:30PM BLOOD Glucose-236* UreaN-45* Creat-0.8 Na-147*
K-4.5 Cl-106 HCO3-29 AnGap-17
___ 03:30PM BLOOD Calcium-9.4 Phos-1.6*# Mg-2.6
___ 03:42PM BLOOD Lactate-2.1*
___ 06:55AM BLOOD Lactate-1.8
___ 03:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 03:30PM URINE RBC-16* WBC-167* Bacteri-FEW Yeast-NONE
Epi-0
On discharge:
___ 06:46AM BLOOD WBC-10.5 RBC-4.43* Hgb-9.1* Hct-30.6*
MCV-69* MCH-20.6* MCHC-29.9* RDW-17.0* Plt ___
___ 06:46AM BLOOD ___ PTT-47.3* ___
___ 06:46AM BLOOD Glucose-129* UreaN-10 Creat-0.3* Na-137
K-3.3 Cl-102 HCO3-26 AnGap-12
___ 06:46AM BLOOD Calcium-7.6* Phos-1.8* ___
Micro:
___ Ucx
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Radiology:
FINDINGS: Single semi-erect frontal view of the chest
demonstrates patient to
be moderately rotated to the left, distorting cardiomediastinal
silhouette.
This likely accounts for apparent mediastinal widening, which is
accentuated
by semisupine position and AP technique. Lung volumes are low,
accentuating
bronchovascular crowding. Allowing for such, there is mild
perivascular
congestion. Streaky bibasilar opacity could represent
aspiration, evolving
infection, or a component of atelectasis. There is no large
effusion or
pneumothorax. A tracheostomy is in place. Mild diffuse osseous
demineralization is present. Moderate right greater than left
glenohumeral
osteoarthritis is present.
IMPRESSION: Limited exam, demonstrating mild perihilar vascular
congestion
and bibasilar streaky opacities which could represent either
aspiration or
resolving infection.
Brief Hospital Course:
___ quadrapelgic with trach, GJ tube, and chronic indwelling
foley presenting from his nursing home with fever.
#Sepsis: Pt initially fulfilled SIRS criteria with leukocytosis
and febrile with multiple sources of infection including
pneumonia (HCAP) and/or urinary (indwelling catheter). On ___
had UCx positive for Proteus and ___ VRE UTI- only
sensitive to linezolid. Lactate was elevated at 2.1 which
normalized after IV fluid boluses. Leukocytosis persistently
elevated after initiation of antibiotics but fever curve trended
down. Linezolid and cefepime were started- linezolid for MRSA
HCAP coverage as well as empiric treatment for VRE UTI; cefepime
for Pseudomonas HCAP coverage and also for potential Proteus
UTI. Indwelling Foley catheter was changed upon admission.
Legionella urine Ag was negative and two sputum cultures were
contaminated. Urine cx grew out Proteus mirabilis and Klebsiella
sensitive to meropenem. Blood cultures had no growth. Pt was
discharged with a PICC and instruction to complete a total 10
day course of linezolid and meropenem for HCAP and UTI
treatment.
#Pneumonia: Pt was on levofloxacin at facility after positive
CXR with leukocytosis, but PNA could be HCAP as pt was recently
hospitalized in ___ and at risk for Pseudomonas and MRSA while
in residential facility. Moreover, patient has been on
levofloxacin with persistent fevers- this may be confounded by
the recurrent UTI. Pt continued to be afebrile while on
antibiotics, and sputum cx were contaminated, and Legionella Ag
negative. Pt at baseline saturates well on room air and was
weaned off of 50% 10L humidifier on Hospital Day 2 and
saturating in high ___ on room air. Pt was restarted on
humidifier on ___ for symptomatic relief in terms of
copious production of secretions (most likely related to
pneumonia). Every 4 hour suctioning by RN was done and
recommended to be done at extended care facility. Pt was
discharged with linezolid for MRSA HCAP coverage (total of 10
days course).
# GJ tube: Initially KUB showed well-positioned tube and was
used throughout Hospital Day 2 for tube feeds and administration
of PO medications. On Hospital Day 3, GJ tube clogged, and
repeated attempts to unclog obstruction were unsuccessful and
thus was sent to angio for revision. GJ tube was unclogged on
___, and pt's tube feeds resumed and transitioned back to PO
medications.
#Anemia: On Hospital Day 2, there was an acute drop in hct from
40 to 33.1 after IVF (3L). This may be dilutional but could not
rule out blood loss or hemolysis. Stools were tested for
hemoccult blood- negative and Hct remained stable at 30. Pt most
likely has chronic anemia and was probably hemoconcentrated on
admission with hct of 40 especially since pt was dehydrated
(soft pressures, hypernatremia, hypoglycemic) when came to
medical floor. Hct had remained stable in low ___ without signs
of bleeding.
#Sacral decubitus ulcers, buttock pressure ulcer: 3 in total on
admission, 2 of which were stage 2 sacral ulcers, the largest
being the buttock ulcer (3 x 2.5 cm)- unstageable. The
appearance of wounds were not concerning as source of infection.
Wound care was consulted and recommended: Turn and reposition
off back q 2 hours and prn; limit sit time to 1 hour at a time
using a pressure redistribution cushion - request ROHO from ___.
Cleanse wound with wound cleanser then pat dry then place sacral
Mepilex border; change every 3 days. Tube feeds were immediately
started on Hospital Day 1 to maintain adequate calories in wound
healing. Tube feeds were transiently held during clogging of GJ
tube and restarted on ___ once tube was again functional.
#Ostomy: Pt has history of C. diff colitis c/b total abdominal
colectomy with end ileostomy. Ostomy was functional and appeared
well without signs of ischemia/necrosis. Ostomy care by wound
nurse included: 2 x weekly pouch changes on ___ with
Coloplast 1 piece sensura drainable pouch.
#Afib: Pt was on coumadin preadmission for Afib history and has
a CHADS2 score of 4. Pt presented in NSR and INR
supratherapeutic (5.4). Levofloxacin interaction was likely
cause of elevated INR and coumadin was held as daily INR
remained elevated. On ___, pt's warfarin was restarted at 5mg.
INR at discharge was 2.7 and pt is to have INR rechecked on ___
to adjust coumadin if needed.
#Type II DM: Pt was on Glargine bedtime and regular insulin SS
preadmission. Initial FSBG on floor was 48- hypoglycemia due to
TFs being on hold while in ED, pt's mental status improved after
1amp dextrose given and after restarting glucerna tube feeds.
Insulin sliding scale and Glargine were restarted on Hospital
Day 2. This was temporarily held while GJ tube was clogged.
Restarted on ___ evening once tube feeds resumed.
#Tracheostomy - on omeprazole-bicarb (non-formulary) as
preadmission med. Lansoprazole disintegrating tab was given via
GJ tube and oral care as per floor routine was done on daily
basis. Pt is to resume omeprazole-bicarb back at ECF.
#Chronic pain, peripheral neuropathy: Pain most likely related
to diabetic neuropathy as major component, and was on baclofen,
fentanyl patch, morphine, gabapentin preadmission. We continued
all of these to manage pain, mainly in Left lower extremity.
When GJ tube was found to be clogged on ___ (Day 3), pain was
controlled with IV morphine. PO morphine transitioned back to on
___ evening after unclogged tube.
# Hypothyroidism - stable. Last documented TSH normal in ___.
Pt was continued on levothyroxine 25 mcg PO DAILY.
# Depression - Stable. Pt's duloxetine was held while he was on
Linezolid (at risk for serotonin syndrome) and Mirtazapine 15 mg
PO HS was changed to PRN. Pt is to follow-up with psychiatrist
at facility to monitor for signs and symptoms for serotonin
syndrome if requires these antidepressants.
Transitional issues:
-Pt is to continue IV antibiotics: Linezolid (Day ___ and
meropenem (day ___ for a total of 10 days for treatment of
HCAP and UTI. Can d/c PICC afterwards.
-Pt is to have regular suctioning as pt is making copious
secretions (most likely related to pneumonia), consider
humidifier mask for symptomatic treatment.
-Pt is to have continued wound care for sacral decubitus ulcers
and R ischial ulcer.
- Pt is to go over antidepressants with psychiatrist regarding
interaction with linezolid. ___ restart after 10 day course of
antibiotics.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/Caregiver.
1. Gabapentin 600 mg PO TID
2. Mirtazapine 15 mg PO HS
3. Warfarin 5 mg PO DAILY16
4. Fentanyl Patch 50 mcg/hr TP Q72H
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze or SOB
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze or SOB
7. Baclofen 10 mg PO QID
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Milk of Magnesia 30 mL PO PRN constipation
10. Multiple Vitamins Liq. 5 mL PO ONCE Duration: 1 Doses
11. Capsaicin 0.025% 1 Appl TP TID:PRN pain
12. Fleet Enema ___AILY:PRN constipation
13. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using Novolin Insulin
14. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million
cell Oral BID
15. omeprazole-sodium bicarbonate *NF* ___ mg Oral daily
16. Morphine Sulfate (Concentrated Oral Soln) 8 mg PO Frequency
is Unknown
17. Levofloxacin 500 mg PO Q24H
18. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum,
hydrophilic;<br>white petrolatum) 2 % Topical daily
coccyx
19. Bacitracin Ointment 1 Appl TP BID
back of neck
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Fleet Enema ___AILY:PRN constipation
3. Fentanyl Patch 50 mcg/hr TP Q72H
4. Baclofen 10 mg PO QID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze or SOB
6. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using Novolin Insulin
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze or SOB
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Milk of Magnesia 30 mL PO PRN constipation
10. Warfarin 5 mg PO DAILY16
11. Morphine Sulfate (Concentrated Oral Soln) 8 mg PO Q4H:PRN
pain
12. Mirtazapine 15 mg PO QHS:PRN agitation, insomnia
13. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum,
hydrophilic;<br>white petrolatum) 2 % Topical daily
coccyx
14. Bacitracin Ointment 1 Appl TP BID
back of neck
15. Capsaicin 0.025% 1 Appl TP TID:PRN pain
16. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million
cell Oral BID
17. Multiple Vitamins Liq. 5 mL PO ONCE Duration: 1 Doses
18. omeprazole-sodium bicarbonate *NF* ___ mg Oral daily
19. Linezolid ___ mg IV Q12H Duration: 7 Days
20. Meropenem 500 mg IV Q6H Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Healthcare associated pneumonia
Urinary tract infection, complicated
Sacral decubitus ulcers
Right Buttock/ischial pressure ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you at the ___.
You were admitted to the hospital for fever and for concerns of
infection in your lungs and urine. Your urine analysis showed
that you had a urinary tract infection and your x-ray of your
chest showed an infection in your chest. You were treated with
antibiotics which you tolerated well. We continued the
medications you were on before admission. Your feeding tube was
clogged on ___, and we managed your chronic pain with IV
morphine until it was unclogged. You are to finish your
antibiotic course as prescribed and instructed.
While you are on linezolid, you should not take duloxetine or
mirtazapine. Your duloxetine (cymbalta) was stopped completely
and the mirtazapine was changed to as needed dosing only. When
you finish the course of antibiotics with linezolid in 1 week,
you should talk with the psychiatrist at the extended care
facility about restarting the duloxetine and mirtazapine.
Followup Instructions:
___
|
10599327-DS-31 | 10,599,327 | 25,284,490 | DS | 31 | 2136-12-23 00:00:00 | 2136-12-24 23:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with hx of CVA (non-verbal & quadriplegic at baseline) now
s/p trach & PEG ___, atrial fibrillation on coumadin,
chronic aspiration PNAs and recurrent UTIs with drug-resistant
organisms, C Diff s/p colectomy with ostomy, DM2, recent
hospitalizations (DC'd on ___ and ___ with recurrent
UTIs/PNAs) presenting from his nursing home with fevers, high
blood sugar, and tachycardia. Of note, he was recently
discharged from this facility after being admitted for treatment
of multi-drug resistant UTI, hypernatremia, and ___.
Additionally, based on fevers and leukocytosis noted when he was
in his nursing home he was started on ___ prior to
presentation today.
In the ED, initial VS were: 104.2 116 139/94 35 100%. At this
time his labs were notable for WBC 21.4, Na 157, Cr 0.6, Glucose
368, INR 3.3, and a dirty UA. He underwent CT abd/pel with
contrast which demonstrated multifocal pneumonia and possible
osteomyelitis secondary to a deep soft tissue ulcer involving
the right proximal posterior medial thigh. Blood and urine
cultures were sent and he was given a dose of vancomycin and
meropenem. VS prior to transfer: 99.8 85 148/86 18 100%.
On arrival to the MICU, he was resting comfortably, was
hemodynamically stable, and was not in any acute distress.
REVIEW OF SYSTEMS:
Patient is non-verbal therefore it was not possible to gather
information on ROS.
Past Medical History:
- Hypertension
- Hypothyroidism
- H/o CVA (bilateral embolic cerebellar ___, hemorrhagic left
thalamic ___
- Type 2 Diabetes mellitus
- Peripheral neuropathy
- Depression
- h/o DVT (? - no ___ records)
- Atrial fibrillation (on coumadin)
- Peripheral vascular disease
- Hyperlipidemia
- Tracheostomy and GJ tube for chronic aspiration (___)-
Portex Bivono, Size 6.0
- C.diff colitis in ___ requiring total abdominal colectomy
with end ileostomy ___, repeat positive C diff toxin ___
(outside facility, ___ here)
Social History:
___
Family History:
Patient has a mother with diabetes and brother with heart
disease
Physical Exam:
Admission:
Vitals: T: 98.1 BP: 125/80 P: 84 R: 18 O2: 94%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucus membranes dry, EOMI
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact
Discharge:
Vitals: afebrile 97.7 110-130/60-90 HR ___ sat 98-100%
RA-35%TM
Gen: NAD
HEENT: moist mucosa, tracheostomy without surrounding erythema
CV: NR, RR, no murmurs
Pulm: CTAB, good air movement
Abd: NT, ND, soft
Pelvis: large right scaral decub that probes to bone
Ext: no peripheral edema
Neuro: does follow commands, EOM intact, nonverbal at baseline
but nods yes and no, quadraplegic
Pertinent Results:
___ 05:57AM BLOOD WBC-5.6 RBC-3.68* Hgb-8.1* Hct-26.9*
MCV-73* MCH-22.0* MCHC-30.0* RDW-18.3* Plt ___
___ 12:00PM BLOOD WBC-21.4*# RBC-5.18# Hgb-11.0*#
Hct-37.2*# MCV-72* MCH-21.2* MCHC-29.5* RDW-18.2* Plt ___
___ 06:14AM BLOOD ESR-101*
___ 02:51PM BLOOD ESR-90*
___ 06:01AM BLOOD Ret Aut-2.3
___ 05:57AM BLOOD Glucose-220* UreaN-13 Creat-0.3* Na-145
K-4.2 Cl-105 HCO3-33* AnGap-11
___ 12:00PM BLOOD Glucose-368* UreaN-37* Creat-0.6 Na-157*
K-3.6 Cl-118* HCO3-25 AnGap-18
___ 05:57AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.5*
___ 03:01AM BLOOD Albumin-2.7* Calcium-7.7* Phos-2.1*
Mg-1.5*
___ 05:48PM BLOOD Lactate-0.9
___ 12:10PM BLOOD Glucose-353* Lactate-2.0 Na-157* K-3.5
___ 2:56 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:00 pm CATHETER TIP-IV Source: PICC.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
__________________________________________________________
___ 1:41 pm BLOOD CULTURE Source: Line-Picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:45 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:45 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:59 pm SPUTUM Source: Induced.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- =>64 R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- 2 I 2 I
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN/TAZO----- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
__________________________________________________________
___ 10:25 pm SWAB Source: Wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 12:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
THIS IS A CORRECTED REPORT ___ 13:30).
Reported to and read back by ___. ___
___ @ 13:40
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days
Susceptibility testing requested by ___. ___
___ ___. FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
PREVIOUSLY REPORTED AS (___).
STAPHYLOCOCCUS AUREUS WITH SENSITIVITIES.
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS EPIDERMIDIS. ___ MORPHOLOGY. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS
EPIDERMIDIS
| |
STAPHYLOCOCCUS EPIDERMIDIS
| | |
CLINDAMYCIN-----------<=0.25 S R <=0.25 S
ERYTHROMYCIN---------- =>8 R =>8 R <=0.25 S
GENTAMICIN------------ =>16 R =>16 R =>16 R
LEVOFLOXACIN---------- 4 R =>8 R 4 R
OXACILLIN------------- =>4 R =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S <=0.5 S
TETRACYCLINE---------- 2 S 2 S 2 S
VANCOMYCIN------------ 2 S 1 S 1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
10:50AM.
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
MICU COURSE:
After being febrile in the ED to ___ F and receiving vanocomycin
and meropenem he became hypotensive to 82/48 on his first day in
the MICU. A deep wound was noted on his right gluteal area
which probed to bone in the same distribution as the possible
osteomyelitis seen on CT scan. Given his history of multi-drug
resistant organisms with Proteus (sensitive to meropenem),
Klebsiella (sensitive to meropenem, cefepime, amikacin) and VRE
(sensitive to linezolid), he was emperically covered for
infectious source with linezolid and meropenem, but since
bacteremia was a concern, he was then switched to daptomycin and
meropenem. His PICC line, which had been in place since ___
was removed and cultured. He was subsequently afebrile and with
stable hemodynamics, but his microbiology studies returned with
several species of coagulase negative staph in the blood and
pseudomonas in his sputum. We then narrowed his antibiotics to
vancomycin with the thought that his sputum Pseudomonas
represented colonization given his chronic tracheostomy.
.
MEDICINE FLOOR:
___ M with hx of CVA (non-verbal & quadriplegic at baseline) now
s/p trach & PEG ___, atrial fibrillation on coumadin,
chronic aspiration PNAs and recurrent UTIs with drug-resistant
organisms, history of C Diff s/p colectomy with ostomy, DM2,
presenting from nursing home with fevers, tachycardia,
bacteremia and consolidations on CXR consistent with pneumonia
now s/p HCAP treatment and will continue IV zosyn for ischial
osteomyelitis.
# Full thickness ulcer / Osteomyelitis: MRI consistent with
ischial tuberosity osteomyelitis. Infectious disease was
consulted for assistance with antibiotic selection. He had been
on antibiotics for multiple days for the HCAP, which would
likely limit the yield of bone biopsy. We considered stopping
antibiotics for one week and then pursuing bone biopsy versus
emperic treatment with broad spectrum antimicrobial. After
discussion withe the family, it was decided to treat emperically
and ID consult recommended zosyn for ___ week course.
The primary team and palliative care team discussed goals of
care with ___ son/HCP throughout the hospitalization. We
discussed that treatment would involve surgical debridement,
antibiotics, and then likely surgical reconstruction versus
alternative palliative approach. Patient's family would like a
comfort-oriented approach. They would like to continue a course
of abx for the osteomyelitis, then would transition to comfort
care without re-hospitalization. Reported that each
hospitalization has been very taxing on patient (see palliative
care notes). PICC line placed. Patient discharged on zosyn with
OPAT ID.
# Recent Bacteremia: On admission, grew Coag negative Staph of
multiple morphologies grew on blood cx ___. Subsequent
blood cx were negative. TTE neg for vegetations. Will continue
zosyn (day 1 abx = ___ as above for osteomyelitis.
# HCAP: Patient with history of aspiration pneumonia with recent
hospitalization and completion of course of cefepime. This
admission he met SIRS criteria (fever, tachycardia,
leukocytosis) with multiple possible sources including pneumonia
(HCAP versus aspiration PNA), UTI, PICC line infection and
osteomyelitis. He completed an 8 day course Meropenem and
Daptomycin for HCAP.
# Atrial fibrillation: He was anticoagulated on heparin drip
during the hospitalization due to potential need for surgical
procedure. Once determined that family not interested in
pursuing surgical option, he was restarted on coumadin with
lovenox bridge given high CHADS2 score.
# Diabetes Mellitus Type II: Blood glucose likely elevated in
the setting of acute illness. Continued home glargine insulin
and sliding scale.
# hx CVA: s/p trach and peg tube placement in ___. Nutrition
consulted for tube feed recs.
# Ostomy: Pt has history of C. diff colitis c/b total abdominal
colectomy with end ileostomy. Ostomy intact.
# Chronic pain, peripheral neuropathy: Pain most likely related
to diabetic neuropathy as major component. Decided against
fentanyl given frequent fevers and variable delivery. Continued
baclofen, morphine, gabapentin. Started methadone, and titrated
up with QTc monitoring. Palliative care consulted for pain
management. Will need monitoring of QTc with EKG with methadone.
Avoid QTc prolonging agents.
# Hypothyroidism: Continued levothyroxine 25mcg daily.
# Depression: Continued duloxetine.
#Hypernatremia: Likely due to insensible water loss due to
fever. Resolved with IVF.
# Hx Recurrent UTIs: Hx of MDR UTI's with resistant Proteus
(sensitive to meropenem), Klebsiella (only sensitive to ___,
cefepime, amikacin) and VRE (sensitive to linezolid).
# COMMUNCATION: ___ (son/HCP) ___ (c)
___ (day) ___ (night)
# CODE STATUS: DNR/DNI
## TRANSITIONAL ISSUES:
-will continue IV Zosyn, and will be followed by ID at ___ to
discuss duration of course
-will need WEEKLY labwork for OPAT monitoring while undergoing
treatment for osteomyelitis: CBC w/ diff, BUN, Creatinine,
LFT's, ESR, CRP. All laboratory results should be faxed to the
___ R.N.s at ___. All questions
regarding outpatient parenteral antibiotics should be directed
to the ___ R.N.s at ___ or to the
on-call ID fellow when
the clinic is closed.
-palliative care was consulted, family interested in
transitioning to hospice/comfort care in near future, if
re-hospitalized in interim would consult ___ care
-please check INR on ___ and again ___
___. Warfarin was started ___, please titrate dose
accordingly and continue to check INR twice weekly. Once patient
has therapeutic INR of ___ for 24 hours, may discontinue
lovenox.
-please check EKG on ___ to ensure QTc is less than
480, if higher, please consider decreasing methadone dose to 6mg
TID and then recheck the following day.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Vitamin D 400 UNIT PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Morphine Sulfate (Oral Soln.) ___ mg PO Q4H:PRN pain
hold for sedation, RR<10
5. Mirtazapine 15 mg PO HS
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H sob/wheezes
8. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using Novolin R Insulin
9. Gabapentin 600 mg PO TID
10. Fentanyl Patch 50 mcg/h TP Q72H
11. Duloxetine 30 mg PO DAILY
12. Baclofen 10 mg PO QID
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezes
14. arginine (L-arginine) *NF* 500 mg Oral BID
Powder Packet
15. Glucerna Hunger Smart *NF*
(nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose
intolerance,soy) 1 Liquid Oral Daily
85cc/hour for 20 hours, start at 2pm
16. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million
cell Oral BID
17. Milk of Magnesia *NF* (magnesium hydroxide) 400 mg/5 mL ORAL
DAILY PRN constipation
18. Nystatin Oral Suspension 5 mL PO QID
19. Meropenem 500 mg IV Q6H
20. Ferrous Sulfate 325 mg PO DAILY
21. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezes
3. Baclofen 10 mg PO QID
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
5. Ferrous Sulfate (Liquid) 300 mg PO DAILY
6. Gabapentin 600 mg PO Q8H
7. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
8. Ipratropium Bromide Neb 1 NEB IH Q6H sob/wheezes
9. Levothyroxine Sodium 25 mcg PO DAILY
do not give within 2 hours of iron or tubefeeds
10. Mirtazapine 15 mg PO HS
11. Morphine Sulfate (Oral Soln.) ___ mg PO Q2H:PRN pain
12. Nystatin Oral Suspension 5 mL PO QID
13. Vitamin D 400 UNIT PO DAILY
14. Ascorbic Acid (Liquid) 500 mg PO DAILY Duration: 10 Days
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
16. Methadone 7 mg PO TID
RX *methadone 5 mg/5 mL 7 mL by mouth three times per day Disp
___ Milliliter Refills:*0
17. Piperacillin-Tazobactam 4.5 g IV Q8H
18. Vitamin A 20,000 UNIT PO DAILY
19. Warfarin 5 mg PO DAILY16
20. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
21. arginine (L-arginine) *NF* 500 mg Oral BID
Powder Packet
22. Duloxetine 30 mg PO DAILY
23. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million
cell Oral BID
24. Milk of Magnesia *NF* (magnesium hydroxide) 400 mg/5 mL ORAL
DAILY PRN constipation
25. Enoxaparin Sodium 70 mg SC BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___, you were admitted to ___
___ for fevers and low blood pressure. While you were
here, you were discovered to have osteomyelitis in your right
hip. You will continue intravenous antibiotics for this
infection. You will continue to be followed by the Infectious
Disease team at ___.
Followup Instructions:
___
|
10599576-DS-19 | 10,599,576 | 25,592,779 | DS | 19 | 2120-06-24 00:00:00 | 2120-06-24 22:06:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / lisinopril
Attending: ___.
Chief Complaint:
fall at home, down for two days, left leg injury
Major Surgical or Invasive Procedure:
-___: Left leg incision & drainage with excisional
debridement of necrotic tissue with removal of hardware
-___: Left calf and thigh debridement with application of
vacuum sponge
-___: Debridement of left leg and thigh
-___: Extensive debridement left leg, extensive fasciectomy
peroneal compartment, anterior compartment, posterior
compartment, arthrotomy washout left knee, total surface area
60x 40cm
-___: Incision and drainage of left leg, debridement of
skin fat fascia muscle, partial closure, Veraflow vac placement
-___: Irrigation and debridement of left lower extremity;
washout of left knee joint; application of negative pressure
wound therapy.
-___: Debridement of left lower extremity wounds;
split-thickness skin graft from right thigh; application of
negative pressure wound therapy.
-___: Superficial debridement of right thigh; debridement
of two individual left lower extremity wounds down to fat and
muscle; removal of staples left lower extremity skin grafts.
History of Present Illness:
___ woman with history of non-insulin-dependent diabetes
with history of left transmetatarsal amputation who presented to
the ED via EMS after a fall at home and being down for 2 days.
Patient states that last week she had a fall to the right side
and twisted her L knee. A few days later her L knee hurt so
badly she was unable to descend the stairs to leave her
apartment. She took aspirin for the pain which resolved a day or
two later. Last ___ she noticed a small dark spot over
her knee she felt was a blood clot. By the next day the dark
spot had expanded and eventually burst open spilling out blood
and clot. Patient states that she was on her way to the bathroom
when she became
lightheaded and fell onto the floor. Denies loss of
consciousness or head strike. Was unable to get up for the next
two days. Was incontinent of stool and urine during this time.
Was eventually able to get to her phone and have it charge ___
her kitchen enough to call her sister who then called EMS and
she was brought to ___.
Past Medical History:
PMH:
poorly controlled Type II DM
HTN
PSH:
Left transmetatarsal amputation at ___ ___
L leg tib-fib fracture ___ years ago with placement of plates and
screws
Social History:
___
Family History:
Paternal grandmother - diabetes
___ aunt - stomach cancer
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 98.6 PO BP: 133/72 L Lying HR: 91
RR:
20 O2 sat: 96% O2 delivery: Ra FSBG: 335
GENERAL: Alert and interactive. ___ no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal ___ size and texture, no nodules. 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 spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation ___ all four quadrants.
EXTREMITIES: Left foot w/ transmetatarsal amputation. Healing
wound on plantar aspect L foot consistent with area podiatry
recently debrided (note ___ OMR). +2 L pedal edema to ankle.
Large
area of erythema over L shin wrapping around laterally to calf.
Whole area of erythema tender to palpation, warm to touch,
swollen. 0.5 cm wound w/ purulent drainage over anterolateral L
knee. RLE non-erythematous, no edema. +2 DP pulses bilaterally
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
========================
DISCHARGE PHYSICAL EXAM:
========================
___ 0725 Temp: 98.2 PO BP: 132/73 L Lying HR: 78 RR: 18 O2
sat: 94% O2 delivery: RA FSBG: 148
GENERAL: AAOx3 and NAD
Skin: Anterior chest, upper arms, upper back, forehead with
scattered/excoriated superficial ulcerations that are scabbed;
no
erythema, edema, fluctuance, crepitus, or drainage noted from
these wounds.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No rhonchi, rales, or
wheezes. No increased work of breathing.
ABDOMEN: Normal bowels sounds, mildly distended, non-tender. no
suprapubic tenderness
EXTREMITIES: Left foot w/ transmetatarsal amputation. Healing
wound on plantar aspect L foot consistent with area podiatry
recently debrided (note ___ OMR). ACE wrap to LLE with
strikethrough. Dressing over right thigh, c/d/I.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 01:41PM BLOOD WBC-15.2* RBC-3.23* Hgb-9.3* Hct-30.1*
MCV-93 MCH-28.8 MCHC-30.9* RDW-14.8 RDWSD-50.4* Plt ___
___ 01:41PM BLOOD Neuts-87.4* Lymphs-5.1* Monos-5.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-13.31* AbsLymp-0.77*
AbsMono-0.85* AbsEos-0.00* AbsBaso-0.04
___ 05:45PM BLOOD ___ PTT-23.6* ___
___ 01:41PM BLOOD Glucose-474* UreaN-49* Creat-1.2* Na-137
K-5.6* Cl-94* HCO3-18* AnGap-25*
___ 05:55AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.9
___ 01:41PM BLOOD CK(CPK)-195
___ 03:45PM BLOOD calTIBC-152* Hapto-353* Ferritn-769*
TRF-117*
___ 05:55AM BLOOD CRP-219.8*
___ 03:44PM BLOOD ___ pO2-33* pCO2-41 pH-7.35
calTCO2-24 Base XS--3
___ 01:56PM BLOOD Lactate-2.5*
===============
PERTINENT LABS:
===============
___ 05:55AM BLOOD %HbA1c-15.1* eAG-387*
===============
DISCHARGE LABS:
===============
___ 05:13AM BLOOD WBC-9.6 RBC-3.06* Hgb-8.9* Hct-28.8*
MCV-94 MCH-29.1 MCHC-30.9* RDW-15.8* RDWSD-54.7* Plt ___
___ 05:13AM BLOOD Glucose-155* UreaN-20 Creat-0.8 Na-137
K-5.4 Cl-98 HCO3-28 AnGap-11
======
MICRO:
======
Urine Culture (___)
5:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
=====
Vaginal Swab (___)
1:06 pm SWAB Site: VAGINA Source: vaginal.
**FINAL REPORT ___
YEAST VAGINITIS CULTURE (Final ___:
YEAST. MODERATE GROWTH.
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
Indeterminate. Altered vaginal flora that does not meet
criteria for
diagnosis of bacterial vaginosis. If signs and/or symptoms
persist,
repeat testing may be warranted.
Interpretive criteria have only been established for
pre-menopausal
women and post-menopausal women on hormone replacement
therapy. As
low estrogen levels alter vaginal flora, results should be
interpreted with caution ___ post-menopausal women. Refer
to the on
line laboratory manual.
Note, neither lactobacilli nor
Gardnerella/Bacteroides/Mobiluncus
morphotypes observed. The absence of these morphotypes
likely
represents normal flora ___ post-menopausal women.
2+ ___ per 1000X FIELD): BUDDING YEAST.
=====
Left Leg Culture (___)
8:01 pm TISSUE LEFT LEG #1.
GRAM STAIN (Final ___:
Reported to and read back by ___ @ ___ ON
___ - ___.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN G---------- 0.12 S
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
=====
Left Leg Culture (___)
8:00 pm TISSUE LEFT LEG CULTURE #2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___ @ ___ ON
___ - ___.
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SUSCEPTIBILITY PERFORMED PER ___ ___ (___) ON
___.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
=====
Wound Swab (___)
___ 8:15 pm SWAB
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
___ ALBICANS. SPARSE GROWTH. Yeast
Susceptibility:.
Fluconazole MIC OF 0.5MCG/ML SUSCEPTIBLE.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
MORAXELLA CATARRHALIS. RARE GROWTH.
Identification and susceptibility testing performed on
culture #
___.
___. RARE GROWTH. Yeast Susceptibility:.
Fluconazole MIC OF 2.0 MCG/ML =
SUSCEPTIBLE-DOSE-DEPENDENT.
Caspofungin MIC OF 0.03 MCG/ML = SUSCEPTIBLE.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
=====
Stool Sample (___)
11:52 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
=====
Blood cultures from ___ x 2, ___ all with no growth.
========
IMAGING:
========
Left Foot/Ankle/Knee X-Ray (___)
FINDINGS:
Left knee, tibia & fibula: AP lateral oblique views of the left
knee. AP and lateral views of the left tibia fibula. Bones
appear
demineralized diffusely. There is no fracture, dislocation or
joint effusion. Tricompartmental osteoarthritis is moderate with
joint space narrowing, marginal spurring and slight articular
surface irregularity most notably ___ the lateral tibiofemoral
compartment likely the result of prior. Lateral plate and screw
fixation of the proximal tibia noted. A chronic appearing
deformity of the left fibular neck noted. Overlying soft tissues
appear slightly edematous though there is no soft tissue gas. No
signs of hardware failure. No acute fracture involving the left
tibia or fibula.
Left ankle and foot: AP, lateral, oblique views of the left foot
and ankle. The a left ankle mortise is symmetric. Talar dome is
smooth. Heel spurs are noted. Vascular calcifications are
present. There is been prior transmetatarsal amputation of the
left foot. No fracture is seen.
IMPRESSION:
No acute fracture. Mild soft tissue edema along the left knee
and
shin. Degenerative disease as stated with prior ORIF of the
proximal tibia. Generalized demineralization.
=====
Left Lower Extremity US (___)
No left leg DVT
=====
ECG (___)
Sinus rhythm. The P-R interval is normal at 160 milliseconds.
Left axis
deviation. There are tiny R waves ___ the inferior leads
consistent with
possible infarction. Non-specific ST-T wave changes. Compared to
the previous tracing of ___ there is no significant change.
=====
Left Lower Extremity CT (___)
IMPRESSION:
Limited evaluation of the soft tissues, particularly given the
lack of
contrasts.
1. There is diffuse dermal thickening and subcutaneous edema,
nonspecific, but
could correlate to cellulitis.
2. There are pockets of fluid overlying the iliotibial band, and
anterolateral
compartments of the thigh and shin as described above, of mixed
simple fluid
and slightly complex attenuation, that may represent blood or
proteinaceous/cellular material.
3. No findings convincing for septic arthritis, osteomyelitis,
or hardware
infection.
=====
Surgical Pathology Report (___)
1. Soft tissue, left leg, debridement: Extensively necrotic
fibroadipose tissue with acute inflammation
and abscess formation.
2. Soft tissue, left leg, debridement: Extensively necrotic
fibroadipose tissue with acute inflammation
and abscess formation.
=====
Renal U/S (___)
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 11.6 cm
Left kidney: 11.8 cm
The bladder is moderately well distended and normal ___
appearance.
IMPRESSION:
Normal renal ultrasound.
=====
Chest X-Ray (___)
FINDINGS:
There has been interval placement of a right PICC which ends at
the cavoatria junction. Lung volumes are low. No focal
consolidation, pleural effusion, or pneumothorax. The
cardiomediastinal silhouette is mildly enlarged and stable with
mild pulmonary vascular congestion.
IMPRESSION:
Interval placement of a right PICC which terminates at the
cavoatrial
junction.
=====
Chest X-Ray (___)
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Right PIC line ends ___ the low SVC. Lung volumes remain low
exaggerating mild pulmonary vascular engorgement. Mild
cardiomegaly recently unchanged, increased since ___. No
pleural abnormality.
=====
Chest X-Ray (___)
IMPRESSION:
___ comparison with the study of the ___, the patient has
taken a
better inspiration. Again there is substantial enlargement of
the cardiac
silhouette with mild elevation of pulmonary venous pressure. No
evidence of acute focal pneumonia or pleural effusion.
Brief Hospital Course:
SUMMARY STATEMENT:
==================
Ms. ___ is a ___ w/ PMHx Type 2 Diabetes, HTN, Left
transmetatarsal amputation, and L tibial fracture s/p repair
presenting after fall at home and down for two days, found to be
hyperglycemic with anion gap metabolic acidosis and have a
likely cellulitis of LLE with deep L knee wound with sinus tract
draining purulent gray fluid. She s/p OR with orthopedics for
removal of hardware, with subsequent repeated return to OR for
debridement and washout. She is to complete a extended course of
CTX as an outpatient, ending ___.
==============
ACTIVE ISSUES:
==============
#Left Lower Extremity Infection
#L tibial fracture s/p repair - hardware removed on ___
#Complicated LLE soft tissue infection s/p debridement and
washout
---Washout and NPWT placement (___)
---STSG from Right Thigh to Left Lower Extremity (___)
---Final debridement with removal of NPWT (___)
Pt admitted with leukocytosis with LLE cellulitis that is
continuous with an open sinus tract draining gray purulent pus,
potentially with fecal contamination. Ortho was consulted and
performed an incision and drainage with wound washout,
debridement, and removal of L tibial hardware on ___. During
this procedure, "copious amounts of gray, black pus" were noted
- samples of which were sent to microbiology and pathology, and
muscle appeared to be largely viable with low suspicion for
necrotizing fasciitis. She returned to the OR on ___ for repeat
debridement and washout of the wound, at which time a wound vac
was placed over the wound. Plastic surgery was consulted for
possible flap repair of her wound and was taken back to the OR
on ___. A STSG was harvested from the
right thigh and placed on the LLE on ___. Final trip to OR was
___ with a NPWT removal, debridement of wound. While inpatient,
ID was consulted given primary OR cultures and advised IV
vancomycin/ceftriaxone. Her wound and OR cultures were found to
grow Group B Strep, coagulase negative Staph, Moraxella, and
___. She was switched to Vancomycin/Cefepime/Fluconazole.
Eventually, switched to Ceftriaxone 2 g q24 for a 6-week course
to end ___ and Doxycycline 100 mg BID for a 2-week course
that ended ___ (for GBS, Moraxella coverage (___). Patient
has PICC line that was placed on ___.
#Poorly controlled Type 2 Diabetes - A1c 15.1
#Anion Gap Metabolic Acidosis - Resolved
Patient down for two days at home after a fall. Had a glass of
water which she sipped for two days but no other PO intake.
Glucose on arrival to ED was 453. UA was positive for ketones,
AGap 25->20, HCO3 18->24, pH 7.35->7.41 after IVF and Insulin ___
ED. Acidosis ___ setting of DKA resolved with insulin and
fluids. Gap remained closed throughout the rest of admission.
Lactic acidosis on admission likely ___ setting of hypovolemia
from poor PO intake and less likely ___ home metformin as
patient had not been taking this med for past week. She was
started on insulin regimen with 7u lantus qPM, with Humalog ISS
with meals. She will be discharged on an insulin regimen and
would benefit from diabetic/insulin education.
___ - Resolved
Cr on admission was 1.2 and uptrended to 3.6. Stabilized around
___ by discharge. Bladder scans on ___ showed no signs of
obstruction and renal ultrasound on ___ showed no signs of
obstruction. Renal was consulted given this continuing ___ who
were suspicious for ATN (though no muddy brown casts on urine
sediment) given that patient was down for two days at home and
had been NPO for OR procedures during hospitalization without
optimized hydration. Urine sediment with no eosinophils and
urine chemistries consistent with prerenal etiology. She was
hydrated with IVFs to maintain euvolemia, though was noted to be
___ spacing into her abdomen with low albumin (?malnutrition vs.
___ setting of acute infection). She was also transfused a total
of 10 units of PRBC while ___ house (9 different occasions)
primarily due to blood loss from OR and NPWT.
#Anemia - Resolved
Hgb noted with anemia Hgb 9.3 on admission. No acute source of
bleed, though reported to have been taking NSAIDs as outpatient
for pain and may gastritis with occult upper GI bleed - for
which she was started on a PPI. Iron studies showed iron
deficiency and anemia of chronic disease; hemolysis labs did not
show signs of hemolysis. She did have post-procedural anemia
from blood loss and was transfused on nine different occasions
to maintain Hgb>7.0. One of those occasions required 2 units of
PRBC, for a total of 10U pRBC this admission. Hemoglobin
remained stable around 9.0.
#DVT Prophylaxis
Given patient's age, BMI, s/p multiple lower extremity
surgeries, current PICC line, limited mobility for the last
month, anticoagulation is warranted until PICC line removed and
patient
is more mobile. Caprini VTE Score = 13 points and suggests >10%
risk of VTE and 30 days of prophylaxis.
-30 days Heparin 5000 units BID upon discharge
#Hyperkalemia
Stable. Patient has been borderline hyperkalemic since ___.
Might be heparin-induced; however, given stability and
familiarity on ___ continue course.
-Education regarding low potassium diets
-Low potassium diet ordered
#Pruritic Rash - Resolving
Developed excoriations along arms, upper chest, upper back,
forehead that ulcerated. Patient evaluated by dermatology and
found to possibly have opioid-induced prurigo. Her regimen was
switched from PO Oxycodone to PO Morphine that reduced pruritis
significantly. Sarna lotion was applied daily as well as
mupirocin 2% topical ointment to the scabs.
#Diarrhea - Resolved
Likely secondary to laxatives. C Diff. PCRs negative.
She was given loperamide PRN that helped significantly.
#Hypoxemia - Resolved
Likely due to deconditioning as patient had no out of bed
activity for the month-long stay. She will be WBAT and work with
___ to improve conditioning. CXR's taken that were unremarkable.
She was encouraged to use incentive spirometer hourly while
awake. She was stable on room air by discharge.
#Vulvar erythema and swelling
Likely candidal infection - vaginal swab obtained which showed
moderate yeast growth. Was treated with fluconazole x1 and
clotrimazole cream with good effect.
=======================
CHRONIC/STABLE ISSUES:
=======================
#HTN
History of hypertension per patient. this admission she was
started on amlodipine 5mg daily.
#Transmetatarsal Amputation (left foot ___
Amputated iso poorly healing ulcer when found to have occluded
left posterior tibial and peroneal artery. Felt would give her
best chance of preserving foot without BKA.
#Demineralization noted on X-ray
Will need to work up for osteoporosis as outpatient.
#Hoarding/Home Safety
Per EMS report "extrication (from home) was delayed due to
hoarding conditions and size of stairwell. An improvised sled
was used to extricate pt to the ambulance." Please ensure safe
discharge from rehab.
====================
TRANSITIONAL ISSUES:
====================
[]Complete 30 day course of subcutaneous heparin (5000 units
BID) given increased risk for VTE
[]Needs a PCP upon discharge from rehab, as has not had one for
the past ___ years
[]Newly started on insulin this admission for very poorly
controlled diabetes with A1c at 15%. Please provide diabetes and
insulin teaching.
[]Bone demineralization noted on LLE x-rays: recommend DEXA for
evaluation of osteoporosis with treatment as appropriate.
[]Continued management of Stage I/II HTN; please uptitrate
amlodipine as tolerated.
[]Ongoing work with ___ at rehab. OT evaluation regarding
hoarding/home safety
[]Wean pain regimen (currently on Morphine ER 15 mg BID with
Morphine ___ 15 mg as needed up to 6 times a day (only takes
one))
==================
Antibiotic Therapy
==================
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: CefTRIAXone 2 gm IV Q24H
Start Date: ___
Projected End Date: ___ (6 weeks for bone/joint GBS
infection)
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
===============
WOUND CARE RECS
===============
Wound care:
Site: Right thigh
Type: Other
Change dressing: qd
Comment: Donor site RIGHT THIGH - Xeroform changed once daily.
Wound care:
Site: Left leg
Comment: Xeroform changed once daily to skin graft sites.
Kerlix wrap. Flex-master (double ace-wrap).
Wound care:
Site: left knee and left posterior thigh
Comment: packed with moist kerlix gauze changed once daily -
this areas are marked
=====
Activity: Activity: Ambulate twice daily if patient able With
Assist: Walker
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Patient is WBAT to LLE. She is able to bend the left knee a
little bit but still trying to reduce shearing/inhibition of
graft uptake.
=========
ADMISSION WEIGHT: 222 lbs (Bed)
DISCHARGE WEIGHT: 216.93 lbs (Bed)
#CODE: DNAR, OK to intubate, OK to transfer to hospital (MOLST
___ chart)
#CONTACT: HCP: ___ (Brother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Vitamin E Dose is Unknown PO DAILY
4. Vitamin D Dose is Unknown PO DAILY
5. Potassium Chloride Dose is Unknown PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. CefTRIAXone 2 gm IV Q24H
3. Heparin 5000 UNIT SC BID Increased risk for DVT Duration: 30
Days
4. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. LOPERamide 2 mg PO QID:PRN Diarrhea
7. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth twice a day
Disp #*15 Tablet Refills:*0
8. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth Every four hours Disp
#*15 Tablet Refills:*0
9. Mupirocin Ointment 2% 1 Appl TP BID
10. Polyethylene Glycol 17 g PO DAILY
11. Ranitidine 150 mg PO BID:PRN Heart burn
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14.Outpatient Lab Work
DX: ICD L03.116. DATE: ___, and once every week thereafter.
LABS: CBC with differential, BMP, LFTs, CRP. ATTN: ___
CLINIC - FAX: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Osteomyelitis of the Left Tibia/Fibula
Type 2 diabetes
___
Anemia
SECONDARY DIAGNOSIS:
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You presented to the ___ ER on ___, after a
fall at your home. Your left knee was examined by the orthopedic
doctor that determined you would need to go to the operating
room.
What did you receive ___ the hospital?
- You had surgery on your left leg. Your left thigh, knee, and
leg were found to have an infection. The plates and screws ___
your tibia were removed and the infection was cleaned out. Due
to the difficulty of the infection, the orthopedics and plastic
surgery team had to take you for surgery a few more times.
Alongside surgery, you received intravenous antibiotics and had
negative pressure wound therapy applied or a "wound vacuum"
used.
- Upon reviewing your blood work when you first came it the
hospital, it was found that you had high blood sugar. This was
not surprising as you have a history of diabetes. While ___ the
hospital, we gave you insulin each night and after each meal.
However, one blood test that we performed, known as "Hemoglobin
A1c," suggests that your blood sugar levels have not been
adequately controlled. This number represents your body's
average blood sugar over a few months. Your HbA1c was 15.1%
which suggests that your blood sugar levels have been
consistently high. We recommend seeing a primary care doctor to
be prescribed medication to help control these levels as
nutrition alone will not be sufficient.
- You pointed out your high blood pressure to us and we
confirmed that your blood pressure was consistently high with
our daily measurements. We understand, as you have told us, that
you have had poor reactions to medications ___ the past for
lowering your blood pressure. However, you should also follow up
with a primary care doctor to have this addressed, as well, as
high blood pressure is detrimental to one's health.
- We had a nutritionist speak to you to help us optimize your
meals, vitamins, and nutrients you were taking ___ each day.
- We had our physical therapist and occupational therapists
evaluate you. We frequently have these teams see patients to
help explore what patients may need help with to facilitate
return to daily life. Our physical therapists suggested that you
go to a rehabilitation facility. At this facility, the
therapists will help you with exercises and make sure you are
set to go back home.
What should you do once you leave the hospital?
- You should follow up at the doctors' appointments we have
set up for you. Please make sure that you follow up with plastic
surgery and orthopedics. Please also follow up with a primary
care doctor once you are discharged from rehab.
- Please work with physical therapy to regain your strength at
rehab.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10599576-DS-21 | 10,599,576 | 26,475,769 | DS | 21 | 2121-01-05 00:00:00 | 2121-01-06 08:44:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of DM, HTN, PVD,
multiple foot infections s/p L TMA amp (___), L tib-fib ORIF
with hx of necrotizing fascitis s/p hardware removal (___) as
well as recent hospitalization for MRSA bacteremia, gangrenous
toe s/p right TMA amp, and LLE osteomyelitis requiring IV abx
who presents with shortness of breath and cough.
The patient reports an onset of URI symptoms, including
postnasal drip, sneezing, and cough a week ago. she had no
congestion, rhinorrhea, or sore throat. Over the next couple of
days, she developed a worsening cough, intermittently productive
of greenish sputum, worsening dyspnea on exertion, fatigue and
intermittent rib pain with coughing. No chest pain, shortness of
breath at rest or palpitations. No fever or chills. Given
persistent coughing, she had a CXR done at her rehab facility
that showed a right perihilar infiltrate, for which she was
initiated on levofloxacin ___ days ago. She continued to feel
symptomatic and not "improving as quickly as the staff were
expecting", prompting transfer to our ED. She also notes she had
increased leg swelling and mild orthopnea without PND over the
last week. Also feels her weight has gone up. She reports
postnasal drip has been improving slowly and her other URI
symptoms remain stable.
Of note, the patient was recently admitted to ___ from
___ for necrotizing SSTI of the LLE. She underwent
multiple debridements/I&Ds and removal of hardware. She
ultimately underwent STSG to the LLE. Cultures were
polymicrobial but GBS predominant. She was treated with broad
spectrum antibiotics before narrowing to CTX/doxycycline for
SSTI vs osteomyelitis. She was then readmitted to ___ from
___ for right gangrenous toe initially covered with
broad spectrum abx. Blood cultures at ___ grew MRSA for which
she was narrowed to vanc/CTX and underwent right great toe
amputation on
___. While here, she underwent LLE angiography, angioplasty of
the right peroneal artery and then right TMA on ___. Given
concern for osteomyelitis underlying the left TMA stump
(purulent drainage/probed to bone), the patient was discharged
on IV vancomycin. She completed 4 weeks of IV vancomycin and
transitioned to minocycline per ID recs. She was last seen by ID
on ___ who recommended continuing abx for ~3 months for
undebrided osteomyelitis (minocycline until early ___.
In the ED, initial vitals: Temp ___ BP 139/66 HR 81 RR 18 97%
on RA
Exam notable for: Audible wheeze, RRR, diffuse scattered
rhonchi, crackles at the left base, 2+ pitting edema to knee at
RLE, well healing graft over LLE
Labs notable for: Na 134, K 6.3->4.6, CO2 21, BUN/Cr 37/1.1, WBC
10.2, H/H 7.8/26, plt 418, BNP 3304, UA negative
Imaging notable for:
- CXR: Low lung volumes, mild pulmonary vascular congestion
without frank pulmonary edema, bilateral atelectasis. No pleural
effusion. Vague increased opacity projecting over the right
upper lung laterally. Possibly of superimposed infection.
Pt given: Duoneb, IV CTX, IV Lasix 20mg
Consults: None
Vitals prior to transfer: Temp 98.9 BP 145/87 HR 89 RR 24 95%
on RA
Upon arrival to the floor, the patient reports feeling well
overall. She notes persistent cough and dyspnea on exertion as
well as ___ edema.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
DM type II
Hypertension
Diabetic foot ulcers
Anemia
GERD
PSH:
Major Surgical or Invasive Procedure:
Left transmetatarsal amputation at ___
L leg tib-fib fracture ___: Left leg incision & drainage with excisional
debridement of necrotic tissue with removal of hardware
-___: Left calf and thigh debridement with application of
vacuum sponge
-___: Debridement of left leg and thigh
-___: Extensive debridement left leg, extensive fasciectomy
peroneal compartment, anterior compartment, posterior
compartment, arthrotomy washout left knee, total surface area
60x 40cm
-___: Incision and drainage of left leg, debridement of
skin fat fascia muscle, partial closure, Veraflow vac placement
-___: Irrigation and debridement of left lower extremity;
washout of left knee joint; application of negative pressure
wound therapy.
-___: Debridement of left lower extremity wounds;
split-thickness skin graft from right thigh; application of
negative pressure wound therapy.
-___: Superficial debridement of right thigh; debridement
of two individual left lower extremity wounds down to fat and
muscle; removal of staples left lower extremity skin grafts.
-___: Right TMA
Social History:
___
Family History:
Paternal grandmother - diabetes
___ aunt - stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 98.3F BP 159/72 HR 92 RR 18 96% on RA
GENERAL: Obese female in NAD. Lying comfortably in bed.
HEENT: AT/NC, anicteric sclera, MMM.
NECK: supple, no LAD, JVP difficult to asses ___ body habitus
though does not appear elevated.
CV: RRR with normal S1/S2, no murmurs, gallops, or rubs
PULM: Normal respiratory effort. Diffuse wheezing thorough.
Bibasilar crackles. No rhonchi.
GI: Soft, mildly distended and tympanic to percussion. No TTP,
guarding or masses appreciated.
EXTREMITIES: Warm, well perfused. LLE with large skin graft,
appears to be healing well. Left foot wrapped. Right foot with
TMA amputations of all toes. 4x2 cm area of mild purulent
drainage over medial aspect without surrounding erythema. Wound
otherwise appears to be healing well. 2+ pitting edema over RLE
up to the knee.
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
all extremities.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
___ 0718 Temp: 97.9 PO BP: 139/75 R Lying HR: 80 RR: 18 O2
sat: 94% O2 delivery: Ra FSBG: 120
GENERAL: Lying down in bed. NAD.
NECK: JVP difficult to asses ___ body habitus
CV: RRR with normal S1/S2, no murmurs, gallops, or rubs
PULM: Normal respiratory effort. Few wheezes in RUL posteriorly.
No rales or rhonchi.
GI: Soft, mildly distended. Non-tender to palpation, no
rebound/guarding.
EXTREMITIES: Warm. No ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-10.2* RBC-2.88* Hgb-7.8* Hct-26.0*
MCV-90 MCH-27.1 MCHC-30.0* RDW-16.3* RDWSD-54.2* Plt ___
___ 08:30PM BLOOD Plt ___
___ 08:30PM BLOOD Glucose-92 UreaN-37* Creat-1.1 Na-132*
K-6.6* Cl-97 HCO3-20* AnGap-15
___ 09:30PM BLOOD proBNP-3304*
___ 08:37PM BLOOD Lactate-2.3* K-6.3*
Urine culture negative
CXR:
1. Low lung volumes. Mild pulmonary vascular congestion without
frank
pulmonary edema. Bibasilar atelectasis.
2. Vague increased opacity projecting over the right upper lung
laterally. Possibility of superimposed infection would be
possible. Consider PA and lateral to further characterize if
patient is amenable.
___:
No evidence of deep venous thrombosis in the right lower
extremity veins.
ABI:
Moderate bilateral tibial artery disease. No significant change
when compared to the prior study.
DISCHARGE LABS:
___ 06:23AM BLOOD WBC-9.9 RBC-2.83* Hgb-7.5* Hct-25.3*
MCV-89 MCH-26.5 MCHC-29.6* RDW-15.8* RDWSD-51.8* Plt ___
___ 06:23AM BLOOD Plt ___
___ 06:23AM BLOOD Glucose-112* UreaN-37* Creat-1.0 Na-139
K-5.1 Cl-100 HCO3-26 AnGap-13
___ 06:23AM BLOOD Calcium-8.7 Phos-5.6* Mg-1.9
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] She currently has a MOLST noting DNI, OK for CPR and
non-invasive ventilation. Per discussion with the patient, she
had previously been DNR/DNI and is considering switching her
code status back to DNR/DNI. This should be further discussed in
the primary care setting.
[ ] She was actively diuresed with 20mg IV Lasix boluses during
this admission. A TTE showed pulmonary hypertension, but did not
show signs indicative of diastolic dysfunction. She therefore is
not being discharged home on PO Lasix.
[ ] Her weight should be closely monitored after discharge and,
if increasing, can consider starting PO Lasix 20mg to maintain
her weight.
[ ] A TTE performed during this admission showed pulmonary
hypertension. We suspect this may be due to underlying OSA. A
polysomnogram would be helpful to further evaluate. You may also
consider a pulmonology referral.
[ ] Her pantoprazole was held during this admission and at
discharge because we think it was causing her hyperkalemia. It
should not be restarted.
[ ] Iron studies were sent on the day of discharge that showed
iron deficiency anemia in addition to anemia of chronic disease.
She is being discharged on iron supplementation and should
receive a bowel regimen to make sure she does not become
constipated.
SUMMARY
========
Ms. ___ is a ___ y/o female with a history of DM, HTN, PVD,
multiple foot infections s/p L TMA amp (___), L tib-fib ORIF
with hx of necrotizing fascitis s/p hardware removal (___) as
well as recent hospitalization for MRSA bacteremia, gangrenous
toe s/p right TMA amp, and LLE osteomyelitis requiring IV abx
who presented with shortness of breath and cough.
ACUTE ISSUES:
=============
#Shortness of breath
Confirmed RUL pneumonia on PA and lateral CXR, treated as
community-acquired pneumonia. Patient also presented volume
overloaded (10 lbs over dry weight with ___ edema and elevated
BNP). No known history of diagnosis of heart failure. She was
treated with ceftriaxone and azithromycin for a five day course
(last day ___. She was also actively diuresed with Lasix.
She was not discharged with a prescription for Lasix, but her
weight should be monitored and Lasix can be started if her
weight increases.
- Discharge weight: 201.1 lb
- Discharge Cr: 1.0
#Hyperkalemia
Reports a recent history of hyperkalemia, felt by her facility
to be due to a medication (unclear which one). Hyperkalemia due
to PPI use has been documented in case reports, so we
discontinued her pantoprazole. She additionally was actively
diuresed with Lasix. She never had EKG changes. Her K on
discharge was 5.1.
#AGMA
#Lactic acidosis
Possibly in the setting of infection vs home metformin. Low
concern for sepsis. Resolved prior to discharge.
CHRONIC ISSUES:
===============
#Bilateral TMA, S/p STSG
#Osteomyelitis
Several recent hospitalizations for SSTI/osteomyelitis requiring
ambulation. S/p IV vanc x4 weeks, now on prolonged course of
minocycline. Exam notable for mild purulence from right RLE
wound, no surrounding erythema. Vascular surgery was consulted.
She underwent ABI/PVR studies which showed stable moderate
vascular disease of bilateral tibial arteries. She was continued
on minocycline and home oxycodone.
#PVD s/p multiple procedures
Discharged from prior admission on ASA/Plavix with plan to dc
Plavix after 30 days. She reported on admission she was no
longer taking aspirin for unknown reasons. After discussion with
vascular surgery, patient was placed back on aspirin 81 mg QD.
#DM
Discharged on lantus but reportedly became hypoglycemic. On
metformin and glipizide per outside facility records though she
denies taking glipizide.
- Held home metformin/glipizide
- SSI
#Hypertension
- Continued home amlodipine
#Code status
MOLST form shows DNI, okay for CPR and non-invasive ventilation.
Patient reports she was previously DNR/DNI but this was switched
in the setting of her procedures. She is considering switching
back to DNR/DNI.
CORE MEASURES:
==============
#CODE: DNI, okay for CPR/non-invasive ventilation
#CONTACT: ___ (Sister) ___
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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
2. GlipiZIDE 10 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO BID
4. Minocycline 100 mg PO Q12H
5. amLODIPine 10 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral
daily
8. Loratadine 10 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
11. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line
12. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. GlipiZIDE 10 mg PO DAILY
7. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell
oral daily
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. Loratadine 10 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
11. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second
Line
12. Minocycline 100 mg PO Q12H
13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Community acquired pneumonia
Volume overload
SECONDARY DIAGNOSIS
====================
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you here at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you were short of breath, and it was
discovered that you had a pneumonia and some extra fluid in your
body.
WHAT WAS DONE WHILE I WAS HERE?
- You were given antibiotics for your pneumonia.
- You were given medications through your IV to get rid of the
extra fluid.
- You were seen by the vascular surgery team for your right foot
wound.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Please take all of your medications as prescribed.
- Please keep all of your appointments.
- Please weigh yourself daily. If your weight goes up by 3 lbs
or more within a day, you should talk to the doctors at your
facility.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10599715-DS-5 | 10,599,715 | 20,082,646 | DS | 5 | 2174-04-13 00:00:00 | 2174-04-22 14:22:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
pedestrian struck
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with a past medical history
significant for opiate abuse, insulin dependent diabetes,
hepatits C, hypertension, and high cholesterol that was
transferred to ___ on ___ as a pedestrian struck. He
presented to the OSH with altered mental status and an unclear
story about what had happened to him. There was a report that he
has been a ped struck by car and also a report that he was found
lying next to a car. At the OSH he
was found to have a sternal fracture as well as L humeral head
fracture and L rib fractures that were of unclear age. Patient
does not recall what happened to him. He admits to using heroin
last evening.
Past Medical History:
IDDM
HTN
Hyperlipidemia
Hep. C
Opiate Abuse on methadone
Chronic Pancreatitis
Social History:
___
Family History:
none contributory
Physical Exam:
Physical Exam On Admission ___:
Temp: 97.2 HR: 103 BP: 166/78 Resp: 18 O(2)Sat: 98% Normal
Constitutional: Uncomfortable
HEENT: L periorbital ecchymosis and edema; no midface
instability or focal TTP, Pupils equal, round and reactive
to light, Extraocular muscles intact
Oropharynx within normal limits, no midline TTP or steps
Chest: Clear to auscultation, TTP over the sternum
Cardiovascular: Mild tachycardia, Normal first and second
heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema, brace on L
shoulder s/p fall with proximal humeral fracture in ___;
Skin: Abrasions on bilateral knees
Neuro: Speech fluent, CN 2 - 12 intact, motor ___ R=L in UE
and ___ sensation to light touch intact
Psych: Normal mood, Normal mentation
Discharge PE ___:
Vitals:
General: comfortable appearing man, no apparent distress
CV: S1, S2, RRR, no mumurs, rubs or gallops
Lungs: CTAB, diminished in bilateral bases R>L
Abd: Soft, nontender, nondistended
Extrem: Warm, well perfused, + PP
Neuro: Alert and oriented, PERRL 3 mm Bilat, MAE to command
Pertinent Results:
___ 02:00PM WBC-7.8 RBC-3.16* HGB-8.4* HCT-26.8* MCV-85
MCH-26.7* MCHC-31.5 RDW-15.2
___ 02:00PM ___ PTT-34.0 ___
___ 02:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-POS
___ 02:18PM GLUCOSE-149* LACTATE-2.1* NA+-140 K+-3.3
CL--112* TCO2-21
___ 03:12AM BLOOD WBC-9.6 RBC-3.45* Hgb-9.1* Hct-28.9*
MCV-84 MCH-26.3* MCHC-31.3 RDW-15.1 Plt ___
___ 03:12AM BLOOD Plt ___
___ 09:30AM BLOOD Glucose-114* UreaN-25* Creat-0.9 Na-137
K-4.5 Cl-101 HCO3-24 AnGap-17
___ 09:30AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
___: BAL: + MRSA and H. Inlfuenzae
___: CXR: Several left rib fractures are seen. These
specifically involve the left third, sixth, seventh, eighth ribs
with possible involvement of the ninth and tenth ribs.
___: Humerus (AP & Lateral) Acute, comminuted, mildly
displaced fracture involving the left humeral head and surgical
neck
___: CT Chest: Numerous left-sided acute rib fractures as
described above. Additional chronic-appearing anterior left rib
fractures of the seventh through tenth ribs.
2. Mildly displaced sternal fracture. New left humeral head
and surgical neck fracture in addition to subacute comminuted
left humeral shaft fracture.
3. Small left pleural effusion. No pneumothorax.
4. Bilateral non-obstructing renal calculi, measuring up to 6
mm on the left.
5. 4-mm left lower lobe nodule. Follow-up CT Chest is
recommended in 12
months if this patient is high-risk for lung cancer
___: CXR: New opacity overlying the right lung base,
consistent with aspiration.
___: CXR: There has been some interval partial re-expansion
of the right lower and middle lung lobes, however there
continues to be substantial volume loss in these regions. There
are bilateral pleural effusions right greater than left,
___: CXR: Again there is opacification with an oblique
upper margin at the right base, consistent with lower lobe
collapse and pleural effusion. The left lung is essentially
clear and there is no definite vascular congestion.
Brief Hospital Course:
Mr. ___ is a ___ y.o. male with PMH significant for Hepatitis
C, insulin dependent diabetes, and chronic opiate abuse on
Methadone maintenance who was admitted to ___ from an outside
facility on ___ after trauma of unclear circumstances. Per
patient report, he was caught in the car door while exiting and
was inadvertently dragged. Patient does report loss of
conciousness and is vague on any further details. At the
outside facility, he was found to have a sternal fracture as
well as left humeral and left rib fractures that were of unclear
age. At which point he was transferred to ___
___.
Primary and seconday survey revealed T1/T11 compression
fractures, left ___ rib fractures of indeterminate age with
acute left rib fractures ___, minimally displaced sternal
fracture and new and old left humeral head fx.
Orthopaedics was consulted and recommended non operative
management of the new left humeral head fracture with a
___ brace and sling. Neuro-Spine recommended TLSO brace
for comfort and will follow up on the T1 and T11 compression
fractures.
Tertiary survey was unremarkable.
Mr. ___ remained alert and oriented X3. Acute Pain service
was consulted to maximize his pain control with his rib
fractures. He was restarted on his Methadone 145 mg daily,
placed on a Dilaudid PCA, Toradol, and a Clonidine patch. Pt.
reported adequate pain control and was able to cough and deep
breath without splinting. He remained hemodynamically stable
throughout his stayl; however on ___ he had an increasing O2
requirement up to 100% NRB. He reported no increased pain or
shortness of breath at this time. An arterial blood gas was
obtained revealing a PAO2 of 61 with a normal pH and CO2. Chest
X-Ray at this time demonstrated a new opacity overlying the
right lung base, consistent with aspiration. Pt. the patient
was transferred to the ICU at this time due to oxygen
requirement but without significant respiratory distress or
hemodynamic compromise. CTA was negative for pulmonary embolus.
While in the ICU, he underwent bronchoscopy and was initiated on
antibiotics for aspiration pneumonia. Post bronchoscopy Chest
X-Ray showed a right lower lobe collapse.
He was transferred to the floor on ___. Subsequently, the
patient was weaned from oxygen. At the time of discharge, the
patient was hemodynamically stable with an O2 Sat of 96% on room
air. He remained afebrile with a normal white blood cell count.
He ws transitioned to Levaquin and was discharge on a 10 day
course. He was tolerating a regular diet without nausea and had
a bowel movement prior to discharge. Blood glucose control was
labile and ___ Diabetes was consulted. The patient was
discharged on Lantus 8 units BID and a regular insulin sliding
scale. He was comfortable with self administration and planned
to follow up with ___ on ___. He was ambulating
independently and completing ADL's with ___ brace in
place. He will follow up with orthopeadic surgery and neuro
spine. He will follow-up with acute care surgery on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 50 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Creon 12 2 CAP PO TID W/MEALS
4. Methadone 145 mg PO DAILY
5. Lantus 10 units QAM
6. Lanuts 23 Units QPM
7. Omeprazole 20 mg Daily
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Creon 12 2 CAP PO TID W/MEALS
3. Lisinopril 40 mg PO DAILY
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. Levofloxacin 750 mg PO Q24H
Your last dose will be on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp
#*10 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Methadone 145 mg PO DAILY
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
9. Glargine 8 Units Breakfast
Glargine 8 Units Bedtime
Humalog 1 Units Breakfast
Humalog 1 Units Lunch
Humalog 1 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog] 100 unit/mL 1 unit SC before meals
Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
polytrauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ after an accident where you were
dragged by a car. Your injuries included a left humeral head
fracture, left rib fractures ___, and a sternal fracture. You
were also found to have T1 and T11 compression fractures of your
vetebrae and were seen by Neuro-Spine. You are ready to return
home to recover.
Rib Fractures:
* 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 wear your ___ brace at all times to allow for
healing of the fracture of your left humerus. Continue to move
you elbow, wrist, and shoulder as occupational therapy educated
you to maintain mobility.
Due to your compression fractures, please call with any changes
in sensation, weakness, or inability to control your
bowels/bladder.
The ___ Diabetes Team will be following you as an outpatient
for your diabetic management. Please keep a log of your blood
sugars prior to each meal and at bedtime. Cover your blood
sugar as directed by your scale. You will take ***
Signs of a low blood sugar are feeling shakey, sweating, or
disorientation.
Followup Instructions:
___
|
10599715-DS-6 | 10,599,715 | 20,334,548 | DS | 6 | 2174-08-17 00:00:00 | 2174-08-17 16:46:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / nafcillin
Attending: ___.
Chief Complaint:
Bradycardia
Mechanical Fall
Bilateral Mandibular Fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ M with PMHx polysubstance abuse on
methadone maintenance, HCV, T2DM on insulin, HTN, chronic pain,
who presents s/p mechanical fall complicated by bilateral
mandibular fracture. He was running up the narrow steep
staircase in his home, excited after a purchase of an iphone,
when he caught his toe on the steps and fell onto his jaw. He
denies prodromal or aftermath lightheadedness, dizziness,
vertigo, syncope, presyncope, chest pain, palpitations, and
dyspnea.
He initially presented to OSH. There, labs notable for: WBC 8.6,
Hb 12.9, Hct 38.5, plt 233, Dimer 2662, INR 1.05, PTT 31.8, ___
12.2, Ca 9.1, CO3 26, Na 138, Alk P ___, Mg 1.5, urine neg.
Imaging notable for:
CT face/mandible: Comminuted fracture of both mandibular
condyles w/ shortening, anterior displacement onto promontories.
CT PE: Possible inflammatory stranding around upper poles of
both kidneys.
In the ED, initial vitals: 97.6 56 138/76 16 100% 2L RA
ECG is notable for sinus bradycardia to 40's, QTc 527ms, no
ischemic changes.
Labs here notable for K+ 3.5, Mg 2.9. Serum tox negative. Urine
tox positive for opiates, methadone, and cocaine.
He was given KCl 40mEq and hydromorphone 1mg IV x3.
Currently, feels okay but has ___ left chest pain and ___
bilateral jaw pain and is very hungry. Under care of ___, ___.
Past Medical History:
T2DM on Insulin
HTN
Hyperlipidemia
Hepatitis C
Opioid/Polysubstance Abuse on methadone
Chronic Pancreatitis
Social History:
___
Family History:
Reviewed and noncontributory (few relatives)
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
Vitals- T 98.0, BP 172/82, HR 55, RR 16, SaO2 100% on RA, Pain
___
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, numerous ecchymoses on lower extremities
Neuro- ___ intact, motor function grossly normal
========================
DISCHARGE PHYSICAL EXAM:
Vitals- Afebrile, HR ___, BP ___, RR 18, SaO2 99% on
RA, no strict I/Os, Tele = ___ with alarms for PVCs @5:00
General- Alert, oriented, no acute distress, A+Ox3
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, numerous ecchymoses on lower extremities
Neuro- ___ intact, motor function grossly normal
Pertinent Results:
___ 06:10AM URINE ___
___
___ 03:03AM EKG Sinus bradycardia. Prolonged ___ interval.
Compared to the previous tracing of ___ no diagnostic
change.
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
50 178 92 ___ 72 35 59
Brief Hospital Course:
Mr ___ is a ___ M with h/o polysubstance abuse on methadone
maintenance, HCV, ___ t2DM, HTN, chronic pain, who
presents s/p mechanical fall complicated by bilateral mandibular
fracture and was admitted for bradycardia and prolonged QTc.
================
Active Issues:
#Bradycardia/Prolonged QTc: On admission, had HR 40 and QTc 527
felt to be secondary to atenolol 50 mg and methadone 155mg
(recently increased) but was essentially asymptomatic. HR
improved to ___ on discharge and QTc improved to 470s. He
was kept on telemetry for his safety, his atenolol was titrated
from 50 to 25 and discontinued on discharge due to
bradycardia/hypertension and concern about cocaine use.
Labetolol 100mg PO was given for an episode of SBP ___
secondary to a medication administration gap. A letter was set
to his ___ clinic detailing the QTc issue.
#Mechanical Fall/Bilateral Jaw Fracture: Fall occured when he
was rapidly running up stairs when he tripped on a step and fell
onto his jaw. He denied cardiac prodromal or aftermath
symptoms. He has evaluated by Oral and Maxillofacial Surgery in
the ED and they gave recommendations (Hydromorphone 4mg q6h po
for 10 days [interval decreased due to poor bridging], no
antibiotics, Peridex mouthwash to area for 3 days, Ice pack for
3 areas, full liquid diet for 4 weeks, follow up with OMFS on
___ at 10:00 AM (___, ___,
___ floor, Oral and Maxillofacial Surgery clinic), patient can
call ___ in case of question, or follow up with OMFS
earlier as needed by calling ___
at 7:00 AM every day except weekends. Hydromorphone was
controlling his pain and he was discharged with the above
instructions.
#HTN:Hypertensive due to combination of cocaine and atenolol.
Was on lisinopril 40 and atenolol 50. Meds adjusted to
lisinopril 40, atenolol titrated off as above, and started on
amlodipine 5. SBP was briefly in ___ but decreased to 170s
at discharge, allowing PCP ___.
#Polysubstance Abuse: On methadone 155mg by Habit ___ in
___. Denied current opioid/heroin and cocaine use but
tested positive for both in the ED. Social work was consulted
for ongoing substance abuse. ___ clinic was updated
regarding last methadone dose and EKG abnormalities.
================
Inactive Issues:
#T2DM: ___ on Glargine 8unit BID, Lispro 1unit TID
with meals, and Lispro SS of 2 units per 50mg/dL after 200.
Last HbA1c was 6.9%. ___ glucose was >___ue to medication administration delay. No change was made to
his regimen otherwise.
#HCV: Documented history of this issue with no active
liver/kidney disease. No interventions were performed and no
issues were noted.
===============
Transitional Issues:
#Goals of Care: Full Code discussed with patient and HCP is in
system
#Readmission Risk: Possible secondary to poor transportation
options and polysubstance abuse including current cocaine/heroin
use
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Creon 12 2 CAP PO TID W/MEALS
3. Lisinopril 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Methadone 155 mg PO DAILY Opioid Dependence
6. Glargine 8 Units Breakfast
Glargine 8 Units Bedtime
Humalog 1 Units Breakfast
Humalog 1 Units Lunch
Humalog 1 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Creon 12 2 CAP PO TID W/MEALS
2. Glargine 8 Units Breakfast
Glargine 8 Units Bedtime
Humalog 1 Units Breakfast
Humalog 1 Units Lunch
Humalog 1 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Lisinopril 40 mg PO DAILY
4. Methadone 155 mg PO DAILY Opioid Dependence
5. Omeprazole 20 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
7. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain Duration: 4
Days
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth Every 4
Hours Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical Fall
Mandibular Fracture
Sinus Bradycardia
Prolonged QTc
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you during your time at ___
___. You were admitted because you
fractured your jaw. Your medications (___) were
adjusted and you were were seen by a social worker. Best of
luck in your future health.
Followup Instructions:
___
|
10599715-DS-9 | 10,599,715 | 26,943,502 | DS | 9 | 2178-06-10 00:00:00 | 2178-06-11 13:09:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / nafcillin / Neurontin
Attending: ___.
Chief Complaint:
___ h/o polysubstance abuse, here after a fall from toilet with
small frontal SAH, orbital floor fx, nasal bone fx
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o polysubstance abuse, here after a fall from toilet with
small frontal SAH, orbital floor fx, nasal bone fx
Past Medical History:
Diabetes -- A1c 14.2%. Complications:
Nephropathy (CKD3)
Neuropathy
Retinopathy
HCV -- diagnosed ___, remission ___ s/p interferon,
relapsed ___
Heroin use -- ___ years, quit ___, on methadone
Tobacco use -- 50 pack-years, quit just prior to admission
Recurrent falls c/b jaw, rib, and sternal fractures
Recurrent lower extremity cellulitis
Seizures while on gabapentin
Social History:
___
Family History:
Mother -- lung cancer, EtOH, Alzheimer's
Father -- does not know
Physical Exam:
Admission Physical Exam:
BP: 136/87 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Intubated and sedated
HEENT: Normocephalic, atraumatic
Chest: Right chest wall tenderness, coarse breath sounds
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
Extr/Back: Trace edema
Skin: Skin turgor in the left upper extremity
Neuro: Sedated but responds to painful stimuli, occasionally
reaching for ET tube
Discharge Physical Exam:
VS: T: 97.6 PO BP: 172/81 HR: 61 RR: 18 O2: 94% Ra
GEN: A+Ox2 to name and place, disoriented to time
HEENT: mild b/l ecchymosis
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: b/l UE with skin tears, scabbing. wwp b/l. RUE with PICC
Pertinent Results:
IMAGING:
___: CT Chest:
1. Confluent ground-glass opacity noted in the dependent aspect
of the right
upper lobe likely represents atelectasis
2. No evidence of solid organ injury within the imaged chest,
abdomen and
pelvis.
3. Multiple old fractures as described above. No definite
evidence of acute
fractures.
4. Vertebral body height loss at multiple levels in the thoracic
and lumbar
spine without CT evidence to suggest acuity and most likely
chronic.
5. Cirrhotic liver with small volume ascites. Slightly enlarged
spleen
measuring 12.2 cm.
6. Chronic pancreatitis.
7. Enteric tube and endotracheal tube in appropriate positions.
___: WRIST(3 + VIEWS) LEFT:
No acute fracture or dislocation.
There is a geographic lucency at the radial styloid which may
represent more
prominent osteopenia, however underlying mass cannot be
excluded.
Curvilinear radiodense material along the dorsal soft tissues
overlying the
distal radius may represent bandage material. Clinical
correlation
recommended.
RECOMMENDATION(S): Non emergent mass infection MR protocol with
contrast of
the left wrist to further evaluate lucency in the radius.
___: ELBOW (AP, LAT & OBLIQUE) LEFT:
No acute fracture or dislocation.
___: EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because
of discontinuous, slow background activity. It became more
continuous with
predominantly mixed theta/delta activity with rare generalized
runs of sharp
wave discharges with triphasic morphology, which is indicative
of moderate
diffuse encephalopathy that is nonspecific in etiology. Common
causes are
medication effect, infections, or toxic/metabolic disturbances.
There was
nearly continuous focal slowing over the left hemisphere,
indicative of focal
cortical dysfunction. This recording captured no pushbutton
activations,
epileptiform discharges or electrographic seizures. Compared to
the prior
day___s recording, the background was more continuous and the
focal hemisphere
slowing became more evident.
___: ECHO:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Suboptimal image quality.
___: Carotid series complete:
Mild heterogeneous atherosclerotic plaque involving both carotid
arteries with
less than 40% stenosis of each internal carotid artery.
___: DX CHEST PORTABLE PICC :
Interval repositioning of the right PICC line whose tip now
projects over the distal SVC.
___: CT Head:
1. Mild interval increase size of right superior frontal sulcus
subarachnoid
hemorrhage, with minimally increased adjacent white matter edema
pattern.
Minimal increase trace dependent hemorrhage within the left
occipital horn.
2. Subarachnoid hemorrhage at the quadrigeminal plate cistern
appears overall
similar.
3. No evidence of acute large territory infarct. However, if
there is high
clinical concern and there is no contraindication, MRI would be
more sensitive
for acute infarct.
4. Additional findings as described above.
___: CTA Head:
1. Unchanged areas of scattered subarachnoid and
intraventricular hemorrhage
as detailed above. No new areas of hemorrhage are identified.
2. Please refer to the prior studies for full description of the
left orbital
and facial fractures.
3. Unchanged bilateral hemosinus.
4. Evidence of mild white matter small vessel disease.
___ 04:51AM BLOOD WBC-6.0 RBC-2.90* Hgb-7.9* Hct-24.7*
MCV-85 MCH-27.2 MCHC-32.0 RDW-15.5 RDWSD-47.8* Plt ___
___ 09:45PM BLOOD Neuts-81.8* Lymphs-10.6* Monos-6.3
Eos-0.3* Baso-0.3 Im ___ AbsNeut-7.04* AbsLymp-0.91*
AbsMono-0.54 AbsEos-0.03* AbsBaso-0.03
___ 04:51AM BLOOD Plt ___
___ 01:29AM BLOOD ___ PTT-29.6 ___
___ 01:29AM BLOOD ___
___ 04:51AM BLOOD Glucose-364* UreaN-23* Creat-0.9 Na-138
K-3.3* Cl-99 HCO3-25 AnGap-14
___ 09:45PM BLOOD ALT-79* AST-162* AlkPhos-226* TotBili-0.5
___ 12:54AM BLOOD cTropnT-<0.01
___ 04:51AM BLOOD Calcium-7.3* Phos-4.5 Mg-2.2
___ 04:51AM BLOOD %HbA1c-9.9* eAG-237*
___ 03:01AM BLOOD Type-ART pO2-76* pCO2-38 pH-7.50*
calTCO2-31* Base XS-5
___ 03:01AM BLOOD Lactate-0.8
___ 01:52AM BLOOD freeCa-1.06*
Brief Hospital Course:
Mr. ___ is a ___ year old male with a hx of EtOH abuse,
Hepatitis C, T2DM, HTN, opioid dependence, who presented to
___ on ___ from a ___ facility s/p fall in the
bathroom following a large bowel movement. He was found to have
a small frontal SAH, orbital floor fractures and nasal bone
fractures. The patient was taken to OSH ED where he was
intubated for worsening mental status. Upon arrival to ___ ED
he was started on a nicardipine gtt for blood pressure control
and a phenobarbital taper. Patient was seen and evaluated by
neurosurgery who determined injuries to be non-operative at this
time and do not require neurovent. Neurosurgery recommended
keppra 1000mg BID for 7 (seven) days and that he follow-up in
the Traumatic Brain Injury Clinic as needed.
The patient was also seen by Plastic Surgery for his facial
fractures. No acute surgical intervention indicated for
patient's facial fractures. It was recommended he remain on
sinus precautions for 1 (one) week. Ophthalmology was consulted
to rule out concomitant globe injury. Ophthalmology saw the
patient and no ophthalmic interventions were needed.
On HD4, the patient had a foley placed which was reported to be
a difficult placement. It was recommended he have a voiding
trial in approximately ___ days. On HD4, it was noticed that
the left hemibody was weaker than the right. A CT head was
ordered which showed a mild interval increase size of right
superior frontal sulcus subarachnoid hemorrhage. There was no
evidence of acute large territory infarct. A CTA head was
ordered which was unchanged from the CT head.
Speech & swallow evaluated the patient and recommended thin
liquids & soft solids. His blood pressure was controlled
The ___ was consulted for help managing the
patient's blood sugars. He received glargine and a Humalog
insulin sliding scale.
The patient received po methadone, a home medication, for pain
control. He remained stable from a cardiovascular standpoint.
He received his home BP medications and IV prn hydralazine for
blood pressure control.
The patient tolerated a soft solids & thin liquids diet.
Patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, foley was patent, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Sertraline 50 mg PO DAILY
2. Prazosin 4 mg PO QHS
3. Rosuvastatin Calcium 5 mg PO QPM
4. Isosorbide Mononitrate 30 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Carvedilol 3.125 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Creon 12 2 CAP PO TID W/MEALS
10. HydrOXYzine 25 mg PO QHS:PRN itching insomnia
11. Aspirin 81 mg PO DAILY
12. Glargine 12 Units Bedtime
Discharge Medications:
1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
2. Docusate Sodium 100 mg PO BID
hold for loose stool
3. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
4. Glucose Gel 15 g PO PRN hypoglycemia protocol
5. Heparin 5000 UNIT SC BID
6. HydrALAZINE ___ mg IV Q6H:PRN SBP >160
7. LevETIRAcetam 1000 mg PO Q12H Duration: 2 Days
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Carvedilol 6.25 mg PO/NG BID
11. Glargine 10 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
12. Isosorbide Dinitrate 10 mg PO TID
13. amLODIPine 10 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Creon 12 2 CAP PO TID W/MEALS
16. HydrOXYzine 25 mg PO QHS:PRN itching insomnia
17. Lisinopril 20 mg PO DAILY
18. Methadone 105 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Prazosin 4 mg PO QHS
21. Rosuvastatin Calcium 5 mg PO QPM
22. Sertraline 50 mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Fall
-Left orbital floor fracture with evidence of hemosinus
-Nasal bone fracture
-Small frontal subarachnoid hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after
a fall. You were found to have a small area of internal head
bleeding and you sustained facial and nasal bone fractures. You
were evaluated by the Neurosurgery service and your head injury
was stable. It was recommended that you receive a medication
called Keppra (Levetiracetam) for 1 (one) week to prevent
seizures. The Plastic Surgery service evaluated your facial
fractures which did not require surgery. It was recommended you
remain on sinus precautions for 1 (one) week and follow-up in
the outpatient plastic surgery clinic. The Ophthalmology
service evaluated your eyes for any injury and no intervention
was warranted.
While you were in the Intensive Care Unit, a foley catheter was
placed for urine output monitoring. It is recommended this
catheter be removed in the next ___ days for a voiding trial.
You are now ready to be discharged to the ___ hospital to
continue your recovery. Please note the following discharge
instructions:
You are no Weigh yourself every morning, call MD if weight goes
up more than 3 lbs.
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.
Sinus Precautions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved.
Traumatic Brain Injury Instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms
Followup Instructions:
___
|
10599735-DS-7 | 10,599,735 | 25,964,046 | DS | 7 | 2120-10-19 00:00:00 | 2120-10-20 10:23:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
environmental (dust, mold, grass)
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o gentleman who has had recurrent episodes
of SBO since ___. He underwent single-incision ileal resection
with Dr. ___ revealed a small bowel ulcer. Subsequent
capsule endoscopies and enteroscopies have identified multiple
such ulcers throughout his small bowel, consistent with Crohn's
disease on biopsy. He has continued to have recurrent
obstructive symptoms on and off, which have increased in
intensity since early ___. He had been taking azathioprine
for control of his Crohn's disease, and was restarted on
Budesonide ___ per the direction of Dr. ___. Despite this,
his abdominal pain peaked yesterday after eating a chicken
sandwiches for lunch, and he developed nausea and vomiting. He
reports passing several small bowel movements through the day
yesterday but no flatus. He has not had any fevers or chills.
Currently his pain is minimal, though he did receive IV pain
medication 15 minutes ago. He has not been nauseous since
arriving in the ED.
Past Medical History:
SBO
BPH
seasonal allergies
GERD/hiatal hernia
Social History:
___
Family History:
No FH of colon cancer, other cancers, or IBD.
Mother with h/o diverticular disease
Physical Exam:
AFVSS
Gen - NAD, AAOx3
HEENT - MMM, PERRL
CV - RRR, nml S1/S2, no M/R/G
Resp - CTAB, no W/R/R
Abd - S, NT/ND, +BS
Ext - WWP, no C/C/E
Neuro - CN2-12 grossly intact
Pertinent Results:
Admission Labs
___ 03:40AM BLOOD WBC-8.5 RBC-4.38* Hgb-14.2 Hct-41.0
MCV-94 MCH-32.3* MCHC-34.5 RDW-13.8 Plt ___
___ 03:40AM BLOOD Neuts-85.2* Lymphs-10.3* Monos-3.9
Eos-0.4 Baso-0.2
___ 03:40AM BLOOD ___ PTT-32.6 ___
___ 03:40AM BLOOD Glucose-129* UreaN-18 Creat-1.1 Na-144
K-3.9 Cl-105 HCO3-30 AnGap-13
___ 03:40AM BLOOD ALT-14 AST-20 AlkPhos-59 TotBili-1.8*
___ 03:40AM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.2 Mg-2.0
___ 03:44AM BLOOD Lactate-1.0
Brief Hospital Course:
Mr. ___ was admitted to the hospital on ___ with a
small bowel obstruction. A CT scan on admission showed
high-grade small bowel obstruction with a transition point is in
the mid abdomen in the general vicinity of a prior small bowel
anastomosis, suggestive of adhesions as the cause. He was
treated with a nasogastric tube, IV fluids and NPO. He
inadvertently removed his NGT on ___ but was not nauseated and
overall felt better and it was not reinserted. The
gastroenterology service was consulted due to his history of
complex Crohns and recommended IV steroid therapy as well as an
MRE. He was started on solumedrol 20Q8H.
He started to pass flatus into ___, and his diet was advanced
appropriately. His pain was reduced, and he began having bowel
movements. He had an MRE on ___ which demonstrated a 1.6 cm
long segment of narrowing with active inflammation seen in the
mid ileum with mild prestenotic dilation up to 2.7 cm (decreased
from 3.6 cm on the prior CT study). After consultation with Dr.
___ was switched to a prednisone taper of 40mg x 7d,
decreasing by 5mg/wk, while continuing his azathioprine and
d/c'ing his budesonide. He was D/C'ed home on ___ in good
condition with instructions for follow-up with both the
colorectal surgery service and Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 150 mg PO DAILY
2. Budesonide 9 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Azathioprine 150 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Multivitamins 1 TAB PO DAILY
4. PredniSONE 40 mg PO DAILY Duration: 7 Days
RX *prednisone 5 mg See below tablet(s) by mouth Once a day Disp
#*130 Tablet Refills:*1
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 for a small bowel obstruction. You had an NGT
placed and were treated with intravenous fluids. You had an MR
enterography on ___.
In the coming days, please get plenty of rest, keep yourself
hydrated and be sure to call us or come into the ED with
recurrent or worsening symptoms.
Followup Instructions:
___
|
10599735-DS-8 | 10,599,735 | 26,441,399 | DS | 8 | 2121-05-04 00:00:00 | 2121-05-04 12:59:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
environmental (dust, mold, grass)
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
None, obstruction conservatively managed.
History of Present Illness:
This is a ___ yo male with Crohn's disease and past SBO
presenting with multiple episodes vomiting and abdominal
pain c/w past sbo. Decreased gas output. No fevers,
diarrhea, flank pain, urinary symptoms.
Past Medical History:
SBO
BPH
seasonal allergies
GERD/hiatal hernia
Social History:
___
Family History:
No FH of colon cancer, other cancers, or IBD.
Mother with h/o diverticular disease
Physical Exam:
Discharge Physical:
98.5 54 110/62 18 99%RA
Gen: NAD, A&Ox3
CV: RRR, S1S2
Pulm: CTAB
Abd: scaphoid, soft, non-tender, non-distended
Pertinent Results:
___ 07:50AM BLOOD WBC-8.1 RBC-3.99* Hgb-13.4* Hct-38.4*
MCV-96 MCH-33.7* MCHC-35.0 RDW-15.5 Plt ___
___ 01:10AM BLOOD WBC-7.2 RBC-3.78* Hgb-12.7* Hct-36.0*
MCV-95 MCH-33.5* MCHC-35.3* RDW-15.9* Plt ___
___ 01:10AM BLOOD Neuts-75.4* Lymphs-16.8* Monos-5.3
Eos-2.2 Baso-0.4
___ 07:50AM BLOOD Glucose-122* UreaN-18 Creat-0.9 Na-142
K-4.0 Cl-102 HCO3-28 AnGap-16
___ 01:10AM BLOOD Glucose-102* UreaN-11 Creat-0.9 Na-143
K-3.7 Cl-105 HCO3-29 AnGap-13
___ 01:10AM BLOOD ALT-11 AST-24 AlkPhos-52 TotBili-2.5*
Brief Hospital Course:
The patient was admitted to the colorectal service on ___.
An NGT had been placed in the ED. He was managed conservatively
on IV pain meds, IVF, and nothing per os. Serial abdominal exams
were performed.
On hospital day #2, the patient began to feel better and had
minimal pain. His NGT output was below 400cc over 24 hours. He
began to pass gas. With these findings, the NGT was clamped. The
patient did not have nausea nor any residual fluid once the NGt
was re-hooked to suction, therefore, the NGT was removed. He was
slowly advanced from sips to clears and tolerated this very
well. Overnight on hospital day #2, the patient continued to
pass flatus.
On hospital day #3, he continued to pass gas and had complete
resolution of his pain. He was advanced to a regular diet and
tolerated this well. He was dicharged home with appropriate
instructions from the GI team regarding his steroid taper and
with appropriate follow up.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
___: Humira 80 QOW, Azathioprine 150', Fish oil, Flomax 0.4',
Probiotic, MVI, saw ___
ALL: NKDA
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
Will taper steroids by 10mg every 7 days. Please make appt with
Dr. ___.
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*100
Tablet Refills:*0
2. Tamsulosin 0.4 mg PO HS
3. Multivitamins 1 TAB PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
please take home dose
5. Azathioprine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstructions related to Crohns Stricture
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. You will be
discharged on the medication Prednisone. You should take 40mg
daily and taper the dose every 7 days by 10mg. So, please take
40mg daily until ___. On ___ please taper the dose to
30mg of Prednisone daily for 7 days. On ___ take 20mg of
Prednisone for 7 days. On ___ take 10mg of Prednisone for 7
days and your last dose of prednisone will be ___. During
this time, you will need to monitor youself for signs of steroid
withdrawal including: Weakness, fatigue, decreased appetite,
weight loss, nausea, vomiting, diarrhea (which can lead to fluid
and electrolyte abnormalities), and abdominal pain are common.
Blood pressure can become too low, leading to dizziness or
fainting. You should take your Azathioprine.
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!
You must make a follow-up appointment with Dr. ___ 2
weeks as mentioned below and follow-up with Dr. ___ as needed.
Please call the colorectal surgery clinic if you develop any
increased abdominal pain.
Followup Instructions:
___
|
10599735-DS-9 | 10,599,735 | 21,125,280 | DS | 9 | 2122-05-29 00:00:00 | 2122-05-29 22:35:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
environmental (dust, mold, grass)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Diagnostic laparoscopy and laparoscopic small bowel
resection
History of Present Illness:
Mr. ___ is a ___ year old male with a history of small bowel
Crohn's disease complicated by small bowel obstruction, status
post ileal resection in ___ presenting with crampy abdominal
pain. Patient has a history of recurrent SBOs, most recently
admitted in ___ which was treated conservatively with IVF,
IV pain meds and NGT to suction. SBO resolved without any
further intervention. He does note that he had some symptoms in
___ which resolved without requiring hospitalization.
Patient notes that the abdominal pain started at 3pm on day of
presentation with some slight abdominal cramps. He initially
thought it was possibly muscle strain from working out or from
eating too many sunflower seeds. The pain progressively worsened
and around 10pm he started to have bilious emesis associated
with the pain. That is when he decided to go to the hospital.
For his Crohn's disease, the patient has previously been on
Adalimumab and Azathioprine but since ___ he has been
getting Infliximab infusions. Per GI notes, he was in clinical
remission in ___. Patient's last Remicade therapy was
___.
In the ED, initial vital signs were: 98.9 68 119/58 16 98% RA
Labs were notable for Na 146, Cr 1.1, WBC 9, H/H 13.6/40.7.
Imaging showed SBO with "dilated, fecalized loops leading to a
discrete transition point in the left mid abdomen which
demonstrates narrowed caliber and probable wall thickening a
suggesting region of active Crohn disease or stricture resulting
in upstream obstruction." Colorectal surgery team was consulted
and NGT was placed.
Past Medical History:
GI History: Crohn's disease
- Mid-ileal inflammation and stricture (MRE ___
- Jejunal ulcerations (small bowel enteroscopy ___ and
___
- Mid-jejunal stenosis (small bowel enteroscopy ___
- Duodenitis and duodenal ulcers (small bowel enteroscopy
___
___ esophagus (EGD ___
Osteopenia
BPH
seasonal allergies
GERD/hiatal hernia
Social History:
___
Family History:
Mother has colitis. Daughter has GI symptoms. No history of
colon cancer
Physical Exam:
On admission,
Vitals- T 98.2 BP 123/90 P 64 RR 18 O2 99%RA
General: Appears stated age, has NGT in place, dry
heaving/vomiting into basin, NAD
HEENT: Anicteric, PERRL, MMM, O/P clear, some erythema noted in
posterior pharynx, NGT in place
Neck: supple
CV: RRR, no m/r/g
Lungs: CTAB no w/r/r
Abdomen: + hyperactive right sided bowel sounds, somewhat
diminished bowel sounds in LLQ. Abdomen is soft, nondistended,
mildly tender in the epigastrium and LLQ. No rebound or
guarding. Faint reticular rash noted on predominantly right
sided abdomen.
GU: Deffered
Ext: No edema, warm, 2+ pulses
Neuro: A&Ox3, CN II-XII grossly intact, normal strength
Skin: rash noted on abdomen as above, otherwise no ulcers or
lesions noted
On discharge,
General: AVSS, well-appearing, in no acute distress
Cardiopulmonary: RRR, no murmurs. CTAB
Abdomen: Soft, non-distended, appropriately tender. Incisions
appear clean, dry and intact.
Extremities: Well-perfused. Atraumatic, without clubbing,
cyanosis or edema
Neurologic: Alert and oriented x 3. Grossly intact
Pertinent Results:
ADMISSION LABS:
=============================
___ 07:30PM SED RATE-8
___:00AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 04:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
___ 04:00AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:50PM GLUCOSE-121* UREA N-19 CREAT-1.1 SODIUM-146*
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-30 ANION GAP-12
___ 11:50PM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-49 TOT
BILI-1.6*
___ 11:50PM CRP-0.6
___ 11:50PM WBC-9.0# RBC-4.08* HGB-13.6* HCT-40.7
MCV-100* MCH-33.4* MCHC-33.5 RDW-14.6
___ 11:50PM NEUTS-82.5* LYMPHS-8.9* MONOS-7.8 EOS-0.5
BASOS-0.3
___ 11:50PM PLT COUNT-244
PERTINENT LABS:
=============================
___ 07:30AM BLOOD VitB12-601
___ 07:30AM BLOOD ALT-13 AST-16 AlkPhos-40 TotBili-1.8*
___ 04:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
___ 04:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
IMAGING:
=============================
KUB ___
COMPARISON: Abdominal radiograph ___.
UPRIGHT AND SUPINE FRONTAL VIEWS OF THE ABDOMEN: There are
non-dilated loops of small and large bowel. There is no free
intraperitoneal air, pneumatosis or portal venous gas. No
abnormal calcifications are identified. The osseous structures
are unremarkable.
IMPRESSION: Non-obstructive bowel gas pattern.
CT ABD/PELVIS ___:
FINDINGS:
The lung bases are clear.
Tiny hypo attenuating lesions in the left lobe of the liver are
again noted potentially cysts or hemangiomas. The liver is
otherwise unremarkable as are the spleen, adrenal glands,
kidneys, gallbladder, and pancreas.
The stomach is grossly unremarkable although mildly distended.
Proximal small bowel appears normal. There is a distended loop
of small bowel, likely ileum, with fecalized intraluminal
contents leading up to a discrete transition point in the left
mid abdomen (series 601b image 25). At and distal to this
transition point the bowel is relatively decompressed and does
have the appearance of circumferential wall thickening. The
small bowel distal to this region are relatively decompressed,
including a distal small
bowel anastomosis.
Small amount of stool seen in the ascending colon. Remaining
portion of the colon is relatively decompressed and grossly
unremarkable. The bladder appears normal. The bladder,
prostate, and seminal vesicles are unremarkable. There is trace
free fluid in the pelvis. There is no free intraperitoneal air
no intra-abdominal adenopathy.
No suspicious osseous lesions identified.
IMPRESSION:
Small bowel obstruction with dilated, fecalized loops leading to
a discrete transition point in the left mid abdomen. Small
bowel at and distal to the transition point demonstrates
narrowed caliber and probable wall thickening suggesting region
of active Crohn's or stricture resulting in upstream
obstruction.
CXR ___
IMPRESSION: NG tube in appropriate position.
KUB ___:
IMPRESSION:
Multiple air-fluid levels and dilated loops of small bowel with
air and stool within the colon, consistent with a partial small
bowel obstruction. No definite oral contrast has reached the
large bowel.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of small bowel
Crohn's disease complicated by small bowel obstruction, status
post ileal resection in ___ presenting with crampy abdominal
pain in setting of SBO.
ACTIVE ISSUES:
=======================
# SBO: Patient with history of recurrent SBO's in setting of
stricturing small bowel Crohn's disease, most recent flare in
___. He has had previous ileal resection in ___ for
recurrent small-bowel obstruction with abnormal small-bowel
follow-through. Seen by Colorectal surgery in ED who did not
think any acute surgical needs initially. NGT placed in ED.
Possible etiology of SBO could include adhesions from prior
surgery, viral gastroentiritis (given rash and chills),
sunflower seed/carrot intake could also be contributing factor.
Patient is not yet due for Remicade so less likely related to
medication noncompliance or failure at this time. He was kept
NPO and started on IVF as well as IV anti-emetics and pain
medications. He was additionally started on Cipro/Flagyl per GI
recommendations. He did well initially but after clamping NGT,
had worsening abdominal pain and nausea. KUB second day of
admission showing multiple air fluid levels consistent with
partial SBO. Patient was then transferred to the Colorectal
Surgery service for further management given possible need for
surgical intervention.
Given non-improvement of symptoms, decision was made to take
patient to the operating room. The risks and benefit of an
exploratory (possible open) laparoscopy (laparotomy) with
possible bowel resection were discussed with the patient who
consented to proceed. He thus underwent an exploratory
laparoscopy with laparoscopic small bowel resection with primary
anastomosis (please see Operative Note for further details). He
tolerated the procedure well and was transferred to the surgical
ward after a brief and uneventful stay in the PACU. The NGT was
kept in place for decompression.
He remained alert and oriented throughout the postoperative
period. A Dilaudid PCA was initially used with good pain
control. He was transitioned to oral pain medications once
tolerating oral intake. Vital signs were routinely monitored and
patient remained afebrile, hemodynamically stable. NGT was
removed on POD#1 and patient diet was slowly advanced with good
tolerance. Foley was also removed at this point, and patient
voided shortly afterwards, although small amounts and with
considerable straining effort. Symptoms resolved after resuming
his home dose of Flomax. By POD#2, patient had already tolerated
a regular diet, was ambulating and voiding without assistance.
Given adequate postoperative response, he was deemed suitable to
be discharged home.
At the time of discharge, ___ was doing great. His pain was
under control, requiring only non-narcotic medications. He was
ambulating, voiding, and ambulating without assistance. He was
afebrile and hemodynamically stable. He received discharge
teaching and follow-up instructions with verbalized
understanding and agreement with the discharge plan.
# Crohn's Disease: Patient was in remission from active Crohn's
disease on Infliximab and Azathioprine, now with recurrent SBO
as above. Azathioprine held in setting of NPO, N/V and was
restarted when tolerating oral medications. His LFTs were within
normal limits except for an elevated T.bili which is persistent
per chart review and near patient's baseline. All medications
were resumed prior to discharge, including azathioprine. He will
follow up for further Remicade therapy as outpatient.
CHRONIC ISSUES:
========================
# BPH: Continued Tamsulosin when tolerating PO.
# Allergies: Continued home Flonase after NGT pulled.
# Osteopenia: Continued Calcium and Vitamin D supplements when
tolerating PO.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lactobacillus acidophilus unknown oral daily
2. Krill Oil (Omega 3 & 6) (krill-om3-dha-epa-om6-lip-astx)
unknown oral daily
3. saw ___ unknown oral daily
4. Calcium Carbonate 500 mg PO Frequency is Unknown
5. Tamsulosin 0.4 mg PO HS
6. Vitamin D Dose is Unknown PO DAILY
7. Magnesium Oxide 400 mg PO Frequency is Unknown
8. Cyanocobalamin Dose is Unknown PO DAILY
9. Fluticasone Propionate NASAL Dose is Unknown NU DAILY
10. Azathioprine 150 mg PO DAILY
11. Infliximab 400 mg IV Q8WEEKS
Discharge Medications:
1. Tamsulosin 0.4 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*40 Capsule Refills:*0
4. Azathioprine 150 mg PO DAILY
5. Infliximab 400 mg IV Q8WEEKS
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
___ hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction secondary to Crohn's disease
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 here at ___
___. You were admitted to the hospital for
a small bowel obstruction associated to your Crohn's disease.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Unfortunately your symptoms did not resolve with such
conservative approach and you were thus taken to the operating
room and underwent a diagnostic laparoscopy
and small bowel resection. You have recovered from this
procedure well and you are now ready to return home. Samples
from your small bowel were taken and this tissue has been sent
to the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you regarding these
results they will contact you before this time. 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.
You have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures. These are healing well
however it is important that you monitor these areas for signs
and symptoms of infection including: increasing redness of the
incision lines, white/green/yellow/malodorous drainage,
increased pain at the incision, increased warmth of the skin at
the incision, or swelling of the area. Please call the office if
you develop any of these symptoms or a fever. You may go to the
emergency room if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips) instead of
Dermabond, these will fall off over time, please do not remove
them. Please no baths or swimming for 6 weeks after surgery
unless told otherwise by Dr ___.
You will be prescribed a small amount of the pain medication
called Dilaudid. Please take this medication exactly as
prescribed. You may take Tylenol as recommended for pain. Please
do not take more than 4000mg of Tylenol daily. Do not drink
alcohol while taking narcotic pain medication or Tylenol. Please
do not drive a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr ___.
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:
___
|
10599849-DS-16 | 10,599,849 | 24,003,345 | DS | 16 | 2123-10-12 00:00:00 | 2123-10-12 13:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye / Bactrim / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Ultram / moxifloxacin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with PMHx asthma with several prior intubations
who was BIBA to an OSH for two days of increasing shortness of
breath. She presented to her PCP's office first at the end of
___ with increasing productive cough and wheezing. She was given
a 5-day course of prednisone for asthma exacerbation. At that
time, she was also referred to a pulmonologist given history of
recent recurrent exacerbations. Of note, she was treated for a
pneumonia on ___ with azithromycin and prednisone. She initially
improved, but after completing steroids her symptoms worsened
again. She called her PCP's office on ___ and was recommended to
restart prednisone for a prolonged taper. However, her sypmtoms
worsened throughout the day.
She called EMS and was noted to be hypoxic at home to the ___
and tachypneic. She was given albuterol neb x 1 and duoneb x 1
in the ambulance and was placed on CPAP on arrival. She stated
feeling improved and was taken off CPAP. On exam, she ws noted
to have diffuse wheezing, a prolonged expiratory phase,
retractions with respiration, and speaking in ___ word
sentences. She was given duoneb x 2, albuterol neb x 2, 80mg IV
solumedrol, and 2g magnesium. CXR showed a "patchy infiltrate on
right side" and she was given 500mg azithromycin and 1g
ceftriazone for community-acquired pneumonia. ABG on 100% NRB
was 7.38/47/261. She initially improved and was going to be
admitted to the medical floor, but she noted worsening dyspnea
and given his history of prior intubations (for which the
patient occured in the setting of rapidly worsening symptoms),
was transferred to ___ for ICU-level care.
In the ___ ED, initial VS: T 98.4 HR 110 BP 126/90 RR 20 SaO2
92% RA. She received albuterol nebs x 2 and was placed on 2L NC.
MD noted tachypnea to the ___ and was speaking in short phrases.
Prior to transfer VS were: T 98.0 HR 109 BP 124/70 RR 16 SaO2
94% 2L NC.
Past Medical History:
- Migraines
- Seasonal Allergies
- History of ADHD
- Tobacco dependence
- Asthma - intubated at least twice for exacerbations, triggers
include environmental allergies and respiratory infections
- PTSD (post-traumatic stress disorder)
- Anxiety state, unspecified
- Hypertriglyceridemia without hypercholesterolemia
- Osteopenia
- Lung nodules
--___ chest CT: There are 2 small right lung nodules
unchanged from the comparison study, for which continued CT
follow-up is advised (___ recommendations advise
initial follow in ___ year, then repeated at 24 months if the
patient has malignancy risk factors.
--___ - new 8mm RLL nodule. follow-up low dose CT thorax
could be performed at 3, 6, 12 and 24 months based on ___
___ recommendations.
--___ - NEEDS F/U CT
- Crack cocaine use
- History of juvenile dermatomyositis
Social History:
___
Family History:
No history of asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.4 HR 107 BP 105/35 RR 26 SaO2 92% on 2L NC
General: Alert, oriented, speaks in full sentences, using
accessory muscles
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse inspiratory and expiratory wheezing
CV: Tachycardic, 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
___ 03:43AM BLOOD WBC-13.0* RBC-4.78 Hgb-14.4 Hct-42.6
MCV-89 MCH-30.1 MCHC-33.9 RDW-12.6 Plt ___
___ 03:43AM BLOOD Neuts-94.5* Lymphs-3.6* Monos-1.4*
Eos-0.4 Baso-0.1
___ 03:43AM BLOOD ___ PTT-31.8 ___
___ 03:43AM BLOOD Glucose-147* UreaN-13 Creat-0.7 Na-134
K-4.0 Cl-101 HCO3-25 AnGap-12
___ 03:43AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1
___ 04:14AM BLOOD ___ Temp-36.9 pO2-63* pCO2-40
pH-7.41 calTCO2-26 Base XS-0
___ 04:14AM BLOOD Lactate-1.5
IMAGING:
TTE ___
Conclusions
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 thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). A
mid-cavitary gradient is identified. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
CXR ___
FINDINGS: Heart is upper limits of normal in size, and
accompanied by mild pulmonary vascular congestion. Interval
progression of bilateral
peribronchiolar thickening, accompanied by increasing poorly
defined areas of peribronchiolar consolidation, predominantly in
the mid and lower lungs. These findings most likely represent a
viral or other atypical pneumonia in this patient with asthma
exacerbation. ABPA is an additional consideration.
Brief Hospital Course:
___ year old woman with history of moderate persistant asthma,
presenting with asthma exacerbation with pneumonia and
transferred to the ICU for hypoxia and increased work of
breathing.
Active Issues
# Pneumonia and asthma exacerbation:
She has been taking her twice daily ___ without missing
doses. She was given IV solumedrol x1, switched to PO prednisone
40mg. Initially given q1hr nebs, spaced out and much improved.
Started on Azithro and ceftriaxone for community-acquired
pneumonia treatment. TTE showed EF > 55% and borderline
pulmonary artery systolic hypertension. Utox was checked to rule
out chemical pneumonitis given history of crack cocaine use,
cocaine was positive on utox.
Chronic Issues
# Allergic rhinitis
Continued loratidine and monteleukast.
# Tobacco abuse
Patient requested a nicotine patch.
# Methadone maintenance
Confirmed home dose of 65mg daily with ___ clinic nurse
and this was continued.
Transitional Issues
# History of pulmonary nodules
Patient has been followed by her PCP with serial CT scans. She
is ___ overdue for her next CT scan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
2. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN sob, wheeze
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob, wheeze
4. Loratadine 10 mg PO HS
5. Montelukast 10 mg PO HS
6. Methadone 65 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Loratadine 10 mg PO HS
2. Methadone 65 mg PO DAILY
3. Montelukast 10 mg PO HS
4. Omeprazole 20 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob, wheeze
6. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
7. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN sob, wheeze
8. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
9. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth q12 Disp #*24 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with pneumonia and an asthma exacerbation. You
had a urine toxicology screen that indicated that you had used
cocaine recently. Sometimes using cocaine or crack can cause
breathing problems. Please stop using cocaine and tobacco.
Please take the steroids and antibiotics that are prescribed.
Followup Instructions:
___
|
10599949-DS-27 | 10,599,949 | 22,735,926 | DS | 27 | 2165-06-25 00:00:00 | 2165-06-25 17:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
acetaminophen-codeine / lisinopril
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED ATTENDING INITIAL NOTE
DATE: ___
TIME SEEN 330 AM
==================================
HPI:
___ yo female with history of pulmonary hypertension, multiple
myeloma, presents after syncope. She was getting into her
daughter's car when she was noted to be unresponsive, eyes
rolling to the back of her head and was noted to have shaking
movements. She was pulled out onto the curb and layed flat, she
was noted to have continued shaking movements without enuresis.
No fecal incontinence. After she recovered consciousness on the
order of minutes she was noted to be oriented. Patient denies
any prodrome other than "feeling funny" to the ED physician but
to author she reports feeling very short of breath. She felt as
though she was going to die. She denies feeling as though the
curtains were closing and she was going to pass out. She denied
shortness of breath with baseline activity but her dtr reported
to her RN that she does get SOB with exertion. She reported L
sided anterior ___ chest pain, worse with inspiration.
She does not report other pains. She was wearing a scarf when
this occurred but this is normal for her in the winter. No sx
when she turns her head. She felt well prior to the incident and
had eaten dinner approximately an hour before her daughter came
to pick her up. She denies chest pain on exertion. At baseline
she has lower extremity edema but this is improved compared to
her baseline. She had a good full BM in the ED in the commode
prior to coming to the floor. No report of dark or bloody stool.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [+] Per HPI
CARDIAC: [+] per HPI
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [+] L hand resting tremor
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
ONCOLOGIC HISTORY: Mrs. ___ is a ___ ___ female
with a past medical history of osteoporosis and multiple
traumatic compression fractures who presented with new back and
right hip pain in ___. Initial X-rays revealed lumbar
spine degenerative changes, most pronounced at L5-S1, no
compression fractures, but multiple subtle lucencies were seen.
She was admitted on ___ for pain control and was noted to
have anorexia, fatigue, and a 20 lb weight loss over the last 6
months. Her initial imaging was notable for 2 subcentimeter
lesions in the mid femur on the right causing endosteal
scalloping and cortical thinning up to 50%, but without
associated stress fracture, cortical breakthrough or soft tissue
component. She was felt to be too high risk for surgery as she
was found to have severe pulmonary HTN and severe 4+ TR by ECHO.
V/Q scan was low likelihood for PE. She received radiation to
her
R femur from ___ to ___ (20 Gy total). Bone marrow
biopsy
on ___ confirmed a hypercellular BM with involvement by a
plasma cell dyscrasia, with 37% plasma cells seen on aspirate
and
making up 70-80% of marrow cellularity by CD138 staining.
Cytogenetics revealed a normal karyotype, but ___ nuclei were
positive for 13q deletion and ___ nuclei showed IGH-CCND1
rearrangement. Her initial labs were notable for Ca ___, alb
3.3; B2 microglobulin 6.2; SPEP abnormal with IgG of 4284
(monoclonal IgG kappa), IgA 38, IgM 15; free K/L ratio 18.90;
and
UPEP negative for Bence ___ protein. She began her first cycle
of velcade/dexamethasone on ___. She developed pain in her R
humerus and received 800 cGy in a single fraction on ___.
Her
second cycle began on ___. She received Zometa on ___.
She started her ___ cycle on ___. She was admitted from
___ due to R groin pain and she was found to have
fractures of the R hemisacrum, superior and inferior pubic rami.
These were managed medically with rest and pain medication. She
was discharged to rehab but started C4 velcade/dexamethasone on
___ and received Zometa on ___ as well. She started C5 of
velcade/dexamethasone on ___, but her D8 and D11 treatments
were held due to persistent eye symptoms. She resumed treatment
on ___ and received C6, C7, and C8 on schedule. She was on a
treatment holiday from ___ until ___ but due to a
slight increase in her SPEP, she was started on Revlimid
maintenance on ___, 10mg PO daily for three weeks followed
by
one week off. Revlimid held in ___ due to deconditioning and
failure to thrive at home thought not to be secondary to
multiple myeloma.
OTHER PAST MEDICAL HISTORY
Osteoporosis
HTN
Pulmonary hypertension
Social History:
___
Family History:
Daughter with breast cancer.- pt could not remember this
Mom died at ___ due to bleeding after tooth extraction.- per OMR
Dad had DM.
Physical Exam:
On Admission:
orthostatic VS in ED:
Orthostatic Laying
77 128/77 19
Orthostatic Sitting
73 125/79 21 100% RA
Orthostatic Standing
77 102/65 22 99% RA
Vitals: 98.7 PO 154 / 89 R 78 16 97 RA 0 0 9
10
CONS: NAD, comfortable appearing
HEENT: ncat anicteric MMM
Elevated JVP
CHEST: Positive kyphosis
+ chest wall tenderness
CV: s1s2 rrr ___ loud holosystolic murmur heard at the ___
RESP: b/l basilar crackles
GI: +bs, soft, NT, ND, no guarding or rebound
reducible ventral hernia present
MSK:no c/c/e DPP pulses barely palpable b/l
SKIN: brawny thickening of skin on b/l lower extremities
NEURO: face symmetric speech fluent
+ resting tremor of RUE
PSYCH: calm, cooperative
LAD: No cervical LAD
Discharge exam:
VITALS: 98.7, 133/83, 64, 18, 96% on RA
Orthostatic vitals negative yesterday
GEN: Chronically ill appearing, kyphotic, lying in bed
comfortably, right
sided resting tremor
HEENT: EOMI, sclerae anicteric, dry mucous membranes, OP clear
NECK: No LAD, no JVD
CARDIAC: Regular rate and normal rhythm, ___ SEM at RUSB
PULM: CTAB, no wheezing or rhonchi, severe kyphosis
GI: soft, protuberant abdomen ___ kyphosis, normoactive bowel
sounds, nontender throughout
MSK: No visible joint effusions or deformities. Left sided
anterior chest pain, reproducible on exam
DERM: No visible rash. No jaundice
NEURO: AAOx3. No facial droop, right sided resting tremor
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
On Admission:
___ 11:27PM K+-3.9
___ 11:15PM GLUCOSE-136* UREA N-23* CREAT-1.1 SODIUM-137
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
___ 10:03PM K+-8.2*
___ 10:00PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
___ 10:00PM URINE RBC-2 WBC-13* BACTERIA-FEW YEAST-NONE
EPI-2
___ 10:00PM URINE HYALINE-1*
___ 09:00PM GLUCOSE-154* UREA N-24* CREAT-1.1 SODIUM-135
POTASSIUM-5.8* CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
___ 09:00PM estGFR-Using this
___ 09:00PM WBC-11.2*# RBC-4.73 HGB-11.4 HCT-37.0 MCV-78*
MCH-24.1* MCHC-30.8* RDW-15.1 RDWSD-42.8
___ 09:00PM NEUTS-87.1* LYMPHS-5.6* MONOS-6.1 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-9.77*# AbsLymp-0.63* AbsMono-0.69
AbsEos-0.02* AbsBaso-0.03
___ 09:00PM PLT COUNT-216
================================================================
Interval:
___ 11:15PM BLOOD CK-MB-4 cTropnT-0.10*
___ 07:50AM BLOOD CK-MB-3 cTropnT-0.04*
___ 01:05PM BLOOD CK-MB-3 cTropnT-0.03*
Imaging:
___ CXR
1. No definite evidence of pneumonia.
2. Stable cardiomegaly with vascular engorgement, but no overt
pulmonary
edema.
___ CT Head
Limited examination due to motion artifact and patient position.
Within these limitations, no evidence of fracture or
intracranial hemorrhage.
___ CTA
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Multiple thyroid nodules, measuring up to 1.2 cm on the
right.
3. Diffuse pancreatic ductal prominence within area focal
dilation measuring up to 8 mm, increased from ___.
Recommend correlation with prior abdominal imaging, if
available. Otherwise, recommend follow-up with CT or MRI, if not
recently performed, to exclude an obstructing lesion.
4. Multiple thoracic vertebral body compression fractures at
T3-T6 and T9-T10, similar to ___. Remote fractures of the
left lateral second rib and sternum.
RECOMMENDATION(S): Correlation with prior abdominal imaging to
determine
chronicity of pancreatic ductal dilation. If no recent imaging
is available, recommend follow-up with CT or MRI to exclude an
obstructing lesion.
___ ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. There is mild 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%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
no major change.
DISCHARGE LABS:
___ 07:37AM BLOOD WBC-8.5 RBC-4.45 Hgb-10.9* Hct-34.7
MCV-78* MCH-24.5* MCHC-31.4* RDW-15.1 RDWSD-42.3 Plt ___
___ 07:37AM BLOOD Plt ___
___ 07:37AM BLOOD Glucose-94 UreaN-18 Creat-0.8 Na-140
K-3.7 Cl-102 HCO3-26 AnGap-16
___ 07:45AM BLOOD ALT-68* AST-27 AlkPhos-40 TotBili-0.7
___ 07:37AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a history of pulmonary
hypertension and multiple myeloma who presents with syncope
after getting into her daughters car.
# Syncope: Highest on the differential is orthostasis vs cardiac
etiology. Orthostatic signs are positive with precipitation of
her symptoms. Concern for worsening RV function in the setting
of pulmonary hypertension. No evidence of PE on CTA. EKG at
baseline, troponins elevated on admission, though downtrended.
CK-MB flat. Telemetry without evidence of arrhythmias. Low
suspicion for seizure activity or vasovagal. ECHO revealed no
changes from prior.
# Orthostatic hypotension: Patient presented with symptomatic
Orthostasis. Differential included worsening RV function as
above vs autonomic dysfunction, vs adrenal insufficiency, aging,
and the effect of medications. ECHO revealed no changes from
prior. AM cortisol was wnl. B12 level was WNL. Home
antihypertensives were initially held. She wore TEDS during her
admission and HOB was kept elevated 30 degrees. Side effect of
donepezil was also considered, but this was continued as her
orthostatic hypotension resolved with fluids and improved PO
intake.
# Multiple myeloma: S/P induction velcade with clinical and
laboratory response. Now off of treatment, though with evidence
of multiple compression fractures throughout on CT.
# Left sided chest pain: CTA with evidence of numerous
fractures, including left sided 2nd rib fracture, which is
consistent with where the patient is experiencing pain. Pain
control with standing Tylenol, lidocaine patch, and tramadol
PRN.
# Memory impairment: Continued donepezil
# Insomnia: Continued remeron
***TRANSITIONAL ISSUES***
- Pancreatic lesion: CTA at admission incidentally noted diffuse
pancreatic ductal prominence with an area of focal dilation
measuring up to 8mm, increased from ___. No interval
imaging available for comparison. Consider MRCP for further
evaluation as outpatient. Patient's lipase and LFTs overall
unremarkable and patient was asymptomatic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 20 mEq PO DAILY
2. Acetaminophen 1000 mg PO TID
3. Aspirin 81 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
6. Senna 17.2 mg PO DAILY
7. Acyclovir 400 mg PO Q8H
8. Mirtazapine 7.5 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. melatonin 3 mg oral QHS
11. Hydrochlorothiazide 12.5 mg PO DAILY
12. Donepezil 10 mg PO QHS
13. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
5. Docusate Sodium 100 mg PO BID
6. Donepezil 10 mg PO QHS
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. melatonin 3 mg oral QHS
9. Mirtazapine 7.5 mg PO QHS
10. Senna 17.2 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
orthostatic hypotension
syncope
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 because you had a fainting spell. You
underwent an extensive workup. We believe your symptoms are due
to orthostasis. At this time we feel that you are safe for
discharge back to your skilled nursing facility.
It was a pleasure to be a part of your care,
Your ___ treatment team
Followup Instructions:
___
|
10600115-DS-10 | 10,600,115 | 25,117,868 | DS | 10 | 2150-06-20 00:00:00 | 2150-06-20 16:29:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male, with no significant prior medical history in
___, s/p fall in ___ with TBI and C-spine fracture, who is
presenting after recent discharge in ___, for concerns for
septic shock. Patient being admitted to the MICU for refractory
hypotension and concern for septic shock.
History obtained by patient's son. He reports that after
discharge, he has been staying at the ___ long-term
___. Over the past 2 weeks, he has been deteriorating. He
used to be able to somewhat track to voice, however that has now
stopped intermittently, and therefore thought to be more
confused. He also has been having increased secretions in his
airway, and also has been having difficulties with his G-tube.
He was supposed to have this replaced, but for the past week, he
has been having increased nausea/vomiting (for which his
C-collar was intermittently removed), and unable to tolerate
tube feeds. Per his son, at the rehab they have also been
dealing with hyponatremia for which he has been receiving IVF.
Patient then was to attend an appointment to have his G-tube
exchanged, and upon arrival of EMS, re-routed to ___
___ at which point patient underwent CXR concerning for
PNA. Patient received reportedly 1L of IVF, started on levophed
@ 0.1 mcg for intermittent pressures. Patient was found to be
hypothermic to 94, placed on a warming blanket. Patient had a
___ collar in placed, with trach-mask at 40% FIO2. At ___,
patient was given 2gram Cefepime, 1 gram vancomycin, 500 cc NS
bolus, and started NS @125 cc. Lactate 2.
Patient was originally discharged from a very complicated
hospital course (___) from ___ SICU. Hospital
course summarized below. He initially presented in ___ as
somewhat of a transfer from ___. It is somewhat difficult to
discern course of events as summarized by organ system, but
patient initially fell ___ stories in ___ and underwent
complicated hospital course in ___ with several traumatic
fractures, hemorrhagic, septic shock, and intubated several
times, and was treated for a septic shock like picture requiring
levophed and dopamine, and course was complicated with severe
gastric hemmorhage with coffee ground emesis and bleeding from
the ETT. Patient's course complicated with multiple infections
for meningitis, "Sepsis", and was on vancomycin, ceftriaxone,
cefazolin and gentamycin. Patient then transferred out of ___
in ___, cardiac arrested in the flight requiring emergency
landing in the ___, got ROSC en route. Possible cardiac
events were bradycardic in nature. Patient underwent CT imaging
showing a C1 burst fracture, C6 lamina fracture, left lacunar
infarctions, and extensive sinonasal disease.
Patient was then admitted to ___ after transferring from
___, on ___ - > until ___ on the surgical
service, and hospital course included an exploratory laparotomy
in ___, IVC filter placed in ___, and percutaneous
tracheostomy and endoscopic gastrostomy in ___. Patient
was found initially to not have any spontaneous movement off
sedation, acute renal failure requiring dialysis. On
presentation, EEG showed severe encephalopathy with prolonged
runs of generalized periodic discharges consistent with seizure
activity. Patient was given Dilantin / Ativan, and neurology
commented that meaningful recovery would be poor. Patient then
underwent tracheostomy, as arrived intubated, and bronchoscopy
showed severe destruction of airway membranes. BAL at that time
showed acinetobacter, klebseilla and psueodmonas. It was thought
that patient underwent mesenteric perforation repair in ___,
and patient had PEG tube placed with continuous fluids. During
hospitalization patient was in renal failure requiring HD, and
was placed on intermittent HD. Patient also had a CT Imaging
showing a DVT within the left common iliac vein, common femoral
vein extending into the Left deep femoral vein. Patient was
thought to have HITT, but assay negative, and therefore IVC
filter placed on ___ given continued bleeding with clot burden.
Surgerical intervention for his C1 burst fracture was deferred
given no benefit in recovery, and patient was placed in
C-collar. He has C1 and C6 fractures, and surgery recommended
keeping hard cervical collar.
In the ED, initial vitals: 98.4, 100, 100/70, 20, 100% RA
- Exam notable for Trach mask, 40%. Temp of 94 degrees.
- Labs were notable for WBC 18.9, Hgb 6.8, Hct 22.6, PMN 91%,
Bands 2%. Sodium 160, Chloride 128. BUN 89, Creatinine 2.5. Mag
3.1. Phos 4.3. Lactate 1.4. Urinalysis: > 182 WBC, Large Leuk,
Negative Nitrite, Few Bacteria.
- Imaging showed:
AP portable upright view of the chest. Tracheostomy tube
projects over the mediastinum. A lft upper extremity access
PICC line extends into the lower SVC. An IVC filter projects
over the mid abdomen. An azygous fissure is noted. There is
minimal retrocardiac opacity which could reflect atelectasis
versus pneumonia/aspiration. Lungs are otherwise clear.
Cardiomediastinal silhouette is stable. No acute bony
abnormalities.
- Patient was given:
___ 18:08 IV Levofloxacin 750 mg
___ 18:08 IV DRIP Norepinephrine Started 0.09 mcg/kg/min
___ 18:10 IVF 1000 mL NS 1000 mL
___ 18:30 IVF 1000 mL NS 1000 mL
- Consults: None
ROS: unable to obtain
Past Medical History:
summarized above in HPI
Notable for
fall c/b TBI
CVA
C-spine fracture
Seizure
DVT
___ / ARF requiring HD
s/p trach / PEG
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: HR 77, BP 117/63 Afebrile, RR 12.
General: ___ J collar in place, there is significant
secretions and audible tracheal sounds. He is not tracking to
voice, withdraws to painful stimuli.
HEENT: Sclera anicteric, mucous membranes dry, oropharynx is
somewhat difficult to see with ___ J, but appears dry. PERRL.
EOMI somewhat intact, but does not track grossly.
Neck: ___ J collar in place.
Lungs: There are course lung sounds heard throughout the lunds,
with rhonchi.
CV: Regular, II systolic murmur heard throughout precordium.
Abdomen: G-tube in LUQ. There is tenderness along the G-tube
site, without specific erythema. Tenderness in the RUQ, no
rebound appreciated however difficult, and no guarding.
Extremities: Emaciated. No ___ edema bilaterally. There is a
sacral 3+ decuibuts ulceration, and healed ulceration on the
left foot.
DISCHARGE PHYSICAL EXAM:
=========================
Pertinent Results:
ADMISSION LABS:
=====================
___ 05:40PM BLOOD
WBC-18.9*# Hgb-6.8* Hct-22.6* MCV-90 RDW-18.0* Plt ___ PTT-25.5 ___
Glucose-111* UreaN-89* Creat-2.5*# Na-160* K-3.5 Cl-128*
HCO3-19* AnGap-17
ALT-33 AST-26 LD(LDH)-204 AlkPhos-139* TotBili-1.0 Lipase-264*
Albumin-3.0* Calcium-8.7 Phos-4.3# Mg-3.1*
Lactate-1.4
IMAGING:
====================
___ PCXR
FINDINGS:
AP portable upright view of the chest. Tracheostomy tube
projects over the mediastinum. A left upper extremity access
PICC line extends into the lower SVC. An IVC filter projects
over the mid abdomen. An azygous fissure is noted. There is
minimal retrocardiac opacity which could reflect atelectasis
versus pneumonia/aspiration. Lungs are otherwise clear.
Cardiomediastinal silhouette is stable. No acute bony
abnormalities.
IMPRESSION:
As above.
___ KUB
IMPRESSION:
GJ-tube projects over the left upper quadrant with the tip in
the region of the ligament of Treitz. Nonobstructive bowel gas
pattern.
___ GJ Tube Check
IMPRESSION:
The GJ tube with the J limb ending in the region of the ligament
of Treitz.
MICROBIOLOGY:
====================
___ Blood cultures x 2 sets
___ 5:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefepime sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 4 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
___ Urine Culture: >= 3 bacterial colony types
___ Blood culture
___ 5:57 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
___ ALBICANS, PRESUMPTIVE IDENTIFICATION.
DEFINITIVE IDENTIFICATION TO FOLLOW.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Aerobic Bottle Gram Stain (Final ___:
BUDDING YEAST.
Reported to and read back by ___ ___ AT
2037.
.
___ Respiratory viral screen and culture: NEGATIVE
___ MRSA screen: NEGATIVE
___ Blood culture set #2: No growth (FINAL)
Brief Hospital Course:
___ year old male, with past history of fall with cervical spine
fracture and TBI vs anoxic brain injury in ___ in ___, s/p
GI surgery, s/p hemorrhagic and septic shock requiring ICU
admission ___, s/p chronic trach/PEG, also
complicated by seizure disorder on AED and DVT, s/p IVC filter
for DVT, now presenting as transfer from OSH and SNF with
hypotension and septic shock.
# Septic Shock: Growing Klebsiella bacteremia and candidemia.
Initially admitted to ICU on broad-spectrum antibiotics and
pressors. Given poor prognosis, HCP and family wanted to avoid
aggressive measures and transition to more comfort focused care.
Broad spectrum antibiotics were DC'ed. Source of infection was
possibly his long-term PICC line.
# GOC: Patient transitioned to comfort focused care given his
critical illness, and goals to avoid prolonged discomfort and
pain. Pressors were stopped after conversation with HCP
(___) on AM of ___. Patient was transferred to General
Medical Service on morphine gtt. All blood draws were stopped.
Tube feeds and IV antibiotics also stopped. Foley and PICC line
left in place for comfort. Scopolamine patch was added, as was
standing Ativan per recommendation of Palliative Care consult.
Patient was then transitioned to Fentanyl TD and weaned off
morphine GTT. Family / HCP declined inpatient hospice consult.
He died on the AM of ___. Case referred to M.E. per
admission office when death called, and accepted (based on
history of trauma). Family declined voluntary autopsy.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Heparin 5000 UNIT SC BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. LeVETiracetam Oral Solution 500 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO Q6H
11. Scopolamine Patch 1 PTCH TD ONCE
12. Senna 8.6 mg PO BID:PRN constipation
13. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
14. TraMADOL (Ultram) 25 mg PO Q8H
15. TraZODone 50 mg PO 20:00
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Heparin 5000 UNIT SC BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. LeVETiracetam Oral Solution 500 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO Q6H
11. Scopolamine Patch 1 PTCH TD ONCE
12. Senna 8.6 mg PO BID:PRN constipation
13. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
14. TraMADOL (Ultram) 25 mg PO Q8H
15. TraZODone 50 mg PO 20:00
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock due to:
gram-negative rod bacteremia
fungemia
Discharge Condition:
not applicable
Discharge Instructions:
Patient was brought to the hospital with hypotension and you
were admitted to the ICU. Patient was found to have severe
infection with bacterial and fungal blood stream infection.
After discussion with ICU team, family / HCP decided to pursue
CMO treatment for the patient only. The patient was transferred
from the ICU to the general medical floor. The palliative care
consult team assisted with symptom management and end-of-life
management. Patient expired and was pronounced at 08:31am on
___. Case referred to medical examiner, family informed
(who declined voluntary autopsy).
Followup Instructions:
___
|
10600719-DS-14 | 10,600,719 | 23,072,548 | DS | 14 | 2193-07-19 00:00:00 | 2193-07-19 14:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Benadryl / Benadryl / Tylenol / naproxen / Statins-Hmg-Coa
Reductase Inhibitors
Attending: ___.
Chief Complaint:
Left lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of recent L total hip replacement presenting
with increasing edema of L thigh and urinary retention at rehab.
Pt underwent a L THR by Dr. ___ at ___
on ___, and has been at ___ for rehab since his
surgery. On ___ night, two days prior to presentation, he
noticed increased scrotal edema without associated pain. On the
day prior to presentation, he found the edema extending to his L
thigh, without erythema or marked pain. He denies fevers,
chills,
vomiting, SOB, chest pain. He did note some lightheadedness when
working with ___ at rehab, as well as some slight nausea the day
prior to presentation without emesis or chest pain. Of note, he
has had difficulty with urinary retention in the past, but
reports that he never required Foley placement. Since his
surgery
he has noted increased difficult both with spontaneous voids. At
rehab he has intermittently had a Foley catheter in place, and
has failed multiple voiding trials. He has been seen by urology
in the past, and was reportedly told that his urinary retention
was related to a neuropathy, although details are not available
in OMR. Per paper notes, on ___ he developed urinary retention,
at which time GU ultrasound revealed PVR of 550 cc with
trabeculated bladder wall with diverticula and mild
prostatomegaly. He takes finasteride at baseline.
Past Medical History:
1st degree AV block, left anterior hemiblock, s/p dual chamber
PPM ___
LVH
Appendicitis ___
s/p hernia repair ___
Hypercholesterolemia
Glucose intolerance
GIB ___ AVM
Social History:
___
Family History:
Father died at age ___ from complications of COPD. He was a
heavy smoker. Mother died at age ___. Interestingly, in her
late ___ had recurrent GI bleeding of undetermined etiology. He
has one brother who is well, another brother who had mastoid
surgery at age ___ and a half years and died. There is no known
family history of colon cancer.
Physical Exam:
ADMISSION EXAM
--------------
T 98.2, 166/72, 70, 18, 98% RA
GEN: elderly man, lying comfortably in bed, no acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes
LYMPH: no anterior/posterior cervical, supraclavicular,
axillary
adenopathy
CARDIOVASCULAR: PMI nondisplaced, regular rate and rhythm
without murmurs, rubs, or gallops. JVP 7 cm H20
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
ABDOMEN: soft, mildly distended with normal active bowel
sounds.
EXTREMITIES: dressing in place over L hip, C/D/I. Extensive
ecchymoses extend around L flank. Pressure dressing applied to L
leg, edema is appreciated despite dressing, unable to assess
pitting. Thigh is minimally TTP. Distal extremities are WWP.
PSYCH: normal mood and affect
DISCHARGE EXAM
--------------
VS: T 98.6 BP 149/68 P 67 R 16 Sat 99%RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, moderately distended, + bowel sounds.
EXTR: ACE bandage in place, edema of LLE seems improved, no
clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 10:00PM BLOOD WBC-11.0 RBC-3.41*# Hgb-9.5*# Hct-29.1*#
MCV-85 MCH-28.0 MCHC-32.8 RDW-13.8 Plt ___
___ 10:00PM BLOOD Neuts-80.0* Lymphs-12.4* Monos-5.9
Eos-1.4 Baso-0.3
___ 10:00PM BLOOD ___ PTT-29.2 ___
___ 10:00PM BLOOD Glucose-106* UreaN-9 Creat-0.7 Na-136
K-3.8 Cl-100 HCO3-25 AnGap-15
___ 08:15AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7
DISCHARGE LABS
--------------
___ 08:05AM BLOOD WBC-11.4* RBC-3.35* Hgb-9.4* Hct-28.1*
MCV-84 MCH-28.1 MCHC-33.5 RDW-14.5 Plt ___
___ 08:05AM BLOOD ___ PTT-32.3 ___
___ 08:05AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-134
K-3.7 Cl-99 HCO3-26 AnGap-13
___ 02:05PM BLOOD ___
MICROBIOLOGY
------------
Urine culture ___:
___ 10:26 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
CLINDAMYCIN REQUESTED ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
CIPROFLOXACIN--------- <=0.5 S
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
IMAGING
-------
Left lower extremity ultrasound ___:
No deep vein thrombosis in the left lower extremity. Diffuse
subcutaneous edema.
CT pelvis ___:
IMPRESSION:
1. Moderate hematoma adjacent to the posterior aspect of the
hip in quadratus femoris.
2. Small volume of surgical emphysema related to the recent
surgery.
3. Mild degenerative changes in the left knees.
Left hip X-ray ___:
Compared with ___, the patient has undergone placement of a
left THR, with non-cemented femoral stem, in overall anatomic
alignment. No periprosthetic lucency to suggest loosening and
no focal osteolysis is detected. Residual subchondral cyst
along lateral acetabulum noted. Again seen is severe
osteoarthritis of the right hip. Lower lumbar spine and sacrum
are considerably obscured by overlying bowel gas, but there are
likely degenerative changes in the lower lumbar spine.
Brief Hospital Course:
___ year old male s/p left total hip replacement with new left
thigh edema concerning for postoperative hematoma.
ACTIVE ISSUES
-------------
# Left lower extremity edema: Left lower extremity ultrasound
was negative for clot. There was no discernible evidence of
volume overload. Other potential etiologies included
obstruction and fluid collection, concerning for
hematoma/postoperative bleeding at surgical site. CT pelvis/leg
showed quadratus femoris hematoma. Hematocrit remained stable.
Orthopedics was consulted and stated this would likely take
weeks to resolve and recommended restarting warfarin for
prophylaxis after hip replacement. Compression dressings and
ACE bandages were applied. Patient will follow up with his
orthopedic surgeon after discharge, within ___ weeks.
Compression stockings and ACE bandage should stay in place upon
discharge.
# Urinary retention: patient has history BPH and retention, and
has had
urology evaluation in the past. He has recently required a
Foley catheter and has failed voiding trials. CT pelvis was
obtained and showed no urinary obstruction. Urology was
contacted and recommended outpatient follow-up for formal
voiding trial and to discuss possible future surgical options.
Finasteride was continued during hospital stay. Foley will stay
in place upon discharge.
# Urinary tract infection: patient had evidence of leukocytosis
and urinalysis was suspicious for UTI, culture pending at time
of discharge. He will be discharged on ceftriaxone, which was
changed to ciprofloxacin after speciation showed sensitive
Enterococcus species. He will require a total seven day course
of therapy.
# Status post Left total hip replacement: patient received
physical therapy during the course of his stay. He was
restarted on warfarin once an acute bleed was ruled out. INR
was 1.2 at the time of discharge. INR was drawn directly before
discharge, and results of this lab will be communicated to the
extended care facility after it becomes available. He will need
daily INR monitoring until INR is stable at ___. INR may be
labile due to concurrent antibiotic therapy. Lovenox is being
used as bridging therapy until INR is therapeutic, upon which it
should be stopped. He will follow up with Orthopedics upon
discharge for post-surgical care and to discuss his hematoma
noted on imaging while admitted.
INACTIVE ISSUES
---------------
# Hyperlipidemia: patient's Tricor was held while he was
admitted. He should restart this medication upon discharge.
TRANSITIONS OF CARE
-------------------
# Follow-up: Patient will follow up with his orthopedic surgeon
after discharge, within ___ weeks. Compression stockings and
ACE bandage will stay in place upon discharge. Urology was
contacted and patient will have outpatient follow-up for formal
voiding trial and to discuss possible future surgical options.
INR should be checked until it is stable at ___. Lovenox should
be stopped at that point.
# Code status: DNR/DNI, confirmed with patient
# Contact: Life partner, ___, HCP - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fenofibrate 48 mg Oral daily
2. Finasteride 5 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Ascorbic Acid Dose is Unknown PO Frequency is Unknown
5. Aspirin 81 mg PO DAILY
6. biotin 5000 mcg Oral daily
7. flaxseed oil unknown Oral unknown
8. Multivitamins 1 TAB PO DAILY
9. Psyllium 1 PKT PO Frequency is Unknown
10. Warfarin 1 mg PO DAILY16
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Warfarin 1 mg PO DAILY16
5. Docusate Sodium 100 mg PO BID
6. Senna 1 TAB PO BID
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
8. Ascorbic Acid 0 mg PO Frequency is Unknown
9. Aspirin 81 mg PO DAILY
10. biotin 5000 mcg Oral daily
11. fenofibrate 48 mg Oral daily
12. flaxseed oil 0 units ORAL Frequency is Unknown
13. Psyllium 1 PKT PO Frequency is Unknown
14. Outpatient Lab Work
Please check INR daily until stable at ___. Enoxaparin Sodium 30 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
16. Ciprofloxacin HCl 500 mg PO Q12H
Please stop after ___. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
-----------------
Left leg hematoma/edema
Urinary retention
Urinary tract infection
Secondary diagnosis
-------------------
status post Total hip replacement
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 caring for you at the ___. You came for
further evaluation of left leg swelling and urinary retention.
Further tests showed that your leg swelling is likely related to
a hematoma, or blood collection in your leg. This will likely
resolve over the course of a few weeks. As for your urinary
retention, you will follow up with Dr. ___ in Urology to
determine if you will need a Foley catheter in the future, and
also to discuss possible surgical options. You also had a
urinary tract infection noted while here, which is currently
being treated. It is important that you continue to take your
medications as prescribed and follow up with the appointments
listed below.
Good luck!
Followup Instructions:
___
|
10600719-DS-16 | 10,600,719 | 29,175,745 | DS | 16 | 2197-06-12 00:00:00 | 2197-06-13 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Benadryl
Attending: ___.
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with complex PMH including lateral medullary
stroke, cardiac amyloid, symptomatic bradycardia s/p dual
chamber
pacemaker, chronic intermittent SOB and lightheadedness who
presents with three days shortness of breath and malaise.
4 days prior to admission, Mr. ___ reports a new sensation of
dizziness/lightheadedness. While in bed, he was looking at the
wall and saw the room slide back and forth for 2 minutes. He had
no weakness, loss of sensation, word finding difficulty, nausea,
no change in hearing, nor palpitations. He does have bilateral,
baseline, low-grade tinnitus, which has not changed. Reports
shortness of breath that is also chronic. This vision change
reoccurred several minutes later for a period of some seconds
when he kneeled down at home. Over the last three days he has
been using a cane for "extra support" but denies weakness. No
fevers, chills, cough, abdominal pain, diarrhea, n/v.
He presented to ___ on ___. Workup was notable
for elevated troponin t to 0.099 (~troponin I of 0.01-0.02). He
had a head CT that was negative for acute process. He was given
aspirin 325 mg p.o. ×1 and Nitropaste. He was transferred to
___ for neurologic and cardiology evaluation.
Past Medical History:
Past Medical History:
- HLD
- Glucose intolerance.
- Bradycardia, PR prolongation and left anterior hemiblock s/p
DDDR pacemaker implantation ___ for recurrent syncope (in
the setting of vasodilator circumstances such as eating, GI
bleeding, and standing quickly). He had further syncope in
___
and his pacemaker setting was changed to include a "Rate Drop"
feature.
- Clinical left lateral medullary stroke without MRI correlate
___ felt likely due to small vessel disease. Managed on
aspirin. - Patient had complained of dizziness and unsteadiness
on his feet from ___ and on examination, there was
evidence of a left Horner's syndrome, left gaze nystagmus,
ipsilateral facial sensory loss with contralateral arm and leg
sensory loss and left-sided dysmetria. MRI/MRA head and neck was
negative for an acute stroke but limited in detecting a subacute
lateral medullary stroke given onset of symptoms 1 month before
imaging was performed. He had a follow-up CTA head and neck
which
showed mild calcifications at the common carotid artery
bifurcations and intracranial cavernous carotid arteries. He was
started on aspirin 81mg qd.
- Previous significant GI bleeds with angiodysplasia on EGD in
___ and terminal ileum erosions on capsule endoscopy ___ H
pylori positive. These were felt to be due to either the
nonspecific erosions seen in his ileum and/or more likely
acquired vascular ectasia in either the small bowel or upper GI
tract as noted.
- Cervical spondylosis with MRI C spine showing multilevel
degenerative changes particularly at C5-C6 where there is
moderate-to-severe bilateral foraminal narrowing and managed
with
a soft collar but has stopped wearing this as he could not
tolerate it.
- Arthritis in bilateral hips
-PERIPHERAL NEUROPATHY
He was seen in the sleep disorders clinic with Dr ___ on
___ for several years of sleep difficulties and was felt
to
have sleep maintenance insomnia related to anxiety and was
advised regarding good sleep hygiene and meditation techniques.
He then had a left total hip replacement at the ___ on
___
after being medically cleared and was started on warfarin for
DVT
prophylaxis. He was transferred from rehab to the ___ ED with
increased left lower extremity swelling on ___ and CT
pelvis/leg showed a quadratus femoris hematoma and his
haemoglobin remained stable. He also had urinary retention and
CT
showed no obstruction and a urinary catheter as placed with a
large post-void residual. He was found to have an enterococcus
UTI and was treated for this. He was discharged on ___ to
rehab and was seen by urology on ___ with catheter still
in-situ. He was discharged from rehab on ___.
Past Surgical History:
- s/p left THR ___
- s/p dual chamber pacemaker implantation ___
- s/p ___ surgery left lateral lower leg ___ for basal
cell
ca
- s/p hernia repair ___
- s/p appendectomy ___
- s/p tonsillectomy
Social History:
___
Family History:
Father died at age ___ from complications of COPD. He was a
heavy smoker. Mother died at age ___. Interestingly, in her
late ___ had recurrent GI bleeding of undetermined etiology. He
has one brother who is well, another brother who had mastoid
surgery at age ___ and a half years and died. There is no known
family history of colon cancer.
Physical Exam:
GENERAL: No acute distress, pleasant gentleman lying comfortably
in bed
HEENT: NCAT, EOMI, moist mucous membranes, oropharynx clear
NECK: supple
CV: RRR, S1S2 appreciated without extra heart sounds, no JVD, 2+
radial pulses b/l
RESP: lungs CTAB, no increased work of breathing
GI: normoactive bowel sounds, soft, NDNT, no organomegaly
EXTREMITIES: no edema, cyanosis, or clubbing
SKIN: No rashes or petechiae
NEURO: AAOx3, strength and sensation grossly normal throughout.
Notable for nystagmus with lateral gaze with contralateral
(right) upper and lower extremity sensory impairment to light
touch.
PSYCH: normal affect, good mood
Pertinent Results:
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30PM D-DIMER-2312*
___ 05:30PM cTropnT-0.04*
___ 05:30PM GLUCOSE-119* UREA N-26* CREAT-1.0 SODIUM-133
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-18* ANION GAP-15
___ 05:41PM LACTATE-1.7
___ 06:15PM WBC-6.6 RBC-4.72 HGB-13.1* HCT-39.1* MCV-83
MCH-27.8 MCHC-33.5 RDW-14.7 RDWSD-44.4
___ 06:15PM proBNP-1699*
___ 06:15PM ALT(SGPT)-9 AST(SGOT)-18 ALK PHOS-37* TOT
BILI-0.4
___ 06:20PM %HbA1c-5.8 eAG-120
___ 06:15PM CK-MB-6 cTropnT-0.04*
___ 09:16PM CK-MB-5 cTropnT-0.03*
___ 06:13AM CK-MB-5 cTropnT-0.04*
___ 06:13AM CK(CPK)-113
ECHO:
The left atrial volume index is moderately increased. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Quantitative (3D) LVEF = 60%. 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 arch 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. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Prominent symmetric LVH with normal global and
regional biventricular systolic function. Mild aortic
regurgitation. Mild mitral regurgitation. Mildly dilated
ascending aorta.
CT HEAD:
IMPRESSION:
1. The no significant interval change from prior head CT
performed ___. No evidence of new infarction, hemorrhage, edema, or
mass.
VQ SCAN:
FINDINGS: Ventilation and perfusion images demonstrate moderate
matched
nonsegmental defects in the region of the superior and
anteromedial basal
segments of the left lower lobe.
Chest x-ray shows no infiltrates or opacities.
IMPRESSION: Low likelihood ratio for acute pulmonary
thromboembolism.
Brief Hospital Course:
PATIENT SUMMARY:
___ year old man with PMH lateral medullary stroke, cardiac
amyloid, symptomatic bradycardia s/p pacemaker placement with
recent unremarkable interrogations, who presented with shortness
of breath, new visual changes, Troponin of 0.04, with negative
neurologic workup.
ACUTE ISSUES:
# Presyncope:
# Visual changes concerning for stroke:
CT Head and follow-up scan at 24h: negative for acute
intracranial process. Neuro exam unchanged from baseline.
Neurology evaluated and recommended outpatient follow up with
neurology and no change in management. D-dimer was checked in
the setting of presyncope and was found to be elevated. VQ Scan
(___) low probability for PE. He had an echo which showed
prominent symmetric LVH with normal global and regional
biventricular systolic function, mild aortic regurgitation, mild
mitral regurgitation, and a mildly dilated ascending aorta. He
was discharged on aspirin 81 per neurology recommendations.
# NSTEMI, type II: likely demand ischemia, unclear etiology, ekg
without signs of ischemia, asymptomatic. Monitored on telemetry
with no events.
CHRONIC ISSUES:
# ___ lateral medullary stroke: mild Horner's syndrome
with lateral gaze nystagmus. No new neurological symptoms,
stable neuro exam per neurology.
# Bradycardia s/p pacemaker: paced rhythm with no new changes.
Not interrogated in setting of recent unremarkable
interrogations.
# Cardiac amyloid, biopsy-confirmed in ___
# ___
# HLD
# Arthitis
TRANSITIONAL ISSUES:
[] inpatient neuro consult recommended considering switching
Aspirin to Plavix
[] F/u with Dr. ___ 2 weeks
[] Consider outpatient TTE with bubble to evaluate for PFO/ASD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN constipation
5. Fenofibrate 48 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. biotin 5,000 mcg oral DAILY
9. flaxseed 1000 mg oral DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. boswellia ___ xt (bulk) unknown miscellaneous DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. biotin 5,000 mcg oral DAILY
3. Fenofibrate 48 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. flaxseed 1000 mg oral DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin D 1000 UNIT PO DAILY
11. HELD- boswellia ___ xt (bulk) unknown miscellaneous
DAILY This medication was held. Do not restart boswellia
___ xt (bulk) until you follow up with your primary care
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Presyncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted for visual changes and shortness of breath
concerning for a new stroke, as well as lab results concerning
for a pulmonary embolism.
WHAT HAPPENED IN THE HOSPITAL?
- You received CAT scans of your head, which did not show any
evidence of a new stroke.
- You received a V/Q scan which looked at your lungs and
determined that you did not have a blood clot in your lungs that
could explain your symptoms
WHAT SHOULD YOU DO AT HOME?
- You should continue to take all your medications as
prescribed. You were prescribed no new medicines.
- You should also follow up with your PCP and neurologist
___ you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10601314-DS-6 | 10,601,314 | 29,060,924 | DS | 6 | 2117-07-11 00:00:00 | 2117-07-11 15:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Quinolones
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP with sphincterotomy, sphincteroplasty, and
stone/sludge extraction
___: Laparoscopic cholecystectomy
History of Present Illness:
___ is a ___ woman with who presented to the
___ with RUQ pain. She was transferred to ___ for
consideration of ERCP consultation given LFT abnormalities.
In the ___, initial VS were: 98.1 80 130/64 16 97%RA. LFTs were
elevated - ALT 523, AST 275, Tbili 2.3, AP 220. Ultrasound
showed
cholelithiasis without gallbladder wall thickening. She was
given
reglan for nausea. She was transferred to medicine for further
management.
On arrival to the floor, she reports developing acute pain on
___ after eating an egg and cheese breakfast sandwich
located
in her RUQ/epigastrium that was crampy and constant with
intermittent periods of worsening associated with nausea and
emesis. She went to ___, was diagnosed with gastritis and
discharged from the ___. Her pain recurred the evening of the
___
about 1.5hr after trialing a small amount of food. She woke up
on
the ___ still in pain so went to the ___ at ___. At ___,
she was found to have gallstones and transferred to ___.
She currently rates her pain ___. She also had nausea, bilious
emesis x 3 and chills but no fevers. She denied any diarrhea or
constipation. She denies sick contacts.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Endometriosis s/p laparoscopy as a teenager
Kidney stones
Gallstones - diagnosed ___ ago during ___ pregnancy
Social History:
___
Family History:
Mother with COPD, vascular disease from smoking
Father passed away from stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ ___ Temp: 97.8 PO BP: 114/70 L Lying HR: 63 RR: 18
O2 sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
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, RUQ/epigastric TTP, 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:
VS: 98.2, 111/67, 65, 18, 97 Ra
Gen: A&O x3, lying in bed in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, obese, NT/ND. Lap sites x4 CDI closed with dermabond
Ext: No edema
Pertinent Results:
ADMISSION
___ 11:45PM BLOOD WBC-6.7 RBC-4.62 Hgb-12.3 Hct-37.9 MCV-82
MCH-26.6 MCHC-32.5 RDW-13.2 RDWSD-39.6 Plt ___
___ 11:45PM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-139
K-4.2 Cl-104 HCO3-21* AnGap-14
___ 11:45PM BLOOD ALT-528* AST-275* AlkPhos-220*
TotBili-2.3* DirBili-1.6* IndBili-0.7
LIVER OR GALLBLADDER US
Cholelithiasis without definite gallbladder wall thickening.
Gallbladder is collapsed around multiple calculi.
MRCP (MR ABD ___
Cholelithiasis and choledocholithiasis without specific imaging
findings of acute cholecystitis or cholangitis.
ERCP
The scout film was normal.
The major papilla appeared normal.
During this difficult biliary cannulation, the pancreatic duct
was partially filled with contrast and visualized proximally.
In order to facilitate biliary cannulation the double guidewire
technique was utilized. A guidewire was left in the pancreatic
duct (with its distal tip placed across the minor papilla).
The bile duct was then successfully cannulated using a Rx
sphincterotome preloaded with a 0.035in guidewire. Contrast was
injected and there was brisk flow through the ducts. Contrast
extended to the entire biliary tree.
Contrast injection revealed a filling defect in the lower third
CBD consistent with a stone. The CBD was mildly dilated up to 8
mm.
A biliary sphincterotomy was successfully performed with the
sphincterotome. There was no post-sphincterotomy bleeding.
The sphincterotome was exchanged for a balloon. A biliary
sphincteroplasty was successfully performed using a 8-10mm CRE
balloon up to 9mm.
The biliary tree was then swept with a 9-12mm balloon starting
at the bifurcation. One stone and sludge were successfully
removed.
The CBD and CHD were swept repeatedly until no further stones
were seen. The final occlusion cholangiogram showed no evidence
of filling defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically. I supervised the acquisition and
interpretation of the fluoroscopic images. The quality of the
fluoroscopic images was good.
Discharge Labs:
___ 04:00AM BLOOD WBC-4.8 RBC-4.32 Hgb-11.5 Hct-36.0 MCV-83
MCH-26.6 MCHC-31.9* RDW-13.0 RDWSD-39.3 Plt ___
___ 06:20AM BLOOD WBC-6.1 RBC-4.56 Hgb-12.2 Hct-37.5 MCV-82
MCH-26.8 MCHC-32.5 RDW-12.9 RDWSD-38.4 Plt ___
___ 06:18AM BLOOD WBC-6.3 RBC-4.90 Hgb-13.0 Hct-40.5 MCV-83
MCH-26.5 MCHC-32.1 RDW-13.2 RDWSD-39.8 Plt ___
___ 04:00AM BLOOD Glucose-94 UreaN-6 Creat-0.7 Na-141 K-4.1
Cl-104 HCO3-26 AnGap-11
___ 06:20AM BLOOD Glucose-77 UreaN-8 Creat-0.6 Na-140 K-3.9
Cl-103 HCO3-25 AnGap-12
___ 06:18AM BLOOD Glucose-104* UreaN-5* Creat-0.6 Na-142
K-4.3 Cl-104 HCO3-24 AnGap-14
___ 04:00AM BLOOD ALT-229* AST-80* AlkPhos-131* TotBili-0.4
___ 06:20AM BLOOD ALT-283* AST-136* AlkPhos-153*
TotBili-0.6
___ 06:18AM BLOOD ALT-295* AST-94* AlkPhos-182* TotBili-0.5
___ 04:00AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
___ 06:20AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7
___ 06:18AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
Brief Hospital Course:
This is a ___ year old female with past medical history of
Cholelithiasis admitted ___ with nausea, epigastric pain
and abnormal LFTs concerning for choledocholithiasis with
obstruction. Patient underwent MRCP that showed cholelithiasis
and choledocholithiasis. Patient was seen by advanced endoscopy
team who performed an ERCP, which was complicated by difficult
biliary cannulation, otherwise notable for biliary
sphincterotomy and balloon extraction of stone and sludge.
Patient was subsequently seen by general surgery service who
recommended same admission cholecystectomy. Patient was
transferred to general surgery and underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating liquids, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 335___ gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis, choledocholithiasis
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:
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:
___
|
10601565-DS-15 | 10,601,565 | 29,230,575 | DS | 15 | 2147-12-06 00:00:00 | 2147-12-08 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with no PMH who presented to the ED on ___ for abdominal
pain and fever (100.2F at home). The abdominal pain is located
on the right side. The pain was described as dull with
occasional throbbing and worse with movement. Currently rated
___, although it was rated ___ on presentation. Patient also
complained of nausea and NBNB vomiting x3. Patient also reports
poor appetite, chills, lightheadedness, and increased urinary
frequency. She denies dysuria.
In the ED, initial vitals were: Temp: 99.0 HR: 121 BP: 124/65
Resp: 16 O(2)Sat: 98. She had an elevated WBC with left shift
and UA revealed pyuria and bacteriuria. She was started on IVF
and Cipro IV. However, because patient continued to complain of
nausea and pain, she was admitted to medicine for further
management.
Past Medical History:
Seasonal allergies
Social History:
___
Family History:
Denies FH of cardiovascular disease and DM. PGF with bladder
cancer, PGM with breast cancer. Maternal uncle, aunt, and 2
cousins with stomach cancer.
Physical Exam:
ON ADMISSION:
Vitals: T: 98.3 BP:104/60 P:100 R:16 O2:99% RA
General: Thin, appears stated age. Non-toxic appearing. NAD.
HEENT: PERRL, EOMI. Oropharynx without erythema or edmema.
Neck: Supple, no cervical lymphadenopathy.
CV: RRR, normal S1, S2. No S3, S4 or murmurs.
Lungs: Clear to auscultation bilaterally. No crackles or
wheezes.
Abdomen: + Bowel sounds. Pain with palpation of right upper and
lower quadrant.
Back: + CVA tenderness on right side.
Ext: Peripheral 2+ and symmetrical. No edema.
Neuro: CN II-XII grossly intact. Strength in upper and lower
extremities ___.
Skin: Dry, no rashes.
ON DISCHARGE:
Vitals: T: 100.7 BP:111/60 P:98 R:16 O2:100% RA
General: Thin, appears stated age. Non-toxic appearing. NAD.
HEENT: PERRL, EOMI. Oropharynx without erythema or edmema.
Neck: Supple, no cervical lymphadenopathy.
CV: RRR, normal S1, S2. No S3, S4 or murmurs.
Lungs: Clear to auscultation bilaterally. No crackles or
wheezes.
Abdomen: + Bowel sounds. Pain with palpation of right upper and
lower quadrant, better compared to yesterday's exam.
Back: + CVA tenderness on right side.
Ext: Peripheral 2+ and symmetrical. No edema.
Neuro: CN II-XII grossly intact. Strength in upper and lower
extremities ___.
Pertinent Results:
ON ADMISSION:
___ 12:37AM BLOOD WBC-12.6* RBC-4.04* Hgb-12.7 Hct-35.6*
MCV-88 MCH-31.4 MCHC-35.6* RDW-12.3 Plt ___
___ 12:37AM BLOOD Neuts-89.1* Lymphs-6.1* Monos-4.0 Eos-0.5
Baso-0.3
___ 12:37AM BLOOD Glucose-118* UreaN-8 Creat-0.7 Na-138
K-3.2* Cl-103 HCO3-20* AnGap-18
___ 12:37AM BLOOD ALT-19 AST-25 AlkPhos-82 TotBili-0.6
___ 12:37AM BLOOD Albumin-4.3 Calcium-9.3 Phos-2.3* Mg-1.8
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
PENDING:
Urine culture
Brief Hospital Course:
___ F with no PMH who presents with fever and abominal pain
found to have pyelonephritis.
# Pyelonephritis:
Patient was extremely nauseous and could not tolerate PO. She
was given IVF. She was started on Ciprofloxacin IV and
transitioned to PO when she was able to tolerate food. She will
continue Cipro for a total of 14 days (___) Patient's
fever was treated with Tylenol, nausea treated with Zofran, and
pain treated with oxycodone. Blood cultures grew E. coli, with
sensitivities only showing resistance to Ampicillin. Urine
culture pending on discharge.
# Birth control:
Pt currently on generic form of yaz. Because she will be on a
long course of abx, she was counseled to stop taking it this
month, and re-start with her next menstrual cycle. We counseled
her on barrier protection.
TRANSITIONAL ISSUES:
- Urine culture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. YAZ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg-mcg Oral
Daily
2. Claritin *NF* 5 mg Oral Daily Seasonal Allergies
Discharge Medications:
1. Claritin *NF* 5 mg Oral Daily Seasonal Allergies
2. YAZ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg-mcg Oral
Daily
3. Acetaminophen 650 mg PO Q6H:PRN Fever
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 8 hours Disp #*10
Tablet Refills:*0
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days
Last Day is ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*26 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Senna 1 TAB PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis (Kidney Infection)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital with a kidney infection. You improved with
antibiotics, medicine for nausea, and pain medications. You will
need to continue the antibiotics for a total duration of 14 days
(___).
Followup Instructions:
___
|
10601663-DS-3 | 10,601,663 | 25,227,083 | DS | 3 | 2177-06-07 00:00:00 | 2177-06-07 20:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
None during this admission
History of Present Illness:
___ + for ETOH was walking down street looking at phone, saw a
car coming down street and was startled, took a step back and
fell striking head. She attempted to get up and had fallen back
down. Reports having a bottle of wine per day. She was taken to
___ ___ and workup revealed a Right sided traumatic
subarachnoid hemorrhage and a question of a small left sided
SDH.
Cervical collar was cleared at the OSH. She was subsequently
transferred to ___ for further management and care.
Past Medical History:
HTN
hyperlipidemia
EtOH abuse
seasonal allergies
Social History:
___
Family History:
Family Hx:
Skin Cancer in father
Physical ___ at presentation:
: T:98.1 BP: 145/93 HR:88 R:20 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: ___ EOMs. chin laceration, multiple facial
lacerations.
Extrem: Warm and well-perfused. Palms of hands have lacerations.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout with exception of L
tricept ___. No pronator drift.
Sensation: Intact to light touch
Toes downgoing bilaterally
Exam at discharge:
VS: AVSS
GEN: AOx3, NAD
HEENT: laceration c/d/i
Neuro: CN2-12 intact
Pertinent Results:
___ 07:50AM BLOOD WBC-4.8 RBC-4.21 Hgb-14.5 Hct-41.0 MCV-98
MCH-34.5* MCHC-35.3* RDW-14.0 Plt ___
___ 04:00PM BLOOD WBC-5.4 RBC-4.50 Hgb-15.0 Hct-44.4
MCV-99* MCH-33.3* MCHC-33.7 RDW-14.2 Plt ___
___ 04:00PM BLOOD Neuts-70.4* ___ Monos-4.6 Eos-0.8
Baso-0.7
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-107* UreaN-10 Creat-0.6 Na-142
K-3.6 Cl-104 HCO3-25 AnGap-17
___ 04:00PM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-145
K-5.4* Cl-108 HCO3-22 AnGap-20
___ 07:50AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.5*
Brief Hospital Course:
Mrs. ___ was directly transferred from ___ for
traumatic subarachnoid hemorrhage and subdural hematoma. She was
admitted to the Neurosurgery service with Keppra 1000mg initial
load and Keppra 500mg BID. She was placed on a ___ protocol
given her history of EtOH abuse. Her neurovascular exam was
intact on admission.
___: She tolerated a regular diet. She was making adequate
urine output. Pain was well-controlled on PO pain meds. Her
neural exam remained to be intact. She was safe to be discharged
to home.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/HA
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*12 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
***You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine, you will not require blood work
monitoring. Please take this for a total of 7 days since your
admission.
Do not drive until your follow up appointment.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10602364-DS-12 | 10,602,364 | 26,614,373 | DS | 12 | 2187-08-25 00:00:00 | 2187-09-12 14:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
cortisone injections
Attending: ___.
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient with a history of chronic lower back pain secondary to
lumbar scoliosis now status post L4-S1 ALIF (___) T12-L4
XLIF (___) T11-ilium posterior thoracolumbar laminectomy and
fusion (___). Recently discharged from the hospital and
presents to the ED today with presyncopal episodes and decreased
Po intake since being in rehab. Patient also states that she has
developed left leg weakness since the surgery but apparently was
told that her psoas muscle was severed and as a result cannot
properly use her left leg. In addition to her difficulty with
tolerating po intake, she endorses being increasingly confused
which she believes is secondary to the pain medications she has
been receiving. She denies any fever or chills, no shortness of
breath or chest pain, no numbness or tingling in any of her
extremities.
Past Medical History:
HTN, hyperlipidemia, hyperclacemia, allergic rhinitis, urinary
retention, left ventricular hypertrophy, OA
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: 98.5 HR 90, BP 142/72, RR 18, 99% RA
General: Well appearing in NAD
Cards: RRR, no murmurs
Pulm: CTAB
Abd: soft, non distended
Skin: incision sites in the mid abdomen, right flank and back
are
healing well with no evidence of dehiscence, no erythema or
purulent discharge
Neuro: Alert and oriented, cranial nerves grossly intact
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 2 5 4 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
Pertinent Results:
___ 02:45PM URINE HOURS-RANDOM
___ 02:45PM URINE UHOLD-HOLD
___ 02:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:42PM COMMENTS-GREEN TOP
___ 01:42PM LACTATE-1.4
___ 01:32PM GLUCOSE-105* UREA N-11 CREAT-0.7 SODIUM-141
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
___ 01:32PM WBC-21.9* RBC-3.19* HGB-9.4* HCT-29.8* MCV-93
MCH-29.5 MCHC-31.5* RDW-16.3* RDWSD-51.4*
___ 01:32PM NEUTS-79.7* LYMPHS-8.6* MONOS-7.4 EOS-2.3
BASOS-0.5 NUC RBCS-0.1* IM ___ AbsNeut-17.49* AbsLymp-1.89
AbsMono-1.62* AbsEos-0.50 AbsBaso-0.10*
___ 01:32PM PLT COUNT-876*
___ 01:32PM ___ PTT-24.5* ___
Brief Hospital Course:
Patient was admitted to Orthopedic Spine Service on ___ for
further management. Overnight patient had change in mental
status requiring Haldol and restraints. On ___ patient had a
bedside tapo of superficial seroma followed by ___ drainage of
subfascial collection. WBC was elevated to 20 and patient was
started empirically of vancomycin / ceftriaxone. Patient's
midlin catheter was removed which was placed at rehab and sent
for culture. ID was consulted for further management. Cultures
were negative due to previous cefepime dosing at rehab. ID
recommended 4 weeks of ceftriaxone and d/c vancomycin.
During her course her delirium improved and wBC dropped from 25
to 12.9. In addition her left leg weakness improved.
Now, Day of Discharge, patient is afebrile, VSS, and neuro
intact with improvement of radiculopathy. Patient tolerated a
good oral diet and pain was controlled on oral pain medications.
Patient ambulated independently with some assistance. Patient's
wound is clean, dry and intact. Patient noted improvement in
radicular pain. Patient is set for discharge to acute rehab in
stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Lisinopril 10 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Ranitidine 150 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
7. Glucosamine Daily Complex (glucosamine-D3-Boswellia ___
___ mg-unit-mg oral DAILY
8. calcium carbonate-vit D3-min 600 mg (1,500 mg)-200 unit oral
DAILY
9. Aspirin 81 mg PO DAILY
10. Ascorbic Acid ___ mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV once
a day Disp #*28 Intravenous Bag Refills:*0
2. Cyclobenzaprine 5 mg PO TID:PRN spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*90 Tablet Refills:*0
5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*90 Tablet Refills:*0
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. calcium carbonate-vit D3-min 600 mg (1,500 mg)-200 unit oral
DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Glucosamine Daily Complex (glucosamine-D3-Boswellia ___
___ mg-unit-mg oral DAILY
12. Lisinopril 10 mg PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
leukocytosis
fever
orthostasis
lumbar stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With Fusion
Follow-up Appointments
After you are discharged from the hospital and settled at home
or rehab, please make sure you have two appointments:
1.2 week post-operative wound check visit after surgery
2.a post-operative visit with your surgeon for ___ weeks after
surgery.
You can reach the office at ___ and ask to speak
with your surgeons surgical coordinator/staff to schedule or
confirm your appointments
Wound Care
If not already done in the hospital, remove the incision
dressing on day 2 after surgery.
You may shower day 3 after surgery. Starting on this ___ day,
you should gently cleanse the incision and surrounding area
daily with mild soap and water, patting it dry when you are
finished.
Some swelling and bruising around the incision is normal. Your
muscles have been cut, separated and sewn back together as part
of your surgical procedure. You will leave the hospital with
back discomfort from the surgical incision. As you become more
active and the incision and muscles continue to heal, the
swelling and pain will decrease.
Have someone look at the incision daily for 2 weeks. Call the
surgeons office if you notice any of the following:
___ redness along the length of the incision
___ swelling of the area around your incision
___ from the incision
___ of your extremities greater than before surgery
___ of bowel or bladder control
___ of severe headache
___ swelling or calf tenderness
___ above 101.5
Do not soak or immerse your incision in water for 1 month. For
example, no tub baths, swimming pools or jacuzzi.
Activity Guidelines
You MAY be given a RIGID BRACE that you will wear whenever
sitting up, standing, or walking. You will wear it for ___
weeks after surgery. See the last page of these instructions for
details on wearing the brace.
Avoid strenuous activity, bending, pushing or holding your
breath. For example, do not vacuum, wash the car, do large
loads of laundry, or walk the dog until your follow-up visit
with your surgeon.
Avoid heavy lifting. Do not lift anything over ___ pounds for
the first few weeks that you are home from the hospital.
Increase your activities a little each day. Walking is good
exercise. Plan rest periods and try to avoid hills if possible.
Remember, exercise should not increase your back pain or cause
leg pain.
Reaching: When you have to reach things on or near the floor,
always squat (bending the knees), rather than bending over at
the waist.
Lying down: when lying on your back, you may find that a pillow
under the knees is more comfortable. When on your side, a
pillow between the knees will help keep your back straight.
Sitting: should be limited to 40-60 minutes at a time for the
first week. Slowly increase the amount of sitting time,
remembering that it should not increase your back pain.
Stairs: use stairs only once or twice a day for the first week,
or as directed by the surgeon. Climb steps one at a time,
placing both feet on the step before moving to the next one.
Driving: you should not drive for ___ weeks after surgery. You
should discuss driving with your surgeon /nurse practitioner
/physician ___. You may ride in a car for short distances.
When in the car, avoid sitting in one position for too long.
If you must take long car rides, do not ride for more than 60
minutes without taking a break to stretch (walk for several
minutes and change position.).
Sexual activity: you may resume sexual activity ___ weeks after
surgery (avoiding pain or stress on the back).
Reduction in symptoms: patients who have experienced back and
radiating leg pain for a short window of time before surgery
should anticipate a significant decrease in pre-operative
symptoms. If the pain has been present for a longer period
(months to years), the pre-operative symptoms will recover on a
more gradual basis week by week. It is not practical to expect
immediate relief of symptoms. Routinely, pain will gradually
improve on a weekly basis, weakness on a monthly basis, and
numbness in a range of 6 months to ___ year.
Followup Instructions:
___
|
10602608-DS-20 | 10,602,608 | 24,123,034 | DS | 20 | 2180-12-01 00:00:00 | 2180-12-05 10:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLQ pain and pregnancy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old G1 at 5w3d by LMP with positive home pregnancy who
presented with one day of RLQ/flank and bilateral low back pain.
Has worsened throughout the day and sometimes worse with
movement. Not associated with eating, no other exacerbating or
relieving factors. No n/v/fevers. Has also has ___ days of
brown vaginal spotting.
This pregnancy is highly desired. She was just starting an
infertility evaluation at ___ after ___ years of trying to become
pregnant with her husband of ___ years with regular intercourse.
She denies history of pelvic infections or STI. Does have a
history of extremely painful periods when she was young. Often
causing her to miss school or even pass out from the pain.
ROS otherwise negative.
Past Medical History:
PMH:
-chronic constipation
-chronic low back pain since falling down stairs a few years ago
-hyperlipidemia
-insomnia
-vitamin D deficiency
Denies history of heart disease, HTN, VTE.
PSH:
-breast fibroadenoma excision x6
-foot surgery
Denies anesthesia or post-operative complications.
Obhx: G1
Gyn hx:
q28-31 day periods. reports history of menorrhagia as teenager
severe enough to cause her to miss school and sometimes pass out
from pain. Started on OCPs with marked improvement in
menorrhagia.
Denies history of STI, cysts, fibroids, PID.
Mutually monogamous relationship with her husband of ___ years.
Social History:
works as a ___ grade ___. Married ___ years. Husband is
a
___ at a local ___. denies tob/etoh/drugs.
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding
Ext: no TTP
Pertinent Results:
___ 07:40PM ALT(SGPT)-28 AST(SGOT)-29
___ 07:40PM WBC-5.1 RBC-4.56 HGB-12.4 HCT-38.1 MCV-84
MCH-27.2 MCHC-32.5 RDW-14.0 RDWSD-42.8
___ 07:40PM PLT COUNT-252
___ 07:40PM ___ PTT-29.8 ___
___ 10:56PM GLUCOSE-92 UREA N-15 CREAT-0.9 SODIUM-136
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17
___ 10:56PM estGFR-Using this
___ 10:56PM HCG-1338
___ 10:56PM WBC-4.2 RBC-4.47 HGB-11.9 HCT-38.0 MCV-85
MCH-26.6 MCHC-31.3* RDW-13.8 RDWSD-43.0
___ 10:56PM NEUTS-53 BANDS-0 ___ MONOS-8 EOS-3
BASOS-1 ATYPS-1* ___ MYELOS-0 AbsNeut-2.23 AbsLymp-1.47
AbsMono-0.34 AbsEos-0.13 AbsBaso-0.04
___ 10:56PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 10:56PM PLT SMR-NORMAL PLT COUNT-262
___ 08:20PM URINE HOURS-RANDOM
___ 08:20PM URINE UCG-POSITIVE
___ 08:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
IMAGING
___ PUS
IMPRESSION:
1. Edematous right ovary measuring up to 7.1 cm with preserved
vascular flow, unchanged compared to prior, which remains
concerning for intermittent torsion. Unchanged appearance of
the simple and complex cysts within the right ovary.
2. Small amount of fluid within the endometrial canal. No
definite gestational sac visualized.
3. Small amount of simple free fluid.
___ MRI A/P
IMPRESSION:
1. Nonvisualization of the appendix in the right lower quadrant,
with no
secondary signs of acute appendicitis.
2. Markedly enlarged right ovary measuring 6.5 x 5.8 cm
containing a 3.4 cm simple cyst and a 2.3 cm complex cyst. The
asymmetrically enlarged right ovary raises suspicious for
ovarian torsion. There is diffusely thickened endometrium
without identification of a discrete gestational sac. This
could be related to very early gestation. Normal appearance of
the left ovary.
3. Small amount of simple free fluid in the pelvis.
___ US Appendix
IMPRESSION:
Appendix not visualized. If there is a high clinical concern
for appendicitis, MRI is recommended.
___ PUS
IMPRESSION:
1. The right ovary is markedly enlarged compare the left ovary
raising the suspicion of ovarian torsion, despite the presence
of flow surrounding the complex cyst within the right ovary.
The right ovary also demonstrates presence of an anechoic simple
cyst measuring 3.0 cm.
2. A complex cystic lesion in the ovary without internal
vascularity measuring up to 2.2 cm. There is also complex free
fluid in the right adnexa. These findings are most compatible
with a ruptured hemorrhagic cyst. Ectopic pregnancy is less
likely.
3. Diffusely thickened and heterogeneous endometrium measuring
up to 3 cm
without visualization of intrauterine gestational sac. The
thickened
endometrium is likely secondary to an early intrauterine
pregnancy.
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
for observation of RLQ/flank/back pain in the context of
pregnancy of unknown location (5+ weeks by LMP).
She underwent an pelvic US in the ED which revealed an R ovary
markedly enlarged compared to L ovary concerning for ovarian
torsion though there was presence of flow around a complex cyst
w/o internal vascularity within R ovary measuring 2.2cm. These
findings were more compatible with a ruptured hemorrhagic cyst,
less likely ectopic. There was also an additional anechoic
simple cyst on the R ovary. There was a diffusely thickened and
heterogeneous endometrium without visualization of an
intrauterine gestational sac, likely early intrauterine
pregnancy. Appendix was not visualized on US and MRI was
recommended. MRI again did not visualize the appendix, there
were also no signs of acute appendicitis. It also confirmed
findings on US and there was a small amt of simple free fluid. A
repeat US showed an edematous R ovary up to 7.1cm w/ preserved
flow, unchanged from prior, as were the presence of simple and
complex cysts in the R ovary. Again, there was a small amt of
fluid within endometrial canal w/o visualized gestational sac.
Her beta-hCG was found to be 1338 (at 22:56 on ___ at the
time of admission which increased to 1859, 36 hours later (at
05:40 on ___. Her hct was 38 at the time of admission which
dropped to 35.3 on HD2. She was hemodynamically stable. She was
kept NPO overnight with serial abdominal exams and her pain
improved with Tylenol. On HD2, she was advanced to a regular
diet without issues. Given her clinical improvement, she was
discharged to follow up in clinic for a repeat beta-hCG the
following day (___).
Medications on Admission:
PNV
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
pregnancy of unknown location
Discharge Condition:
stable
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 call the office with any
questions or concerns ___. Please follow the
instructions below.
General instructions:
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* 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
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10602633-DS-19 | 10,602,633 | 27,809,806 | DS | 19 | 2144-04-06 00:00:00 | 2144-04-11 19:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
fluid retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female w/ hx of DMII, HTN, morbid
obesity, dCHF and chronic venous stasis who presents to the ED
with several days of worsening lower extremity pain and lower
extremity edema. There are now lower extremity ulcers from the
weeping swelling. She states she had been treated as an
outpatient for cellulitis earlier in the year (months ago). The
swelling and pain in her lower extremities has been getting
worse for many weeks. She also states that she has some
dyspnea, for about two weeks.
The patient has a history of lower extremity edema in her legs,
and per recent cardiology appointment with Dr. ___, is
attributed primarily to suspected chronic venous insufficiently.
He had recommended evaluation by Dr. ___.
She reports no fevers recently, and no changes in medications.
She reports she has been compliant with her medications and has
not had any recent changes in diet. States may have gained five
pounds in the past month, but fluctuates. Denies recent
long-haul travel. Does not take OCPs. She does smoke. She has
no family history of blood clots. She has mild orthopnea, no
PND, no nocturnal coughing.
In the ED, initial vitals were 99.4 107 145/73 16 97% RA
Labs revealed Lactate 2.5.
Na 137, K 3.7, Cl 101, CO2 26, BUN 17, Cr 0.9.
Glucose 203.
WBC 11.2, Hct 40.6, Plt 294.
Blood cultures were sent. Patient was given morphine.
CXR demonstrated no acute intrathoracic abnormalities
identified. Persistent mild cardiomegaly.
EKG NSR 98, LAD, no TWI, no STE.
Vitals on transfer: 98.3 95 134/74 18 100% RA
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
-CONGESTIVE HEART FAILURE, DIASTOLIC
-DEPRESSION
-DIABETES TYPE II
-HYPERLIPIDEMIA
-HYPERTENSION
-MORBID OBESITY
-URINARY INCONTINENCE
-VITAMIN D DEFICIENCY
-NECK PAIN
-H/O TOBACCO ABUSE
Social History:
___
Family History:
Maternal grandmother with heart disease. No history of blood
clots in family.
Physical Exam:
ADMISSION:
97.8 170/76 90 18 95%RA
General: NAD, sitting in chair comfortably
HEENT: MMM
Neck: JVP approx 9cm H20, difficult to assess secondary to
habitus
CV: RRR, no m/r/g, nondisplaced PMI
Lungs: CTAB, no wheeze or rhonchi
Abdomen: soft, obese, BS+
GU: no foley
Ext: 2+ edema b/l, nonpitting, to knee
Neuro: AOx3
Skin: bilateral hyperpigmentation and hyperkeratinization in
bandlike distribution mid-tibial; multiple small skin breaks,
clean, pink, without exudate on anterior and posterior surfaces
of skin; no warmth, mild erythema; very mild tenderness to deep
palpation of these areas
PULSES: DP and ___ pulses palpable
DISCHARGE:
Vitals: 97.9 142/55 62 20 95% RA
General: obese middle aged woman in recliner, NAD
HEENT: MMM, OP clear
Neck: no JVD appreciated
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi, decreased breath sounds
throughout
Abdomen: soft, obese, multiple annular scars, some with
overlying eschar, no bleeding or drainage
GU: no foley
Ext: trace - 1+ ___ edema b/l below knees, non-pitting
Skin: bilateral erythema improved from prior in bandlike
distribution mid-tibial; multiple clean-appearing superficial
ulcerations without purulence predominantly on L anterior and R
posterior surfaces of lower legs; no warmth; tender to palpation
but less so than prior
Pertinent Results:
========================
Labs:
========================
Admission labs:
___ 01:15PM BLOOD WBC-11.2* RBC-4.47 Hgb-12.8 Hct-40.6
MCV-91 MCH-28.5 MCHC-31.5 RDW-13.9 Plt ___
___ 01:15PM BLOOD Neuts-73.2* ___ Monos-4.3 Eos-2.9
Baso-0.6
___ 01:15PM BLOOD Glucose-203* UreaN-17 Creat-0.9 Na-137
K-3.7 Cl-101 HCO3-26 AnGap-14
___ 01:15PM BLOOD proBNP-54
___ 01:15PM BLOOD Calcium-9.4 Phos-2.6*# Mg-2.2
___ 01:23PM BLOOD Lactate-2.5*
Discharge labs:
___ 06:00AM BLOOD WBC-10.5 RBC-4.39 Hgb-12.6 Hct-40.3
MCV-92 MCH-28.7 MCHC-31.3 RDW-14.1 Plt ___
___ 06:00AM BLOOD Glucose-110* UreaN-29* Creat-1.0 Na-136
K-4.0 Cl-97 HCO3-29 AnGap-14
___ 06:00AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.2
Other labs:
___ 07:50AM BLOOD Lupus-NEG
___ 07:50AM BLOOD ProtCFn-105 ProtSFn-145
___ 07:50AM BLOOD ACA IgG-7.8 ACA IgM-8.3
___ 07:50AM BLOOD PTH-83*
___ 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 07:50AM BLOOD ANCA-NEGATIVE B
___ 07:50AM BLOOD ___
___ 07:50AM BLOOD RheuFac-8
___ 07:50AM BLOOD C3-174 C4-32
___ 07:50AM BLOOD HCV Ab-NEGATIVE
___ 07:50
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB <9 <=20 ___
========================
Studies:
========================
___ 1:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
========================
Studies:
========================
ECG Study Date of ___ 1:20:44 ___
Baseline artifact. Borderline resting sinus tachycardia. Left
atrial
abnormality. Left ventricular hypertrophy. Right ventricular
conduction
delay. Horizontal but not frankly leftward QRS axis.
Non-specific ST-T wave change, especially in leads I and aVL.
Compared to the previous tracing of ___ sinus rate is
faster. Ventricular ectopy is not seen. Non-specific ST-T wave
changes are now seen. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
98 ___ 55 -14 85
CHEST (PA & LAT) Study Date of ___ 1:32 ___
FINDINGS: The heart size is normal. The hilar and mediastinal
contours are normal. The lungs are clear without evidence of
focal consolidations
concerning for pneumonia. There is no pleural effusion or
pneumothorax. The visualized osseous structures are
unremarkable.
IMPRESSION: No acute intrathoracic abnormalities identified.
Persistent mild cardiomegaly.
KNEE( (SINGLE VIEW) BILAT Study Date of ___ 7:26 ___
IMPRESSION: Osteoarthritis both knees. Bones otherwise normal
& no soft
tissue calcifications.
BILAT LOWER EXT VEINS Study Date of ___ 11:57 AM
IMPRESSION: No evidence of DVT in the bilateral lower extremity
veins.
Peroneal veins not visualized.
Brief Hospital Course:
___ female w/ hx of DMII, HTN, morbid obesity, dCHF and
chronic venous stasis who presented to the ED with several days
of worsening lower extremity pain and lower extremity edema.
# Possible cellulitis, bilateral lower extremity edema, ___ pain:
Pt with subacute onset ___ pain and edema. Felt most likely
due to chronic venous sufficiency with possible cellulitis. ___
also be component of neuropathy given DM. Ultrasound negative
for DVT. There was concern for possible vascultitis, but lab
investigations for vasculitis were unremarkable. She was treated
with IV antibiotics x 2 days, increased torsemide x 2 days, leg
wraps, and leg elevation. Her leg edema improved significantly,
and her pain improved slightly. She and her husband were
instructed on home care, including lotion keep legs moisturized,
wrapping legs, and keeping legs elevated. Discharged off
antibiotics as her legs did not appear infected at discharge.
# Chronic diastolic heart failure: ___ echo with EF > 55%. On
admission did have signs consistent with R heart failure of JVD
and ___, though ___ may have been due to chronic vehous stasis.
Pro BNP was only 54, not consistent with acute exacerbation. ___
edema improved with torsemide 60mg daily x 2 days. Pt was
discharged on home torsemide 40mg daily. Continued on carvedilol
which was uptitrated but then reduced to home dose due to
hypotension (see below). Continued on home spironolactone and
losartan. Pt instructed to call PCP if weight increases 5 lbs or
more.
# Hypotension: BP dropped to ~80/40 at one point, likely due to
increased carvedilol dose and initial increased torsemide. BP
improved with 500cc bolus. Carvedilol dose was reduced back to
home dose of 12.5mg BID.
# HTN: BP initially elevated with systolic 140-170s. Patient
states is compliant with medications. BP improved on increased
dose of carvedilol, but became hypotensive to ~80/40, and
carvedilol dose was reduced per above. Continued on losartan and
amlodipine.
# DMII: Chronic issue. Home metformin held; treated with humalog
sliding scale during admission. Burning sensation in legs may be
indicative of neuropathy. Consider gabapentin as outpt.
# Depression: Stable. Continued on citalopram.
==============================
Transitional issues:
==============================
-pt to space dosing of anti-hypertensives throughout day to help
keep BP more even
-please titrate cardiac meds including torsemide as needed; last
weight prior to discharge: 147.4kg on ___.
-pt and husband instructed to keep legs moisturized, wrapped,
and elevated
-pt to follow up with PCP and vascular surgery
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
8. Spironolactone 50 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
12. Vitamin D ___ UNIT PO DAILY
13. Multivitamins 1 TAB PO EVERY OTHER DAY
14. ___ Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. ___ Oil (Omega 3) 1000 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Multivitamins 1 TAB PO EVERY OTHER DAY
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
9. Spironolactone 50 mg PO DAILY
10. Torsemide 40 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Equipment
Eqipment: Bariatric Rolling Walker
Dx: venous insufficiency, diastolic CHF, cellulits
prognosis: good
Length of need: lifetime
Reason: gait instability
15. Carvedilol 12.5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-chronic venous insufficiency
Secondary:
-___
-HTN
-DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to increased fluid in your legs. You
were given increased doses of diuretics to help removed the
fluid. You were also treated with antibiotics for possible
cellulitis. We do not believe your legs are actively infected at
this time. Please keep your legs elevated, wrapped, and
moisturized. Please take your medications as prescribed, and
attend your follow up appointments.
To help keep your blood pressure more stable throughout the day
please take:
-spironolactone in the morning
-torsemide in the morning
-amlodipine at mid-day
-losartan at mid-day
-carvedilol in the morning and at night
Please take your next dose of torsemide 40mg tomorrow, ___
___.
Weigh yourself every morning, call MD if weight goes up more
than 5 lbs.
Followup Instructions:
___
|
10602633-DS-20 | 10,602,633 | 23,782,317 | DS | 20 | 2145-09-30 00:00:00 | 2145-10-06 19:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
cardiac catherzation ___ s/p 1 ___ via RRA
History of Present Illness:
Ms. ___ is a ___ year old female with past history of Type
II Diabetes Mellitus Type II, hypertension, hyperlipidemia, and
morbid obesity, and systolic heart failure, presenting with
chest pain and dyspnea.
Patient reports that over the past 2 weeks, she has felt
increased dyspnea on exertion, with substernal chest pain that
has resolved with rest. She denied any fevers, cough, vomiting,
and had some lower extremity edema. She is unclear what her
previous weight is. She reports that she feels chest pains with
exertion. Endorses chest pressure x 1 week feels like an
"elephant sitting on my chest."
At her PCP's office, patient reported that she has not been
feeling well for the past 1 week. Patient reports that
"everything hurts", and that she feels that her chest feels
heavy and that she cannot breathe. Patient reports some light
headedness, but pain in the back of her head (cervacalgia). She
has not had any sleep, and she continues to be very anxious.
When she wakes up, she can't get out of the chair. She sleeps in
a recliner.
She feels chest pressure, and that an "elephant" is sitting on
her chest for the past month, and that last night she could not
deal with it anymore, and had a worsening episode at 2:30 AM.
She has not gone to work because of her increased anxiety. The
last time she felt well, was a year ago. Since then she has
gained about 40lbs. She did stop smoking ___ years ago.
Prior to arrival in the ED, patient received nitroglycerin and
aspirin. Per PCP note from ___, she stopped taking all of her
medications for 6 months prior and gained at least 18 lbs.
In the ED, initial vitals were 97.5 62 194/112 20 96% RA.
EKG NSR 80, TWI laterally and STD V5 which is new
Labs: troponins 0.18, BNP 1690, and K 5.3. She was given 10
amlodipine, 80 atorvastatin, 12.5 carvedilol, 100 losartan, and
40 torsemide and was started on a heparin drip. Imaging: CXR
showed no definite acute cardiopulmonary process. Decision was
made to admit for NSTEMI and CHF.
On arrival to the floor, patient reports that her SOB has
improved considerably from this morning, and she denies any CP,
abdominal pain, fevers/chills.
Past Medical History:
Congestive Heart Failure
Depression
Diabetes Mellitus Type II
Hyperlipidemia
Hypertension
Morbid Obesity
Urinary Incontinence
Neck Pain
History of Tobacco Abuse
Social History:
___
Family History:
Mother- heart disease and DM. Grandmothers both died from heart
disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 99.1 150/90 78 20 97%RA
Admission Weight: 147 kg
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, obese, NT/ND, BS+
Ext: WWP, chronic venous stasis changes bilaterally, with
pitting edema to ankle
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 128/68 64 97% RA
Last 24 hours I/O: ___
Weight on admission 147
Today's weight: 146->145.3-> 144.2 ->145.4 -> 145.1
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, poor air movement at bases, no w/r/r
Abdomen: soft, obese, NT/ND, BS+
Ext: WWP, chronic venous stasis changes bilaterally, with no
edema to ankle
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
___ 12:40PM ___ PTT-27.6 ___
___ 12:40PM PLT COUNT-239
___ 12:40PM NEUTS-67.2 ___ MONOS-6.1 EOS-2.9
BASOS-0.5 IM ___ AbsNeut-5.72 AbsLymp-1.97 AbsMono-0.52
AbsEos-0.25 AbsBaso-0.04
___ 12:40PM WBC-8.5 RBC-4.86 HGB-13.9 HCT-42.9 MCV-88
MCH-28.6 MCHC-32.4 RDW-14.3 RDWSD-45.7
___ 12:40PM CK-MB-3 proBNP-1690*
___ 12:40PM cTropnT-0.18*
___ 12:40PM CK(CPK)-83
___ 12:40PM estGFR-Using this
___ 12:40PM GLUCOSE-104* UREA N-14 CREAT-0.8 SODIUM-136
POTASSIUM-5.3* CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
___ 12:48PM K+-4.6
___ 06:10PM CK-MB-3 cTropnT-0.17*
___ 06:10PM CK(CPK)-57
___ 08:36PM PTT-61.9*
___ 11:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:41PM URINE COLOR-Straw APPEAR-Clear SP ___
Studies:
___- ECHO
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Doppler
parameters are indeterminate for left ventricular diastolic
function. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
DISCHARGE LABS:
___ 08:25AM BLOOD WBC-8.0 RBC-5.05 Hgb-14.7 Hct-45.4*
MCV-90 MCH-29.1 MCHC-32.4 RDW-14.4 RDWSD-46.9* Plt ___
___ 08:25AM BLOOD Plt ___
___ 08:25AM BLOOD Glucose-124* UreaN-36* Creat-1.3* Na-137
K-4.3 Cl-95* HCO3-31 AnGap-15
___ 08:25AM BLOOD Calcium-9.8 Phos-5.1* Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ year old female with CHF with preserved
EF, hypertension, anxiety and diabetes, presenting with weeks of
chest pressure and positive troponin elevation, and weight gain
found to have NSTEMI and CHF exacerbation.
# NSTEMI: Patient presented with increased chest pressure and
chest pains, in the setting of likely decompensation of heart
failure. Patient has been noting this for several weeks, and
initial troponin T 0.18 peaked with MB 2 and trop 0.17.
Patient's TIMI score is 3 (chest pain, positive CBM, and CAD
risk factors). Cardiac catherzation was performed ___ and 1
DES was placed in the RCA via a right radial approach. We
continued aspirin 81 mg daily, started atorvastatin 80 mg,
continued carvedilol 12.5. The patient will continue to take
Plavix 75mg for at least 6 months and was Plavix loaded on ___.
# Heart Failure with Preserved EF: TTE ___ with LVEF > 55%,
proBNP 1690 and the patient presented with increased dyspnea,
orthopnea and weight gain. We diuresed her inpatient with IV
diuretics for a goal of net negative ___ L/day and then
transitioned her to her home dose of 40mg/day torsemdie.
CHRONIC ISSUES:
# Hypertension: Amlodipine 10 was stopped because of low resting
BP and dizziness with standing. Her spironolactone was held in
the context of normal K, low BP and concern for overdiuresis.
Given the ___ data consideration should be given to
restarting as an outpatient as she assumes a diet that will
likely be higher in sodium. She was continued on losartan and
carvedilol.
# Anxiety: Continue lorazepam 0.5 as needed.
TRANSITIONAL ISSUES:
====================
Discharge Cr: 1.3
Discharge Weight: 145.1 kg
# DES: Continue Plavix for at least 6 months, and ASA life long.
# Social Work: Patient was anxious during hospital stay with
diagnosis, consider outpatient psychiatrist / social work for
further eval and treatment.
# HFpEF: Patient's spironolactone was discontinued in favor of
other diuretic. Discharged on 40mg torsemide daily
# Home amlodipine stopped since patient dizzy with BPs in ___
systolic. ___ need to restart as an outpatient
# CODE: Full
# EMERGENCY CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Multivitamins 1 TAB PO EVERY OTHER DAY
6. Spironolactone 50 mg PO DAILY
7. Torsemide 40 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Carvedilol 12.5 mg PO BID
12. Nystatin Cream 1 Appl TP BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
6. Hydrocerin 1 Appl TP BID
RX *white petrolatum-mineral oil [Eucerin] apply to legs twice
a day Refills:*3
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually every 10 min
Disp #*10 Tablet Refills:*0
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral
BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Multivitamins 1 TAB PO EVERY OTHER DAY
11. Nystatin Cream 1 Appl TP BID
12. Vitamin D ___ UNIT PO DAILY
13. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. NSTEMI 2. Acute on Chronic Heart Failure
with Preserved Ejection Fraction.
SECONDARY DIAGNOSIS:
1. Hypertension
2. Diabetes Mellitus Type II
3. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted with worsening heart failure
and a small heart attack. While you were here, we gave you
diuretics, which are medications to help you urinate. First, we
did this through your IV and then we switched you to an oral
regimen.
You also underwent cardiac catheterization for your heart attack
which revealed a blocked right coronary artery. You had one drug
eluting stent placed.
It is very important to take all of your heart healthy
medications.
You are now on aspirin. You need to take aspirin everyday. If
you stop taking aspirin, you risk the stent clotting and death.
Do not stop taking aspirin unless you are told by your
cardiologist.
You are now on Plavix (also known as clopidogrel). This
medication helps keep your stent open. Do not stop taking plavix
unless you are told by your cardiologist. No other doctor can
tell you to stop taking this medication. You will need to be on
it for at least 6 months, possibly a year or longer.
You should take 40mg of torsemide daily. Do not take any
torsemide today. You can start taking it tomorrow morning. At
discharge, you weighed 319.2 lb. You should call your doctor if
your weight goes up or down by more than 3 lb.
Please also continue to apply Eucerin lotion to your legs. It is
important that they don't get dried up because that can lead to
infection.
Your blood pressure here was sometimes low. Please stop taking
your amlodipine for now. If your blood pressure starts to
increase, your primary care doctor can restart your amlodipine
as an outpatient.
We wish you all the ___,
Your ___ Cardiology team
Followup Instructions:
___
|
10602633-DS-21 | 10,602,633 | 26,768,536 | DS | 21 | 2146-12-24 00:00:00 | 2146-12-26 07:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
Cough and dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx CAD, CHF, type 2 DM, HTN, HLD, morbid obesity, presenting
with productive cough and dyspnea.
Pt states she had cough productive of green sputum and
congestion starting 3 days ago associated with difficulty
breathing that has progressively worsened. Associated with
increased ___ edema she noticed last year. Pr patient, her dry
weight is 335 lbs and she is currently at 324 lbs. Reports
taking her torsemide at home as prescribed. Very mild constant
chest pain during this time that is worse with coughing, no
hemoptysis. She states she has had some nausea but no vomiting.
In the ED, initial vitals were: 96.8, 73, 98/60, 22, 95% RA.
ED exam notable for moderate JVD, crackles and wheezing in the
mid and lower lung fields bilaterally, 2+ edema to the shins.
Labs notable for negative troponin x2, BNP 87 (has been as high
as 1690 in the past), WBC 10.7, BUN/Cr at baseline.
EKG revealed NSR with IVCD, Q waves in the lateral leads, TWI
in aVL, unchanged from prior.
Imaging notable for CXR with mild cardiomegaly and mild
pulmonary vascular congestion with bibasilar atelectasis.
Patient was given:
___ 09:38 IH Albuterol 0.083% Neb Soln 1 Neb
___ 09:38 IH Ipratropium Bromide Neb 1 NEB
___ 10:29 IV Furosemide 80 mg
___ 15:17 PO PredniSONE 60 mg
___ 15:17 PO Azithromycin 500 mg
___ 15:19 IH Albuterol 0.083% Neb Soln 1 NEB
___ 15:19 IH Ipratropium Bromide Neb 1 NEB
___ 16:55 IH Albuterol 0.083% Neb Soln 1 NEB
Decision was made to admit for COPD exacerbation because she
failed her ambulatory sat trial (although no ambulatory O2 is
documented).
On the floor patient relays the above and in addition: Patient
stated that everyone around her at work has had recent illness.
Cough started ___ and is mostly dry. Had sore throat since
one week ago. She also had associated rhinorrhea. Denies fevers,
+chills. Has baseline nausea, no diarrhea or vomiting. States
she has previously had coughing fits 2x/year. She noted that her
ankles were swollen yesterday morning. Takes medication for CHF
faithfully. No changes in diet in last week that would make her
short of breath. Was unaware of any history of COPD.
Of note, she has previously had CXRs for complaints of dyspnea
in the past, which have not shown volume overload. She also has
a 20 pack year smoking history.
Vitals on transfer: no temp recorded, 89, 99/86, 20, 92% RA
Review of systems:
10 point review of systems positive as per HPI otherwise
negative.
Past Medical History:
Congestive Heart Failure, diastolic
Depression
Diabetes Mellitus Type II
Hyperlipidemia
Hypertension
Severe Obesity
Urinary Incontinence
Neck Pain
History of Tobacco Abuse
Social History:
___
Family History:
Mother- heart disease and DM. Grandmothers both died from heart
disease
Physical Exam:
On Admission:
VS: 98.0 PO 145 / 68 R Sitting 69 19 92 RA
Gen: Obese woman appearing stated age in NAD lying down
HEENT: Dry mucous membranes, sclera anicteric, facial
telangiectasias, PERRLA, EOMI, supple neck, no thyromegaly, JVP
flat sitting upright.
CV: S1/S2, RRR, no murmurs appreciated
Pulm: decreased air entry throughout, inspiratory and
expiratory wheezes appreciated in upper lung fields posteriorly
and anteriorly. Dry crackles at mid back R>L
Abd: Obese, non-tender, non distended, BS+
Ext: Warm, well perfused, no cyanosis, clubbing. Trace-1+
pitting edema to the mid shin on left leg, and trace edema at
ankle/foot on right leg
Skin: telangiectasias on face as above
Neuro: A&O x 3, Strength intact in UEs and ___
___: appropriate affect and mood.
On Discharge:
Vitals: Tmax 97.9 BP 142/66 HR 73 RR 18 O2sat 91-98% RA
Gen: AOx3, appears comfortable sitting upright in bedside chair,
speaking in full sentences
HEENT: MMM, sclera anicteric, facial telangiectasias on left and
right cheek, PERRL, EOMI, supple neck, JVP not appreciated given
large neck
CV: Distant heart sounds, S1/S2, RRR, no murmurs appreciated
Pulm: Decreased air entry throughout, but good chest expansion,
no expiratory wheezes or crackles
Abd: Obese, non-tender, non distended, BS+
Ext: WWP, trace to 1+ pitting edema to mid-shin bilaterally
Pertinent Results:
On Admission:
___ 09:40AM BLOOD WBC-10.7* RBC-4.29 Hgb-12.2 Hct-38.9
MCV-91 MCH-28.4 MCHC-31.4* RDW-14.7 RDWSD-48.7* Plt ___
___ 09:40AM BLOOD Neuts-66.0 ___ Monos-6.2 Eos-3.7
Baso-0.4 Im ___ AbsNeut-7.08* AbsLymp-2.50 AbsMono-0.67
AbsEos-0.40 AbsBaso-0.04
___ 09:40AM BLOOD Plt ___
___ 09:40AM BLOOD Glucose-124* UreaN-26* Creat-0.9 Na-140
K-3.5 Cl-98 HCO3-28 AnGap-18
___ 09:40AM BLOOD proBNP-87
___ 09:40AM BLOOD cTropnT-<0.01
Micro:
__________________________________________________________
___ 9:40 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging:
Chest XR (___)
Impression:
Mild cardiomegaly and mild pulmonary vascular congestion with
bibasilar
atelectasis.
On Discharge:
___ 07:06AM BLOOD WBC-15.8* RBC-4.33 Hgb-12.5 Hct-39.9
MCV-92 MCH-28.9 MCHC-31.3* RDW-14.8 RDWSD-49.8* Plt ___
___ 09:40AM BLOOD Neuts-66.0 ___ Monos-6.2 Eos-3.7
Baso-0.4 Im ___ AbsNeut-7.08* AbsLymp-2.50 AbsMono-0.67
AbsEos-0.40 AbsBaso-0.04
___ 07:06AM BLOOD Glucose-93 UreaN-37* Creat-1.0 Na-143
K-4.5 Cl-98 HCO3-30 AnGap-20
___ 09:40AM BLOOD cTropnT-<0.01
___ 07:06AM BLOOD Calcium-8.9 Phos-4.8* Mg-3.7*
IMAGING:
Chest XR (___)
Impression:
In comparison with the study of ___, the cardiac
silhouette remains at the upper limits of normal or mildly
enlarged with mild pulmonary vascular congestion and bibasilar
atelectatic changes. No evidence of acute focal pneumonia.
Brief Hospital Course:
___ hx CAD, diastolic HF, type 2 DM, HTN, HLD, severe obesity,
presenting with productive cough and dyspnea most likely
representing a COPD exacerbation.
#COPD Exacerbation: Pt presented with dyspnea, hypoxemia, and
cough. CHF exacerbation was felt to be unlikely as BNP was low
(87), CXR did not show significantly increased vascular
congestion, and pt did not appear to be volume overloaded on
exam. PNA was also unlikely as pt was afebrile w/o a
leukocytosis, influenza testing was negative, and CXR showed no
consolidation. Although she has not been formally worked up for
COPD, she has a significant smoking history. Her presentation
was felt to be most c/w a COPD exacerbation ___ viral
bronchitis. Pt was treated empirically for COPD exacerbation w/
prednisone 60 mg x1 initially then prednisone 40 mg QD x5 days
(___), followed by rapid taper, azithromycin x5 days
(___), standing duonebs, PRN albuterol nebs, and chest
pulmonary hygiene w/ flutter valve and incentive spirometry. Her
cough worsened through the hospital admission and she also
became anxious when it was difficult at times to breathe. We
added cough syrup with codeine, cepacol losanges, and lorazepam
for anxiety. Supplementary O2 was provided and patient was
discharged w/ ambulating O2 sats of 93-98% RA.
CHRONIC ISSUES:
#Chronic diastolic HF: Continued home toresemide and carvedilol
#CAD s/p NSTEMI with drug eluding stent to RCA in ___:
Continued home ASA, clopidogrel, atorvastatin, and carvedilol
#Depression: Continued home sertraline
#Diabetes Mellitus Type II: Placed on ISS while inpatient, home
glyburide and metformin held
#Hyperlipidemia: Continued home atorvastatin
#Hypertension: Continued home carvedilol and losartan
#Supplements: Continued home calcium, vitamin D, and MVI
TRANSITIONAL ISSUES:
================
#Consider outpatient pulmonary follow up to confirm COPD
diagnosis c PFTs and consider addition of long acting medication
for reactive airway
#discharged on albuterol 2 puffs IH Q4H PRN, prednisone taper
(30 mgx2days, 20mgx2days, 10mgx2days)
#CODE: Full (confirmed)
# CONTACT: Health Care Proxy - ___ husband: ___
>30 minutes spent in discharge related activities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Carvedilol 25 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. GlyBURIDE 1.25 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Sertraline 50 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
12. Vitamin D ___ UNIT PO DAILY
13. Multivitamins 1 TAB PO EVERY OTHER DAY
14. White petrolatum-mineral oil handful topical BID:PRN
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 PUFFS IH every four
(4) hours Disp #*1 Inhaler Refills:*2
2. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
3. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL ___ mL by mouth at
bedtime Refills:*0
4. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
5. PredniSONE 30 mg PO DAILY
Take 30mg for 2 days, take 20 mg for the next 2 days, take 10 mg
for the next 2 days then stop
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*12 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Carvedilol 25 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. GlyBURIDE 1.25 mg PO DAILY
11. LORazepam 0.5 mg PO DAILY:PRN anxiety
12. Losartan Potassium 100 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Multivitamins 1 TAB PO EVERY OTHER DAY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Sertraline 50 mg PO DAILY
17. Torsemide 40 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: COPD Exacerbation, Viral Bronchitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
(___) due to a cough and shortness of breath. We conducted lab
tests and imaging on your heart and lungs to determine what the
cause of your symptoms were. Fortunately, you were not having an
exacerbation of your congestive heart failure and you do not
have pneumonia. Most likely you developed viral bronchitis,
which caused your lungs and airways to become reactive to the
inflammation and unable to work as normally as they do. We
treated you with oxygen, steroids, nebulizers, and antibiotics.
We feel you most likely experienced a chronic obstructive
pulmonary disease (COPD) exacerbation.
We recommend you follow up closely with your outpatient
providers at your scheduled appointments to formally conduct the
tests that will determine whether or not you have COPD. Keep up
the good work with not smoking! Thank you very much for allowing
us to be involved in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10602633-DS-24 | 10,602,633 | 21,305,860 | DS | 24 | 2149-02-23 00:00:00 | 2149-02-24 08:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with PMH CAD (s/p
PCI
to RCA in ___, HFpEF (LVEF 55%), HTN, T2DM, morbid obesity,
COPD (not on home O2), and depression who was referred to ED for
weight gain and progressive dyspnea for the past 2 weeks, worse
in the past 1 week.
Pt states that she last felt "normal" with regards to her
breathing and activity 2 months ago. She first began feeling
short of breath 2 weeks ago; this was fairly mild dyspnea and
provoked by her usual activity level (able to walk approximately
a half a block before being limited by knee pain and dyspnea).
Starting ___ days ago, however, the patient's SOB began getting
worse. She has had markedly limited activity, to the point
where
she is barely able to get from her hospital bed to the bathroom
today without getting dyspneic.
Pt states her dyspnea is constant, and worse with any activity
or
"when I get agitated/when my nerves get up." She has stable
orthopnea at baseline, and this is unchanged. She has not tried
any medications for her SOB, though reports taking all of her
doses on time and without skipped meds. She feels that her SOB
improves when she calms herself down with deep breathing and
relaxation techniques.
Pt presented to her PCP's office today because her dyspnea had
become progressive. Given her degree of subjective dyspnea, Pt
was referred to the ___ ED for further evaluation.
- In the ED, initial vitals were: 97.9 87 147/99 16 100% 2L NC
- Labs were notable for: proBNP 3026, WBC 10.2, BUN/Cr ___,
Trop-T 0.02
- Studies were notable for:
___ CXR PA/LATERAL: Patchy opacities in the lung bases
likely
reflect areas of atelectasis. Early infection is difficult to
exclude in the correct clinical setting.
___ EKG:
Compared to most recent prior dated ___. Normal sinus
rhythm at a rate of 83bpm with intermittent PVC's. Left axis
deviation. LVH, likely ___. Likely J-point elevation in V1 and
V2. QTc borderline at 486, otherwise intervals WNL.
Compared to most recent prior, PVC's are present. There are no
new ischemic changes.
-The patient was given: CTX 1 g IV, Azithromycin 500 mg IV,
Ipratropium-Albuterol Neb 1 NEB, furosemide 100 mg IV
On arrival to the floor, patient endorses the above history.
Her
dyspnea she said really improved with the duoneb in the ED.
She further notes an 11 lb weight gain over the past week
(usually weighs between 320-325 lbs, and currently is 333lbs),
progressive lower extremity swelling and pain from the knees
down, dry cough, subjective chills, palpitations, intermittent
left-sided chest pain that lasts for minutes (relieved by deep
breathing as above), and intermittent dizziness. She denies
fevers, sputum production, abdominal pain, N/V/D, headaches,
blurry/double vision.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Congestive Heart Failure, diastolic (EF 55%)
Depression
Diabetes Mellitus Type II, not on insulin
Hyperlipidemia
Hypertension
Severe Obesity
Obstructive sleep apnea; not compliant with her CPAP at home as
it is a difficult device to set up
Social History:
___
Family History:
Mother had "heart conditions" and also a history of renal
cancer.
Mother's side of the family has heart disease and heart attacks,
all > ___ y/o per Pt report. Father's side has similarly
advanced
___ y/o onset of heart disease. There is a maternal uncle who
had "back cancer" before he was ___ years old, which Pt is not
able to elucidate further.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.3 BP 194/112 HR 97 RR 26 O2 95% on RA
GENERAL: Morbidly obese Caucasian woman, sitting up at edge of
bed. Pleasant and cooperative, mildly dyspneic at rest.
HEENT: Sclerae anicteric, MMM.
NECK: JVP difficult to assess owing to habitus; at least 10cm
H2O
while lying at 30 degrees in bed. Difficult to appreciate
hepatojugular reflux. Exam is cut short owing to orthopnea.
CHEST: Pt points to one spot on the left anterior chest wall
that was the source of her earlier chest pain. This pain is
reproducible with palpation.
CARDIAC: Distant heart sounds. RRR, normal S1/S2, no M/R/G.
LUNGS: Faint bibasilar crackles, upper airway sounds auscultated
___ in upper fields. No frank wheezing.
ABDOMEN: Hypoactive BS. Abdomen is soft, non distended,
non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: There is lower extremity edema to just above the
ankles bilaterally. Brawny venous stasis changes on the
anterior
shins.
NEUROLOGIC: Moves all four extremities with purpose. Negative
pronator drift, normal finger-nose-finger bilaterally.
DISCHARGE PHYSICAL EXAM:
========================
Temp: 97.6 (Tm 99.2), BP: 126/66 (105-149/57-70), HR: 62
(61-69),
RR: 18, O2 sat: 95% (91-95), O2 delivery: Ra, Wt: 318.6
lb/144.52
kg
GENERAL: Morbidly obese Caucasian woman, sitting in chair.
Pleasant and cooperative, comfortable.
HEENT: Sclerae anicteric, MMM.
CARDIAC: RRR, normal S1/S2, no M/R/G.
LUNGS: Faint bibasilar crackles.
ABDOMEN: Non distended, non-tender to deep palpation in all four
quadrants. No organomegaly.
EXTREMITIES: No visible edema, brown venous stasis changes on
the
anterior shins.
NEUROLOGIC: AOx3, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 02:44PM BLOOD WBC-10.2* RBC-4.73 Hgb-13.3 Hct-43.1
MCV-91 MCH-28.1 MCHC-30.9* RDW-13.7 RDWSD-46.5* Plt ___
___ 07:50PM BLOOD Neuts-63.8 ___ Monos-5.4 Eos-3.6
Baso-0.6 Im ___ AbsNeut-6.51* AbsLymp-2.69 AbsMono-0.55
AbsEos-0.37 AbsBaso-0.06
___ 02:44PM BLOOD UreaN-13 Creat-1.0 Na-144 K-4.3 Cl-101
HCO3-26 AnGap-17
___ 02:44PM BLOOD ALT-12 AST-11
___ 02:44PM BLOOD proBNP-3026*
___ 07:50PM BLOOD CK-MB-2 proBNP-2892*
___ 02:44PM BLOOD Cholest-193
___ 07:50PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
___ 02:44PM BLOOD %HbA1c-6.3* eAG-134*
___ 02:44PM BLOOD Triglyc-219* HDL-43 CHOL/HD-4.5
LDLcalc-106
___ 02:44PM BLOOD TSH-1.9
DISCHARGE LABS:
___ 07:34AM BLOOD WBC-9.7 RBC-4.90 Hgb-13.8 Hct-44.2 MCV-90
MCH-28.2 MCHC-31.2* RDW-14.3 RDWSD-47.8* Plt ___
___ 07:34AM BLOOD Plt ___
___ 01:24PM BLOOD Glucose-169* UreaN-48* Creat-1.2* Na-140
K-4.4 Cl-96 HCO3-29 AnGap-15
___ 07:34AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1
MICRO:
n/a
IMAGING:
TTE: ___
The left atrial volume index is normal. There is moderate
symmetric left ventricular hypertrophy with a normal
cavity size. There is normal regional left ventricular systolic
function. Overall left ventricular systolic function is
normal. The visually estimated left ventricular ejection
fraction is 55-60%. There is no resting left
ventricular outflow tract gradient. Diastolic function could not
be assessed. Mildly dilated right ventricular
cavity with normal free wall motion. The aortic sinus diameter
is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal.
The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is
moderate mitral annular calcification. There is mild
[1+] mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension.
There is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate symmetric left
ventricular hypertrophy with
normal cavity size and regional/global left ventricular systolic
function. Unable to assess diastolic
function. Mild right ventricular dilation, unable to asess
function. At least moderate pulmonary
hypertension.
Compared with the prior TTE ___ , the estimated pulmonary
artery systolic pressure is now
increased.
CXR:
Patchy opacities in the lung bases likely reflect areas of
atelectasis. Early
infection is difficult to exclude in the correct clinical
setting.
Brief Hospital Course:
SUMMARY ASSESSMENT
====================
Ms. ___ is a ___ woman with a history of
heart failure with preserved ejection fraction (LVEF 55%), CAD
s/p PCI
to RCA (___), hypertension, type 2 diabetes, morbid obesity,
chronic obstructive pulmonary disease, and depression who was
referred to ED for weight gain and progressive dyspnea
concerning for HFpEF exacerbation. Patient underwent diuresis in
hospital with 100 mg IV Lasix twice per day. Patient was
discharged at weight of 318.61 pounds.
ACUTE/ACTIVE ISSUES:
====================
# Dyspnea
# Acute HFpEF exacerbation
Patient presented to ___ with worsening dyspnea and lower
extremity edema concerning for a heart failure exacerbation. She
had some chest pain on exertion but no evidence of ischemia was
observed on EKG. Etiology thought to be due to medication
noncompliance. Patient underwent diuresis with 100 Lasix BID.
Patient was continued on home amlodipine, losartan and
carvedilol.
___:
Baseline creatinine around 1.0. Creatinine rose to 1.4 likely
from overdiuresis and downtrended to 1.2 prior to discharge.
#Medication adherence
Per patient's pharmacy, patient had not filled prescriptions in
six months. Patient reported that she did not fill her
prescriptions because she had "lots of leftover pills".
Importance of adherence for prevent heart failure exacerbations
was stressed to patient.
#Lightheadedness:
Patient reported episode of lightheadedness when rising out of
bed rapidly. EKG was unremarkable and troponins negative.
Orthostatics were within normal limits. She had no events on
telemetry.
# Hypertension:
# OSA:
Patient presented with SBP 190s. SBP decreased with IV diuresis.
Likely due to CPAP noncompliance as well. She was strongly
encouraged to get a better fitting cpap machine.
# Likely adjustment disorder:
Pt with significant psychosocial stressors over the past 6
months, including the death of her husband and recent
psychiatric
hospitalization of her son. Social work consult for coping with
stressors, identifying resource gaps at home.
CHRONIC/STABLE ISSUES:
======================
# T2DM:
Patient was treated with ISS while in house. Patient's Metformin
1000 mg PO BID and glyburide 1.25 mg PO daily were held while
inpatient but resumed on discharge.
# ?NEUROPATHY:
Patient was continued on home duloxetine.
# CAD:
Patient was continued on home aspirin 81 mg PO, clopidogrel 75
mg PO daily and atorvastatin 80 mg PO QPM.
TRANSITIONAL ISSUES
=======================
[ ] repeat lipid labs as outpatient when fasting as
triglycerides were elevated on admission (219).
[ ] consider stress test on discharge given chest pain with
exertion
[ ] Patient reports non-adherence to CPAP machine due to poor
fit. Consider referral for new machine.
[ ] please assess volume status and adjust diuretic as needed
[ ] check creatinine and electrolytes within 1 week
[ ] diuresis:
--discharge weight: 318.61 pounds
--discharge diuretic: torsemide 80mg PO daily
--discharge creatinine: 1.2
# CODE: Full, confirmed, with limited trial of life sustaining
efforts
# CONTACT: Sister and HCP, ___ ___ cell;
___ home)
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 QPM
4. CARVedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. DULoxetine 60 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
9. GlyBURIDE 1.25 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Torsemide 80 mg PO DAILY
14. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
15. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
affected areas
16. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 25 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. GlyBURIDE 1.25 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
13. Torsemide 80 mg PO DAILY
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
affected areas
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Heart failure with preserved ejection fraction
Secondary Diagnoses:
Depression
Diabetes Mellitus Type II, not on insulin
Hyperlipidemia
Hypertension
Severe Obesity
Obstructive sleep apnea; not compliant with her CPAP at home
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you were having a heart failure
exacerbation.
WHAT WAS DONE WHILE I WAS HERE?
We gave you medication through your IV, furosemide, to help you
urinate.
WHAT SHOULD I DO WHEN I GO HOME?
-You should take your medications as instructed. You should go
to your doctors ___ as below.
-Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs in two days or more than 5 lbs in one
week.
-Try to limit your salt intake
We wish you the ___!
-Your ___ Care Team
Followup Instructions:
___
|
10602639-DS-13 | 10,602,639 | 21,232,717 | DS | 13 | 2110-01-31 00:00:00 | 2110-01-31 21:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, Pneumothorax
Major Surgical or Invasive Procedure:
Chest tube placement ___
History of Present Illness:
___ year old man with history of COPD (Home O2 2L), chronic
hypoxemia, active tobacco use, LLL lung adenocarcinoma s/p
chemoradiation (radiation therapy completed ___ 4th dose
of Carboplatin and Alimta held due to toxicities; declined for
surgery due to pulmonary status), who presented after
thoracentesis, with PTX.
Patient has recently identified L sided pleural effusion. He
reports increased fatigue and poor energy for the past few
months. Reports weight loss of 10lbs over the last ___ months,
partly intentional. Denies fever/chills, SOB, CP, N/V, abd pain,
___. Reports baseline intermittent mild cough with sputum.
Continues to smoke 1PPD.
Day of admission, he underwent thoracentesis in clinic for
pleural effusion, with 20ml removed (per procedure note).
However, post-procedure CXR demonstrated L apical PTX.
In the ED, initial vitals: 98.6 , 88 , 99/39 , 22 , 95% RA
- Exam notable for: Decreased breath sounds on left, clear to
auscultation on right, patient no acute distress, on home oxygen
here.
- Labs notable for: K 5.2, otherwise unremarkable
- Imaging notable for: post-procedure PTX, enlarging slightly
on
serial CXRs.
- IP was consulted who: placed chest tube, recommend to keep
chest tube to suction -20cmH20, repeat CXR in the morning
- Pt given:
___ 16:56 PO OxyCODONE (Immediate Release) 5 mg
- Vitals prior to transfer: 82 , 121/84 , 16 , 97% RA
On the floor, patient reports feeling well, no complaints.
Denies
SOB, CP, or pain.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Obstructive sleep apnea
COPD
Bilateral carotid artery repair
Prostate cancer s/p stereotactic radiotherapy
resection of a diverticular mass
S/p SBO w SBR, colostomy s/p reversal.
RBBB
Meningioma
stage IIIA (T2b N2 M0) non-small cell lung cancer of
the left lung
depression
Social History:
___
Family History:
There is no family history of lung cancer, but mother had colon
cancer, father had prostate cancer and sister had a gynecologic
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VITALS: 98.1PO 123 / 79L Lying 84 18 96 2l
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Dry mucous membranes.
Oropharynx
is clear.
NECK: Supple. no JVP.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Poor air movement, bibasilar crackles, comfortable on 2L
NC without accessory muscle use.
CHEST: L anterior superior chest tube, no surrounding soft
tissue
crepitus, draining small amount sanguinous fluid.
BACK: no CVA tenderness.
ABDOMEN: Normal bowels sounds, soft, protuberant, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: No rash
NEUROLOGIC: A&Ox3, no facial droop, moving all extremities with
purpose.
DISCHARGE PHYSICAL EXAM
======================
24 HR Data (last updated ___ @ 838)
Temp: 98.5 (Tm 98.5), BP: 126/74 (123-126/74-79), HR: 80
(80-84), RR: 18, O2 sat: 94% (94-96), O2 delivery: 2L, Wt:
169.97
lb/77.1 kg
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Dry mucous membranes.
Oropharynx
is clear.
NECK: Supple. no JVP.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Poor air movement, bibasilar crackles, comfortable on 2L
NC without accessory muscle use.
CHEST: L anterior superior chest tube site is clean dressed, no
surrounding soft tissue crepitus
BACK: no CVA tenderness.
ABDOMEN: Normal bowels sounds, soft, protuberant, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema
NEUROLOGIC: A&Ox3, no facial droop, moving all extremities with
purpose.
Pertinent Results:
ADMISSION LABS
=============
___ 02:30PM BLOOD WBC-9.4 RBC-5.56 Hgb-16.6 Hct-52.6*
MCV-95 MCH-29.9 MCHC-31.6* RDW-14.2 RDWSD-49.5* Plt ___
___ 02:30PM BLOOD Neuts-74.7* Lymphs-6.0* Monos-8.0
Eos-10.1* Baso-0.6 Im ___ AbsNeut-7.04* AbsLymp-0.57*
AbsMono-0.75 AbsEos-0.95* AbsBaso-0.06
___ 02:30PM BLOOD ___ PTT-30.1 ___
___ 02:30PM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-139
K-5.2* Cl-98 HCO3-31 AnGap-10
___ 02:30PM BLOOD ALT-13 AST-15 LD(LDH)-191 AlkPhos-58
TotBili-0.4
___ 02:30PM BLOOD TotProt-6.8 Albumin-4.3 Globuln-2.5
DISCHARGE LABS
==============
___ 05:10AM BLOOD WBC-8.7 RBC-5.20 Hgb-15.5 Hct-49.1 MCV-94
MCH-29.8 MCHC-31.6* RDW-13.9 RDWSD-48.7* Plt ___
___ 05:10AM BLOOD Glucose-91 UreaN-20 Creat-0.8 Na-135
K-4.7 Cl-94* HCO3-30 AnGap-11
___ 05:10AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
IMAGING
=======
___ CXR #1
In comparison with the CT scan of ___, there is
continued substantial
left pleural effusion, though suggestion of some improved
aeration in the left
lower lobe.
The right lung and upper left lung remain clear without vascular
congestion or
acute consolidation. Old healed rib fracture is again seen in
the right mid
zone and calcified granulomas are again noted in the right upper
lung.
___ CXR #2
1. New small left pneumothorax.
2. Interval improvement in left pleural effusion, now small to
moderate in
size.
3. Small nodular opacity seen only on frontal projection in the
left lower
lung was not well visualized on prior exam and is incompletely
characterized
on current study.
___ CXR #3
Mild enlargement of a left-sided pneumothorax compared to study
performed 1
hour prior.
___ CXR #4
PA and lateral views of the chest provided. A left apical
pneumothorax is
slightly increased from the prior though remains small in
overall size. There
is increasing left basal atelectasis. Right lung remains clear
aside from
multiple calcified granulomas. Cardiomediastinal silhouette is
unchanged and
position midline. Chronic right-sided rib deformities noted.
IMPRESSION:
Left apical pneumothorax appears marginally increased with
slightly increased
left basal atelectasis.
___ CXR #5
AP portable upright view of the chest. There has been interval
placement of a
left pigtail chest tube with interval re-expansion of the left
lung and no
discernible residual left pneumothorax. The pigtail catheter
tip resides
along the left medial pleura abutting the mediastinum.
___ CXR #1
1. Stable position of a left pigtail catheter without evidence
of residual
pneumothorax.
2. Small left pleural effusion is slightly increased compared to
most recent
prior.
___ CXR #2
Interval removal of a left pigtail catheter without evidence of
residual
pneumothorax. Small left pleural effusion perihilar edema are
unchanged.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of COPD (Home O2
2L), active tobacco use, LLL lung adenocarcinoma s/p
chemoradiation, who presented after outpatient thoracentesis for
new pleural effusion, c/b PTX s/p chest tube placement now with
improving pneumothorax and s/p chest tube removal with
resolution of pneumothorax.
ACUTE ISSUES:
=============
# Pneumothorax
Pneumothorax likely iatrogenic iso recent thoracentesis. Patient
also with extensive pulm history including COPD, active tobacco
use, chronic hypoxemia, and lung cancer. L sided pleural
effusion s/p thoracentesis ___. Interval CXR on ___ showed
mild enlargement of PTX so chest tube was placed. Denies
increased dyspnea. Chest tube was clamped on the morning of
___ with interval improvement in pneumothorax and chest tube
was pulled on ___ with x-ray showing no return of PTX
post-chest tube removal.
# Exudative Pleural effusion
# Lung cancer
Patient with new L sided pleural effusion s/p diagnostic
thoracentesis ___. Pleural fluid analysis showing TNC 3706, 1%
poly, 1% lymph, 75% eos, 3% meso, 14% macro, 6% other. Concern
for potential recurrent malignant etiology of effusion.
Exudative based on light criteria. Pleural fluid culture and
cytology pending at the time of discharge.
CHRONIC ISSUES:
===============
# HTN
Held labetolol on admission. Restarted at discharge.
# COPD
On home 2L O2, though does not consistently use. Reports he does
not usually use home duoneb respimat. Continued home advair
# Depression
Patient reports taking mirtazapine 15 qhs, but pharmacy fill
records suggest he is not taking this -- did not order
mirtazapine. continued home duloxetine -- ordered for BID.
Continue Xanax.
TRANSITIONAL ISSUES
===================
[] Ensure follow up with interventional pulmonology in 1 month
[] Follow up pleural fluid cytology from outpatient
thoracentesis performed ___
#emergency contact: ___
Relationship: WIFE
Phone: ___
Other Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 40 mg PO QPM
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Severe
4. DULoxetine 60 mg PO BID
5. Labetalol 200 mg PO BID
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN
7. TraZODone 400 mg PO QHS
8. ALPRAZolam 0.25 mg PO BID
Discharge Medications:
1. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Severe
2. ALPRAZolam 0.25 mg PO BID
3. DULoxetine 60 mg PO BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN
6. Labetalol 200 mg PO BID
7. Rosuvastatin Calcium 40 mg PO QPM
8. TraZODone 400 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Pneumothorax
Exudative pleural effusion
SECONDARY DIAGNOSIS
====================
Hypertension
COPD
History of lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you had a pneumothorax after your
thoracentesis. You had a chest tube placed by the interventional
pulmonary team. The pneumothorax improved and your chest tube
was removed. You should follow up with the interventional
pulmonary team in one month.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10602639-DS-16 | 10,602,639 | 24,588,580 | DS | 16 | 2112-01-09 00:00:00 | 2112-01-09 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
oxycodone
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 641)
Temp: 97.5 (Tm 98.1), BP: 156/66 (86-156/55-68), HR: 71
(71-129), RR: 18 (___), O2 sat: 92% (92-95), O2 delivery: 3L
(2L-3 L), Wt: 162.7 lb/73.8 kg
GENERAL: Well developed, well nourished. no acute distress
HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.
NECK: Supple. JVP mid neck at 45 degrees
CARDIAC: irregular rhythm, normal rate, normal S1/S2, no m/r/g
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Decreased breath sounds
on L, crackles at R base
EXTREMITIES: warm, well perfused. no pitting edema
SKIN: No significant lesions or rashes.
NEURO: AOx3. Nonfocal exam.
ADMISSION LABS:
===============
___ 04:35PM BLOOD WBC-10.3* RBC-4.49* Hgb-12.5* Hct-43.0
MCV-96 MCH-27.8 MCHC-29.1* RDW-15.8* RDWSD-53.9* Plt ___
___ 04:35PM BLOOD Neuts-81.3* Lymphs-7.4* Monos-10.2
Eos-0.3* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-8.37*
AbsLymp-0.76* AbsMono-1.05* AbsEos-0.03* AbsBaso-0.02
___ 04:35PM BLOOD ___ PTT-26.6 ___
___ 04:35PM BLOOD Glucose-72 UreaN-35* Creat-1.0 Na-138
K-4.6 Cl-81* HCO3-39* AnGap-18
___ 04:35PM BLOOD ALT-13 AST-23 AlkPhos-111 TotBili-0.7
___ 04:35PM BLOOD Albumin-4.2 Calcium-9.6 Phos-4.0 Mg-2.0
ADDITIONAL LABS:
================
___ 04:35PM BLOOD cTropnT-0.03* proBNP-9518*
___ 04:57PM BLOOD Lactate-3.6*
___ 06:41PM BLOOD Lactate-1.4
___ 01:02AM BLOOD Lactate-1.2
___ 04:57PM BLOOD ___ pO2-61* pCO2-103* pH-7.26*
calTCO2-48* Base XS-14
___ 06:39PM BLOOD ___ pO2-70* pCO2-89* pH-7.33*
calTCO2-49* Base XS-16
___ 01:02AM BLOOD ___ pO2-66* pCO2-89* pH-7.36
calTCO2-52* Base XS-19
DISCHARGE LABS:
===============
___ 11:55AM BLOOD WBC-8.8 RBC-4.33* Hgb-12.0* Hct-41.4
MCV-96 MCH-27.7 MCHC-29.0* RDW-15.7* RDWSD-54.0* Plt ___
___ 11:55AM BLOOD Glucose-171* UreaN-32* Creat-1.0 Na-138
K-4.0 Cl-80* HCO3-47* AnGap-11
___ 11:55AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.9
MICROBIOLOGY:
=============
URINE CULTURE (Final ___: < 10,000 CFU/mL.
STUDIES:
========
Chest Xray ___:
Interstitial pulmonary edema with small pleural effusions.
Volume loss and fibrosis in the left hemithorax
Chest Xray ___:
1. Worsened moderate pulmonary edema.
2. A pleural effusion appears resolved, however this may be due
to positional differences and redistribution; actual volume is
overall similar
3. Re-demonstrated left hemidiaphragm elevation in keeping with
chronic volume loss and radiation fibrosis.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
Discharge Weight: 159.17lb
Discharge Cr: 1.0
Discharge Diuretic: torsemide 40 daily (this is increased from
furosemide 40 daily at home previously)
MEDICATION CHANGES: He was switched from furosemide 40 daily to
torsemide 40 daily. He was started on apixaban 5 BID and
diltiazem ER 120 daily for paroxysmal atrial flutter.
[] His diuretic was increased as above to torsemide 40 daily. He
should have BMP checked at PCP follow up appointment on ___, as
well as adjusting his diuretic as appropriate.
[] He is not currently scheduled for cardiology follow up. This
would need to be scheduled if it is deemed necessary.
SUMMARY:
========
Mr. ___ is a ___ yoM with HFpEF (EF 68%), paroxysmal a-fib
not on anticoagulation, COPD on ___ L home oxygen, history of
___ s/p chemo and XRT ___, recurrent pleural effusions s/p
multiple thoracentesis most recently with pleurodesis and
catheter removal on ___ who presented to ___ for
syncopal episode and reportedly found to be hypoxic to mid-___.
CXR at ___ c/w pulmonary edema and BNP elevated. He was given
Lasix IV 40 x1 and transferred to ___ for further management
of hypoxic respiratory failure requiring BiPAP, which responded
well to IV diuresis (Lasix 40mg) with O2 requirement returned to
baseline within the day of admission. He was transitioned to
torsemide 40 daily by discharge for diuretic regimen. He was
also noted to have paroxysmal atrial flutter on telemetry, for
which he was started on diltiazem and apixaban for
anticoagulation.
ACUTE ISSUES:
=============
#Acute hypoxic respiratory failure:
#Decompensated heart failure:
#Recurrent pleural effusion:
Presented with syncope, found to be hypoxic requiring BiPAP. CXR
and BNP c/w pulmonary edema, likely secondary to decompensated
heart failure. Elevated lactate suggesting poor perfusion c/f
cardiogenic shock, although downtrended with diuresis. Trop 0.03
likely demand in setting of heart failure. BPs in 100s/70s.
Unclear precipitating event for decompensation: recent echo with
preserved EF and global systolic function although with evidence
of right heart pressure/volume overload and moderate pulmonary
hypertension. Weaned to 4L NC with 40mg IV ___ boluses over
the first day of admission, then back to home ___ NC by
discharge. He was started on diltiazem and apixaban as below for
paroxysmal atrial flutter.
#Tachyarrhythmia
#History of Paroxysmal aFib
#Paroxysmal Atrial Flutter
Appeared on telemetry to be irregularly irregular consistent
with atrial flutter. Patient was refusing EKGs. Given 12.5mg
metop tartrate ___ evening for rate control w/ good effect and
transitioned to diltiazem 30mg q6h (due to comorbid COPD), then
diltiazem 120mg ER at discharge. CHADSVASC of 3, apixaban 5mg
BID started.
#NSTEMI:
Likely type II in setting of acute decompensated heart failure.
Trop 0.03.
#Syncope
Patient with a syncopal event the morning of ___ while
reportedly being hypoxic to the mid-___. On discussion with his
wife, he has reportedly syncopized in the past, also w/
associated hypoxia. Episodes appear to happen suddenly, without
prodrome, and not situational. Suspect hypoxia induced pulmonary
vasoconstriction leading to transient RV failure given pHTN and
RV dysfunction at baseline.
#COPD:
On ___ O2 at home. Patient without cough or increased sputum
production. Unlikely to be significantly contributing, as
hypoxia improved as expected with diuresis. He was stable on
___ O2 NC at time of discharge.
CHRONIC ISSUES
=======================
#NSCLC s/p chemo and XRT ___: Last seen by oncology ___.
Followed by ___, MD. ___ CT chest ___
showing no evidence of disease recurrence.
#Peripheral artery disease status post bilateral CEA
Continued rosuvastatin 40mg daily
#GERD:
Continued omeprazole 20mg daily
#Depression/anxiety:
Continued Buspirone 30mg BID, duloxetine 60mg twice a day,
Mirtazipine 45 mg qHS, gabapentin 100mg QHS
#Nicotine dependence:
Continued Nicotine patch 21mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO QPM
3. Nicotine Patch 21 mg/day TD DAILY
4. Omeprazole 20 mg PO DAILY
5. BusPIRone 10 mg PO TID
6. DULoxetine ___ 60 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Gabapentin 100 mg PO QHS
9. Mirtazapine 45 mg PO QHS
10. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
2. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*2
3. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
4. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Mild
5. BusPIRone 10 mg PO TID
6. DULoxetine ___ 60 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Gabapentin 100 mg PO QHS
9. Mirtazapine 45 mg PO QHS
10. Nicotine Patch 21 mg/day TD DAILY
11. Omeprazole 20 mg PO DAILY
12. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
-acute hypoxemic respiratory failure
-acute on chronic heart failure
-recurrent pleural effusion
-paroxysmal atrial flutter
-syncope
Secondary diagnoses:
-chronic obstructive pulmonary disease
-peripheral artery disease
-gastroesophageal reflux disease
-anxiety/depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you had a fainting
episode with difficulty breathing.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have fluid congestion in your lungs. This
was felt to be due to a condition called heart failure, where
your heart does not pump well enough and fluid backs up into
your lungs.
- You were given a diuretic medication through the IV to help
get the fluid out.
- You improved considerably and were ready to leave the
hospital.
- You were also found to have an arrhythmia with a fast heart
rate and you were started on a medication to slow your heart
down, as well as a blood thinner to protect you from stroke.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Your weight at discharge is 159lb. Please weigh yourself today
at home and use this as your new baseline.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs in one day or
more than 5 lbs in one week.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10603001-DS-10 | 10,603,001 | 29,406,312 | DS | 10 | 2158-05-25 00:00:00 | 2158-05-25 17:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / benztropine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a past medical
history significant for atrial fibrillation on apixaban, chronic
diastolic heart failure, who presents with tachycardia and
dyspnea.
Over the past few months, Mr ___ has had several admission
for atrial fibrillation, heart failure and asthma. Throughout
his inpatient and outpatient visits, he has been started on
Lasix for ___ which has been titrated. He has also been on
various nodal agents for his afib, and they have been titrated
up/down several times. He was most recently admitted for
orthostatic syncopal episode where his lisinopril and furosemide
were stopped .
He presents today for shortness of breath. Pt reports that he
has had shortness of breath for approximately one week that has
been worsening gradually. His family recommended he go to the
clinic, where he was found to be in AF with RVR at a rate in the
140's. EMS gave 10mg dilt with improvement of his HR to the
108-110. Pt reports intermittent chest pain for several days.
Denies any known weight gain, recent illness, cough, orthopnea,
dysuria, hematuria, fevers, abdominal pain.
ED COURSE
- In the ED, initial vitals 97.9 118 128/97 18 96% Nasal
Cannula
- Labs notable for bnp of 362, negative D-dimer and x1 negative
trop
- EKG showed AF with RVR 122 borderline RAD QTc 483, 1mm STE in
V2-3, TWF III and aVF, consistent with prior EKG's
- CXR with some vascular congestion
- Pt was given PO dilt 30mg and x1 duoneb
Upon arrival to the floor patient reports that this feels like
his asthma exacerbations. He denies any sick contacts. He does
feel that his legs have been getting swollen over the last few
days.
Past Medical History:
Hypertension
Long QT
Hyperlipidemia
CKD Stage 2
Hypothyroidism
Cerebral palsy
Sleep apnea
GERD
Morbid obesity
Anxiety
Constipation
Social History:
___
Family History:
Father Cancer - ___ Diabetes - Type II
Physical Exam:
ADMISSION
Vitals: 98.2 124 / 62 86 24 95 RA
GENERAL: Pleasant, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM
CARDIAC: irregularly irregular rhythm, normal rate. Normal S1,
S2. No murmurs, rubs or gallops. JVP unable to be assessed given
body habitus
LUNGS: no wheezing, poor air movement
ABDOMEN: NABS. Soft, NT, ND
EXTREMITIES: edema 1+ to mild shins
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. ___ strength
throughout. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
DISCHARGE
Vital Signs: 97.9 127/59 77 20 98ra
24H I/O: ___
GENERAL: Pleasant, in NAD
CARDIAC: irregularly irregular rhythm, normal rate. Normal S1,
S2. No murmurs, rubs or gallops. JVP unable to be assessed given
body habitus
LUNGS: no wheezing or crackles, poor air movement
ABDOMEN: NABS. Soft, NT, ND
EXTREMITIES: warm, no pitting edema
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. ___ strength
throughout. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION
___ 04:57PM BLOOD Neuts-66.4 ___ Monos-11.4
Eos-0.9* Baso-0.3 Im ___ AbsNeut-6.34* AbsLymp-1.93
AbsMono-1.09* AbsEos-0.09 AbsBaso-0.03
___ 04:57PM BLOOD WBC-9.6 RBC-5.19 Hgb-15.0 Hct-46.7 MCV-90
MCH-28.9 MCHC-32.1 RDW-13.2 RDWSD-43.0 Plt ___
___ 04:57PM BLOOD ___ PTT-32.8 ___
___ 04:57PM BLOOD Glucose-110* UreaN-22* Creat-1.2 Na-138
K-5.5* Cl-97 HCO3-31 AnGap-16
___ 04:57PM BLOOD proBNP-362*
___ 04:57PM BLOOD cTropnT-<0.01
___ 06:39PM BLOOD D-Dimer-321
___ 05:05PM BLOOD Lactate-1.5 K-3.9
PERTINENT
___ 04:57PM BLOOD proBNP-362*
___ 04:57PM BLOOD cTropnT-<0.01
___ 06:39PM BLOOD D-Dimer-321
___ 05:05PM BLOOD Lactate-1.5 K-3.9
DISCHARGE
___ 07:30AM BLOOD Glucose-97 UreaN-25* Creat-1.1 Na-140
K-3.4 Cl-97 HCO3-34* AnGap-12
MICROBIOLOGY
None
IMAGING
___ Imaging CHEST (PORTABLE AP)
FINDINGS:
Low lung volumes again noted. There is prominence of the
pulmonary vascular markings likely due to in part low lung
volumes and overlying subcutaneous tissues noting that pulmonary
vascular congestion is also suspected. There is no large
pleural effusion. Cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Probable pulmonary vascular congestion without obvious
consolidation based on this limited portable exam.
Brief Hospital Course:
___ h/o atrial fibrillation on apixaban, chronic diastolic heart
failure and asthma who presents with shortness of breath and
tachycardia, found to have atrial fibrillation with rapid
ventricular rate as well as acute on chronic diastolic heart
failure exacerbation and a mild asthma exacerbation.
#SHORTNESS OF BREATH: Patient presented to PCP with dyspnea and
was found to be in afib with RVR with rates to 150s-160s likely
causing flash pulmonary edema given his history of diastolic
heart failure. Patient has had several of these episodes in the
past. CXR now with some evidence of vascular congestion. Last
ECHO (___) with preserved EF. D-dimer negative and no
fever/leukocytosis to suggest infection. Trop x2 negative and
EKG at baseline. Evidence of mild volume overload on CXR is
likely from tachycardia causing flash pulmonary edema. No signs
of infection or pain, no recent downtitration of diltiazem or
metoprolol though compliance has been an issue in the past.
Although patient does not have wheezing on exam, he does have a
significant asthma history and has intermittent compliance with
taking his inhalers, therefore poorly controlled asthma may be
contributing to the patient's symptoms. Patient was started on
montele___. He also received teaching/evaluation from ___
and RT regarding his medication compliance/education and was
discharged to rehab with expectation that patient will require
less than 30 days of rehab.
#AFIB WITH RVR: Unclear etiology although patient has had
numerous episodes and admission for this. It is likely related
to poor medication compliance at home. Patient on multiple nodal
blocking agents, both of which have been titrated up and down
over past few months with previous difficulty with compliance.
Low suspicion for PE and D-dimer negative. Infection possible,
but no localizing symptoms and blood cultures were NGTD at
discharge. EKG without signs of new MI and trop negative x2. No
obvious signs of overt volume overload, CXR findings may be due
to flash pulmonary edema due to RVR in setting of ___. Has had
difficulty tolerating uptitration of rate control agents due to
hypotension. He received a bolus of IV diltiazem on admission
with quick improvement of his heart rate though remained in
afib. Patient was restarted on home medications and tolerated
well.
#Chronic Diastolic Heart Failure: CXR with vascular congestion
likely due to afib with RVR as above. No obvious pitting edema,
unable to assess JVP due to habitus. Respiratory status stable.
pro-BNP though difficult to interpret given obesity. Was given
20mg furosemide IV x1 with large UOP. It was decided to restart
patient on maintenance furosemide 20mg 3x/week with 20mEq of KCl
QD.
# Depression/anxiety:
- continued on home risperidone, bupropion
- cont. home lorazepam
# HTN: Continue home regimen
# BPH: Continue home tamsulosin and finasteride
# HLD: Continue home atorvastatin
# Hypothyroidism: Continue home levothyroxine
# GERD: Continue home Omeprazole
Patient to be discharged to rehab facility and is expected to
require less than 30 days of rehab.
TRANSITIONAL ISSUES
[]follow up compliance with new and old medications
[]Check Chem 7 in 3 days
# CONTACT:
___ (sister) ___
___ (case manager) ___
# CODE: Full
DISCHARGE WEIGHT 100.9 kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Levothyroxine Sodium 25 mcg PO DAILY
9. LORazepam 0.5 mg PO DAILY:PRN anxiety
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. RisperiDONE 2 mg PO QAM
14. RisperiDONE 3 mg PO QPM
15. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. LORazepam 0.5 mg PO DAILY:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth daily Disp #*5 Tablet
Refills:*0
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. RisperiDONE 2 mg PO QAM
13. RisperiDONE 3 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
16. Montelukast 10 mg PO DAILY
RX *montelukast 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
17. Furosemide 20 mg PO 3X/WEEK (___)
RX *furosemide 20 mg 1 tablet(s) by mouth Three times a week
Disp #*12 Tablet Refills:*0
18. Potassium Chloride 20 mEq PO DAILY
Hold for K >
RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
19. CPAP
CPAP while patient sleeps for OSA
Settings: Minimum 4 Maximum 20
Please use home machine/mask
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
Asthma
Atrial Fibrilation
Chronic Diastolic Heart Failure
SECONDARY DIAGNOSIS
HTN
HLD
Hypothyroidism
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 taking care of you in the hospital. You came
to the hospital because you were having difficulty breathing.
Your heart rate was found to be very fast. We think your
shortness of breath was because of your fast heart rate and
possibly also due to your asthma. We gave you medication to
control your heart rate and also started an oral medication to
take for your asthma.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Your discharge medications and follow up appointments are
detailed below.
We wish you the best!
Your ___ Care team
Followup Instructions:
___
|
10603001-DS-11 | 10,603,001 | 24,177,006 | DS | 11 | 2158-06-12 00:00:00 | 2158-06-13 10:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / benztropine
Attending: ___
Chief Complaint:
Dysarthria, generalized weakness, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with cerebral palsy, A-fib
(on Apixaban), and diastolic HF who presented to the ___ ED on
___ with 1 day of dysarthria, generalized weakness, and
altered mental status.
Of note, the pt was recently hospitalized at ___
(___) for asthma exacerbation and flash pulmonary
edema due to A-fib with RVR. The pt is highly volume sensitive,
and has a history of frequent syncope due to over-diuresis. The
pt was discharged to a ___ ___) on
Lasix and Montelukast. He was also recently started on Cogentin
PO BID on ___ for Parkinsonism due to his chronic
Risperidone.
Per collateral from the SNF, the pt began to have confusion and
generalized weakness causing difficulty ambulating on ___.
That evening, he began to have mumbled speech. He also had 2
syncopal episodes (which is not unusual for him), and his vitals
were stable during those episodes. He has not had any vomiting,
diarrhea, abdominal pain, or dysuria. He denies any chest pain
or SOB. He does endorse that his speech is more sloppy than his
baseline.
On ___, he was brought to the ___ ED. There, his vitals
were Temp 96.7, HR 109, BP 125/87, RR 26, SpO2 96% on RA. He
was AAOx2. Labs were notable for WBC 12.0 with 71.6%
neutrophils. Non-contrast head CT was negative for any acute
bleed, and CXR was negative for pneumonia. ECG showed A-fib,
but no ischemia. He was started on O2 by NC, and was transferred
to ___ 7, and there were no overnight events.
This morning, the pt states he is unsure why he is in the
hospital. He denies any pain. He endorses that his speech is
unusual.
Past Medical History:
-Hypertension
-Long QT
-Hyperlipidemia
-CKD Stage 2
-Hypothyroidism
-Cerebral palsy
-Sleep apnea on CPAP
-GERD
-Morbid obesity
-Anxiety
-Constipation
-Asthma
Social History:
___
Family History:
Father Cancer - ___ Diabetes - Type II
Physical Exam:
>>>ADMISSION EXAM:
Vital Signs: 98.8, 126/86, 93, 18, 99 on 2L, 92.5 kg
General: Alert, oriented to year but not location (thought
___" or month ___, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: unable to assess JVP due to soft tissue
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mildly distended, no organomegaly, no
rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: Exam limited, but EOMI (R eye lateral deviation), PERRL,
able to move all extremities and follow commands, poor motor
control throughout, face symmetric, he will have periods of
mildly pressured speech that is mumbled, but otherwise is not
dysarthric, it is unclear if he has word finding difficulties
>>>DISCHARGE EXAM:
Vitals:
-Temp 97.7-98.6, currently 98.4
-HR 64-84, currently 84
-BP 101-115/60-83, currently 110/62
-RR 20
-SpO2 92 on RA
-Weight: 97.1 kg (dry weight is 100.9 kg)
Orthostatic Vitals:
-Laying: BP 118/73, HR 79
-Sitting: BP 116/81, HR 74
General: NAD
HEENT: MMM, sclera anicteric
Heart: irregularly irregular rhythm, no murmurs
Lungs: CTAB, no wheezes or crackles
Abdomen: protuberant, but soft and non-tender. Liver spans 8cm
below R costal margin. No RUQ tenderness, negative ___
sign. Normoactive bowel sounds.
Extremities: WWP
Skin: no ulcers
Neuro:
-alert; orientedx3; appropriate and conversational; performs
days of week backwards; recalls events during this
hospitalization
-mild L sided facial droop (forehead is spared), R exotropia,
and intermittent R ptosis; otherwise CN II-XII grossly intact
-dysarthric speech, but improves with reminding pt to speak w/
lips and tongue
-strength ___ in UEs bilaterally, no asterixis
-strength ___ in ___
-DTRs 2+ and symmetric throughout
Pertinent Results:
>>>IMPORTANT LABS:
-CBC (___): WBC 12.0, Hgb 15.8, Hct 48.5%, Plt 232
-BMP (___): Na 142, K 4.5, Cl 103, HCO3 28, BUN 21, Cr 1.1,
Anion gap 16
-UA (___): neg nitrite, neg leukocyte esterase, 36 WBCs
-Pro-BNP (___): 245
-CBC (___): WBC 11.2, Hgb 16.5, Hct 51.4%, Plt 228
-BMP (___): Na 142, K 3.9, Cl 100, HCO3 27, BUN 23, Cr 1.3,
Anion gap 19
-LFTs (___): ALT 30, AST 29, ALkPhos 109, Tbili 2.3
-CBC (___): WBC 10.4, Hgb 15.4, Hct 47.6%, Plt 204
-BMP (___): Na 143, K 3.7, Cl 101, HCO3 34, BUN 23, Cr 1.3,
Anion gap 12
-LFTs ___ at 7:14 AM): ALT 102, AST 66, AlkPhos 169, Tbili
1.8, Dbili 0.5, IBili 1.3
-LFTs ___ at 8:40 AM, sample grossly hemolyzed): ALT 85,
AST 92, AlkPhos 146, Tbili 1.7
-CBC (___): WBC 10.5, Hgb 14.6, Hct 45.3%, Plt 199
-BMP (___): Na 140, K 3.5, Cl 100, HCO3 29, BUN 18, Cr 1.2,
Anion gap 15
-LFTs (___): ALT 93, AST 45, AlkPhos 145, Tbili 1.1, Dbili
0.4, Ibili 0.7
-Coags (___): ___ 18.3, INR 1.7, PTT 35.2
-CBC (___): WBC 9.7, Hgb 15.1, Hct 46.8%, Plt 212
-BMP (___): Na 143, K 3.8, Cl 101, HCO3 29, BUN 23, Cr 1.3,
Anion gap 17
-LFTs (___): ALT 61, AST 26, AlkPhos 129, Tbili 0.6
>>>MICROBIOLOGY:
-Blood Cx (___): pending
-Urine Cx (___): no growth (final)
>>>IMAGING:
-CXR (___): No focal consolidation convincing for pneumonia
is identified on this limited exam. Probable small bilateral
pleural effusions.
-Non-contrast head CT (___):
1. Motion limited study. No acute intracranial process is
identified.
2. Ventriculomegaly is similar to before.
3. Unchanged bilateral basal ganglia hypodensities, perhaps
chronic lacunar infarcts or prominent perivascular spaces.
-Non-contrast head CT (___):
1. No acute intracranial abnormality. Vascularity however is
not assessed on this noncontrast examination.
2. Unchanged ventriculomegaly.
3. Unchanged bilateral basal ganglia hypodensities, could
reflect chronic lacunar infarcts and small vessel disease,
versus prominent perivascular spaces.
-RUQ US (___): Cholelithiasis and mild intrahepatic biliary
dilatation and common duct dilatation. The distal common bile
duct cannot be imaged nor can the pancreas be visualized due to
overlying gas. Therefore the etiology of the biliary dilatation
is not defined.
-MRCP (___):
1. Single 2 cm gallbladder calculus located in the neck without
evidence of acute cholecystitis. This calculus does not cause
any surrounding
obstruction.
2. There is uniform mild-to-moderate dilation of central
intrahepatic bile
ducts with dilation of the CBD to 9 mm, the CBD however tapers
gradually towards the ampulla without abrupt transition. No
mass lesion identified in the periampullary region or the
pancreatic head. No choledocholithiasis. Pancreatic duct is
not dilated. Conglomeration of these findings may reflect
sphincter of Oddi dysfunction as a possible underlying cause for
the biliary ductal dilation.
3. Normal signal in density of the pancreatic parenchyma without
evidence for acute pancreatitis.
Brief Hospital Course:
___ is a ___ man with cerebral palsy, A-fib
(on Apixaban), and diastolic HF who presented to the ___ ED on
___ with 1 day of dysarthria, generalized weakness, and
confusion.
#Toxic metabolic encephalopathy: The pt began to have confusion,
generalized weakness, and dysarthria the day prior to admission.
At admission, the pt was A&Ox2, but otherwise followed commands
appropriately. The etiology of his delirium is likely a
combination of recent initiation of anticholinergic medication
(Cogentin, to treat antipsychotic-induced Parkinsonism) and
sleep hypoventilation (the pt states he had not been using his
CPAP for OSA recently prior to admission). UA and urine Cx were
negative for UTI, and CXR was negative for pneumonia. Cogentin
was held this admission and CPAP was resumed, and the patient's
mental status improved rapidly. At discharge, he was A&Ox3,
appropriately conversational, and at his baseline mental status.
#Leukocytosis: The pt's WBC count was 12.0 on admission. He had
no fevers or localizing signs of infection. UA and urine Cx were
negative for UTI, and CXR was negative for pneumonia. The
etiology of his mild leukocytosis is unclear. His WBC count
downtrended during admission, and was 9.7 at discharge.
#Mild transaminitis: The developed a mild transamanitis on
___ (with mild mixed hyperbilirubinemia and elevated
AlkPhos), up from WNL the day before. Per OMR, the pt has never
had transaminitis in the past. On exam, the pt's liver is
enlarged (likely due to chronic CHF), but there is no RUQ
tenderness or asterixis. RUQ showed only cholelithiasis and mild
dilatation of the intrahepatic and common bile ducts, but no
hepatic parenchymal changes. MRCP showed no mass lesions of
periampullary region/pancreatic head and no choledocholithiasis.
The pt's AST and Tbili downtrended since then. The etiology of
this transaminitis was likely a passed gallstone. At discharge,
the pt's ALT was 61 and AST was 26. His LFTs should continue to
be monitored in the outpatient setting.
#L facial droop: The patient was noted to have subtle L-sided
facial droop (sparing the forehead) on ___, unclear if
baseline. Repeat non-contrast head CT (obtained immediately
after the L facial droop was noted) showed no acute intracranial
abnormality. This remained stable during admission. It is likely
that the patient's L facial droop is his baseline, but it was
not documented previously.
#Syncope: The pt has A-fib and history of frequent syncope in
setting of overdiuresis. Per staff at his SNF, the pt had 2
brief syncopal episodes on the evening of ___, during which
his head flopped backwards for a few seconds. He did not have
any tonic-clonic movements or post-ictal confusion. The pt does
not remember these episodes himself. These events are likely ___
orthostasis in the setting of overdiuresis, as the pt's weight
was 92.5 kg on admission (down from 100.9 kg the last admission)
and he was orthostatic on admission (laying BP 124/87 and HR
100; standing BP 87/56 and HR 134). During this admission, the
patient's Lasix was held. He received a 250 cc bolus of NS on
___. At discharge, he was no longer orthostatic from laying
to sitting (laying BP 118/73 and HR 79; sitting BP 116/81 and HR
74). His discharge weight was 97.1 kg.
#Parkinsonism: The pt has had difficulty ambulating for the past
several months, which was originally thought to be due to
Risperdal-induced Parkinsonism. Non-contrast head CTs this
admission should bilateral basal ganglia hypodensities,
reflecting lacunar infarctions vs. small vessel disease. The
patient's Parkinsonism should continue to be evaluated in the
outpatient setting. This may also be contributing to his
orthostasis (see above).
#A-fib: The patient is on chronic anticoagulation with Apixaban.
His CHADS-VASC score is 2 (for CHF and HTN). His Apixaban,
Diltiazem, and Metoprolol were continued throughout this
admission. He was monitored with telemetry, and remained in
A-fib throughout this admission.
#Diastolic heart failure: The pt has brittle volume status,
alternating between pulmonary edema and syncope. Weight was 92.5
kg on admission, down from 100.9 kg at previous discharge. CXR
negative for pulmonary edema. Lasix was held during this
admission, given significantly decreased weight compared to
previous admission.
#Code: full (per ___ paperwork)
#Communication: ___, sister, ___
#TRANSITIONAL ISSUES:
-The pt states he has had difficulty ambulating for the past few
months. He was recently started on Cogentin for possible
Risperidone-induced Parkinsonism, which was discontinued this
admission due to delirium. Non-contrast head CT this admission
notable for old lacunar infarcts of the basal ganglia. Please
follow this up as an outpatient, and consider initiation of
dopaminergic medication or physical therapy.
-The pt states he has not been using his CPAP recently while he
was living at home (he states he is using it at rehab). Please
ensure that he always uses his CPAP at night.
-The pt's LFTs became newly elevated this admission, likely due
to a passed gallstone. Please continue to monitor his LFTs and
clinically monitor.
-During this admission, the pt's Lasix (Furosemide) was held,
given orthostasis and evidence of significant weight loss from
his previous admission. The patient should resume his Lasix but
at a decreased frequency (2x/week instead of 3x/week) starting
when he is back to his dry weight of 100.9 kg. Please continue
to appropriate titrate his Lasix in the future.
-Please minimize Benzodiazepine use in the future, as they are
deliriogenic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. LORazepam 0.5 mg PO DAILY:PRN anxiety
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. RisperiDONE 2 mg PO QAM
13. RisperiDONE 3 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, SOB
16. Montelukast 10 mg PO DAILY
17. Furosemide 20 mg PO 3X/WEEK (___)
18. Potassium Chloride 20 mEq PO DAILY
19. Benztropine Mesylate 1 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, SOB
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. RisperiDONE 2 mg PO QAM
15. RisperiDONE 3 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
17. Furosemide 20 mg PO 2X/WEEK (___)
please restart once pt's weight returned to dry weight
18. LORazepam 0.5 mg PO DAILY:PRN anxiety
please hold for AMS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
1. Medication-induced delirium
2. Obstructive sleep apnea
3. Syncope
4. Atrial fibrillation
5. Cerebral palsy
6. Diastolic congestive heart failure
7. Cholelithiasis
8. Transaminitis
SECONDARY DIAGNOSES:
-Hypertension
-Hyperlipidemia
-Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___.
1. Why was I here?
You were admitted to the ___ because you were confused, weak,
and slurring your speech at rehab.
2. What was done for me while I was here?
We stopped one of your medications (Benztropine) that may have
been contributing to your confusion and weakness. We also gave
you CPAP for sleep apnea.
3. What should I do after I leave the hospital?
You should take all of your medications as prescribed. You
should always use your CPAP at night.
We wish you the best!
-Your ___ care team
Followup Instructions:
___
|
10603001-DS-12 | 10,603,001 | 25,196,121 | DS | 12 | 2161-03-05 00:00:00 | 2161-03-06 11:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / benztropine
Attending: ___.
Chief Complaint:
abdominal distension, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with cerebral palsy, A-fib (on Apixaban), HFpEF,
hydrocephalus s/p VP shunt, presented to ED with abdominal
distention and shortness of breath.
Patient reports that for the past 2 days has been having very
minimal amount of loose leakage but has not had a full bowel
movement in ___ days. Not passing gas. Today, he noticed
worsening abdominal distention which also caused him to have
worsening dyspnea. Did not have any cough, chest pain or
pressure. No fevers or chills. EMS was called found him to have
diffuse wheezing. He received albuterol treatment. Also found to
be in A. fib with RVR in the rates in the 170s. Received 25 mg
diltiazem and by EMS.
He was last seen at ___ in ___ for altered mental status and
his discharge summary states that his volume status in tenuous -
he has the propensity to syncopize when overdiuresed and
develops
flash pulmonary edema frequently after fluid resuscitation.
In the ED, initial HR 140, up to high of 154, for which he
received multiple boluses of diltiazem and ultimately started on
a drip with improvement in HRs to 110s. SBPs ranged from 99 -
157, and was 137 on transfer. He also received ~1L LR, CTX for
?UTI, duonebs, Mg repletion, and was started on a heparin gtt
for
anticoagulation.
CT A/P (non-con given contrast allergy) showed "likely partial"
SBO. Lactate was checked once at 0056 and was 2.6, with other
labs notable for WBC 13, Cr 1.8 from 1.3. He was seen by surgery
who recommended NGT to suction and admission to the MICU for
monitoring with serial abdominal exams. NGT was placed to
suction
with immediate return of 1.2L of bilious contents. He
subsequently had an episode of vomiting, NGT was flushed.
On arrival to the MICU, he reports that he developed new
abdominal pain yesterday afternoon, associated with several
episodes of diarrhea. He denies nausea/vomiting. He also notes
some leg weakness/difficulty walking that has been going on for
several weeks. He does not believe he has missed any doses of
medications at his nursing home. He denies chest pain,
palpitations, dizziness, current abdominal pain, or nausea.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
-Hypertension
-Long QT
-Hyperlipidemia
-CKD Stage 2
-Hypothyroidism
-Cerebral palsy
-Sleep apnea on CPAP
-GERD
-Morbid obesity
-Anxiety
-Constipation
-Asthma
-Hydrocephalus s/p VP shunt placed at ___ (?___)
Social History:
___
Family History:
Father Cancer - ___ Diabetes - Type II
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in metavision
GEN: Lying in bed, NAD
EYES: No scleral icterus
HENNT: Slightly dry MM, NGT in place to suction
CV: Tachycardic, irregularly irregular, no r/m/g
RESP: Scattered wheeze
GI: Moderately distended, mildly TTP diffusely, hyperactive BS
EXT: WWP, no ___ edema
SKIN: Warm, dry
NEURO: AO x 3, no focal deficits
PSYCH: Affect appropriate
DISCHARGE PHYSICAL EXAM
========================
VS: 24 HR Data (last updated ___ @ 558)
Temp: 97.6 (Tm 99.1), BP: 142/83 (108-142/74-94), HR: 88
(76-91), RR: 22 (___), O2 sat: 95% (91-97), O2 delivery: CPAP,
Wt: 225.53 lb/102.3 kg
GEN: In NAD
HEENT: PERRL, dry mucous membranes, oropharynx clear without
exudates
NECK: No visible JVD, no cervical lymphadenopathy
CV: Irregular rhythm but regular rate, no murmurs/gallops/rubs
PULM: CTAB, no wheezing/crackles/rhonchi
ABD: Soft, less distended, tympanic to percussion, non tender
EXTREM: No ___ edema. Pulses +2 ___P, ___ bilaterally
SKIN: No rashes
NEURO: A&Ox3, chronic right CN III palsy otherwise intact, motor
and sensation grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 12:50AM BLOOD WBC-13.8* RBC-5.80 Hgb-17.4 Hct-53.5*
MCV-92 MCH-30.0 MCHC-32.5 RDW-12.7 RDWSD-42.7 Plt ___
___ 12:50AM BLOOD Neuts-82.4* Lymphs-3.7* Monos-13.1*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.35* AbsLymp-0.51*
AbsMono-1.81* AbsEos-0.00* AbsBaso-0.03
___ 12:50AM BLOOD ___ PTT-39.6* ___
___ 12:50AM BLOOD Glucose-138* UreaN-25* Creat-1.8* Na-138
K-4.3 Cl-94* HCO3-26 AnGap-18
___ 12:50AM BLOOD ALT-27 AST-33 AlkPhos-90 TotBili-0.9
___ 12:50AM BLOOD Lipase-27
___ 12:50AM BLOOD proBNP-1366*
___ 12:50AM BLOOD cTropnT-<0.01
___ 12:50AM BLOOD Albumin-4.4 Calcium-9.1 Phos-2.7 Mg-1.5*
___ 12:56AM BLOOD ___ pO2-63* pCO2-45 pH-7.42
calTCO2-30 Base XS-3
___ 12:56AM BLOOD Lactate-2.6*
IMAGING
=======
___ KUB
IMPRESSION:
There is an enteric tube which terminates in the body of the
stomach. The
enteric contrast has passed through the small bowel in is
predominately within the colon. There are multiple dilated
loops of small bowel measuring up to 6.1 cm, which have
increased in size and are concerning for a partial small bowel
obstruction. There are no dilated loops of large bowel. There
is no evidence of free intraperitoneal air although evaluation
is limited by portable supine technique. No suspicious
radiopaque calculi or acute osseous abnormalities are
identified.
___ SHUNT SERIES
IMPRESSION:
Visualized portions of the shunt catheter appear intact, with
the abdominal portion not in field-of-view.
Multiple dilated loops of small bowel concerning for small bowel
obstruction or ileus.
Diffuse interstitial prominence of the lungs with cardiomegaly
in keeping with pulmonary edema. Infection is not excluded.
___ CT ABDOMEN PELVIS
IMPRESSION:
1. Small bowel obstruction, likely partial, with gradual
transition to very decompressed ileum in the right central
abdomen. Mild mesenteric edema. No evidence of bowel ischemia
or perforation on noncontrast exam.
2. Partially visualized right middle lobe pulmonary opacities
may reflect
atelectasis, aspiration, or possibly infection.
3. Likely unchanged multilevel chronic vertebral body
compression deformities, severe at L4 with 4 mm of retropulsion.
4. Hepatic steatosis. See recommendations.
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude
cirrhosis or significant liver fibrosis which could be further
evaluated by ___. This can be requested via the Liver
Center (FibroScan) or the Radiology Department with either MR
___ or US ___, in conjunction with a
GI/Hepatology consultation" *
* ___ et al. The diagnosis and management of nonalcoholic
fatty liver disease: Practice guidance from the ___
Association for the Study of Liver Diseases. Hepatology ___
67(1):328-357
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-9.4 RBC-4.80 Hgb-14.3 Hct-46.0 MCV-96
MCH-29.8 MCHC-31.1* RDW-12.4 RDWSD-43.8 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-114* UreaN-15 Creat-1.3* Na-147
K-3.7 Cl-97 HCO3-35* AnGap-15
___ 06:45AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9
Brief Hospital Course:
PATIENT SUMMARY
======================
___ w/ PMH cerebral palsy, AFib (on apixaban), HFpEF (EF 55%),
hydrocephalus s/p VP shunt p/w abdominal distension and dyspnea,
found to have partial SBO, AFib w/ RVR, requiring brief ICU
admission for rate control, now resolved.
ACUTE ISSUES
=============
#Partial SBO: Pt presented with vomiting and abdominal
distention. CT A/P found likely partial SBO. No history of
abdominal surgery, although had VP shunt placed. ACS evaluated
him and recommended conservative management with NPO, fluid
resuscitation, NG tube to low wall suction, as well as
performing serial KUBs with oral contrast to evaluate for
progression of obstruction. Immediately after placing the NG
tube, there was copious return of 1.2L of bilious contents,
which improved his symptoms. Managed conservatively with NG tube
initially to suction, subsequently clamped. He was maintained on
a bowel regimen, and diet was advanced as tolerated. At time of
discharge, able to tolerate a regular diet with regular bowel
movements and passing gas.
#AFib with RVR: Likely iso hypovolemia and pain from SBO.
Initially refractory to IV dilt boluses, requiring ICU transfer.
In the ICU he was loaded with IV amiodarone, which helped with
rate control. Upon transfer to the floor, amiodarone was
discontinued and he was maintained on fractionate doses of his
home diltiazem and metoprolol with good effect. While he was
NPO, he was maintained on a heparin drip in place of his home
apixaban. Apixaban was resumed once able to tolerate PO meds.
CHRONIC/RESOLVED ISSUES
=========================
___ on CKD
Cr 1.8 on admission from recent baseline 1.3. Received
significant fluid resuscitation in the ICU with improvement in
creatinine. Creatinine 1.3 on discharge.
#Hypernatremia: 153 on ___, likely ___ NPO and gastric suction,
resolved after D5W.
#?Hydrocephalus s/p VP shunt: Pt reports placed at ___, likely
___. Per imaging, VP shunt series appear intact, although
cannot see entire abdomen.
#HFpEF: Initially his home furosemide was held I/s/o
hypovolemia, but was restarted once he was clinically stable.
#HLD: Continued home atorvastatin
#COPD/Asthma: Continued PRN Duonebs, restarted home Montelukast.
Wore CPAP at night once NGT was removed.
#Hypothyroidism: Continued home levothyroxine
#Cerebral palsy/Anxiety: Continued home risperidone, buproprion
#GERD: Continued home PPI
#BPH: Continued home finasteride, tamsulosin
#CODE: Full (confirmed)
#CONTACT: ___ (Sister) ___ ___, c ___
TRANSITIONAL ISSUES
======================
- Hepatic steatosis noted on CT A/P, please continue to follow
and consider fibroscan if persists
- Incidental imaging finding: Multilevel chronic vertebral body
compression deformities, severe at L4 with 4 mm of retropulsion.
Consider evaluation for osteoporosis.
- Gross hematuria noted after Foley removal, please repeat UA in
outpatient setting to ensure resolution
- Please recheck complete metabolic panel on ___ to ensure
stable creatinine (1.3 on discharge)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, SOB
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. RisperiDONE 2 mg PO QAM
15. RisperiDONE 3 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
17. Furosemide 40 mg PO DAILY
18. LORazepam 0.5 mg PO DAILY:PRN anxiety
19. Sertraline 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, SOB
9. Levothyroxine Sodium 25 mcg PO DAILY
10. LORazepam 0.5 mg PO DAILY:PRN anxiety
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Potassium Chloride 20 mEq PO DAILY
16. RisperiDONE 2 mg PO QAM
17. RisperiDONE 3 mg PO QPM
18. Sertraline 12.5 mg PO DAILY
19. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
===================
Partial small bowel obstruction
Atrial fibrillation
SECONDARY DIAGNOSIS
====================
Heart failure with preserved ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___?
WHY DID YOU COME TO THE HOSPITAL?
You were having trouble keeping food down with nausea and
vomiting
WHAT HAPPENED WHILE YOU WERE HERE?
We discovered that you had a bowel obstruction. Our surgery team
evaluated you and did not think you needed surgery. We put a
tube down your nose and into your stomach to empty out your
belly, and with time the obstruction cleared and you were able
to eat again. Your heart rate was also found to be very fast
because of your atrial fibrillation, so we used medications to
improve this.
WHAT SHOULD YOU DO WHEN YOU GO BACK TO YOUR FACILITY?
Please continue to take all of your medications and follow up
with all of your doctors. ___ yourself every morning, call MD
if weight goes up more than 3 lbs.
Followup Instructions:
___
|
10603001-DS-9 | 10,603,001 | 25,001,186 | DS | 9 | 2158-02-05 00:00:00 | 2158-02-09 22:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr ___ is a ___ year old man with a past medical
history significant for atrial fibrillation on apixaban, chronic
diastolic heart failure, who presents with dizziness and
hypotension.
Over the past few months, Mr ___ has had several admission
for atrial fibrillation, heart failure and asthma. He was most
recently admitted for an asthma exacerbation. Throughout his
inpatient and outpatient visits, he has been started on Lasix
for ___ which has been titrated. He has also been on various
nodal agents for his afib, and they have been titrated up/down
several times.
He presents today for low blood pressure and dizziness. He
claims that his blood pressures have been lower since his last
admission. However, within the past few days he also reports an
intermittent lightheadedness. He was seen by his PCP ___ ___
where his BP was low, but was given IVF and BP improved (along
with symptoms). However, he again had similar symptoms today and
for this reason was brought to the ED by his family. He overall
feels more unsteady on his feet. Unclear if related to
positional changes. No vertigo, pre-syncope/syncope. No vision
or hearing changes. No dysphagia. No numbness/tingling. No focal
weakness other than baseline CP deficits (left-sided)
He endorses having more frequent loose stools than usual over
the past week. Claims his PO intake may be slightly down, and
that he is more frequently thirsty. Denies urinary frequency,
vomiting, or excess sweating. No blood loss by GI or GU. He did
fall once ___ days ago. No headstrike/LOC. He has fallen in the
past and his frequency of falls has not increased.
His family also expresses concern about his polypharmacy and
nutritional needs. They feel he would benefit from more
intensive rehab while hospitalized/post-discharge.
ED COURSE
- In the ED, initial vitals 0 97.7 61 98/51 18 97% RA
- ED Exam was unremarkable
- Labs notable for Cr 1.8 (baseline 1.2), mild leukocytosis
- CXR without acute cardiopulmonary process
- Pt was given 500cc NS
- Vitals prior to transfer: sleeping 97.4 82 125/69 16 96% RA
Upon arrival to the floor patient and his family report that he
is feeling well. Not dizzy or lightheaded at present. Thirsty.
ROS: Denies headache, sore throat, chest pain, abdominal pain,
nausea, vomiting, constipation, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Hypertension
Long QT
Hyperlipidemia
CKD Stage 2
Hypothyroidism
Cerebral palsy
Sleep apnea
GERD
Morbid obesity
Anxiety
Constipation
Social History:
___
Family History:
Father Cancer - ___ Diabetes - Type II
Physical Exam:
ADMISSION EXAM
================
Vitals: 93.8kg 104/61 80 18 95/RA
GENERAL: Pleasant, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM
CARDIAC: irregularly irregular rhythm, normal rate. Normal S1,
S2. No murmurs, rubs or gallops. JVP unable to be assessed given
body habitus
LUNGS: diffuse wheezing throughout, poor air movement
ABDOMEN: NABS. Soft, NT, ND
EXTREMITIES: edema 1+ to mild shins
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. ___ strength
throughout. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately,
pleasant
DISCHARGE EXAM
=================
Vitals: 93.8kg 101-109/65 ___ 18 98% RA.
GENERAL: Pleasant, in NAD; sitting in chair comfortably
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM
CARDIAC: irregularly irregular rhythm, normal rate. Normal S1,
S2. No murmurs, rubs or gallops. JVP no elevated.
LUNGS: Poor air movement, no wheezing
ABDOMEN: NABS. Soft, NT, ND
EXTREMITIES: trace edema bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate.
PSYCH: Listens and responds to questions appropriately,
pleasant
Pertinent Results:
ADMISSION LABS
==================
___ 05:20PM PLT COUNT-191
___ 05:20PM NEUTS-75* BANDS-0 LYMPHS-13* MONOS-9 EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-1* AbsNeut-8.85* AbsLymp-1.77
AbsMono-1.06* AbsEos-0.00* AbsBaso-0.00*
___ 05:20PM WBC-11.8* RBC-4.30* HGB-12.7* HCT-39.5*
MCV-92 MCH-29.5 MCHC-32.2 RDW-13.6 RDWSD-45.9
___ 05:20PM GLUCOSE-97 UREA N-32* CREAT-1.8* SODIUM-142
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-22 ANION GAP-17
___ 08:45PM URINE RBC-5* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:45PM URINE COLOR-Straw APPEAR-Clear SP ___
IMAGES/STUDIES
==================
ECG ___:
RatePRQRSQTQTc (___) QRS T
61 ___ 48
CXR ___:
FINDINGS:
AP upright and lateral views of the chest provided. Lung
volumes are low.
Allowing for this, there is no focal consolidation, large
effusion or
pneumothorax. The cardiomediastinal silhouette is stable. No
acute bony
abnormalities.
IMPRESSION:
No acute findings.
DISCHARGE LABS
=================
___ 07:40AM BLOOD WBC-10.2* RBC-4.72 Hgb-13.9 Hct-43.1
MCV-91 MCH-29.4 MCHC-32.3 RDW-13.8 RDWSD-46.3 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-115* UreaN-20 Creat-1.1 Na-142
K-4.0 Cl-102 HCO3-28 AnGap-16
___ 07:40AM BLOOD Calcium-9.7 Phos-4.6* Mg-2.1
Brief Hospital Course:
Mr ___ is a ___ year old man with a past medical
history significant for atrial fibrillation on apixaban, chronic
diastolic heart failure, who presents with dizziness and
unsteadiness, found to be hypotensive with SBP in ___.
ACUTE ISSUES
# Dizziness/Hypotension: Patient was reportedly orthostatic in
the ED. Patient had been on multiple nodal blocking agents, and
Lasix and Lisinopril. Patient not orthostatic on arrival to
floor, s/p IVF. No overt signs of CHF. Infection possible, but
no localizing symptoms. Discussion with case manager from
"___ Families ___," revealed that pt had been taking
his medications from before his previous admission (Dilt 120mg
TID and Metop 25mg TID, and also Lasix 20mg every other day).
Patient's sister also notes that patient decreases his PO intake
because the water pill makes him use the bathroom repeatedly and
so he has decreased his PO intake recently. Patient improved
with IVF. Patient given Diltiazem 360 ER and Metoprolol 100 XL.
Furosemide and Lisinopril were held. Patient's BPs remained
stable (SBPs 101-138). Set up ___ services at home for
medication management. Pt does not seem to do well with routine
change, and so will benefit from nursing for some period of
time.
# ___: Admission creatinine 1.8, up from baseline of 1.2-1.4.
Likely pre-renal from decreased PO, also exacerbated by Lasix
and Lisinopril. Creatinine improved to baseline after IVF and
holding Lasix and Lisinopril.
CHRONIC ISSUES
# Atrial fibrillation: Rates remained well controlled. Patient
had episodes of RVR during last admission and so will have high
threshold to decrease dilt or metop. Continued diltiazem,
metoprolol, apixaban.
# Chronic heart failure with preserved EF: Held home furosemide
as above.
# Depression/anxiety: Continued home risperidone, bupropion,
lorazepam.
# HTN: Held home lisinopril as above.
# BPH: Continued home tamsulosin and finasteride.
# HLD: Continued home atorvastatin.
# Hypothyroidism: Continued home levothyroxine.
# GERD: Continued home Omeprazole.
TRANSITIONAL ISSUES/MEDICATION CHANGES:
===========================================
- LISINOPRIL STOPPED
- FUROSEMIDE HELD FOR NOW
- METOPROLOL AND DILTIAZEM SWITCHED TO LONG ACTING
[ ] Medication compliance/accuracy will be important to follow
up.
[ ] Furosemide may need to be restarted but we held at this time
given our concern that he possibly had over-diuresis. It was
unclear what he was taking at home.
[ ] Patient was noted to have microhematuria. Further workup
needed.
[ ] CONTACT:
- ___ (sister) ___
- ___ (case manager from ___)
___
[ ] CODE: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
2. Lorazepam 0.5 mg PO DAILY:PRN anxiety
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Apixaban 5 mg PO BID
5. Atorvastatin 20 mg PO QPM
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. RISperidone 2 mg PO QAM
13. RISperidone 3 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15. Furosemide 10 mg PO EVERY OTHER DAY
16. Diltiazem Extended-Release 360 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*1
6. Finasteride 5 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Lorazepam 0.5 mg PO DAILY:PRN anxiety
10. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*1
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. RISperidone 2 mg PO QAM
14. RISperidone 3 mg PO QPM
15. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
dizziness
SECONDARY:
hypertension
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 Mr. ___,
You were admitted to the hospital for dizziness and
unsteadiness. We think this may have been an effect of your
blood pressure medications, so we made changes to your
medications and monitored your blood pressure.
It is very important to review your discharge medication list
carefully and compare that with the medicine you have at home.
Your visiting nurse should help you do this and help you set up
your medications.
You should also follow up with your PCP and cardiologist; the
appointments are listed below.
It was a pleasure taking care of you and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10603088-DS-13 | 10,603,088 | 25,238,519 | DS | 13 | 2146-09-13 00:00:00 | 2146-09-17 12:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a pleasant ___ yo F who presents with a ___ wk hx
of epigastric pain, feeling like "someone punched me in the
stomach". She initially when to her PCP who started her on a 20
mg daily of omeprazole. She has been taking it regularly and
has not noticed any improvement. She denies EtOH or NSAID use,
has been taking tylenol for the pain with no significant
improvement. She also endorse N/V with coffee ground emesis and
25 lb wt loss in 3 wks due to decreased appetite and pain from
eating as the pain is worse with PO intake. She hasn't had a BM
in a week. She denies dark or bloody stools.
In the ED, initial vital signs were 98.3 89 150/94 18 100% RA.
KUB and ct abd/pelvis were unremarkable. Labs were WNL. She
was given morphine, zofran, donnatal with some improvement in
her sxs.
On arrival to the floor she complains of ___ epigastric pain.
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
none
Social History:
___
Family History:
grandmother died of cancer (unknown type)
Physical Exam:
ON ADMISSION:
Vitals: 97.9 104/60 68 18 99% RA
General: somnolent and uncomfortable
HEENT: sclera anicteric, MMM
CV: RRR, no MRG
Lungs: CTA B
Abdomen: TTP in abd, soft, + BS
Ext: wwp/no cce
Neuro: somnolent but aaox3, strength grossly intact
Skin: no rashes/lesions
Discharge exam:
VSS, afebrile
Appears comfortable
Unchanged abdominal exam
Pertinent Results:
LABS ON ADMISSION:
___ 01:00AM BLOOD WBC-5.5 RBC-4.27 Hgb-13.2 Hct-39.3 MCV-92
MCH-30.9 MCHC-33.5 RDW-13.1 Plt ___
___ 01:00AM BLOOD Neuts-38.8* Lymphs-49.0* Monos-6.0
Eos-5.8* Baso-0.4
___ 01:00AM BLOOD Glucose-72 UreaN-5* Creat-0.8 Na-137
K-4.3 Cl-101 HCO3-23 AnGap-17
___ 01:00AM BLOOD ALT-13 AST-28 AlkPhos-116* TotBili-0.6
___ 01:00AM BLOOD Albumin-4.8
IMAGING:
___ KUB: Unremarkable bowel gas pattern.
___ CT abd/pelvis: No acute intra-abdominal process.
___ RUQ US: The gallbladder contains sludge and likely some
tiny non shadowing calculi. There are no associated findings
such as gallbladder wall thickening, distention of the
gallbladder or pericholecystic fluid to suggest acute
cholecystitis.
___ EGD:
Normal mucosa in the esophagus
Mild erythma in the stomach compatible with gastritis (biopsy)
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
___ MRCP: No significant abnormalities, no acute processes,
normal biliary system and vasculature
___ Gastric emptying study:
Abnormally rapid gastric emptying in a patient who had abdominal
pain throughout the exam. Note that patient ingested only a
portion of the
standard meal.
Brief Hospital Course:
Pleasant ___ yo F presents with 2 wk hx of epigastric pain and
coffee ground emesis with nl abd imaging and labs, concerning
for gastritis vs ulcer. She underwent an extensive work-up with
imaging, EGD, MRCP, and gastric emptying study, all which did
not show a clear cause for her symptoms. She was followed by GI
in-house and further work-up will be done in outpatient
follow-up which has been scheduled. She was discharged on pain
medications, PPI for a possible component of gastritis,
dicyclomine for possible abdominal spasms, and ensure
supplements for nutrition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. DiCYCLOmine 20 mg PO QID
RX *dicyclomine 20 mg one tablet(s) by mouth four times a day
Disp #*60 Tablet Refills:*0
3. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis
RX *diphenhydramine HCl 25 mg one tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg one tablet(s) by mouth twice daily
Disp #*30 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 17 gram/dose 17 gram powder(s) by
mouth daily Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg one tablet by mouth twice daily
Disp #*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
do not drink or drive while taking this medication
RX *oxycodone 5 mg one tablet(s) by mouth every eight hours Disp
#*30 Tablet Refills:*0
8. Ensure Plus (food supplement, lactose-free) 0.05-1.5
gram-kcal/mL oral TID
supplement wtih meals
RX *food supplement, lactose-free [Ensure Plus] 0.05 gram-1.5
kcal/mL one can by mouth three times a day 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:
You were admitted to the hospital for abdominal pain. You were
found to have stones in your gallbladder but no other cause of
your pain was identified. You were seen by the GI team and had
multiple tests to help determine the cause of your pain; no
cause was identified. This will require further work-up, so we
have scheduled an appointment with the GI doctor in the coming
weeks.
You are being discharged on medications to help with bowel
movements, with pain (take the oxycodone sparingly, do not drink
or drive while taking this), and with spasms.
Please keep your appointments as scheduled.
Followup Instructions:
___
|
10603088-DS-14 | 10,603,088 | 23,791,885 | DS | 14 | 2146-12-25 00:00:00 | 2146-12-25 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HMED Admission Note
___
cc: epigastric pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo F here with epigastric abdominal pain and vomiting. Pt
reports onset of epigastric pain, non-radiating about a week ago
which has not subsided. This was accompanied by vomiting
multiple times per day and inability to tolerate PO. Saw some
coffee ground material in her vomitus today. Pt presented to the
ED on ___ and discharged after receiving antiemetics and IV pain
medications. Pt returned today with ongoing symptoms which did
not resolve with IV reglan, hydromorphone and morphine. Pt
admitted for further care.
Of note, pt admitted with similar symptoms in ___. She was
seen by GI and had an extensive evaluation which included an EGD
which showed only mild erosive gastritis, negative MRCP, normal
gastric emptying study. Labs also unremarkable aside from alk P
which was slightly above upper limit of normal but returned to
baseline. Pt started on omeprazole and bentyl for presumed
gastritis +/- functional dyspepsia and saw GI in follow up in
early ___. At the time of her follow up, her symptoms had
markedly improved. Pt says that she stopped both bentyl and
omeprazole in ___. She says that she has been having
intermittent pain accompanied by vomiting every other day,
lasting about 3 hours and self resolving. She cannot identify a
specific trigger for her pain. Last BM 5 days ago.
Of note, pt also had D&C for a missed abortion on ___. She has
not been on NSAIDS. Says her current pain was present prior to
her D&C.
ROS: negative except as above
Past Medical History:
Missed abortion s/p D and C on ___
Social History:
___
Family History:
grandmother died of cancer (unknown type)
Physical Exam:
Admission Physical Exam
Vitals: T 98.4 BP 114/77 HR 90 RR 18 100%RA
Gen: NAD
HEENT: no jaundice, no oral ulcers
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, epigastric tenderness, no rebound, normal active
bowel sounds
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Discharge Physical Exam
Vitals: T 98 BP 104/57 HR 83 RR 16 100%RA
Gen: NAD
HEENT: MMM, no jaundice, no oral ulcers
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, epigastric tenderness, no rebound, normal active
bowel sounds
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Psych: depressed mood, denies SI/HI
Pertinent Results:
___ 01:15PM WBC-8.0 RBC-4.52 HGB-14.1 HCT-40.7 MCV-90
MCH-31.2 MCHC-34.6 RDW-13.3
___ 01:15PM PLT COUNT-206
___ 01:15PM GLUCOSE-88 UREA N-6 CREAT-0.7 SODIUM-136
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-17* ANION GAP-22*
___ 01:15PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-103 TOT
BILI-0.7
___ 01:15PM LIPASE-42
___ 01:15PM ALBUMIN-4.8
___ 01:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Abdominal u/s:
Normal abdominal ultrasound.
.
Pelvic u/s:
IMPRESSION:
1. Markedly thickened and heterogeneous appearing material in
the endometrial canal, measuring 3.6 cm. No vascularity is
demonstrated within the endometrial tissue. This is likely to
be hematoma in the setting of recent D&C.
2. Normal size and appearance of the ovaries. Normal
vascularity in the right ovary. Assessment of vascularity of the
left ovary was limited secondary to the positioning of the
ovary. No evidence of ovarian torsion..
.
CT abdomen:
IMPRESSION:
1.The uterus appears enlarged, and contains a large amount of
hemorrhagic
density material. Given the patient's recent history of D&C one
day prior, this may represent retained products of conception or
normal post-operative appearance. Recommend pelvic ultrasound
for additional evaluation, and OB/GYN consult.
2. Trace hemorrhagic density fluid is seen within the pelvis,
which is likely related to recent D&C.
3. No intra-abdominal free air to suggest perforation of the
uterus secondary to recent D&C.
.
CXR:
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ year old presenting with acute on chronic epigastric pain.
Extensive workup during previous admission unremarkable.
Potentially gastritis, but likely functional abdominal pain.
#Epigastric pain/nausea:
#constipation
No concerning findings on extensive work-up, likely worsening
symptoms in setting of stress from recent fetal demise. During
previous admission symptoms improved greatly with bentyl and
bowel regimen. This admission recommended antiemetics, laxatives
for constipation, protonix, and dicyclomine for spasm. Pt was
perservative about receiving opioid medication for her symptoms
which was not offered to the patient as it was not indicated.
The GI service was consulted and also felt that pt had
functional abdominal pain and recommended dicyclomine, daily
protonix, align on discharge, amitryptyline 10mg QHS with
uptitration to 20mg QHS after 1 week, and to continue bentyl
20mg TID-QID. Unfortunately, pt did not agree with the
recommended treatment plan by taking antiemetics and a bowel
regimen. She was also recommended and offered a social work
evaluation as the stress of her recent D+C may be contributing
to the exacerbation of her pain but pt declined this
intervention. Pt did report that she had a BM on the day of
discharge. In addition, she displayed alot of food phobia and
vomiting secondary to that in conjunction with anxiety. Given
that pt continued to remain with similar symptoms despite her
treatment plan which she was not in favor of, it decided it
would be best for discharge (which pt agreed with) in order for
pt to recover at home. Recommended outpt GI, GYN, and PCP ___
up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiCYCLOmine 20 mg PO QID
Discharge Medications:
1. DiCYCLOmine 20 mg PO QID
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Milk of Magnesia 30 mL PO Q6H:PRN constipation
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule 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:
You were admitted with nausea and abdominal pain. Your blood
work and abdominal ultrasound were all normal. You were
restarted on protonix and diclocymine which have both helped
your pain in the past and were started on anti-nausea
medications. Your pain improved and you tolerated a full diet.
Followup Instructions:
___
|
10603088-DS-16 | 10,603,088 | 20,988,178 | DS | 16 | 2147-03-21 00:00:00 | 2147-03-22 23:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
___ Esophagogastroduodenoscopy with biopsy
History of Present Illness:
Ms. ___ is a ___ with PMHx notable for recurrent episodes
of abdominal pain and emesis of unknown etiology with multiple
negative previous work-ups, recently discharged from ___ on
___ who presents for evaluation of nausea, vomiting and
abdominal pain.
Patient states since discharge 5 days ago she has had persistent
epigastric pain with associated nausea and vomiting to the point
where she is unable to keep any liquids down. She describes the
abdominal pain as "being punched in the stomach" located in the
epigastric area with occasional radiation to her back. Symptoms
are worse with eating, better on an empty stomach. No
association with position. Sometimes sleeps with a heating pack
and takes a hot shower that lasts about 1.5 hrs per day. She
reports that the episodes of vomiting wake her up at night. When
she vomits anything in her stomach comes up, usually bile. She
denies any hematemesis, diarrhea, melena or hematochezia. No
coughing or heartburn sensation preceding these episodes. Has an
associated headache without fevers, chills, neck stiffness or
recent sick contacts. No recent new food exposures or dietary
changes. Reports that her mood is good, no recent depression or
anxiety. She feels safe at home and in her current relationship
with her boyfriend. ___ marijuana ___ times per week, most
recently 3 weeks ago.
Of note, pt describes that she has had recurrent episodes of
similar symptoms over the last ___ years. She reports that she had
an initial admission in ___, at which time she was diagnosed
with "ulcers" and told to avoid motrin. Subsequently, she was
admitted several times to various hospitals including ___ and
___. Per patient, her longest hospitalization was at ___ for 3
months while she had an NG tube in place because she was unable
to take any PO. Her longest symptom-free period was about less
than a year over a year ago. Since ___ she reports being in
and out of the hospital. She states that her recurrent symptoms
have made it difficult to hold down a job due to missed time
from work. She was admitted to ___ in ___ for epigastric
pain at which time workup was notable for minimal gastritis,
normal MRCP, a few non-obstructing choleliths, and normal
gastric emptying study. She was treated with dicyclomine and
PPI.
Most recently, pt was admitted to ___ from ___ with
diffuse abdominal pain and vomiting after exposure to seafood
from a local restaurant. Differential at the time included
functional abdominal pain versus gastroenteritis versus food
poisoning. Symptoms resolved within 24 hours. Shortly after
admission she was started on clears then had diet advanced,
which she tolerated well. She was discharged with home PPI and
PRN zofran. Of note,
In the ED, initial vitals were: 98.8 84 126/85 18 96% RA. Her
initial lab work was unremarkable. LFTs were normal, lipase 41.
Urine pregnancy test and UA negative. She required an EJ for IV
access. She was treated with Ativan (total of 2mg IV), zofran
(4mg IV x 2, ODT x 1) for nausea as well as GI cocktail and 1L
IVF. IV tylenol and toradol for pain. She continued to have
persistent nausea, vomiting and pain so was admitted to medicine
for further symptom management.
On the floor, pt reports that her symptoms remain unchanged. She
is unable to tolerate anything by mouth, including liquids and
oral medications. She continues to have epigastric pain ___ in
severity.
Past Medical History:
Missed abortion s/p D and C on ___
GERD
Social History:
___
Family History:
Grandmother died of pancreatic cancer.
Brother with peptic ulcer disease.
Physical Exam:
EXAM ON ADMISSION:
===================
VS: T:98.5 BP:121/83 P:82 R:18 O2:100%RA
GENERAL: Young female. A&O x 3, NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Normoactive bowel sounds. Soft, non-distended, moderately
tender to palpation over the epigastric area, otherwise
nontender. No masses, guarding or rebound tenderness.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Multiple tattoos
NEURO: CN II-XII intact. Grossly normal motor strength and
sensation.
EXAM ON DISCHARGE:
===================
VS: Tm 98.3 ___ 20 100%RA
GENERAL: Young female. A&O x 3, NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: BS hypoactive; soft, nondistended, mildly TTP in the
epigastric area. No rebound tenderness or guarding.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Multiple tattoos
NEURO: CN II-XII intact. Grossly normal motor strength and
sensation.
Pertinent Results:
LABS ON ADMISSION:
===================
___ 12:55AM BLOOD WBC-9.3 RBC-4.40 Hgb-13.3 Hct-38.8 MCV-88
MCH-30.4 MCHC-34.4 RDW-13.7 Plt ___
___ 12:55AM BLOOD Glucose-103* UreaN-14 Creat-0.8 Na-144
K-3.7 Cl-108 HCO3-23 AnGap-17
___ 12:55AM BLOOD ALT-13 AST-21 AlkPhos-110* TotBili-0.4
___ 10:20AM BLOOD Calcium-10.3 Phos-2.2* Mg-1.6
___ 10:20AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:00AM BLOOD Lactate-2.0
___ 02:51AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:51AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:51AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
___ 02:51AM URINE UCG-NEGATIVE
___ 12:19AM STOOL HELICOBACTER ANTIGEN DETECTION-Negative
LABS ON DISCHARGE:
===================
___ 05:53AM BLOOD WBC-6.7 RBC-4.45 Hgb-13.6 Hct-39.5 MCV-89
MCH-30.4 MCHC-34.3 RDW-14.1 Plt ___
___ 05:56AM BLOOD Glucose-79 UreaN-13 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-22 AnGap-17
___ 05:56AM BLOOD Albumin-4.7 Calcium-9.8 Phos-4.0 Mg-2.0
STUDIES/IMAGING:
=================
EGD ___:
Abnormal vascularity in the stomach body (biopsy)
Normal mucosa in the antrum (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow up the biopsies
Other recs per inpatient team and outpatient GI
MRI Brain ___:
Several nonspecific nonenhancing scattered foci of T2/FLAIR
signal
hyperintensity in the subcortical white matter of the left
greater than right frontal lobes. This is a nonspecific finding
and could be seen in the setting of demyelinating disease, prior
infection or inflammation, Lyme disease, migraine headache,
early chronic small vessel ischemic disease, and vasculitis
amongst other entities.
PATHOLOGY:
Biopsy from EGD ___:
1 A. Body: Fundal mucosa with chronic inflammation, mild; stains
for H. pylori are negative(control satisfactory).
2 A. Antrum: Superficial fragments of gastric mucosa with
chronic inflammation; stains for H. pylori are negative (control
satisfactory).
3 A.Duodenum: No diagnostic abnormalities recognized
Brief Hospital Course:
Ms. ___ is a ___ with PMHx notable for recurrent episodes
of abdominal pain and emesis of unknown etiology with multiple
negative previous work-ups, recently discharged from ___ on
___ who presented for evaluation of nausea, vomiting and
abdominal pain that was found to be most likely functional in
nature. Possibly due to cyclic vomiting syndrome with secondary
muscular abdominal wall pain.
# Acute on chronic nausea, vomiting and abdominal pain: Based on
review of records from ___ (available in scanned records) pt has
had multiple previous admissions at several different hospitals
over the last ___ years for nausea, vomiting and abdominal pain of
unclear etiology. During previous admissions to ___ (in
___ and ___ she had negative CT ___, MRCP,
gastric emptying study and RUQ ultrasound. During this admission
her basic lab work, UA and pregnancy test all returned negative.
There was no evidence of active infection such as
gastroenteritis to explain her acute symptoms. She denied any
depression, recent trauma or new recent stressors that may have
contributed to symptom onset. Her symptoms met criteria for
cyclic vomiting syndrome with possible secondary musculoskeletal
abdominal pain. She was admitted for symptom control given
inability to take PO. She received dilaudid in the ED, however
no further narcotic pain medications were given after admission.
She was treated with IV tylenol, toradol, Zofran and Phenergen.
After several days of conservative treatment she remained unable
to tolerate PO due to recurrent nausea/vomiting so the GI
service was consulted. EGD was performed on ___ that did not
show any explanation for her symptoms and biopsy returned
negative. MRI brain was performed to assess for possible central
cause that revealed incidental T2/flair white matter
hyperintensities that according to Neurology are unlikely to be
related to her symptoms. She was encouraged to continue
ambulation, hot showers and supportive care was provided.
Albumin was normal, no indication for nutritional
supplementation. Symptoms slowly began to improve and she was
able to tolerate some oral intake prior to discharge. She was
started on fiber supplementation, coenzyme Q10 and instructed to
drink plenty of fluids after discharge. She will have follow up
with GI after discharge. She would also benefit from outpatient
psych follow-up to establish relationship and treatment plan.
# T2/flair frontal lobe white matter hyperintensities on MRI
brain: Noted on brain MRI obtained to assess for possible
central etiology of persistent nausea/vomiting as above. Pt
denies personal or family history of migraines. No headaches,
neurologic symptoms or focal neuro changes on exam. Neurology
was consulted who felt that findings were nonspecific and in
light of intact neurologic exam do not require further
investigation or follow up.
# Constipation: Pt complained of no BM in several days after
arrival. This is most likely due to a combination of very
limited PO intake as well as constipating medications including
zofran. She was managed with a bowel regimen of senna/colace
with good effect. Fiber supplementation was started. Ambulation
and fluid intake were encouraged.
# GERD: Pt reports history of reflux symptoms for which she
takes pantoprazole daily at home. Transitioned to IV while
unable to tolerate PO then back to home oral form prior to
discharge.
TRANSITIONAL ISSUES:
====================
- Discharged with coenzyme Q10 (rec'd by GI for cyclic
vomiting), fiber supplement, PPI, and zofran for nausea
- Follow up with GI as an outpatient
- Would benefit from further evaluation by psychiatry as an
outpatient to establish a relationship and create treatment plan
- Would avoid any narcotics as this is a chronic issue for
patient and would likely be worsened by such treatment
- CODE: Full
- CONTACT: Mom (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
2. Psyllium Wafer 1 WAF PO DAILY
RX *psyllium [Metamucil] 1.7 g 1 wafer(s) by mouth daily Disp
#*24 Wafer Refills:*0
3. Zofran ODT (ondansetron) 4 mg oral Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 8
hours Disp #*30 Tablet Refills:*0
4. coenzyme Q10 200 mg oral BID
RX *coenzyme Q10 200 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Functional abdominal pain
Cyclic vomiting syndrome
Secondary:
Gastroesophageal reflux disease
History of H. Pylori infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you were having abdominal pain, nausea and vomiting.
Your lab work and urine studies returned normal. You were
treated with medications for nausea and intravenous fluids. A
test was sent that showed you were clear of the helicobacter
pylori infection that you were previously treated for. You were
evaluated by the GI team who felt that your symptoms were most
likely related to cyclic vomiting. An MRI brain was performed
that showed nonspecific findings without any other abnormalities
that would explain your symptoms. The Neurology team was
consulted who did not feel that the finding represented anything
dangerous based on your exam and did not think that any further
work-up or follow up was necessary. Your endoscopy did not
identify anything concerning. Fortunately, your symptoms
improved and you were able to tolerate food by mouth prior to
discharge.
You will have a follow up appointment with your primary care
doctor after discharge. Please take your medications as
prescribed and attend all follow-up appointments as scheduled.
It was a pleasure participating in your care - we wish you all
the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10603830-DS-21 | 10,603,830 | 28,305,119 | DS | 21 | 2111-12-20 00:00:00 | 2111-12-20 12:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: bifrontal contusions s/p head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ M hx IVDA who was found unresponsive by EMS with head
laceration. Pt endorses assault but denies recollection of full
events. OSH head CT showed bifrontal contusions with traumatic
SAH and pt was sent to ___ for further evaluation. C/o headache,
nausea and vomiting.
ROS: no CP, SOB
Past Medical History:
PMHx: hx IVDA
Social History:
___
Family History:
Family Hx: NC
Physical Exam:
PHYSICAL EXAM:
O: HR: 41 BP: 138/56 RR: 16 O2Sat: 99%
Gen: WD/WN, comfortable, NAD.
HEENT: occipital head laceration
Neck: Supple. C-Collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: somewhat lethargic but easily arousable, alert,
cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date but difficulty
with day.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 4
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On Discharge:
Intact
Pertinent Results:
___ 11:00AM CK(CPK)-122
___ 11:00AM CK-MB-2 cTropnT-<0.01
___ 03:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:30PM GLUCOSE-116* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-19
___ 11:30PM CALCIUM-10.0 PHOSPHATE-3.8 MAGNESIUM-1.8
___ 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:30PM WBC-16.4* RBC-4.79 HGB-14.7 HCT-43.4 MCV-91
MCH-30.7 MCHC-33.9 RDW-12.8
___ 11:30PM NEUTS-91.9* LYMPHS-4.1* MONOS-3.9 EOS-0
BASOS-0.1
___ 11:30PM PLT COUNT-281
___ 11:30PM ___ PTT-29.3 ___
CXR ___:
FINDINGS: The inspiratory lung volumes are decreased. The
lungs are clear
without focal consolidation, pleural effusion or pneumothorax.
The pulmonary
vasculature is not engorged. The cardiac silhouette is
accentuated due to
underinflation of the lungs, but likely top normal in size. The
mediastinal
and hilar contours are within normal limits. The visualized
upper abdomen is
unremarkable on this supine view. No acute osseous abnormality
is detected.
IMPRESSION: No acute intrathoracic process, specifically no
pneumothorax.
___ CT Head
1. Unchanged bifrontal hemorrhagic contusions without new focus
of hemorrhage.
2. Global effacement of the sulci and the ventricles with
indistinct
gray-white matter junction suggestive of cerebral edema,
unchanged from prior study.
3. Subgaleal hematoma at the left occiput without underlying
fracture
Brief Hospital Course:
___ yo ___, found down, possible assault, with bifrontal
contusions on head CT, head laceration. Pt was admitted to the
neurosurgery service on ___ for observation. Repeat head CT on
___ was stable.
Pt was persistently bradycardic in ___ this was worked up with
EKG (sinus bradycardia with junctional escape rhythm), TTE
(negative), cardiac enzymes (negative). Cardiology consult was
obtained and they felt there was no need for further cardiac
workup.
Pt's leukocytosis to 16K on admission (no fever), was worked up
w/CXR (no acute process), U/A (wnl), blood cx (no growth to
date). On was mobilized and on ___ was deemed fit for discharge
to home without services. He was given instructions for
follow-up and prescripitons for required medications.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Do not take more than 4grams of acetaminophen in a day
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral contusion
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 on the neurosurgery
service.
Please follow these instructions:
Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10604406-DS-18 | 10,604,406 | 27,342,206 | DS | 18 | 2180-06-27 00:00:00 | 2180-06-28 20:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLQ abdominal pain w/ N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of NIDDM, CVA in ___, HTN, BPH,
polycythemia, who presented to our ED with 2 hours of severe RLQ
pain. He described the pain as dull, ___, with no alleviating
or exacerbating factors. Concomitantly, he endorsed one episode
of non-bloody emesis. No diarrhea, no changes in bowel or
urinary habits.
On arrival to the ED initial vitals were pain 10 98.8 ___ 16 95% ra. Exam notable for moderate distress, soft
mildly distended abdomen TTP in RLQ w/o rebound or guarding or
CVA tenderness. Labs showed WBC 15.2, lactate 2.1, lipase 84,
Cr 1.4 from baseline of 0.8, glucose 273. UA notable for 101
RBC's and 1000 glucose. He was given 10mg IV hydral, 4mg IV
zofran, and 0.5mg IV dilaudid. Pain was controlled but he
remained hypertensive to 170/108. Ct abdomen revealed a 4 mm
stone in the right proximal ureter with hydronephrosis and
stranding about the right kidney, concerning for forniceal
rupture.
Urology was consulted and recommended conservative management.
Past Medical History:
NIDDM
CVA in ___
HTN
BPH
polycythemia
PTSD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
Vitals- 98.3, 93, 181/106, 18, 96%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, completely non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM
Vitals- 97.8, 126/84, 86, 18, 100%RA
General- Alert, oriented, no acute distress, initially sleeping
upon entering the room
HEENT- Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 06:30PM BLOOD WBC-15.2*# RBC-5.83 Hgb-16.7 Hct-48.5
MCV-83 MCH-28.7 MCHC-34.5 RDW-13.0 Plt ___
___ 06:30PM BLOOD Neuts-88.1* Lymphs-8.0* Monos-3.3 Eos-0.1
Baso-0.5
___ 06:30PM BLOOD Glucose-273* UreaN-32* Creat-1.4* Na-136
K-4.8 Cl-97 HCO3-24 AnGap-20
___ 06:30PM BLOOD ALT-26 AST-24 AlkPhos-79 TotBili-0.3
___ 06:30PM BLOOD Lipase-84*
___ 06:30PM BLOOD Albumin-5.1 Calcium-10.1 Phos-4.1 Mg-2.1
___ 06:35PM BLOOD Lactate-2.1*
___ 06:30PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:30PM URINE RBC-102* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
PERTINENT LABS
___ 03:19AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:19AM URINE Color-Straw Appear-Clear Sp ___
___ 03:19AM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
DISCHARGE LABS
___ 08:10AM BLOOD WBC-12.5* RBC-5.57 Hgb-15.9 Hct-47.1
MCV-85 MCH-28.6 MCHC-33.8 RDW-13.4 Plt ___
___ 08:10AM BLOOD Neuts-78.4* Lymphs-15.0* Monos-5.3
Eos-0.8 Baso-0.5
___ 08:10AM BLOOD Glucose-209* UreaN-21* Creat-0.9 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
MICROBIOLOGY - None
PERTINENT IMAGING
___ CT ABD & PELVIS W/O CONTRAST
IMPRESSION: Obstructing proximal right ureteral stone measuring
4 mm with right kidney hydronephrosis and perinephric stranding
consistent with forniceal rupture.
Brief Hospital Course:
___ with a history of NIDDM, CVA in ___, HTN, BPH,
polycythemia, who presented to our ED with 2 hours of severe RLQ
pain found to have an obstructing renal stone with
hydronephrosis and forniceal rupture.
ACTIVE ISSUES
#Obstructing renal calculi with hydronephrosis and forniceal
rupture: Found to have obstructing stone on the right associated
with hydronephrosis and forniceal rupture. Likely RLQ pain
correlates with forniceal rupture. Seen by urology in ED who
recommend conservative management with pain meds and zofran, no
role for surgery. Pt got one dose of IV dilaudid in the ED and
did not report any pain while on the floor. Able to sleep
through the night and tolerate PO intake. Exam totally benign.
Unclear if pt was able to pass stone while at ___. Discharged
with prn toradol to use for pain if stone has not passed yet.
___: Baseline creatinine is 0.8. Creatinine on admission up to
1.4. Thought to be secondary to forniceal rupture. Held home
dose of lisinopril. Resolved without fluids and now on the
morning of discharge found to be back to baseline at 0.9.
#Leukocytosis: 15.3 at time of presentation. Likely secondary to
acute obstruction and resulting forniceal rupture. Pt never
received abx. WBC on the morning of discharge trending down,
now 12.5. Pt afebrile throughout admission.
CHRONIC ISSUES
#HTN and h/o CVA: Patient remained clinically stable on
amlodipine and IV hydralazine started this admission. Home
lisinopril was held in the setting of ___. Will restart
lisinopril on discharge.
#BPH: Patient remained clinically stable on home flomax.
#DM c/b neuropathy: Patient remained clinically stable. Home
metformin was held with a one time lactate level of 2.1. Will
restart at discharge.
TRANSITIONAL ISSUES
___ an appointment with PCP
___ urologist for follow up. Dr. ___ will help you
schedule this appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Ointment 1 Appl TP DAILY
2. Lisinopril 10 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Tamsulosin 0.4 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth
every 8 hours Disp #*15 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Lidocaine 5% Ointment 1 Appl TP DAILY
4. Psyllium 1 PKT PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Obstructive nephrolithiasis with forniceal rupture
Acute Kidney Injury
SECONDARY DIAGNOSES:
Hypertension
Benign Prostatic Hypertrophy
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for abdominal pain
which was caused by a kidney stone. This kidney stone got stuck
in the tube (ureter) which goes from the kidney to the bladder.
The stone caused the ureter to dilate and rupture which caused
you pain. You were seen by a urologist who felt that you did
not need surgery to fix this problem. You were treated with
pain medication and you improved. You continued to remain
stable and pain free overnight and were deemed safe for
discharge home.
We are unsure if you have passed the kidney stone. As you try
to pass the stone, you may have more pain as the stone moves
through your ureter. You are being discharged with some pain
medication to take on an as needed basis if this occurs.
Please take all your medications as prescribed.
You will need to follow up with your primary care doctor and ___
urologist. These appointments have already been made for you
and are included in your discharge paperwork.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10604492-DS-18 | 10,604,492 | 26,902,076 | DS | 18 | 2151-10-09 00:00:00 | 2151-10-09 18:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, chills, night sweats, right flank pain
Major Surgical or Invasive Procedure:
___ Deep cervical lymph node biopsy
___ Pulmonary nodule biopsy
History of Present Illness:
___ year-old ___ male w/ no known significant PMH who
presents with cervical lymphadenopathy, recurrent fevers, night
sweats, and new onset of bony pain in the R hip and R flank.
Approximately two months ago he noticed lumps in his neck, which
from the description are consistent with cervical
lymphadenopathy. For the past two weeks, he has had fevers and
night sweats on a daily basis.
He also developed new R flank and R hip pain over the past two
weeks. The pain is well-localized and varies in intensity.
He has reportedly sought medical care for these concerning
symptoms in ___, but he reports that the physicians he saw
in his home country have not moved to perform any definitive
workup. While visiting his aunt (who lives in ___, he has
decided
to present to ___ for evaluation.
In the ED, his vitals were stable. Labs were without any marked
abnormality, although he has mild leukocytosis (WBC 10), mild
normocytic anemia (Hgb 12.6), mild INR elevation (1.2), and a
mild non-gap acidosis (bicarb 21). CT chest showed: "Multiple
bilateral areas of airspace consolidation and ground-glass
opacities in peribronchial peribronchovascular distribution in
addition to supraclavicular, and mediastinal lymphadenopathy,"
which was felt to be "highly concerning for malignancy, lymphoma
in particular."
He was seen by heme/onc who suggested admission to medicine for
workup of presumed malignancy, with transfer to ___ if needed
when workup is complete.
REVIEW OF SYSTEMS
GEN: as per HPI
CARDIAC: denies chest pain or palpitations
PULM: denies new dyspnea; denies cough
GI: denies n/v, denies change in bowel habits
GU: denies dysuria or change in appearance of urine
Full 14-system review of systems otherwise negative and
non-contributory.
Past Medical History:
none
Social History:
___
Family History:
Uncle with an abdominal malignancy in his ___. No other family
or
personal history of cancer or blood disorders.
Physical Exam:
ADMISSION
=========
VITALS: all vitals since arrival on the medical ward were
reviewed
CONSTITUTIONAL: thin young man in NAD
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear
LYMPHATIC: Cervical LAD, especially on the right side. No
axillary or inguinal LAD appreciated.
CARDIAC: RRR, no M/R/G, JVP not elevated, no edema
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS
GU: no CVA tenderness, suprapubic region soft and nontender
MSK: no visible joint effusions or acute deformities.
DERM: no visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
Discharge:
=========
Gen: Pleasant, calm, no acute distress.
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: JVP not appreciated. Normal carotid upstroke without
bruits. Biopsy sight on right neck clean, dry, non-tender, not
erythematous.
LYMPH: Prominent cervical and supraclavicular lymphadenopathy.
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi.
ABD: NABS. Soft, NT, ND, no palpable masses.
EXT: WWP. No ___ edema.
SKIN: Biopsy site clean/dry, appropriately tender. No
rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: ___ site clean, not erythematous or tender.
Pertinent Results:
___ 09:10AM BLOOD WBC-10.0 RBC-4.72 Hgb-12.6* Hct-39.7*
MCV-84 MCH-26.7 MCHC-31.7* RDW-13.9 RDWSD-42.7 Plt ___
___ 09:10AM BLOOD Neuts-73.1* Lymphs-17.1* Monos-8.2
Eos-0.9* Baso-0.3 Im ___ AbsNeut-7.31* AbsLymp-1.71
AbsMono-0.82* AbsEos-0.09 AbsBaso-0.03
___ 02:18PM BLOOD ___ PTT-36.8* ___
___ 09:10AM BLOOD Plt ___
___ 02:18PM BLOOD ___
___ 09:10AM BLOOD Glucose-84 UreaN-13 Creat-0.8 Na-139
K-6.1* Cl-103 HCO3-21* AnGap-15
___ 09:10AM BLOOD LD(LDH)-657*
___ 06:40AM BLOOD ALT-15 AST-16 LD(LDH)-251* AlkPhos-69
TotBili-1.0
___ 09:10AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 UricAcd-4.4
___ 09:10AM BLOOD HCV Ab-NEG
___ 02:18PM BLOOD HIV Ab-NEG
___ 09:10AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 12:18PM BLOOD K-4.0
==========
IMAGING
CXR
IMPRESSION:
Multifocal pulmonary opacities bilaterally are nonspecific, but
worrisome for multiple pulmonary nodules. Correlate with any
history of malignancy. Alternatively, findings may represent
multifocal pneumonia.
Fullness of the left hilum could be due to underlying
lymphadenopathy.
Chest CT is pending.
R HIP XRAY
IMPRESSION:
No acute fracture or dislocation.
Equivocal 1.2 cm lucency in the lateral proximal femoral shaft
without
overlying cortical destruction. Unclear whether this is
artifactual.
Cross-sectional imaging, such as CT or MRI, would further
assess.
CT hip
1. No evidence of malignancy in the right hip. No correlate
found for lucency seen on hip radiograph which likely represents
irregular projection of normal marrow fat.
2. Free intrapelvic fluid appears slightly increased compared to
prior CT.
CT CHEST
IMPRESSION:
Multiple bilateral pulmonary nodules in addition to
supraclavicular, and
mediastinal and hilar lymphadenopathy, are highly concerning for
neoplastic process and metastatic disease. Lymphoma is a
consideration.
CT AP
IMPRESSION:
Enlarged para-aortic and aortocaval lymph nodes measuring up to
11 mm in short axis. Given the presence of mediastinal, and
bilateral hilar lymphadenopathy in the chest along with
diffusely scattered lung parenchymal nodules, metastatic
disease; lymphoma are differentials. A scrotal ultrasound is
recommended to look for primary neoplasm.
SCROTAL U/S:
IMPRESSION:
No scrotal mass or sonographic finding suspicious for malignancy
in bilateral testes.
PERTINENT:
==========
___ 11:45 am TISSUE LEFT LUNG NODULE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 12:50 pm TISSUE CERVICAL LYMPH NODE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Reported to and read back by ___ (___) AT
815AM
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
SECOND MORPHOLOGY.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
Reported to and read back by ___ ___ AT
15:59.
DEMATIACEOUS MOLD.
CERVICAL LYMPH NODE Bx:
=======================
-CYTOGENETICS
Two of the metaphase cervical lymph node cells examined had a
complex pentaploid karyotype with several structural chromosome
aberrations, including two copies
of an isochromose of the short arm of chromosome 9. These
findings may represent
___ cells or other multinucleated Hodgkin lymphoma
related cells.
-PATHOLOGY
Nonspecific T cell predominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin lymphoma
are not seen in this specimen. Correlation with clinical,
morphologic (see separate pathology report ___ and other
ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
DISCHARGE:
==========
___ 12:00AM BLOOD WBC-10.9* RBC-4.35* Hgb-11.5* Hct-36.4*
MCV-84 MCH-26.4 MCHC-31.6* RDW-15.5 RDWSD-47.2* Plt ___
___ 12:00AM BLOOD Neuts-62.4 ___ Monos-9.7 Eos-4.6
Baso-0.7 Im ___ AbsNeut-6.80* AbsLymp-2.43 AbsMono-1.06*
AbsEos-0.50 AbsBaso-0.08
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD ___ PTT-34.7 ___
___ 12:00AM BLOOD ___
___ 12:00AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-100 HCO3-25 AnGap-15
___ 12:00AM BLOOD ALT-31 AST-23 LD(LDH)-253* AlkPhos-63
TotBili-0.3
___ 12:00AM BLOOD TotProt-7.3 Albumin-3.7 Globuln-3.6
Calcium-9.3 Phos-3.5 Mg-2.1
Brief Hospital Course:
Mr. ___ is a previously healthy ___ YO male who presented
with B symptoms (fevers, chills, night sweats) and right-sided
flank pain, found to have Nodular Sclerosing Hodgkin Lymphoma,
he was transferred to the ___ service for further treatment
planning and work-up.
ACUTE/ACTIVE PROBLEMS:
# Hodgkin's Lymphoma:
Found on ___ cervical biopsy. Stage IV Hodgkin's lymphoma due
to the presence of noncontiguous extra-lymphatic involvement on
CT. TTE was within normal limits (EF 59%). Will hold on sperm
banking due to low risk of infertility with ABVD. PET CT ___
showed cervical and thoracic lymphadenopathy, many pulmonary
nodules, subdiaphragmatic involvement, left iliac bone and
proximal right femur osseous involvement. Cervical biopsy
confirmed NS Hodgkin's lymphoma; however, also grew Dematiaceous
mold and coag negative staph. This is most likely a contaminant,
but he was worked up for infection prior to initiating
chemotherapy. TB Quantiferon, HIV Ab, HCV, and HBV were
negative. Beta-D-glucan was positive in serum, but Aspergillus
galactomannan negative. Obtained biopsy of pulmonary nodule
(___) to rule out infectious process. Gram stain, AFB stain, and
___ prep of nodule were negative. Held off on antifungal
treatment due to low concern of true infection. Cultures still
pending at discharge. He received ABVD therapy on ___, with no
complications. TLS labs were all reassuring. Patient received
TLS prophylaxis with allopurinol
#Immigration/Insurance
He used to live in ___, but is moving here
permanently to be with his son and family. Financial services
and case management are helping investigate emergency ___
coverage and he filled out an application.
CHRONIC ISSUES:
None
TRANSITIONAL ISSUES
[] Will need to establish care with PCP as outpatient
[] Pulling PICC on discharge. Will eventually require
port-a-cath.
[] Discuss the possibility of A+AVD for subsequent cycles, if
insurance will allow it.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once daily Disp #*14
Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight horus Disp
#*14 Tablet Refills:*0
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once daily Disp #*14
Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight horus Disp
#*14 Tablet Refills:*0
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Nodular Sclerosing Hodgkin lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted with side pain, fevers, sweats, and enlarged
lymph nodes. You underwent a lymph node biopsy that confirmed a
diagnosis of Hodgkin lymphoma.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
Because your lymph node biopsy showed some evidence of
infection, you underwent a biopsy of a nodule in your lung to
rule out an infection before beginning chemotherapy. This biopsy
was reassuring that it is safe to proceed with treatment of your
lymphoma. You received testing of your lungs and your heart
prior to starting chemotherapy. You were treated with a
chemotherapy regimen called ABVD.
WHAT SHOULD I DO WHEN I GO HOME?
- Take all medications as prescribed, and attend all scheduled
clinic visits.
- Call your doctor if you develop a cough, fever, chills, or any
other symptoms concerning for infection.
- Let your doctor know if you notice difficulty with breathing.
This is a complication develop due to one of the chemotherapy
drugs that you are receiving.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10604718-DS-9 | 10,604,718 | 21,754,835 | DS | 9 | 2184-02-15 00:00:00 | 2184-02-15 09:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Oxycodone
Attending: ___
Chief Complaint:
left face, arm and leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old right handed man with history of
atrial fibrillation on Coumadin, hyperlipidemia, CAD s/p CABG
and
___ s/p evacuation in ___ who presents with fluctuating
symptoms of left face/arm/leg weaness and dysarthria as a
transfer from OSH. This afternoon, Mr. ___ was watching
television and fell asleep on the couch for what he thinks was
only several minutes. When he woke up at ~2:30pm, he noted that
he was very weak in the left arm and leg. He had to slide
himself along the floor to reach the phone and called ___. When
speaking on the phone, he noted that his speech was very slurred
and it was difficult to understand what he was saying. Denies
any associated headache, vision changes, numbness, clumsiness,
nausea. When he arrived at ___, per ED note, his
symptoms had fully resolved and his NIHSS was 0. He then was
taken to CT. When he returned at 4pm, his symptoms were back
and
NIHSS was 6 (left arm/leg/face weakness, dysarthria). He was
deemed not a ___ candidate given history of subdural hematoma
and
INR of 3.1. Neurology was consulted as well. Symptoms again
resolved, but once again resurfaced at hour and a half or so
later. Thus, he was transferred to ___ for further care. At
OSH, patient failed speech and swallow at bedside. Currently,
patient feels that his symptoms are much improved from earlier
today, but not quite at baseline. He does tell me that he has
had intermittent mildly slurred speech for the last several
months. This happens rarely, cannot quanitify how long it lasts
because he does not talke much.
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.
On ___ 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:
Hypertension
Hyperlipidemia
L sided subdural hematoma s/p evacuation in ___ (at ___
Atrial fibrillation on coumadin
CAD s/p CABG
Polymyalgia rheumatica
Social History:
___
Family History:
No strokes, seizures, malignancies
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T 97.4 HR 61 BP 138/90 RR 18 O2 98% RA
___: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: irregularly irregular, no murmurs
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 extremely dysarthric
when
sitting up, improved significantly and quickly with lying flat
and fluids. Able to follow both midline and appendicular
commands.There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation. Funduscopic
exam: could not visualize fundi due to miosis.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left nasolabial fold flattening nad decreased activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ 5 4+ 5 4+ 5 4+ 5 5 4+
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, proprioception throughout.
Decreased sensation to pinprick distally in LEs to just below
knees bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor on R, extensor on L.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: deferred.
================
DISCHARGE EXAM:
================
-Mental Status: Alert, oriented x 3. Attentive. Language is
fluent with normal prosody. There were no paraphasic errors.
Speech was not dysarthric. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Face 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: 4 to 4- in bilateral deltoids. Slight left arm
pronation, strength is otherwise full.
- Coordination: Normal FNF bilaterally.
- Gait: normal.
Pertinent Results:
___ 08:55PM URINE HOURS-RANDOM
___ 08:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:55PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:31PM GLUCOSE-91 NA+-142 K+-4.2 CL--101 TCO2-29
___ 07:28PM CREAT-0.9
___ 07:28PM estGFR-Using this
___ 07:17PM UREA N-14
___ 07:17PM ALT(SGPT)-22 AST(SGOT)-27 ALK PHOS-72 TOT
BILI-0.4
___ 07:17PM LIPASE-23
___ 07:17PM cTropnT-<0.01
___ 07:17PM ALBUMIN-4.0 CALCIUM-9.0 PHOSPHATE-3.8
MAGNESIUM-2.1
___ 07:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:17PM WBC-7.9 RBC-4.77 HGB-13.0* HCT-40.3 MCV-85
MCH-27.2 MCHC-32.2 RDW-15.6*
___ 07:17PM NEUTS-67.5 ___ MONOS-7.2 EOS-1.6
BASOS-2.0
___ 07:17PM ___ PTT-46.5* ___
CTA head and neck ___
1. CTA head demonstrates no evidence of focal stenosis,
dissection or
aneurysm greater than 3 mm. Mild to moderate atherosclerotic
disease is seen within the cavernous segments of the bilateral
internal carotid arteries.
2. CTA neck demonstrates no evidence of stenosis, occlusion,
dissection or aneurysm/pseudoaneurysm formation. There is
moderate atherosclerotic disease at the carotid bulbs and origin
of the vertebral arteries.
MR head ___ (neurology read)
restricted diffusion in the right internal capsule suggestive of
acute ischemic stroke
Brief Hospital Course:
___ year old right handed man with history of atrial fibrillation
on Coumadin, hyperlipidemia, CAD s/p CABG and SDH s/p evacuation
in ___ who presents with fluctuating symptoms of left
face/arm/leg weaness and dysarthria as a transfer from OSH. As
per HPI, he had three distinct episodes of these same symptoms
approximately 1.5 hours apart. His initial exam was notable for
left NLF flattening, LUE and LLE weakness (leg weaker than arm).
NCHCT with no large territory hypodensity suggestion of
infarct. CTA head/neck showed only atherosclerosis but no
significant stenosis or occlusion. By hospital day 2, he only
showed subtle pronation of his left hand. His exam localized to
right internal capsule which was confirmed on MRI. Of note, he
did not receive tPA at OSH due to a supratherapeutic INR of 3.1
and the fact that he had a SDH in the past. His INR was 3.5 on
arrival to ___ so warfarin was held (and was restarted at a
lower dose when INR was 2.9). Also, he was given keppra
initially for concern of seizure (given the episodic nature of
the symptoms) but was later on discontinued once the diagnosis
of ischemic stroke was made.
Given the location of the infarct and the stuttering course
producing the same set of symptoms each time, it is most
consistent with a small vessel stuttering lacune as emboli are
unlikely to be affecting the same area each time (and the fact
that he was supratherapeutic makes it less likely that embolic
stroke is the etiology).
For secondary prevention/risk assessment: we recommend continue
control of HTN. His A1c was 5.9%. His labs showed cholesterol
124, triglycerides 94, HDL 51, and LDL 54. Given his h/o SDH,
the risk of starting ASA on top of warfarin is likely going to
outweight the benefit. Therefore, we recommend continuing
warfarin with goal INR of ___ without ASA.
Transitional issues:
- titrate wafarin to goal INR of ___. We decreased his warfarin
dose due to supratherapeutic INR at home dose but increased it
back to home dosing schedule due to fast drop in INR. Recommend
close follow up in ___ clinic.
- follow up in stroke clinic
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Simvastatin 20 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Diltiazem Extended-Release 90 mg PO DAILY
4. TraZODone 75 mg PO HS
5. Tamsulosin 0.4 mg PO HS
6. Warfarin 2.5 mg PO AD
7. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. PredniSONE 10 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. TraZODone 75 mg PO HS
6. Diltiazem Extended-Release 90 mg PO DAILY
7. Warfarin 2.5 mg PO ___ atrial
fibrillation
8. Warfarin 1.25 mg PO ___ atrial
fibrillation
9. Outpatient Physical Therapy
dx: lacunar infarct, residual weakness
Discharge Disposition:
Home
Discharge Diagnosis:
Right internal capusule ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam: left hand pronation. Mild bilateral deltoid
weakness.
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of left face, arm and leg
weakness resulting from an ACUTE ISCHEMIC STROKE in the region
called internal capsule in the right side of your brain. Stroke
is a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
High cholesterol
A fib
We are changing your medications as follows:
- We adjusted your warfarin dose because your INR was too high.
Please go to your ___ clinic and have your INR checked on
___.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10604870-DS-16 | 10,604,870 | 26,753,935 | DS | 16 | 2122-07-02 00:00:00 | 2122-07-02 20:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache and double vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with a past medical history
notable for bladder cancer status post cystectomy, CKD stage
III, hypertension who presents from an outside hospital after
being found to have a small pontine hemorrhage.
The story is obtained from the patient. Earlier this evening,
the patient was in his usual state of health. He did enter into
a verbal altercation with his wife. At around 8:00 in the
evening, he felt an acute onset of headache near the vertex of
his head. This was rated at max about ___ out of 10, with no
radiation, and resolved on its own after a few minutes. At the
same time, he noticed the onset of double vision, most
noticeable when looking straight ahead. Closing one eye resolved
the double vision (closing left eye removed left image and
closing right eye removed right image). His old vision was at
its worst when looking at objects far away. He denied any
weakness, numbness, vertigo at this time. He presented
initially to ___ ___. Systolic blood pressure upon arrival
was reported to be in the 160s. A noncontrast head CT showed a
small pontine hemorrhage. Subsequent blood pressure
measurements were in the range of 130s. No history of
anticoagulants. There was no evidence of coagulopathy. He was
transferred to ___ for further management.
Review of systems otherwise unremarkable, denies recent weight
loss, fevers, chills.
Past Medical History:
Bladder cancer (dx ___ s/p cystectomy with neobladder
placement (___) and multiple revisions including removal of
failed artificial sphincter 3 weeks ago
CKD stage III
Hypertension
Hyperlipideamia
Social History:
___
Family History:
No family history of neurologic disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: 98.1 HR: 79 BP: 135/79 RR: 16 SaO2: 98% on room
air
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to person, time, and
place. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Speech is fluent
with full sentences, intact repetition, and intact verbal
comprehension. Naming intact. Registers 3 out of 3 items and is
able to recall 3 out of 3 in 5 minutes spontaneously. No
paraphasias. No dysarthria. Normal prosody. No apraxia. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to finger wiggle.
The right eye is unable to ABduct fully to the right, otherwise
extraocular movements are intact in all other fields of gaze.
The patient is able to move his left eye in all directions. At
rest, the left eye rests slightly ADducted. There is diplopia
at central gaze. Diplopia is not elicited in other fields of
gaze. There is no nystagmus. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Hearing intact
to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: deferred
DISCHARGE PHYSICAL EXAM:
========================
VS: T 97.7, BP 110s-130s/70s-80s, HR ___, RR 12, O2 95% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: non-labored breathing
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to person, place, month
and year. Able to relate history and name ___ without
difficulty. Speech is fluent with full sentences and intact
verbal comprehension. No dysarthria. Able to follow midline and
appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to confrontation. At
rest, L eye is slightly adducted. R eye unable to abduct fully,
L eye unable to look upward fully. Otherwise EOMI. Diplopia
throughout (except upward gaze), worse looking right, closing R
eye erases R image, closing L eye erases L image. Few beats of
nystagmus to the left. V1-V3 without deficits to light touch
bilaterally. Possible slight right lower facial droop, with good
symmetric activation. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone throughout. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
Bilateral plantar flexor response.
- Sensory: No deficits to light touch bilaterally. No extinction
to DSS.
- Coordination: No dysmetria with FNF bilaterally. Bilateral
intention tremor.
- Gait: Deferred
Pertinent Results:
ADMISSION LABS:
===============
___ 01:12AM BLOOD WBC-6.7 RBC-4.25* Hgb-11.7* Hct-37.8*
MCV-89 MCH-27.5 MCHC-31.0* RDW-15.9* RDWSD-51.0* Plt ___
___ 01:12AM BLOOD Neuts-73.0* Lymphs-12.5* Monos-12.8
Eos-0.7* Baso-0.6 Im ___ AbsNeut-4.91 AbsLymp-0.84*
AbsMono-0.86* AbsEos-0.05 AbsBaso-0.04
___ 01:12AM BLOOD ___ PTT-29.0 ___
___ 01:12AM BLOOD Glucose-105* UreaN-24* Creat-1.6* Na-140
K-5.4* Cl-102 HCO3-24 AnGap-14
___ 09:30AM BLOOD ALT-15 AST-18 LD(LDH)-159 CK(CPK)-61
AlkPhos-70 TotBili-0.4
___ 09:30AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 09:30AM BLOOD %HbA1c-5.6 eAG-114
___ 01:12AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:30AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.0 Mg-2.0
Cholest-153
___ 09:30AM BLOOD Triglyc-350* HDL-29* CHOL/HD-5.3
LDLcalc-54
___ 09:30AM BLOOD TSH-2.9
IMAGING:
========
___ CT (___): There is a 7 mm pontine hemorrhage
posteriorly. No other hemorrhages are identified. There is no
midline shift. The ventricles, sulci and basilar cisterns are
appropriate for patient's age. There are mild periventricular
white matter hypodensities which are nonspecific but can be seen
in patients with small vessel ischemic changes.
___ MRI/MRA head: Small focus of hemorrhage in the posterior
right paramedian pons, with mild surrounding edema. Faint
associated enhancement, can be seen with early subacute
hematoma. Normal MRA.
DISCHARGE LABS:
===============
___ 06:35AM BLOOD WBC-7.2 RBC-3.89* Hgb-11.4* Hct-34.9*
MCV-90 MCH-29.3 MCHC-32.7 RDW-16.1* RDWSD-52.1* Plt ___
___ 06:35AM BLOOD Glucose-96 UreaN-24* Creat-1.6* Na-141
K-4.5 Cl-104 HCO3-19* AnGap-18*
___ 06:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ man with a history of bladder cancer
s/p cystectomy with multiple subsequent revision surgeries, CKD
stage III, HTN, and HLD who presented to ___ with
acute onset headache and double vision, found to have a small
posterior pontine hemorrhage, and subsequently transferred to
___.
#Posterior pontine hemorrhage
___ records revealed 7mm posterior pontine hemorrhage
without mass-effect on cerebral aqueduct. The location of the
hemorrhage explains the patient's exam findings of limited R eye
abduction and worsening diplopia with rightward gaze (CN VI
lesion). The patient also underwent an MRI/MRA of his brain
which revealed the same small focus of hemorrhage in right
posterior pons. The etiology of his stroke was likely
hypertensive given his history and it's location, though an
underlying process - such as vascular malformation vs. mass
lesion - will need to be further investigated with outpatient
MRI in about six weeks. The MRI he received showed no evidence
of vascular malformation. While hospitalized, his BP was
controlled to SBP<140 with his home dose of Lisinopril 5mg
daily. We held his home Pravastatin in the setting of hemorrhage
but restarted it upon discharge. Furthermore, we gave him an eye
patch to wear around the clock, alternating eyes every ___
hours, which he should continue using at home. We recommend f/u
with OT for visual issues as well as neuro-opthalamology.
#Asymptomatic bacteriuria
History of bladder cancer and neo bladder with bowel. Asx so did
not treat.
#CKD Stage III
No acute issues. Stable Cr. Discharge Cr 1.6.
TRANSITIONAL ISSUES:
======================
#NO NEW MEDICATIONS. Advised to continue to wear eye patch,
alternating eyes every ___.
[] Please arrange for follow-up MRI in 6 weeks to assess for
possible underlying lesion (vascular malformation vs. mass)
[] Please arrange for follow-up appointments with
Neuro-ophthalmology within ___ months (patient prefers to have
these through ___. We have scheduled an appointment w/ ___
neurology if he prefers to follow-up here. If not, his
appointment should be cancelled.
[] Recommend outpatient OT referral for eye training.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Pravastatin 30 mg PO QPM
3. methenamine hippurate 500 mg oral BID
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
2. methenamine hippurate 500 mg oral BID
3. Pravastatin 30 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute posterior pontine hemorrhage
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 headache and double
vision resulting from an ACUTE HEMORRHAGIC STROKE, a condition
where there is bleeding in your brain from a blood vessel that
usually provides it with oxygen and nutrients. 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. In your case,
the bleeding occurred in a part of the brain that controls fine
movements of your eyes.
Hemmorrhagic 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:
1. Hypertension (high blood pressure)
- You had an MRI performed showing that you don't have any
underlying vessel malformation to put you at risk for bleed.
Your remaining stroke risk factors include:
2. Hyperlipidemia (high cholesterol)
3. History of cancer
Please take your medications as prescribed. Please also continue
to wear the eye patch around the clock, alternating eyes every
___ hours.
Please follow up with your primary care physician as listed
below ___ @ 10:30am). Your PCP should then arrange for
follow-up appointments with Neurology and Neuro-ophthalmology
within the next ___ months. We have scheduled an appointment in
our neurology clinic, but you may cancel it if you prefer to
follow-up with the ___. As part of your follow-up, you will
undergo a repeat MRI of your brain in about 6 weeks (once the
blood has been reabsorbed) to look for other possible underlying
causes of your stroke.
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:
___
|
10605792-DS-3 | 10,605,792 | 27,039,662 | DS | 3 | 2141-06-21 00:00:00 | 2141-06-24 09:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right facial numbness and leg weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yr old with hx of Right cerebellar stroke in the stetting of
a PFO ___ year ago, surgically repaired and hx DM, peripheral
neuropathy, HTN and hyperlipidemia who presents to the ED with
right face and foot numbness since 3 am.
He reports that he was in his usual state of helath till 3 am
when he woke up and noted his Right leg below the knee including
the foot was numb and tingling. He went back to sleep, woke up
at 9 am with persistent numbness and right cheek tingling and he
think his left foot was tingling too. He reports that he felt
unsteady walking to the kitchen but not particularly weak.
Of note he had a recent Right foot ulcer for which he was in
supportive boots for weeks which were taken off in ___.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness or noted facial droop
by family. Denies bowel or bladder incontinence or retention.
On general review of systems, the patient denies fevers, rigors,
night sweats. Denies chest pain, palpitations, dyspnea, or
cough. Denies nausea, vomiting, diarrhea, constipation, or
abdominal pain. No recent change in bowel or bladder habits.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash.
Past Medical History:
DM on insulin
HTB
Peripheral diabetic neuropathy
Previous Right cerebellar stroke e
PFO s/p repair ___ yrs ago.
Social History:
___
Family History:
NC
Physical Exam:
Admission Exam:
Vitals: T: 98.5 HR: 94 BP:140/71 RR: 16 SaO2: 97% RA
General: NAD, morbidly obese.
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty . Attentive, able to name ___ backward without
difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
Sensory - No deficits to light touch, Increased sensation to
pain and temp on the dorsum of the right foot. No extinction to
DSS.
DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
Gait - deferred
Discharge exam:
vitals: BP 140/80, HR 85, Spo2 97%RA
gen: NAD
Pulm: CTAB
CV: RRR
ABD: NTND
Extremities: no edema
Neuro: Alert and oriented x3. speech is fluent no dysarthria,
face symmetric, EOMI, PERRL, strength ___ throughout, sensation
intact to LT throughout, follows simple and complex commnads
Pertinent Results:
___ 08:23PM ___ PO2-41* PCO2-43 PH-7.36 TOTAL CO2-25
BASE XS--1
___ 08:00PM GLUCOSE-340* UREA N-38* CREAT-1.7*
SODIUM-132* POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-22 ANION
GAP-21*
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE GR HOLD-HOLD
___ 05:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 05:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:42PM ___ PTT-27.7 ___
___ 02:54PM GLUCOSE-460* UREA N-40* CREAT-1.8*
SODIUM-132* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-21* ANION
GAP-21*
___ 02:54PM ALT(SGPT)-36 AST(SGOT)-27 ALK PHOS-97 TOT
BILI-0.6
___ 02:54PM ALBUMIN-4.4 CALCIUM-9.8 PHOSPHATE-3.8
MAGNESIUM-1.8
___ 02:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:54PM WBC-12.4* RBC-4.53* HGB-15.5 HCT-43.4 MCV-96
MCH-34.2* MCHC-35.7 RDW-11.9 RDWSD-41.3
___ 02:54PM NEUTS-62.4 ___ MONOS-9.1 EOS-2.3
BASOS-1.1* IM ___ AbsNeut-7.72* AbsLymp-2.99 AbsMono-1.13*
AbsEos-0.29 AbsBaso-0.14*
CT head
IMPRESSION:
1. No acute intracranial abnormality.
2. Small focal areas of hypoattenuation in the right
periventricular region
and in the right centrum semiovale appear old and likely
represent chronic
infarcts.
MRI c-spine wet read:
Alignment is anatomic. No cord signal abnormality is detected.
There is no
fluid collection within the cervical spinal canal.
MRI/MRA brain
IMPRESSION:
1. Late acute infarct in the posterolateral aspect of the right
inferior
medulla.
2. Multiple supra and infratentorial small chronic lacunar
infarcts as
described.
3. Unremarkable head MRA within limitations of motion artifact.
4. Mucous retention cysts in bilateral maxillary sinuses and
partial fluid
opacification of the right mastoid air cells.
MRI c spine
IMPRESSION:
1. Moderately motion degraded examination.
2. No evidence of spinal canal narrowing or cord compression.
No definite
cord signal abnormality.
MRA neck
IMPRESSION:
Unremarkable neck MRA.
MRA read pending
Brief Hospital Course:
___ yr old male with history of a right cerebellar stroke ___
years ago in the setting of a PFO (surgically repaired), and DM,
peripheral neuropathy, HTN and hyperlipidemia who presented to
the ED with right mid-cheek and lower leg numbness, found to
have multiple areas of hypodensities on CT indicative of chronic
infarcts. MRI brain showed right medullary infarct. MRA neck
showed patent vessels. The etiology is not clear. Based on size
and location and history of poorly controlled DM suggests
possible small vessel disease. However, given his history of
prior cerebellar stroke and prior PFO closure embolic is a
possibility too. ASA stopped and Plavix started. TTE will be
performed as an outpatient.
He was evaluated by ___ who recommended outpatient ___. He was
discharged in stable condition.
We strongly recommended he remains in house for completion of
the workup but patient insisted on leaving, understanding the
risks.
Transitional issues:
- follow up TTE
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 = 77) - () 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? () Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Lisinopril 40 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
2. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
3. Atorvastatin 10 mg PO QPM
4. Citalopram 40 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7.Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right face and left leg
numbness resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
We are changing your medications as follows:
-stop aspirin
-start plavix
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below. Please call the number below to set up an
appointment for outpatient echo.
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:
___
|
10605930-DS-20 | 10,605,930 | 22,371,317 | DS | 20 | 2189-08-15 00:00:00 | 2189-08-19 23:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with no surgical hx presents for eval of RUQ pain. Pt
states that she felt sudden sharp RUQ pain at 2 pm, episodic in
nature, with pain that she describes as contraction type pain,
cannot identify any aggravating or alleviating factors,
non-radiating. Does endorse nausea with vomiting and subjective
fever along with the pain. Otherwise denies any acute
complaints.
Recently started naltrexone for hx opiate abuse. Otherwise
denies chest pain, SOB, dysuria, headache, chills, constipation,
BRBPR.
Past Medical History:
Opiate abuse (heroin)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.8 HR 60 BP 140/89 RR 18 O2 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, nondistended, slightly tender in RUQ, no rebound or
guarding
Ext: No ___ edema, ___ warm and well-perfused
Pertinent Results:
___ 06:44AM BLOOD WBC-5.4 RBC-3.35* Hgb-11.8 Hct-34.4
MCV-103* MCH-35.2* MCHC-34.3 RDW-13.1 RDWSD-49.9* Plt ___
___ 07:15AM BLOOD WBC-6.8 RBC-3.36* Hgb-11.6 Hct-34.2
MCV-102* MCH-34.5* MCHC-33.9 RDW-12.9 RDWSD-48.5* Plt ___
___ 01:20AM BLOOD WBC-7.5 RBC-3.79* Hgb-13.3 Hct-37.7
MCV-100* MCH-35.1* MCHC-35.3 RDW-13.1 RDWSD-47.7* Plt ___
___ 01:20AM BLOOD Neuts-77.1* Lymphs-17.0* Monos-5.2
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.77 AbsLymp-1.27
AbsMono-0.39 AbsEos-0.01* AbsBaso-0.02
___ 06:44AM BLOOD Plt ___
___ 06:44AM BLOOD ___ PTT-29.5 ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-29.3 ___
___ 01:20AM BLOOD Plt ___
___ 06:44AM BLOOD Glucose-110* UreaN-4* Creat-0.7 Na-137
K-3.5 Cl-102 HCO3-24 AnGap-15
___ 07:15AM BLOOD Glucose-109* UreaN-4* Creat-0.6 Na-139
K-3.0* Cl-101 HCO3-22 AnGap-19
___ 01:20AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-136
K-3.4 Cl-97 HCO3-21* AnGap-21*
___ 01:20AM BLOOD estGFR-Using this
___ 01:20AM BLOOD ALT-37 AST-38 AlkPhos-78 TotBili-0.8
___ 01:20AM BLOOD Lipase-15
___ 06:44AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6
___ 07:15AM BLOOD Calcium-8.7 Phos-2.2*
___ 01:20AM BLOOD Albumin-4.6
___ 01:28AM BLOOD Lactate-1.6
GALLBLADDER SCAN ___
Probably normal hepatobiliary scan with delayed GI activity
probably caused by morphine. No evidence of acute
cholecystitis.
LIVER OR GALLBLADDER US (SINGLE ORGAN) ___ 1:17 AM
1. Cholecystitis is thought to be unlikely, but early acute
cholecystitis cannot entirely be excluded in the appropriate
clinical situation.
2. The CHD measures 3 mm, but the CBD dilates up to 11 mm at the
midportion and then tapers to 7 mm. The distal CBD at the
pancreas was not seen. If clinical concern for biliary
abnormality persists, MRCP can be obtained.
Brief Hospital Course:
Dear Ms. ___,
You were admitted to ___ with sudden onset on abdominal pain
associated with nausea and vomiting. You underwent an ultrasound
of your gallbladder which did not show any evidence of
gallbladder wall edema or stones. You started to feel better,
tolerated a regular diet, and were ready to go home. However,
you left without instructions, prescriptions, or follow up
details.
While in the hospital you were found to have a urinary tract
infection. You should take the antibiotic prescribed
ciprofloxacin 500mg by mouth twice a day for seven days.
You contact the Digestive Disease Center at ___ to
schedule a specialized study of your gallbladder as soon as
possible.
You should return to the hospital if you experience any of the
following:
-Increased abdominal pain
-Nausea and vomiting
-Fever, chills, sweats
Close
Notes for dates: ___
ACS - Last Updated by ___ on ___ @ 1007 Patient
Location: ___-___
Antibiotic:Cipro
Anticoagulant:___
Chief Complaint:RUQ pain
PMH: Opiate abuse (heroin)
PSH: None
___: Naltrexone
Events:
___ comfortable, tol clears
___ HTN not controlled, started hydralazine 20mg BID. labs
repleted
___ HIDA no acute cholecystitis, c/o RUQ pain
Assessment:
___ F with RUQ pain
Plan:
[] f/u repeat HIDA w/ CCK for biliary dyskinesia
[] NPO/IVF
[] Serial Abd exams
Medications on Admission:
Naltrexone
Discharge Medications:
Ciprofloxacin 500mg PO BID x7days
Discharge Disposition:
Home
Discharge Diagnosis:
RUQ pain
Discharge Condition:
Good
Discharge Instructions:
Dear Ms ___, it was a pleasure taking acre of you at ___
you were admitted with abdominal pain associated with nausea and
vomiting. you had an abdominal US which was equivocal for
gallbladder edema or stones in your bile ducts. during you
hospital stay you had HAIDA scan which ruled out Acute
inflammation of your Gallbladder.
during your stay analysis of your urine indicated a possib
Followup Instructions:
___
|
10605957-DS-16 | 10,605,957 | 24,385,872 | DS | 16 | 2123-08-20 00:00:00 | 2123-08-22 18:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Sulfa (Sulfonamide Antibiotics) / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
dyspnea on exertion, lower extremity swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
I received verbal signout from medicine nightfloat and agree to
accepting care for this patient. In brief, this is a ___ year old
male with a history of hereditary hemorrhagic telangiectasia
presenting from PCP office after he went in for ___ weeks of
increasing fatigue, bilateral lower extremity edema, orthopnea
and PND. Patient first noticed symptoms when traveling 2 weeks
ago to ___ with slight lower extremity edema. Swelling has
improved somewhat but not returned to baseline. He also has
noted difficulty laying flat at night, and often wakes up
gasping for air. He sleeps with a pillow wedge for HTT to
prevent high blood pressure in his head but has needed to
increase the elevation of the HOB for the past few weeks. He
also endorses orthopnea. He also has noted a new persistent
cough that is non-productive.
He has very occasionally has mild, sharp left-sided chest pain
sometimes associated with sensation of someone squeezing his
left arm that lasts a few seconds at a time. Not clearly
associated with activity. In fact, his activity is somewhat
limited as this often prompts epistaxis, but he can walk for 20
minutes without becoming short of breath.
He does note being told that he has cardiomegaly in the past.
For this he has a stress test in his ___ which was normal, per
his report. In terms of cardiac history, he was hospitalized at
___ ___ for MSSA bacteremia after sinus surgery, which
was felt to have evolved into endocarditis. TEE at the time
showed bicuspid aortic valve and 3+AR. He was treated with 5
weeks of nafcillin and finished with levofloxacin after
developing a rash. He has never seen a cardiologist, but his
Hematologist was planning to refer to him for TTE due lower
extremity edema and persistent low-grade tachycardia.
For his HHT, he is currently on therapy with Avastin every few
weeks per his ___ Hematologist. Last treatment one month ago.
He also receives intermittent pRBC infusions. He also follows
with MEET ENT for sinus surgery and nasal cautery.
In the ED initial vitals were: T99.5, HR 100, BP 127/52, RR 18,
Spo2 99% RA.
EKG: rate 103, sinus, QTc 453, normal axis, LVH, new TWI in
V4-V6 likely related to repolarization changes
Labs showed: WBC 4.4, Hgb 8.0/Hc 30, plt 321. Chem7 WNL. BNP
763. Troponin neg x1. INR 1.3.
CXR showed, "no evidence of cardiac decompensation. Significant
cardiomegaly. Focal opacity at the right costophrenic angle,
potentially atelectasis or small effusion."
POCUS echo showed mild pericardial effusion but no tamponade
effusion.
Patient was given: nothing.
After discussion with ___ cardiology, decision was made to
admit to ___ Cardiology for further work-up.
Vitals on transfer: T 99, HR 104, BP 129/49, RR 22, Spo2 96%RA.
On the floor, the patient had no acute complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: -hypertension, -dyslipidemia, -diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- VALVES: bicuspid aortic valve with 3+ AR (___)
3. OTHER PAST MEDICAL HISTORY:
- Hereditary hemorrhagic telangiectasia with ACVR1 mutation
(Hematologist at ___ Dr. ___ c/b frequent nosebleeds,
chronic iron deficiency (followed at ___), no history of
intracranial AVMs, no hepatic AVMs on liver MRI ___, s/p sinus
surgery ___ at ___; treated with Thalidomide previously,
currently on avastin only
- Iron deficiency anemia on IV iron and receives pRBC infusions
- MSSA bacteremia ___, presumed cardiac source ___ ___ c/b splenic wedge infarcts; treated with nafcillin for 5
weeks until developed a rash
- Chronic leukopenia s/p unremarkable BMBx
- History of epididymitis
- Right inguinal hernia
- Depression, anxiety
Social History:
___
Family History:
No family history of early MI, cardiomyopathies, or sudden
cardiac death. Mother had arrhythmia. Father had HHT. Paternal
aunt with likely HHT.
Physical Exam:
ON ADMISSION
VS: T98.2, BP 128/43, HR 103, RR 20, 99% RA. Wt 84kg standing.
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Scattered telangiectasia across cheeks and on the oral
mucosa. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthelasma.
NECK: Supple with JVP to the earlobe.
CARDIAC: PMI displaced in ___ intercostal space, midaxillary
line. Tachycardic rate, normal S1 and S2, II/VI systolic and
diastolic murmurs, best heard in the aortic position, no
radiation to carotids or axilla.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decrease breath sounds
and crackles in the RLL.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema to the mid-shin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Legs
are pale and mostly hairless.
PULSES: Distal pulses are 2+ and symmetric.
ON DISCHARGE
VS: T98.4, BP 105-114/39-53, HR 86-96, RR 18, 98% RA. Wt 79.3
<-79.4 kg<-80.5<-84kg standing.
Tele: ___ beat Supraventricular tachycardia
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Scattered telangiectasia across cheeks and on the oral
mucosa. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthelasma.
NECK: Supple with JVP to the earlobe.
CARDIAC: PMI displaced in ___ intercostal space, midaxillary
line. Tachycardic rate, normal S1 and S2, II/VI systolic and
diastolic murmurs, best heard in the aortic position, no
radiation to carotids or axilla.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decrease breath sounds
and crackles in the RLL.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace pitting edema to the mid-shin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Legs
are pale and mostly hairless.
PULSES: Distal pulses are 2+ and symmetric.
Pertinent Results:
ON ADMISSION
ON DISCHARGE
IMAGING
ECG ___
Sinus tachycardia. Left ventricular hypertrophy with associated
repolarization abnormalities. Compared to the previous tracing
of ___ findings are similar. The rate is now faster and P-R
interval is shorter.
CXR ___. No evidence of cardiac decompensation.
2. Significant cardiomegaly, in the absence of vascular
congestion or overt
pulmonary edema, suggests cardiomyopathy or pericardial
effusion. If there is persistent clinical concern,
echocardiography for further evaluation could be considered.
3. Focal opacity at the right costophrenic angle, potentially
atelectasis or small effusion.
ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler or saline contrast with maneuvers.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %) with
inferior/infero-lateral hypokinesis. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal with borderline
normal free wall function. The aortic valve is bicuspid. The
aortic valve leaflets arethickened. There is a possible small
(?healed veg) vegetation on the aortic valve (clip #33). There
is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. Moderate to
severe (3+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is a small to moderate
sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of ___,
the severity of AR has increased, the LV cavity has enlarged,
the LVEF has decreased and the aortic valve has a possible small
veg. Consider a TEE for further assessment of the aortic valve
(if indicated).
ECG ___
Sinus rhythm. Borderline atrio-ventricular conduction delay.
Left ventricular hypertrophy with ST-T wave changes consistent
with left ventricular hypertrophy. Compared to the previous
tracing of ___ the ventricular rate is slower
Carotid series ___
Impression no evidence of stenosis in either carotid artery
Brief Hospital Course:
___ with hereditary hemorrhagic telangiectasias with history of
likely endocarditis presenting with new onset lower extremity
edema, PND, orthopnea, elevated JVP, elevated BNP and diastolic
murmur. He was found to have severe AI and new onset HFrEF.
# New onset heart failure with reduced ejection fraction:
patient with symptomatology consistent with new onset heart
failure given PND, orthopnea, elevated JVP, elevated BNP and
lower extremity edema. Given history of HHT, he is at high risk
of high output heart failure, especially with known history of
persistent tachycardia. Bubble echo was negative for
intrapulmonary shunting. Patient with history of endocarditis
with 3+AR seen on TEE in ___ and repeat ECHO during this
admission showed severe AR as well- and bubble was negative. TSH
WNL. Patient was started on IV Lasix boluses and transitioned to
PO two days prior to discharge. He was also started on
lisinopril 10 mg daily. He was evaluated by C surgery and
followed by his home hematologist while in house. He was
determined to be a candidate for surgical aortic valve
replacement with his hematologist guiding operative and
___ anticoagulation. Discharge weight is 79.3 kg/
174.8 lb
#Sinus tachycardia/supraventricular tachycardia: Discussed with
EP while in house. Had one run of SVT, and baseline HR is
___ since MSSA bacteremia in ___. Amiodarone load now with
400 TID until surgery, and 200 daily after surgery x 3 months.
# HHT: patient with no signs of bleeding currently. Maintains
hematocrit ___, per patient/Atrius records. Currently on
Avastin. Surgery for aortic valve repair can be after ___
(4 weeks from last Avastin dose). He was followed by his
hematologist while in house.
Transitional Issues
====================
[]starting amiodarone 400 TID, Lisinopril 10 mg daily, and PO
Lasix 20 mg daily
[]amiodarone started at 400 TID and should be continued up until
his surgery. After surgery, can be 200 daily.
[]should have follow up chem10 after stabilization on lisinopril
and Lasix
[]should have follow up LFTs and TFTs while on amiodarone.
[]Discharge weight is 79.3 kg/ 174.8 lb
# CODE: Full, confirmed
# CONTACT: ___ Wife ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 1 mg PO QHS:PRN anxiety, insomnia
2. Aminocaproic Acid 2.5 gm TP Q1HR:PRN bleeding
3. Feraheme (ferumoxytol) 510 mg/17 mL (30 mg/mL) injection
EVERY 2 WEEKS
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. Simethicone 40-80 mg PO QID:PRN gas pain
6. Bevacizumab (Avastin) 400 mg IV Q2WEEKS
Discharge Medications:
1. Amiodarone 400 mg PO TID
RX *amiodarone 400 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*1
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*2
3. Aminocaproic Acid 2.5 gm TP Q1HR:PRN bleeding
4. Bevacizumab (Avastin) 400 mg IV Q2WEEKS
5. BuPROPion XL (Once Daily) 300 mg PO DAILY
6. Feraheme (ferumoxytol) 510 mg/17 mL (30 mg/mL) injection
EVERY 2 WEEKS
7. Lorazepam 1 mg PO QHS:PRN anxiety, insomnia
8. Simethicone 40-80 mg PO QID:PRN gas pain
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Severe Aortic Insufficiency
Exacerbation of heart failure with reduced ejection fraction
SECONDARY DIAGNOSIS
===================
Hereditary hemorrhagic telangiectasias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
shortness of breath. You were found to have a problem with your
aortic valve, called aortic insufficiency. You heart also was
found to have decreased pumping function as compared to last
year, which most likely caused your shortness of breath and
fluid accumulation. You were given medications to help your
heart, and to take extra fluid off of your body.
Please take your medications as directed and follow up with your
physicians.
It's important that you weigh yourself now every morning. If
your weight goes up by 3 lb then please call your primary care
physician or your new cardiologist, Dr. ___, at ___ so
they can guide any medication adjustments you may need. Your
discharge weight is 174.8 lb.
New medications:
Amiodarone (for heart rate): 400 mg three times daily. If you
experiencing side effects, please reduce your dose to 400 mg
twice daily.
Lisinopril 10 mg daily
Furosemide 20 mg daily
The surgical team will be in touch with you regarding scheduling
of surgery to repair your aortic valve.
It was a pleasure taking part in your care!
Your ___ Team
Followup Instructions:
___
|
10605957-DS-17 | 10,605,957 | 20,689,499 | DS | 17 | 2123-08-31 00:00:00 | 2123-08-31 13:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine / Sulfa (Sulfonamide Antibiotics) / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Lower extremity swelling, PND, orthopnea
Major Surgical or Invasive Procedure:
___
Aortic valve replacement with a 25 mm ___
tissue valve, reference number is ___, serial number
___.
Mitral valve repair with a 28 ___ annuloplasty ring
History of Present Illness:
___ year old male with a history of hereditary hemorrhagic
telangiectasia presenting from PCP office after he went in for
___ weeks of increasing fatigue, bilateral lower extremity
edema, orthopnea and PND. Patient first noticed symptoms when
traveling 2 weeks ago to ___ with slight lower
extremity edema. Edema has improved somewhat but not returned to
baseline. He also has noted orthopnea and PND. He also has
reported a new persistent cough productive of white sputum and 1
episode of mild, sharp left-sided chest pain, not associated
with activity. His activity is somewhat limited as this often
prompts epistaxis, but he can walk for 20 minutes without
becoming short
of breath. He was hospitalized at ___ ___ for MSSA
bacteremia after sinus surgery, which was felt to have evolved
into endocarditis. TEE at the time showed bicuspid aortic valve
and 3+ AR. He was treated with 5 weeks of nafcillin and finished
with levofloxacin after developing a rash.
For his HHT, he is currently on therapy with Avastin every few
weeks per his ___ Hematologist. Last treatment 3 weeks ago. He
also receives intermittent pRBC infusions. He also follows up
with ENT for sinus surgery and nasal cautery yearly. Echo ___
showed AR has increased, the LV cavity has enlarged,
the LVEF has decreased and the aortic valve has a possible small
veg. ___ was consulted for surgical AVR evaluation.
Past Medical History:
Hypertension
dyslipidemia
diabetes
Bicuspid aortic valve with 3+ AR (___)
Hereditary hemorrhagic telangiectasia with ACVR1 mutation
(Hematologist at ___ Dr. ___ c/b frequent nosebleeds,
chronic iron deficiency (followed at ___) - no hepatic AVMs on
liver MRI ___
Iron deficiency anemia on IV iron and receives pRBC infusions
MSSA bacteremia ___, presumed cardiac source ___ ___
c/b splenic wedge infarcts; treated with nafcillin for 5 weeks
until developed a rash
Chronic leukopenia s/p unremarkable BMBx
History of epididymitis
Right inguinal hernia
Depression, anxiety
Past Surgical History
s/p sinus surgery ___ at ___ treated with Thalidomide
previously (stopped ___ due to side effects, currently on
avastin only
Social History:
___
Family History:
No family history of early MI, cardiomyopathies, or sudden
cardiac death. Mother had arrhythmia. Father had HHT. Paternal
aunt with likely HHT.
Physical Exam:
Pulse:90 Resp:12 O2 sat: 98% RA
B/P Right:99/55 Left:
___ Weight:80.5
General: Awake, alert, pleasant
Skin: Dry [x] intact [] , petechaie, telangiectasias over
bilateral cheeks and ears
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Right inguinal hernia
Extremities: Warm [x], well-perfused [x] Edema trace
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right/Left: Transmitted murmur bilaterally
Pertinent Results:
LABS ON ADMISSION
==================
___ 05:27PM BLOOD WBC-5.4# RBC-4.30* Hgb-8.6* Hct-32.1*
MCV-75* MCH-20.0* MCHC-26.8* RDW-22.8* RDWSD-58.9* Plt ___
___ 05:27PM BLOOD Neuts-80.3* Lymphs-8.0* Monos-8.0 Eos-2.4
Baso-0.9 Im ___ AbsNeut-4.34 AbsLymp-0.43* AbsMono-0.43
AbsEos-0.13 AbsBaso-0.05
___ 05:27PM BLOOD Glucose-96 UreaN-43* Creat-1.3* Na-135
K-5.1 Cl-102 HCO3-24 AnGap-14
___ 05:30PM BLOOD ___ PTT-26.7 ___
___ 05:27PM BLOOD ALT-26 AST-43* AlkPhos-149* TotBili-0.7
___ 05:27PM BLOOD proBNP-1471*
___ 05:27PM BLOOD cTropnT-<0.01
___ 05:27PM BLOOD Albumin-4.3 Calcium-8.7 Phos-4.6* Mg-2.5
___ 05:27PM BLOOD TSH-4.3*
___ 05:30PM BLOOD Lactate-1.4
___ 04:38AM BLOOD WBC-8.8 RBC-3.83* Hgb-7.8* Hct-27.9*
MCV-73* MCH-20.4* MCHC-28.0* RDW-22.2* RDWSD-56.4* Plt ___
___ 04:38AM BLOOD Glucose-73 UreaN-30* Creat-0.8 Na-137
K-4.6 Cl-101 HCO3-29 AnGap-12
___ 05:09AM BLOOD WBC-11.8* RBC-3.91* Hgb-8.0* Hct-28.6*
MCV-73* MCH-20.5* MCHC-28.0* RDW-21.9* RDWSD-56.6* Plt ___
___ 03:13AM BLOOD WBC-12.7* RBC-3.81* Hgb-7.8* Hct-28.0*
MCV-74* MCH-20.5* MCHC-27.9* RDW-21.2* RDWSD-54.7* Plt ___
___ 06:33PM BLOOD Hct-29.9* Plt ___
___ 11:54AM BLOOD Hct-29.5* Plt ___
___ 03:13AM BLOOD ___
___ 05:09AM BLOOD ___ PTT-33.9 ___
___ 07:06AM BLOOD ___ PTT-32.9 ___
___ 05:09AM BLOOD Glucose-81 UreaN-39* Creat-0.9 Na-134
K-5.3* Cl-99 HCO3-28 AnGap-12
___ 03:13AM BLOOD Glucose-113* UreaN-32* Creat-1.1 Na-138
K-4.8 Cl-102 HCO3-26 AnGap-15
___ 04:06AM BLOOD Glucose-141* UreaN-32* Creat-1.1 Na-140
K-4.6 Cl-107 HCO3-24 AnGap-14
___ 07:37PM BLOOD UreaN-37* Creat-1.2 Cl-105 HCO3-22
AnGap-16
___ 07:03AM BLOOD Glucose-86 UreaN-43* Creat-1.3* Na-140
K-4.1 Cl-100 HCO3-28 AnGap-16
___ TEE
Pre-bypass:
The left atrium is markedly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= ___ %). with mild global RV free wall
hypokinesis. The ascending aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve is bicuspid. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. A mass is present
on the aortic valve on the left ventricular side and associted
with either the left or non-coronary cusp. Severe (4+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral regurgitation vena contracta is >=0.7cm.
Severe (4+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is a moderate sized pericardial
effusion. Dr. ___ was notified in person of the results at the
time of surgery.
Post-bypass:
The patient is in SR and on a norepi, vasopressin, epi gtt.
LV function appear similar to prior, but has some notable
dyskinesis of the septum. RV function is unchanged.
A prosthetic mitral annuloplasty is in place, there is no
regurgitation. The mean gradient across the valve is 5mmHg.
There is no evidence of ___.
A prosthetic aortic valve is in place, there is no significant
perivalvular leak. There is a trace intravalvular leak. The mean
gradient cross the valve is 11mmHg at C.O. of 10L/min.
The aorta is intact post decanulation.
Brief Hospital Course:
___ year old male with a history of hereditary hemorrhagic
telangiectasia presenting from PCP office after he went in for
___ weeks of increasing fatigue, bilateral
lower extremity edema, orthopnea and PND. He was hospitalized at
___ ___ for MSSA bacteremia after sinus surgery, which
was felt to have evolved into endocarditis. TEE at the time
showed bicuspid aortic valve and 3+ AR. He was treated with 5
weeks of nafcillin and finished with levofloxacin after
developing a rash. For his HHT, he was currently on therapy with
Avastin every few weeks per his ___ Hematologist. Last
treatment 3 weeks ago prior to surgery. Echo ___ showed AR has
increased, the LV cavity has enlarged, the LVEF has decreased
and the aortic valve has a possible small veg. Cardiac surgery
was consulted for surgical AVR evaluation. He was discharged
home but readmitted with CHF symptoms. He underwent cardiac cath
which showed no coronary artery disease. Heme was consulted
preop for anticoagulation management. They said Heparin bolus
was acceptable for bypass but no ASA or other anticoagulation
was recommended post op due to HHT. They also stated that given
recent Avastin, would hold off any surgical procedures for at
least another week (4 weeks from last infusion) and will need to
put off further infusions until at least 4 weeks after any
surgery.
The patient was brought to the Operating Room on ___ where the
patient underwent an aortic valve replacement with a 25 mm St.
___ tissue valve and mitral valve repair with a 28 mm
___ annuloplasty ring. 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 not initiated until
POD3 due to soft blood pressure and first degree AV block. He
had SVT pre opoperatively and it was recommended by EP that he
remain on Amiodarone 200 daily x 3 months. He had no further SVT
postoperatively and remained in sinus rhythm with first degree
AV block. The patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with visiting nurse services in good condition with
appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ativan 1 mg PO QHS:PRN anxiety, insomnia
2. Aminocaproic Acid 2.5 gm TP Q1HR:PRN bleeding
3. Feraheme (ferumoxytol) 510 mg/17 mL (30 mg/mL) injection
EVERY
2 WEEKS
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. Simethicone 40-80 mg PO QID:PRN gas pain
6. Bevacizumab (Avastin) 400 mg IV Q2WEEKS
ALLERGIES:
Morphine - rash, sulfa, Nafcillin (rash, itching)
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
3. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
4. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
5. TraMADol 50 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth Q 6 hours Disp
#*60 Tablet Refills:*0
6. Amiodarone 200 mg PO DAILY Duration: 3 Months
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypertension
dyslipidemia
diabetes
Bicuspid aortic valve with 3+ AR (___)
Hereditary hemorrhagic telangiectasia with ACVR1 mutation
(Hematologist at ___ Dr. ___ c/b frequent nosebleeds,
chronic iron deficiency (followed at ___) - no hepatic AVMs on
liver MRI ___
Iron deficiency anemia on IV iron and receives pRBC infusions
MSSA bacteremia ___, presumed cardiac source ___ ___
c/b splenic wedge infarcts; treated with nafcillin for 5 weeks
until developed a rash
Chronic leukopenia s/p unremarkable BMBx
History of epididymitis
Right inguinal hernia
Depression, anxiety
Heart failure with reduced ejection fraction
Severe Epistaxis requiring trnsfusions
Hereditary hemorrhagic telangiectasias
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10606783-DS-21 | 10,606,783 | 28,831,200 | DS | 21 | 2190-02-19 00:00:00 | 2190-02-19 15:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine Sulfate / Ancef
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
CC: Foot pain
HPI: ___ with insulin dependent DM2, multiple C5-T1 cervical
spine surgeries, neuropathy and bladder dysfunction presents
with approximately 1 month history of back pain and right lower
extremity pain. He was seen in the Emergency Department on
___ for similar complaints. An MRI was obtained at that
time which showed a question of a cervical/thoracic syrinx. He
was started on neurontin at that time which has relieved
paresthesias in his left anterior thigh.
Unfortunately, his pain has increased over the past 3 weeks and
is now constant, even at rest (previously only pain with
standing/walking). He started accupuncture approximately 2
weeks ago which has done little to relieve his symptoms. He has
been unable to walk for the past few days secondary to pain and
has increased his usual percocet dose from 4 to 6 pills per day.
He takes the percocet as baseline for chronic shoulder and neck
pain.
He reports ongoing bladder symptoms. He has had problems with
urinary retention for which he has been told to straight cath
3x/day for more than a year. He says that he actually straight
caths every ___ days because he finds it very inconvenient. He
can usually tell when he needs to go and is able to push on his
bladder to start a stream. He states he sometimes notices that
he leaks when he hears water running when he is shaving in the
morning. We discussed the importance of straight cathing at
regular intervals to prevent bladder dystension and overflow
incontinence.
He denies fecal incontinence of bowel dysfunction. He has no
numbness in a saddle distribution.
In the ED, initial vitals 99 150/89 74 18 98%
The pt underwent a consult by orthospine who recommended
admission to medicine for "pain control" as well as evaluation
by neurosurgery for the possible syringomyelia.
He received 3mg dilaudid IV for pain control
Currently, patient reports longstanding ___ pain located
posteriorly and terminating in the heel. States that it started
5 weeks ago, and has become progressively worse. Reports poor
glycemic control.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
-DM2
-HTN
-Hyperlipidemia
-Chronic left shoulder pain and headaches following most recent
cervical spine surgery
-Cervical spine surgery x3 (both anterior and posterior
approaches, most recent in ___
Social History:
___
Family History:
Fathter with CABG x ___ in late ___ to early ___. Mother died
when he was very young from unknown causes. States most
relatives died of 'massive heart attacks', dying suddenly and in
their sleep. Denies any known cardiac deaths in ___.
Physical Exam:
ADMISSION EXAM
VS - 98.1 142/79 71 20 96RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), R heel very tender to palpation but without
erythema/edema/lesions or ulcers
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, muscle strength ___ throughout, sensation
grossly intact throughout, + straight leg raise on R, range of
motion severely limited due to pain
DISCHARGE EXAM:
VS - 97.8 131/78 75 18 99RA ___
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), R heel continues to be tender but without lesions or
erythema
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, muscle strength ___ throughout, sensation
grossly intact throughout, + straight leg raise on R
Pertinent Results:
ADMISSION LABS
___ 07:35AM BLOOD WBC-4.0# RBC-4.07* Hgb-12.1* Hct-35.5*
MCV-87 MCH-29.9 MCHC-34.2 RDW-13.0 Plt ___
___ 07:35AM BLOOD Glucose-189* UreaN-16 Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-26 AnGap-14
___ 07:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
IMAGING
R Lower Ext Veins ___ (preliminary): No DVT
R FOOT XRAY ___: FINDINGS: Frontal, oblique and lateral
views of the right foot were obtained. There is no fracture or
dislocation. No significant degenerative change. No soft
tissue swelling or ankle joint effusion is seen. No suspicious
osseous lesion is identified.
IMPRESSION: No acute fracture or malalignment.
AP LUMBOSACRAL SPINE ___:
FINDINGS: Frontal and lateral views of the lumbar spine are
compared to MRI of the spine from ___. There is
mild anterior wedging of T11 and T12 vertebral bodies,
potentially degenerative and unchanged from prior MRI. There is
associated disc height loss and endplate osteophyte formation at
these levels. The lumbar vertebral bodies are maintained in
height and alignment. Intervertebral disc spaces are
essentially preserved noting some height loss at L5-S1. Mild
lower lumbar facet joint hypertrophic changes are seen.
Phleboliths identified in the pelvis. Soft tissues are
otherwise unremarkable.
IMPRESSION: No acute fracture or subluxation. Degenerative
changes as above.
Brief Hospital Course:
___ year old male w/ poorly controlled DM, HTN, HLD, s/p C5-T1
spinal fusion presents with worsening sciatica and R heel pain.
# BACK PAIN, R LOWER EXTREMITY, AND R HEEL PAIN: Patient seen by
orthospine in ED and was admitted for pain control. Distribution
and description of pain most consistent with sciatica. In
addition, likely some contribution from peripheral neuropathy
secondary to his poorly controlled diabetes. No erythema, edema,
ulcers or lesions noted on bilateral foot to suggest an
infection. He also remained afebrile with no leukocytosis. CRP
and ESR were not elevated. Xray of the foot and spine ruled out
any fractures. Noted to have some intervertebral disc space
height loss at L5-S1. A MRI of the spine previously done at
___ showed a high signal in the ___ the spinal cord
from the cervical spine through the thoracic spine concerning
for a syrinx. Neurosurgery were consulted and determined that no
surgical interventions were needed at this time. He will need to
follow up with neurosurgery and was given a number at discharge
to arrange for an appointment. A RLE ultrasound ruled out a DVT.
Patient was up-titrated on gabapentin to 300mg TID. His pain
should improve over the next few weeks as he becomes therapeutic
on gabapentin. He was also started on oxycodone 10mg q4h, which
helped improve his pain. He has follow up with the pain clinic
on ___. He has a narcotic contract with his PCP and ___
get his oxycodone prescription from his PCP.
#DIABETES MELLITUS: insulin dependent, poorly controlled as an
outpatient. Diabetic neuropathy likely contributing to current
neuropathic pain. Patient was given glargine 28units daily +
insulin sliding scale while in hospital. He can transition back
to his home levemir with oral hypoglycemic agents as an
outpatient. He was also consuled on the importance of better
glucose control to improve his neuropathic pain. Per patient, he
has a follow up appointment with ___ next month.
#HYPERTENSION: no acute exacerbation of chronic condition. He
was continued on atenolol, lisinopril, hctz
#HYPERLIPIDEMIA: no acute exacerbation of chronic condition. He
was continued on his home simvastatin
TRANSITIONAL ISSUES
-Pt scheduled for pain clinic on ___
-Pt should follow up with neurosurgery in 3 months and have
repeat C and T spine MRI
-PCP should adjust gabapentin dosing to improve pain
-Pt should follow up with ___ re: better glycemic control
-please follow up on R lower extremity ultrasound final read
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO TID
2. Atenolol 100 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. GlyBURIDE 5 mg PO TID
5. lisinopril-hydrochlorothiazide *NF* ___ mg Oral qd
6. MetFORMIN (Glucophage) 1000 mg PO TID
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
8. Simvastatin 40 mg PO DAILY
9. Levemir 28 Units Breakfast
10. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Citalopram 40 mg PO DAILY
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. Levemir 28 Units Breakfast
5. Simvastatin 40 mg PO DAILY
6. GlyBURIDE 5 mg PO TID
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL QD
9. MetFORMIN (Glucophage) 1000 mg PO TID
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
11. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) apply to R heel as needed for
pain once a day Disp #*10 Transdermal Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sciatica
Diabetic Neuropathy
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 evaluated at ___ for leg pain. Your leg pain is
likely caused by Sciatica as well as uncontrolled Diabetes
leading to nerve damage. Your gabapentin was increased, and
this will take some time to improve your pain. You were seen by
orthopedic-spine and neurosurgery who both don't recommend any
new surgeries at this time. Please follow up with neurosurgery
by calling them as listed below. You also have appointments with
pain management, ___, and neurology. Please take your
medications and follow up with your primary care doctor in the
next ___ days. It is very important that you adequately control
your diabetes as it is contributing to your leg and heel pain.
Please make sure to follow up with your diabetes doctors
(___).
Please continue to participate in Physical Therapy.
Followup Instructions:
___
|
10606807-DS-12 | 10,606,807 | 29,633,335 | DS | 12 | 2206-12-03 00:00:00 | 2206-12-09 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, poor PO intake
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
___ T3N2Mx gastric adenoCa s/p subtotal gastrectomy, D2 LND,
Bilroth II reconstruction ___ on ___ and recent admission
for urosepsis from obstructing kidney stone complicated by SVT
s/p L percutaneous nephrostomy tube now presents with several
days of nausea, vomiting of yellow-colored emesis, and poor PO
intake (only tolerating some cereal and hard boiled eggs).
Continues to pass flatus, last BM was yesterday and was small.
No
F/C. No CP/SOB/palpitations. No yellowing of eyes or dark/brown
urine. She now presents to ___ for evaluation and ACS surgery
is now consulted.
Past Medical History:
CAD s/p LAD stent
hypothyroidism,
hypertension
hyperlipidemia
locally advanced breast cancer
Past surgical history : Status post total abdominal hysterectomy
via lower midline abdominal incision in ___. The pathology
revealed leiomyomas and adenomyosis. In ___, she had an
endocervical polyp removed, and in ___, a rectal
polypectomy revealed an oil granuloma. She also had a left sided
partial mastectomy performed at ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.9, HR 88, BP 129/76, RR 19, SPO2 98% RA
GEN: A&Ox3, NAD
CV: RRR. Port site where port was removed last week is clean
with
no erythema or drainage and steri-strips in place
PULM: breathing unlabored
ABD: Soft, upper abdominal distention, nontender, midline
incision well-healed
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Labs on Admission:
___ 05:17PM BLOOD WBC-3.2* RBC-3.20* Hgb-8.0* Hct-25.9*
MCV-81* MCH-25.0* MCHC-30.9* RDW-20.0* RDWSD-58.8* Plt ___
___ 05:17PM BLOOD Glucose-73 UreaN-9 Creat-0.4 Na-144
K-3.1* Cl-105 HCO3-24 AnGap-15
___ 06:43AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0
IMAGING:
=======================================
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
1. Status post Billroth II with fluid-filled dilatation of the
stomach and
afferent loop and completely decompressed efferent loop
concerning for
obstruction at the gastrojejunostomy. Recommend enteric tube
decompression of the stomach.
2. Fluid-filled distended small hiatal hernia and wall
thickening of the
distal esophagus and stomach compatible with esophagitis and
gastritis from recent vomiting.
3. Redemonstration of multiple air locules adjacent to the
duodenal stump in the right upper quadrant, minimally decreased
in the interval, but again dehiscence is not excluded.
4. Interval placement of a left-sided nephroureteral stent with
resolution of previous seen hydroureteronephrosis. No
urolithiasis identified.
5. New small bilateral pleural effusions with mild bibasilar
atelectasis.
6. Small perihepatic and pericholecystic fluid.
___: CXR Portable
IMPRESSION:
1. Enteric tube courses below the level of the diaphragm and
into the stomach,
with tip coiling upward toward the fundus.
2. Persistent low lung volumes with bibasilar atelectasis.
Brief Hospital Course:
___ F T3N2Mx gastric adenoCa s/p subtotal gastrectomy, D2 LND,
Bilroth II reconstruction ___ on ___ and recent admission
for urosepsis from obstructing kidney stone complicated by SVT
s/p L percutaneous nephrostomy tube now presents with several
days of nausea, vomiting of yellow-colored emesis, and poor PO
intake (only tolerating some cereal and hard boiled eggs).
She had a CT abd/pelvis w/ contrast that demonstrated an
obstruction at the G-J anastomosis. An NG tube was placed for
decompression and she was made NPO with IV fluids. Given that
the patient had her gastrectomy operation with Dr. ___
at ___, it was decided that she should be transferred to ___ for
further management in order to promote continuity of care.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg IV DAILY
2. Metoprolol Tartrate 5 mg IV Q6H
3. Pantoprazole 40 mg IV Q24H
4. HELD- Aspirin EC 81 mg PO DAILY This medication was held. Do
not restart Aspirin EC until instructed by your doctor
5. HELD- Atorvastatin 80 mg PO QPM This medication was held. Do
not restart Atorvastatin until instructed by your doctor
6. HELD- Levothyroxine Sodium 150 mcg PO DAILY This medication
was held. Do not restart Levothyroxine Sodium until instructed
by your doctor
7. HELD- Multivitamins 1 TAB PO DAILY This medication was held.
Do not restart Multivitamins until instructed by your doctor
8. HELD- Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain This
medication was held. Do not restart Nitroglycerin SL until
instructed by your doctor
9. HELD- Omeprazole 20 mg PO DAILY This medication was held. Do
not restart Omeprazole until instructed by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Obstruction at the gastrojejunostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. ___
___ was a pleasure providing care for you during your stay at
___.
WHY I CAME TO THE HOSPITAL?
- You came to the hospital because you were feeling nauseas,
vomiting, unable to eat or drink much, and having difficulty
with bowel movements.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
- We did a CT scan that was concerning for obstruction at the
connection between your stomach and small intestine. We placed a
tube through your nose into your stomach to decompress your
stomach (remove some of the built up material in the stomach).
We then arranged for you to be transferred to ___ since Dr.
___ is the surgeon who did your procedure and therefore would
like to be following your care closely.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should follow all instructions provided at ___
- You should take your medications as prescribed
We wish you the best of luck.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10606917-DS-10 | 10,606,917 | 23,195,599 | DS | 10 | 2176-10-10 00:00:00 | 2176-10-10 18:57:00 |
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:
___ Exploratory laparotomy
History of Present Illness:
___ w. hx/o RNY gastric bypass in ___ was transferred from OSH
for further evaluation and treatment of possible small bowel
obstruction.
Mr. ___ notes that he has been doing great since his surgery
in ___ until ___ night when he started having abdominal pain
associated with nausea and vomiting. He reports that he had
multiple episodes of vomiting. He vomited everything that he
ate. On ___ he avoided food, just drank small amount of water
but continued to be nauseous and vomited. Since then he has been
having constant ___ abdominal pain, more prominent in the
epigastric area, which was associated with more intermittent
episodes of severe sharp pains lasting several minutes. He went
to ___ last night where abdominal CT with contrast
was obtained showing signs concerning for small bowel
obstruction, he was then transferred to ___ for further care.
He is still complaining of epigastric pain and nausea. He notes
that he had bowel movement this morning and continues to pass
flatus.
Imaging:CT abd/pelvis OSH
-Dilated small bowel with transition point in mid-abdomen
Past Medical History:
Past Medical History:
HTN, CAD s/p PCI w stents (___) - RCA stented x 3
(cardiologist: ___, DM2, Hyperlipidemia,
Hypertriglyceridemia, OSA req CPAP, Hypothyroidism, hx
nephrolithiasis w lithotripsy x 2, Chronic back pain, R shoulder
melanoma (followed by Dr. ___
Past Surgical History:
RNY gastric bypass in ___, L hand injury req replant tip ___
digit, partial amp ___ digits L hand ___ machine injury
(___), Pilodnidal cyst excision (___), Dental surgery (___),
Rotator cuff shoulder repair (___), R knee arthroscopy (___),
Canceled lap GBP ___ did not stop ASA
Social History:
___
Family History:
obesity, DM, HTN
Physical Exam:
Admission exam:
Vitals:96.7 70 174/100 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, moderate epigastric tenderness, no
rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge exam:
Vitals:100.2/98.6 82 115/65 18 96RA
GEN: A&Ox3, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, minimal epigastric tenderness,
incision c/d/i with staples in place, no erytema, fluctuance or
discharge; no rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Admission labs
___ 02:44AM BLOOD WBC-8.9 RBC-4.67 Hgb-13.4* Hct-41.6
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.3 Plt ___
___ 02:44AM BLOOD Neuts-77.1* Lymphs-14.6* Monos-7.5
Eos-0.6 Baso-0.2
___ 02:44AM BLOOD Plt ___
___ 03:48AM BLOOD ___ PTT-34.8 ___
___ 02:44AM BLOOD Glucose-127* UreaN-25* Creat-1.1 Na-141
K-4.2 Cl-107 HCO3-24 AnGap-14
___ 03:00AM BLOOD Lactate-1.1
Discharge labs
___ 08:15AM BLOOD ___-6.4 RBC-4.09* Hgb-11.9* Hct-36.4*
MCV-89 MCH-29.1 MCHC-32.7 RDW-12.8 Plt ___
___ 08:15AM BLOOD Glucose-176* UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
___ 08:15AM BLOOD Calcium-9.7 Phos-1.6* Mg-1.5* Iron-PND
___ 08:15AM BLOOD VitB12-PND Folate-PND Ferritn-PND TRF-PND
___ 08:15AM BLOOD 25VitD-PND
___ 08:15AM BLOOD VITAMIN B1-PND
Imaging
___ CXR
FINDINGS:
New subsegmental atelectasis is seen at the right base medially
and left
perihilar region and these changes are associated with small
bilateral pleural effusions. The trachea appears displaced
somewhat rightward as it enters the thorax though the aortic
knob is clearly defined and not larger than on the remote study
nor is any density seen in the retrosternal airspace. No central
mass is evident and airways appear patent. Gaseous distention of
the colon is prominent
IMPRESSION:
New findings as described above without specific change to
account for
hemoptysis
Brief Hospital Course:
The patient presented to ED on ___ with abdominal
pain. CT scan from OSH showed transition point in the common
limb. Patient had worsening abdominal pain and abdominal exam in
the ED and the decision was made to take the patient to the OR.
He as an exploratory laparotomy and was found to have a bezoar
within the common limb which was milked into the cecum. There
were no adverse events in the operating room; please see
the operative note for details. Pt was extubated, taken to the
PACU until stable, then transferred to the ward for observation.
NEURO: Pain was well controlled. He was intially given IV pain
medications and once tolerating PO was transitioned to oral
Roxicet prn.
CV: The patient remained stable from both a cardiovascular
standpoint.
PULM: Patient was maintained on CPAP overnight for known sleep
apnea and was comfortable on room air during the day. On POD2
patient noted hemoptysis, streaking of blood in his sputum, and
a chest X ray was obtained which showed atelectasis and small
bilateral pleural effusions. No clear cause of his hemoptysis
was found, although he reported a similar episode after his
bypass. He was instructed to monitor his symptoms and follow up
with his primar care doctor if his symptoms persist.
GI/FEN: The patient was initially NPO with IVF for an ileus, his
diet was advanced as he resumed bowel function. He was
discharged on a stage 4 diet which he tolerated well. Pts
intake and output were closely monitored.
GU: Patient required boluses (500cc x2) for low UOP on POD0, and
his urine output subsequently improved and his urine output
remained adequate throughout the remainder of his
hospitalization.
ID: The patient remained afebrile with stable vital signs
HEME: The patient received subcutaneous heparin as well as
venodyne boots throughout admission; early and frequent
ambulation were strongly encouraged.
The patient was subsequently discharged to home on POD2. The
patient received discharge teaching and followup instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 20 mg PO DAILY
2. Metoprolol Tartrate 75 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. fenofibrate 200 mg oral daily
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Humalog ___ 15 Units Breakfast
Humalog ___ 15 Units Dinner
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral bid
9. Sertraline 25 mg PO DAILY
10. Levothyroxine Sodium 25 mcg PO DAILY
11. cyanocobalamin (vitamin B-12) 500 mcg sublingual daily
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
please crush pills
2. Lisinopril 20 mg PO DAILY
please crush pills
3. MetFORMIN (Glucophage) 1000 mg PO BID
please crush pills
4. Metoprolol Tartrate 75 mg PO BID
please crush pills
5. Rosuvastatin Calcium 40 mg PO DAILY
please crush pills
6. Sertraline 25 mg PO DAILY
please crush pills
7. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
Do not drink alcohol or drive while taking these medications.
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ ml
by mouth every 4 hours Refills:*0
8. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral bid
please crush pills
9. cyanocobalamin (vitamin B-12) 500 mcg sublingual daily
10. fenofibrate 200 mg oral daily
please crush pills
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
RX *docusate sodium 50 mg/5 mL 10 ml by mouth two times a day
Refills:*0
13. Humalog ___ 15 Units Breakfast
Humalog ___ 15 Units Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction due to a bezoar
Atelectasis
Hemoptysis
Hypertension
Diabetes
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 inpatient Bariatric Service for
abdominal pain which was concerning for an obstruction. You had
a surgery to investigate the cause of your abdominal pain and
they found a bezoar (a collection of ingested material) which
caused a small bowel obstruction. You are recovering well from
your procedure and are now safe for discharge home. Please see
your primary care doctor about the blood in your sputum if it
does not improve in the next ___ days.
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage 4 diet until your follow up appointment. Do
not self advance diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. 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.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You must not use NSAIDS (nonsteroidal antiinflammatory drugs)
Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen.
These agents will cause bleeding and ulcers in your digestive
system.
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 staples will be removed when you see Dr.
___ in clinic.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision site.
Followup Instructions:
___
|
10607085-DS-17 | 10,607,085 | 21,603,110 | DS | 17 | 2179-10-12 00:00:00 | 2179-10-14 19:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Right ___ ulcer (chronic) with cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of HTN, BPH, gout, CAD s/p 2 vessel CABG
___, T2DM w/ peripheral neuropathy, chronic osteomyelitis of R
leg who presents in the pain and concern for infection in left
arm and right leg. The patient has a long standing history of
osteomyelitis with multiple episodes of I/D of R leg for abscess
and fistula tracts. The patient was encouraged to come to the
hospital by his daughter (an attending at ___
___, who noted that the patient has a tendency to minimize
symptoms. The leg was reported to be increasingly tender and
more red than usual.
The patient denied any fevers, chills, chest pain, shortness of
breath, nausea, vomit, diarrhea, dysuria.
Of note the patient was seen in ___ by Geriatrics for
increasingly frequent falls, gait disability, and fecal
incontinence. Over the past year the patient has had more
difficulty with his balance and gait. The patient attributes
poor gait due to R shorter than L leg ___ chronic osteomyelitis
and surgeries. On one occasion, he sustained an orbital
fracture; on another he slipped on ice and had numerous
contusions, and about one month ago he suffered facial abrasions
from tripping on an object. He denies any syncopal episodes and
has begun using a cane on his right side to help maintain his
balance. Noted to have sustained an orbital fracture, numerous
contusions and facial abrasions. He denies any syncopal episodes
and has begun using a cane on his right side to help maintain
his balance.
In the ED, initial VS were 97.4, 79, 136/73, 16, 99% RA.
Patient was noted to have tender, erythematous left arm and
right leg with concern for skin infection. Labs demonstrated
WBC 8.8, H/H 13.6/41, plts 183, Na 135, BUN/Cr 40/1.6 from
baseline 1.3 in ___, last known Cr was 1.6 in ___,
INR 1.0, CRP 6.4, lactate 2.3. UA was notable for ___ WBCs, 30
protein, 100 glucose. In the ED the patient received 1g
vancomycin, 1L NS, and blood cultures were sent. Given history
of severe skin and bone infections, and current living
situation, patient admitted for medical management and
observation.
ED Orders:
- Blood and Urine culture
- C-Reactive Protein, Coags
- Vancomycin 1000 mg IV ONCE
- 1000 mL NS Bolus
Labs:
CRP: 6.4
___: 11.1 PTT: 28.1 INR: 1.0
UA: Yellow, Spec ___ 1.020, Neg Leuk/nitrate, neg protein,
glucose 30, 100 ketones, ___ RBC, ___ WBC, Bacteria few
Lactate:2.3
135 | 100 | 40 AGap=17
-------------<258
4.9 | 23 | 1.6
Ca: 9.8 Mg: 1.8 P: 3.1
8.8>13.6/41.0<183
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports no pain. Patient
concerned for worsening leg infection, though denies systemic
symptoms.
ROS: 10-point ROS negative except as noted above in HPI
Past Medical History:
HTN
borderline DM
chronic osteomyelitis with mutiple I and Ds of RLE and left
humerus
BPH
peripheral neuropathy
OA
Dyslipidemia
mild anemia
Social History:
___
Family History:
Brother underwent CABG. Mother died of MI at ? age.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS - 98, 180/88, 70, 20, 99%RA
GENERAL: Elderly, well appearing male, NAD alert and appropriate
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs; chest midline
scar consistent w/ CABG
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no HSM
EXTREMITIES:
- R lower extremity severely deformed, limited ROM at knee due
to deformity and clubbing of foot. medial shin has outlined
lesion with hyperkeratotic scab with fistulas with surrounding
erythema, tender to palpation, slightly warm to touch; +1 pedal
edema. Varus angulation of knee;
- L lower extremity +1 pedal edema, skin intact
- R ___ digit pink, tophaceous
NEURO: CN II-XII intact
DISCHARGE PHYSICAL EXAM:
==========================
VS: AVSS
Gen: NAD
Pulm: comfortable
Neuro: alert, fluent speech
Psych: calm, appropriate
see daily progress note on day of discharge for detailed
physical exam
Pertinent Results:
ADMISSION LABS:
----------------
___ 11:45AM BLOOD WBC-8.8 RBC-4.57* Hgb-13.6* Hct-41.0
MCV-90 MCH-29.8# MCHC-33.2 RDW-13.7 RDWSD-45.0 Plt ___
___ 03:50PM BLOOD ___ PTT-28.1 ___
___ 11:45AM BLOOD Glucose-258* UreaN-40* Creat-1.6* Na-135
K-4.9 Cl-100 HCO3-23 AnGap-17
___ 11:45AM BLOOD Calcium-9.8 Phos-3.1 Mg-1.8
___ 03:50PM BLOOD CRP-6.4*
___ 11:52AM BLOOD Lactate-2.3*
DISCHARGE LABS:
----------------
___ 06:00AM BLOOD WBC-7.1 RBC-3.86* Hgb-11.3* Hct-35.6*
MCV-92 MCH-29.3 MCHC-31.7* RDW-13.9 RDWSD-47.4* Plt ___
___ 06:00AM BLOOD ___ PTT-26.9 ___
___ 06:00AM BLOOD Glucose-117* UreaN-39* Creat-1.4* Na-139
K-4.7 Cl-105 HCO3-25 AnGap-14
___ 06:00AM BLOOD ALT-16 AST-19 LD(LDH)-140 AlkPhos-63
TotBili-0.4
___ 06:00AM BLOOD CRP-6.6*
___ 06:00AM BLOOD SED RATE-19
PERTINENT LABS:
----------------
URINE CULTURES (___): NEGATIVE
BLOOD CULTURES x2 (___): No growth (FINAL)
IMAGING:
----------
R KNEE X-RAY (___):
There is extensive arthropathy in the Knee with sclerosis and
joint space loss in the patellofemoral, medial and lateral
compartments. There is a probable old medial tibial plateau
fracture. There is varus angulation of the Knee. There are no
acute fractures or frank bone destruction. There is patchy
osteopenia. Calcaneal spurs are present. Vascular
calcifications are noted.
Brief Hospital Course:
Mr. ___ is an ___ with a history of HTN, BPH, gout, CAD s/p
2 vessel CABG ___, T2DM w/ peripheral neuropathy, chronic
osteomyelitis of R leg who presents with R leg pain and redness.
The patient was given 1L IVF and Vancomycin in ED. X-ray of R
leg revealed sclerosis and joint space loss, varus angulation of
the Knee without acute fractures or destruction. While inpatient
the patient received 1x IV cefepime and flagyl, before being
transitioned to PO ciprofloxacin and clindamycin. Redness
scabbing reduced and pain at site diminished. Patient was
discharged with plan for 7 day course of antibiotics (Last day
___ and follow up with Orthopedics for further evaluation of
varus deformity.
#R leg erythema / cellulitis: The patient presented with right
lower extremity pain concerning for cellulitis v. osteomyelitis.
While patient had a longstanding history of significant
infections and known T2DM, on presentation there were no signs
of systemic infection (not tachycardic, afebrile, normotensive,
no leukocytosis). CRP was reassuringly low (<7), Patient was
started on Cefepime, vancomyin, and Flagyl initially, and after
1 dose of each, erythema was noted to be receding and site less
painful and the patient was quickly transitioned to an oral
course of Ciprofloxacin and clindamycin for 7 day course total.
Blood cultures with no growth.
#R knee alignment: Patient noted to have limited ROM, with
tibial varus deformity, increasingly becoming misaligned.
Patient reported having difficulty walking, and increasing
deformity of foot. Patient was evaluated by ___ who recommended
home ___ and the use of a walker. Patient was given information
for Orthopedics department if the would like to consider further
evaluation.
___ on CKD: Cr 1.6 on admission, Baseline likely 1.2-1.4.
Concern for pre-renal etiology, received 1L in ED and held Bumex
and lisinopril on night of admission. Returned to 1.4 on day of
discharge and patient was restarted on home Bumex and
lisinopril.
# HYPERTENSION: Hypertensive on admission with systolic BP >180,
asymptomatic. Held home lisinopril and bumetanide due to ___ and
metoprolol due to low BP control. Was instead started on
labetalol on evening of admission with good effect. The
following day, when renal function improved, patient was
restarted on home doses of lisinopril, metoprolol and Bumex.
#CHRONIC ISSUES:
=================
#T2DM: Unclear glycemic control, no HgBA1c on record. Held home
glipizide and maintained on humalog insulin sliding scale with
good effect.
- Follow FSG and ISS
# CAD s/p CABG ___: Stable, Continued home full dose aspirin
(discussed and confirmed) with PCP and ___.
#Benign prostatic hypertrophy: Stable, continued home
finasteride and Tamsulosin.
#Tophaceous gout: Stable, held home allopurinol in setting of
possible ___, restarted given renal improvement.
TRANSITIONAL ISSUES:
======================
[] 7 day course of Ciprofloxacin and Clindaymycin (last day
___.
[] Patient should follow up with PCP to confirm resolution of
infection.
[] Home with physical therapy and will need cane/walker to
assist in ambulation going forward
[] Plan follow up with orthopedics for evaluation and management
of leg deformity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Polyethylene Glycol 17 g PO EVERY OTHER DAY
6. Psyllium Powder 1 PKT PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Bumetanide 0.5 mg PO EVERY OTHER DAY
9. Multivitamins 1 TAB PO DAILY
10. Aspirin (Buffered) 325 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Medications:
1. Aspirin (Buffered) 325 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Bumetanide 0.5 mg PO EVERY OTHER DAY
4. Finasteride 5 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 75 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO EVERY OTHER DAY
9. Psyllium Powder 1 PKT PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Allopurinol ___ mg PO DAILY
12. GlipiZIDE XL 2.5 mg PO DAILY
13. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Q12 Disp #*13
Tablet Refills:*0
14. Clindamycin 450 mg PO Q6H
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every six (6)
hours Disp #*81 Capsule Refills:*0
15. walker 1 unit miscellaneous DAILY
Prognosis: good. Duration: 13 months. Dx: chronic
osteomyelitis. ICD-10 M86.6
RX *walker use as instructed daily Disp #*1 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Cellulitis
SECONADRY:
Hypertension
Benign prostatic hypertrophy
Coronary artery disease s/p 2-vessel CABG in ___,
Type 2 diabetes w/ peripheral neuropathy
Chronic osteomyelitis of his right leg since 1930s
Gout
Hyperlipidemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation of your R leg infection. You were given IV fluids,
antibiotics, and an X-ray was taken in the ED before being
admitted. While inpatient, you received IV antibiotics before
being transitioned to oral antibiotics (Clindamycin and
Ciprofloxacin) which you should take for a total of 7 days.
Please plan to follow up with your PCP to confirm resolution of
leg infection. We have also made and appointment for you to
follow up with orthopedics. Please refrain from driving until
followed up by your PCP.
It was a pleasure taking care of you during your stay. If you
have any questions about the care you received, please do not
hesitate to ask.
Sincerely,
Your Inpatient ___ Care Team
Followup Instructions:
___
|
10607085-DS-18 | 10,607,085 | 22,853,767 | DS | 18 | 2180-06-28 00:00:00 | 2180-06-28 10:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a moderate TBI. He has mild dementia at baseline.
His daughter states that she noticed an increase in confusion
while speaking with him on the phone yesterday. This confusion
continued when she saw him in person and preceded a fall. He did
not lose consciousness. He was taken to ___ where a CT
was completed and showed a subdural hematoma. He was transferred
to ___ for further evaluation and treatment.
Mechanism of trauma: Ground level fall
Past Medical History:
HTN
borderline DM
chronic osteomyelitis with mutiple I and Ds of RLE and left
humerus
BPH
peripheral neuropathy
OA
Dyslipidemia
mild anemia
Social History:
___
Family History:
Brother underwent CABG. Mother died of MI.
Physical Exam:
Exam on Admission
O: T: 97.9 BP: 145/53 HR: 70 RR: 18 O2 Sat: 98%
GCS upon Neurosurgery Evaluation: 14
Airway: [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[x]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to self, hospital, and ___.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. RLE does not have a knee joint so Quad and Ham could
not
be tested. Otherwise, strength full power ___ throughout. No
pronator drift
Sensation: Intact to light touch
Exam on Discharge
___ x 3. NAD. PERRLA.
CN II-XII intact.
LS CTA
RRR
abdomen soft, NTND
___ BUE and BLE. No drift.
Pertinent Results:
___ ___
1. Stable appearance of the known small left frontal subdural
hematoma
measuring 9 mm compared to earlier same-day prior CT.
Brief Hospital Course:
Mr. ___ was admitted to the neuro step down unit on ___
from the ED after receiving platelets for Aspirin use in the
setting of an acute subdural hematoma.
On the morning of ___, the patient underwent a repeat NCHCT
which was stable. He was started on a seven day course of
Keppra. Physical therapy evaluated the patient and felt he would
benefit from rehab.
On ___, the patient's neurological exam remained stable and he
was transferred from the Neuroscience Intermediate Care Unit to
the floor.
On ___, the patient remained neurologically stable.
Intravenous fluids were started for a creatinine of 1.4.
On ___, the patient continued to do well and his neurological
exam was stable. Disposition planning for discharge to acute
rehab remained underway.
On ___ the patient remained hemodynamically and neurologically
stable. He will continue Keppra for seizure prophylaxis for a
total of 7 days. He may restart his ASA today. He will follow
up in the office in 4 weeks with a repeat Head CT.
Medications on Admission:
bumetanide 0.5 mg every other day, glipizide ER 2.5 mg daily,
losartan 50 mg tablet Daily, finasteride 5 mg daily, Flomax 0.4
mg daily, allopurinol ___ mg tablet daily, aspirin 81 mg daily,
atorvastatin 20 mg daily, metoprolol succinate ER 50 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
3. Docusate Sodium 100 mg PO BID
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. Heparin 5000 UNIT SC BID
7. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze
9. LevETIRAcetam 500 mg PO BID
10. Senna 17.2 mg PO HS
11. Allopurinol ___ mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Atorvastatin 20 mg PO QPM
14. Bumetanide 0.5 mg PO EVERY OTHER DAY
15. Finasteride 5 mg PO DAILY
16. GlipiZIDE 5 mg PO BID
17. Losartan Potassium 50 mg PO DAILY
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10607218-DS-21 | 10,607,218 | 24,119,800 | DS | 21 | 2173-06-03 00:00:00 | 2173-06-04 16:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea and cough
Major Surgical or Invasive Procedure:
Chest tube placement
History of Present Illness:
Mr. ___ is a ___ y/o M w/ PMH of HTN who presents as
transfer from ___ for evaluation of necrotizing
pneumonia.
He works as a ___. 6 months ago he was working ___ a
___
coop placing barriers, the day after which he developed a cough
with productive clear phlegm. This cough has been intermittent,
positionally dependent (ie. if he lays on his right side, if he
bends over) and will result ___ him coughing up clear sputum. He
has not coughed up any colored sputum or blood. ~5months ago, he
noted that at night he would intermittently wheeze. No
orthopnea/PND. When asked why he did not come ___ to be
evaluated,
he states he was not bothered by this and that he does not like
doctors. About ___ days ago he noticed gradual onset, worsening
DOE. Pt denies other associated symptoms including fever/chills,
dizziness/lightheadedness, CP/palps, abd pain/swelling, swelling
___ legs, or change ___ bowel or bladder habits. No weight loss,
back pain, night sweats. He denies any smoking history
He presented to ___ due to these worsening symptoms. ___
brief,
CXR showing significant R pleural effusion and signs of
complicated PNA for which he had a CT chest there, which again
demonstrated R pleural effusion and likely necrotizing PNA.
Additionally with elevated BNP but no elevated WBC, neg trop, no
significant electrolyte abnormalities on initial labs.
Transferred for further mgmt.
___ the ___ here he was evaluated by IP who placed a chest tube
which drained 1.4L of serosanginous fluid. he otherwise had an
unremarkable ___ course. He was not started on abx. On arrival to
the floor, he feels better and no longer has a cough or sputum
production.
Past Medical History:
HTN
Has not seen a doctor for 40+ years
Social History:
___
Family History:
Father with COPD, heavy smoker, died from this
Mother with ___
Brother healthy
No children
No family h/o DM, heart disease, cancer.
Physical Exam:
ADMISSION EXAM
VS: 98.6 PO 156 / 97 94 18 95 Ra
GEN: NAD, A&Ox3, appropriate mood and affect
HEENT: NC/AT EOMI MMM sclera anicteric
NECK: No JVD
CV: Tachycardic, no m/r/g nl s1/s2
PULSES: 2+ radial
RESP: CTAB on Left, diminished RUL breath sounds, absent RLL
breath sounds.
ABD: Soft NTND
EXT: 1+ edema to mid-shins BLE
DISCHARGE EXAM
24 HR Data (last updated ___ @ 1249)
Temp: 98.1 (Tm 99.0), BP: 124/84 (124-160/84-97), HR: 89
(73-115), RR: 18, O2 sat: 95% (93-96), O2 delivery: Ra
GEN: NAD. Lying comfortably ___ bed.
HEENT: NC/AT EOMI MMM sclera anicteric
CV: RRR, no m/r/g
RESP: restricted air mvt w/ crackling throughout lung fields,
decreased lung sounds across entire R side, no labored
breathing,
pleurex capped
ABD: Soft NTND
EXT: trace - 1+ edema to mid-shins BLE
Neuro: unable to lift R arm above 10 degrees against gravity,
intact strength of the hand/fingers, normal gross sensation,
unable to maintain arm up when lifted passively, no pain
elicited
on passive ROM
Pertinent Results:
___
___ 07:23AM BLOOD WBC-9.6 RBC-3.45* Hgb-11.5* Hct-35.4*
MCV-103* MCH-33.3* MCHC-32.5 RDW-13.2 RDWSD-49.2* Plt ___
___ 07:23AM BLOOD ___ PTT-25.7 ___
___ 07:23AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-138
K-3.5 Cl-96 HCO3-29 AnGap-13
___ 01:22PM BLOOD ALT-12 AST-16 LD(LDH)-241 AlkPhos-122
TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 07:23AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0
___ 01:22PM BLOOD RheuFac-<10 ___
___ 06:17PM BLOOD Lactate-1.2
IMAGING/MICROBIOLOGY
___. Interval insertion of a right sided chest drain with now
multiloculated
right-sided hydropneumothorax.
2. The minimal re-expansion of the right lung following chest
drain insertion
with visceral and pleural thickening suggests a chronic fibrotic
pleural
process with trapped lung.
3. Heterogeneous appearance and complete collapse of the right
lower lobe is
concerning for malignancy. Postobstructive collapse may also
have this
appearance. Consider bronchoscopy as clinically warranted.
___ liver MRI
NOTIFICATION: The updated findings and recommendation were
discussed by Dr.
___ with Dr. ___ on the telephone on ___ at 9:45
am, 50 minutes
after discovery of the findings.
___ CT abd/pelvis
1. Focal mass-like soft tissue thickening, likely pleural ___
origin, indents
the posterior right hepatic lobe and may suggest pleural-based
neoplasm.
Otherwise, no evidence of metastatic disease within the abdomen
or pelvis.
2. Similar appearance of partially visualized multiloculated
right-sided
hydropneumothorax with collapsed, heterogeneous right lower lobe
and
right-sided chest tube ___ situ.
3. Diffuse cortical thickening of the partially visualized right
seventh rib
likely correlates with the MRI findings suggestive of periosteal
reaction and
is nonspecific.
4. Unchanged grade 1 anterolisthesis of L5 on S1 due to
bilateral pars
defects.
5. Moderate hiatal hernia.
___ MRI head
-Lesions involving the clivus and imaged upper cervical spine,
with pre
vertebral and paravertebral soft tissue enhancement, more marked
on the right
side. Findings are likely ___ keeping with metastatic disease.
The
differential also includes, but less likely, lymphoma and
infection
-Filling defects within the right transverse, sigmoid sinuses
and imaged
superior internal jugular vein, ___ keeping with nonocclusive
thrombus. There
is no associated venous infarct or hemorrhage.
-Epidural soft tissue thickening and enhancement at C1-C2,
causing mild spinal
canal narrowing.
-No intracranial mass is identified. No abnormal intracranial
enhancement.
-No acute infarct or hemorrhage is identified.
___ MRI C-spine
-Stable appearance of the multiple likely metastatic lesion is
___ the upper
cervical spine and clivus.
-Enhancing prevertebral and paravertebral soft tissue at C1-C2
level, more
marked on the right side, surrounding the vertebral arteries
bilaterally ___
the C2 transverse foramina and surrounding the V3 segments
bilaterally, with
preservation of flow voids.
-Anterior epidural/dural thickening enhancement from the
craniocervical
junction to C5 level. Soft tissue enhancement and thickening
around the
posterior arch of C1 and lateral epidural space bilaterally at
C1-C2, causing
mild spinal canal narrowing.
-Bilateral C1-C2 neural foraminal narrowing secondary to soft
tissue
thickening and enhancement.
-Right neural foraminal soft tissue involvement from C4-5 to
C6-7 due to
metastatic disease (3:4 and 7:4).
-No cord abnormality is identified within the imaged cord. No
cord
compression.
-Soft tissue enhancement at the right lung apex and sclerosis of
the right
second rib posteriorly, concerning for malignancy.
-Filling defects within the right transverse and sigmoid sinuses
___ keeping
with venous sinus thrombosis.
___ MRI brachial plexus
1. Expansile soft tissue thickening and enhancement along
metastatic
involvement the right second rib which may contact the T1 and T2
nerve roots
along their course, but without gross encasement. Otherwise no
mass or soft
tissue enhancement along the remainder of the brachial plexus.
2. Redemonstration of a right lung mass with right
hydropneumothorax and
metastatic disease ___ the clivus, upper cervical spine with
extensive
surrounding soft tissue involvement, as well as the T3 vertebral
body and
right sixth rib.
___ Fine needle aspiration, lung, right lower lobe mass:
POSITIVE FOR MALIGNANT CELLS.
Adenocarcinoma. See note.
Note: By immunohistochemistry the tumor cells are negative for
P40, TTF-1 and Napsin. See
concurrent cytology (___- ___) and surgical pathology
___ for further characterization.
___ Pleural fluid, right:
POSITIVE FOR MALIGNANT CELLS.
Metastatic adenocarcinoma. See note.
Note:The tumor cells are immunoreactive for MOC31, B72.3, CEA,
and Leu M1 and negative for
calretinin, TTF-1, and WT1.
See concurrent surgical biopsy (___) for further
characterization.
___ 1:02 pm BRONCHIAL WASHINGS RIGHT MAIN STEM WASH.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
ENTEROBACTER CLOACAE COMPLEX. ___ CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SERRATIA MARCESCENS. 10,000-100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| SERRATIA MARCESCENS
| |
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
YEAST.
DISCHARGE LABS
___ 04:50AM BLOOD WBC-9.8 RBC-3.26* Hgb-10.9* Hct-33.3*
MCV-102* MCH-33.4* MCHC-32.7 RDW-12.9 RDWSD-48.4* Plt ___
___ 04:50AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-136
K-4.9 Cl-98 HCO3-25 AnGap-13
___ 04:50AM BLOOD Mg-2.1
Brief Hospital Course:
===================
BRIEF COURSE
===================
Mr. ___ is a ___ w/ h/o HTN, no recent follow up w/ PCP ___
___ yr, who p/w dyspnea and productive cough for 6 months, found
to have a large R sided exudative effusion, with biopsy by
bronchoscopy of a RLL mass confirmed lung adenocarcinoma with
further imaging showing metastasis to the pleura, clivus, and
cervical spine.
===================
TRANSITIONAL ISSUES
===================
[] f/u with thoracic oncology to discuss further workup
including PET scan/treatment options of newly diagnosed stage IV
lung adenocarcinoma
[] Patient received 1 fraction on ___, will receive daily
___
[] f/u with interventional pulmonology to assess status of R
pleurex
[] monitor BP to determined if anti-hypertensive needed, holding
at this time
[] pleural cultures are still pending at the time of discharge,
though low suspicion for infectious etiologies
[] patient was started on lovenox for a non occlusive venous
sinus, incidentally found on brain MRI
CODE STATUS: Full code
CONTACT: ___ (sister) ___
=============
ACUTE ISSUES:
=============
#Dyspnea and productive cough
#Concern for lung entrapment
#Stage IV lung adenocarcinoma
Pt presented with a large R sided effusion, found to be
exudative with lymphocytic predominance, s/p chest tube
placement on ___. His initial chest CT showed possible concern
for malignancy versus necrotizing infection with a collapsed R
lung and pt was started on empiric abxs. Given that he was
persistently afebrile and without leukocytosis, unasyn was
discontinued on ___. Repeat CT chest showed minimal reexpansion
of R lung after CT insertion w/ visceral/pleural thickening and
evidence of trapped R lung. Pleural cytology was sent and was
negative x3. Due to high suspicion for malignancy, pt underwent
a bronchoscopy with biopsy of a RLL mass found on EBUS. Pleurex
was placed on ___ and chest tube removed on ___. Biopsy
pathology confirmed adenocarcinoma, with further staining
studies pending at discharge. Pt underwent additional oncology
work up including a CT abd/pelvis that was remarkable for a
benign liver cyst (confirmed on liver MRI). Of note his
respiratory cultures obtained from bronchoscopy grew serratia
and enterobacter; infectious disease was consulted and ___ the
absence of clinical suspicion for active infection they
determined this was likely respiratory flora colonization, but
that patient is at high risk for post-obstructive pneumonia, ___
which case he should be treated with a fourth generation
cephalosporin to cover these organisms. Oncology was consulted
and set up follow up with thoracic oncology. Patient and his
family received teaching for pleurex ___ and lovenox
injections. Palliative ___ also came to speak with patient but
he did not wish to further follow up with them at this time due
to anxiety surrounding the association to palliative ___ and
hospice.
# nonocclusive venous sinus thrombus
Head MRI suggested metastasis to the clivus and paravertebral
cervical spine, as well as a nonocclusive venous sinus thrombus,
for which patient was started on therapeutic lovenox BID. The
___ clinic will manage his anticoagulation.
#Insomnia
#Delirium
Patient had difficulty sleeping during his hospitalization and
was started on ramelteon and trazodone, he had one episode of
disorientation overnight with wandering the halls but was easily
redirectable. He was given trazodone with minimal effect.
#R extremity weakness
Patient noted right extremity weakness that had been ongoing for
several weeks prior to admission, which he believes may have
been related to carrying heavy boxes of paint. He could not lift
his arm past ~10 degrees against gravity, his hand
function/strength was intact, he was unable to maintain arm up
___ the air, noted some dull pain ___ his scapula but no
tingling/shooting pain ___ RUE. Brain MRI was unremarkable other
than bony findings as above. A C-spine and brachial plexus MRI
showed soft tissue thickening and enhancement along metastatic
involvement the right second rib which may contact the T1 and T2
nerve roots along their course. Radiation oncology reviewed the
imaging and elected to have the patient start dexamethasone and
undergo CT Simulation with palliative radiation on ___ of RUE
metastasis, with plan for further radiation treatments
outpatient.
=============
CHRONIC ISSUES:
=============
#HTN: Pt has not seen a doctor for 40+ years, has a reported
history of HTN but was not on an medications. Thorughout his
hospitalization his SBP ranged from 120s-150s. BP should be
followed up outpatient.
#Incidental R liver lobe cyst
Initial CT chest showed indeterminate 6 mm hypodensity ___ the R
liver lobe, he had normal LFTs, and liver MRI confirmed this was
a benign cyst
Agree with discharge summary as documented. 35 minutes spent ___
coordination of ___ and discharge planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY
============================
Stage IV lung adenocarcinoma
Right extremity weakness
SECONDARY
============================
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 here at ___
___!
WHY WAS I ___ THE HOSPITAL?
================================
- You were admitted to ___ due to difficulty breathing and
cough for the past months.
WHAT HAPPENED ___ THE HOSPITAL?
================================
- You were noted to have a large fluid collection near the lung.
- The lung doctors (___) drained the fluid out with a
chest tube.
- You were started on empiric antibiotics but an infection was
considered unlikely to cause the fluid you had around your lungs
and antibiotics were discontinued
- You had a bronchoscopy to obtain biopsy samples from a mass ___
your right lung, which was found to be cancer (adenocarcinoma)
- You had an MRI of your head that showed possible metastasis of
the cancer to the cervical spine
- You had an MRI of your should to evaluate the weakness ___ your
arm caused by the cancer.
- You received a fraction of radiation to start. This was day 1
of 5 fractions.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
================================
- Follow up with your new primary ___ doctor and other doctors
listed at the scheduled appointments
- Take all your medications as instructed, including the lovenox
injections twice a day
We wish you all the best!
Your ___ ___ team
Followup Instructions:
___
|
10607290-DS-23 | 10,607,290 | 26,906,006 | DS | 23 | 2198-02-05 00:00:00 | 2198-02-07 21:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex / tacrolimus / cephalexin
Attending: ___
Chief Complaint:
Proteinuria
Major Surgical or Invasive Procedure:
Renal biopsy (___)
History of Present Illness:
___ with ESRD s/p ECD transplant ___, HTN, ___ recieving
radiation, diabetes who presents with allograft dysfunction and
worsening proteinuria in the setting of supratherapuetic
sirolimus.
Mr. ___ reports that he is here because he was told to come
in after his recent lab work showed that his kidney function was
worsening. He reports he had labs drawn as an outpatient and was
told his creatinine is 1.9 where his baseline has been 1.2-1.5.
The patient states that over the past 2 weeks, he has gained 16
pounds. He notes abdominal distention and swelling in his lower
extremities. He states he feels very tired and weak. He gets
tired when he is walking with his walker.
In the ED, initial vitals were: 13:54 0 96.9 71 148/45 16 100%
RA
- Labs were significant for baseline anemia (Hgb 8.8), Cr 1.8.
No hyperkalemia.
- Imaging revealed Elevated resistive indices
- Renal transplant consulted and recommended admission for
workup of allograft dysfucntion.
- The patient was given: 80mg IV lasix
Vitals prior to transfer were: 0 81 163/58 18 97% RA
Upon arrival to the floor, patient is comfortable. He reports
that he feels his breathing is improved slightly and he has no
acute complaints. He denies any fevers or chills. Denies any
cough. Denies any nausea, vomiting, diarrhea. His kidney
transplant medications have been decreased recently but he has
not had any other new medications. He still produces urine and
denies any changes in urination. He has insulin-dependent
diabetes and states his blood glucose has been well controlled.
Of note, his sirolimus levels have been decreased by his
transplant nephrologist from 3mg daily to now 2mg daily;
supratherapuetic levels thought to be the cause of his bump in
cr- ___ labs revealed a sirolimus trough of 18, which
appears to be a true trough, w/ corresponding cr of 1.9. To note
patient also denies change in urinary frequency, hematuria,
change in color, or foamy urine.
On the morning of ___, patient denies SOB, pain,
fevers/chills. No difficulties with
constipation/diarrhea/dysuria. Last BM 24 hours ago was normal.
Past Medical History:
ESRD from diabetic nephropathy, s/p deceased donor kidney
transplant ___
Diabetes mellitus
HTN
SDH after fall, resolved
actinic keratosis
RUE AV fistula creation
CAD
Social History:
___
Family History:
HTN in multiple relatives
Physical ___:
==========================
PHYSICAL EXAM ON ADMISSION
==========================
Vitals: 99.2 139-151/47-64 ___ 20 95RA
FSBG 125, UOP 1550 o/n
GENERAL: NAD, pleasant
HEENT: Slightly dry MMM, Anicteric sclera, PERRLA, EOMI
NECK: Supple, JVP 4cm above clavicle at 60 degress.
CARDS: RRR, ___ systolic murmur at the ___
PULM: CTAB, no w/c/r
ABDOMEN: soft/NT, mildly distended. RLQ renal allograft is NT,
no bruit
EXTREMITIES: Moderate ___ pitting edema up to sacrum, warm, no
cyanosis. R heel with pressure ulcer.
NEURO: No focal deficits, no asterixis
SKIN: Diffuse actinic keratoses over skin. Radiation changes
over L neck.
==========================
PHYSICAL EXAM ON DISCHARGE
==========================
Vitals: T 97.5 BP 134-145/45-71 HR 75 RR 18 93% RA
I/O: 120/300 (8H); 1220/1100 (24H)
GENERAL: NAD, pleasant
HEENT: Slightly dry MMM, anicteric sclerae, PERRLA, EOMI
NECK: Supple, JVP 2cm above clavicle at 60 degrees.
CARDS: RRR, ___ systolic murmur at the ___
PULM: CTAB, decreased lung sounds at bases, no w/c/r
ABDOMEN: Soft/NT, mildly distended. RLQ renal allograft is NT,
no bruit
EXTREMITIES: 1+ bilateral pitting edema to knee with chronic
venous stasis changes
NEURO: No focal deficits, no asterixis
SKIN: Diffuse actinic keratoses over skin. Radiation changes
over L neck with discharge.
Pertinent Results:
=================
ADMISSION LABS:
=================
___ 06:50PM BLOOD WBC-5.2 RBC-3.34* Hgb-8.8* Hct-28.7*
MCV-86 MCH-26.3 MCHC-30.7* RDW-17.2* RDWSD-52.9* Plt ___
___ 06:50PM BLOOD ___ PTT-27.1 ___
___ 06:50PM BLOOD Glucose-92 UreaN-33* Creat-1.8* Na-138
K-4.8 Cl-106
___ 06:50PM BLOOD ALT-10 AST-23 AlkPhos-92 TotBili-0.3
___ 06:50PM BLOOD proBNP-4716*
___ 06:50PM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.7 Mg-2.4
___ 06:55PM BLOOD rapmycn-10.2
___ 07:03PM BLOOD Lactate-0.7
=================
PERTINENT RESULTS:
=================
LABS:
=================
___ 06:50PM BLOOD proBNP-___*
___ 10:50PM URINE Hours-RANDOM Creat-80 Na-41 K-24 Cl-28
TotProt-271 Prot/Cr-3.4*
___ 04:56AM URINE Hours-RANDOM Creat-74 TotProt-197
Prot/Cr-2.7*
___ 11:37AM URINE Hours-RANDOM Creat-80 TotProt-277
Prot/Cr-3.5*
=================
IMAGING
=================
Renal Ultrasound (___): Elevated resistive indices,
increased from prior. Patent main renal artery and vein. No
hydronephrosis or perinephric fluid collection.
===
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 mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
=================
MICROBIOLOGY
=================
Neck wound Culture (___): MIXED BACTERIAL FLORA.
=================
PATHOLOGY:
=================
Renal biopsy (___): Final report pending at discharge.
Preliminary report with no acute findings.
=================
DISCHARGE LABS:
=================
___ 04:29AM BLOOD WBC-4.0 RBC-3.09* Hgb-8.2* Hct-26.9*
MCV-87 MCH-26.5 MCHC-30.5* RDW-17.3* RDWSD-54.0* Plt ___
___ 04:29AM BLOOD Glucose-132* UreaN-30* Creat-1.8* Na-140
K-3.9 Cl-102 HCO3-29 AnGap-13
___ 04:29AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9
====
___ 05:18AM BLOOD Cyclspr-47*
___ 05:52AM BLOOD Cyclspr-54*
___ 04:29AM BLOOD Cyclspr-77*
Brief Hospital Course:
Mr. ___ is a ___ man with ESRD s/p ECD transplant in
___, HTN, and DMII who presented with acute kidney injury found
on routine lab work and volume overload in the setting of
supratherapeutic sirolimus levels. The patient was taking
sirolimus because he was unable to tolerate tacrolimus due to
neurotoxic side effects including seizures and encephalopathy.
Given his degree of continued proteinuria, sirolimus was
discontinued and the patient was started on cyclosporine 100 mg
Q12H with goal level 100. He underwent kidney biopsy on
___, which was negative for rejection. He was diuresed with
Lasix and discharged on Lasix 80 mg daily to be started on
___. Discharge weight was 94.2 kg. On admission, he was also
noted to have a skin infection of his left neck related to
radiation therapy; he completed a 7-day course of cipro/clinda.
=============
ACTIVE ISSUES:
=============
# Allograft Dysfunction: The patient presented with creatinine
of 1.8 increased from his baseline of 1.2-1.5.
Protein/creatinine ratio was 3.4. His sirolimus level on
admission was 10.2. The etiology of his allograft dysfunction
was thought to be due to supratherapeutic levels of sirolimus.
Of note, the patient was taking sirolimus because he was unable
to tolerate tacrolimus due to neurotoxic side effects including
seizures and encephalopathy. Given his degree of continued
proteinuria, sirolimus was discontinued and the patient was
started on cyclosporine 100 mg Q12H with goal level 100. He
underwent renal allograft biopsy on ___, which was negative
for rejection.
# Volume overload: On admission, the patient noted a recent 20
lb weight gain, orthopnea, and lower extremity swelling. ProBNP
on admission was 4716. TTE showed preserved EF. He was diuresed
with Lasix with improvement in his edema and orthopnea, and was
discharged on Lasix 80 mg daily to be started on ___.
Discharge weight was 94.2 kg.
# Skin infection: The patient is undergoing radiation therapy
for SCC of left neck. Per patient, he has had ___ planned
fractions of adjuvant radiation. His left neck showed signs of
infection so a wound culture was obtained that grew mixed
bacterial flora. His infection was treated with a 7-day course
of clindamycin/ciprofloxacin (___).
# ESRD s/p ECD transplant ___: Creatinine on admission 1.8.
Baseline Cr of 1.2-1.5. Allograft dysfunction managed with
discontinuation of sirolimus as above. Started on cyclosporine
100 mg Q12H for goal level 100. Cholecalciferol continued.
Bactrim ppx was continued.
=================
CHRONIC ISSUES:
=================
# HTN: Continued Carvedilol 12.5 mg BID and held amlodipine in
setting of lower extremity swelling.
# Anemia: Secondary to CKD. Stable.
# DM2: Lantus dose was reduced from 22 units QHS to 10 units
QHS. Insulin sliding scale continued.
# Right foot ulcer: Followed wound care recommendations.
======================
Transitional Issues
======================
- Sirolimus discontinued.
- Continue cyclosporine 100 mg Q12H for goal level 100. Patient
to receive labs on ___ to be faxed to ___ transplant clinic,
ATTN ___. ___ at ___.
- Continue Lasix 80 mg daily starting ___ with creatinine 1.8
at discharge.
- Atorvastatin 10 mg was changed to pravastatin 20 mg due to
drug interaction between atorvastatin and immunosuppressant.
- Amlodipine was discontinued in light of lower extremity
swelling.
- Lantus dose was reduced from 22 units QHS to 10 units QHS.
- Valacyclovir and valgancyclovir were stopped as these were no
longer needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Sirolimus 2 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Atorvastatin 10 mg PO QPM
9. Fluoxetine 20 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Nystop (nystatin) 100,000 unit/gram topical BID:PRN rash
12. Famotidine 20 mg PO BID
13. ValGANCIclovir 450 mg PO Q24H
14. ValACYclovir 500 mg PO Q24H
15. Gabapentin 300 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Carvedilol 12.5 mg PO BID
3. Famotidine 20 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Pravastatin 20 mg PO QPM
RX *pravastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
8. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
RX *cyclosporine modified 100 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
9. Furosemide 80 mg PO DAILY
Please start on ___. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Gabapentin 300 mg PO TID
12. Outpatient Lab Work
Please check cyclosporine level, chem7, LFTs, CBC on ___
and fax to ___ ATTN: ___. ___ nephrology
transplant. ICD-10 code: ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis
=================
Allograft dysfunction
Acute kidney injury
Secondary diagnosis
===================
Volume overload
Radiation wound
Hypertension
Anemia
Diabetes mellitus type II
Right foot ulcer
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
admission to ___. You came to
use because your routine labs showed that your kidney function
was worsening, and you were experiencing swelling of your legs
and weight gain. Your decline in kidney function was attributed
to high levels of your immunosuppression medication called
sirolimus. We stopped this medication, and started a new
immunosuppressant called cyclosporine (dose of 100 mg twice a
day). You had a kidney biopsy, which did not show rejection.
We gave you a water pill to help you get rid of the extra fluid
on your body. You should take your Lasix at an increased dose of
80 mg once in the morning starting tomorrow. If you notice your
weight going up or down by 3 pounds over 3 days, please call the
kidney doctor. We also found that you had a skin infection on
your neck related to your radiation treatment; we gave you
antibiotics to treat this, which you have completed.
You will need labs to be drawn on ___ and faxed to the
kidney doctors. ___ have given you a script for this. Please see
below for more information on your medications and follow up
appointments.
We wish you the best of health,
Your ___ Team
Followup Instructions:
___
|
10607380-DS-19 | 10,607,380 | 27,013,081 | DS | 19 | 2168-09-16 00:00:00 | 2168-09-16 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sodium pentathol / dust / pollen / ragweed pollen
Attending: ___.
Chief Complaint:
Confusion and falls
Major Surgical or Invasive Procedure:
- ___: LP attempted and aborted due to small hematoma
formation
History of Present Illness:
___ with hx metastatic breast cancer (known metastases to bone
and liver), blindness ___ congenital glaucoma, depression, and
asthma who was referred from ___'s office for subacute mental
status decline and increasing falls at home.
Patient increased falls over the last several months, she thinks
5 since ___. Her husband notes she has had several in the last
few weeks, and she is now entirely dependent on him to help her
move around without falling. She reports significant 'shakiness'
and weakness when standing, more pronounced in the right leg.
She denies vertigo or presycnopal symptoms. Her last fall was
1.5 weeks ago with no head strike or LOC. Her husband also has
noted some dysarthria and possible confusion. For these
symptoms, she was referred to the ED.
In the ED, initial VS were 98.2 83 119/64 14 100% RA. Labs were
notable for Chem-7 wnl with Cr 0.8 (baseline Cr 0.8-1.0), LFTs
wnl, CBC at baseline with H/H 8.3/25.9 (baseline Hct ___, INR
1.2. CT Head prelim read without acute process. CXR with no
acute process but noted widespread osseous metastases. The
patient is now admitted to ___ for further treatment and
management. VS prior to transfer T 98.1, HR 84, BP 113/62, RR
18, O2 97%RA.
On arrival to the floor, patient has no acute complaint. Denies
recent fevers or chills. She has occaisional sinus headaches,
but non currently. She has some residual vision at baseline
which has not changed. No SOB, mild chronic cough, no chest
pain. No N/V/D. No abdominal pain. She has increased urinary
frequency but no dysuria. No edema. She has had a small skin
lesion on her right foot, for which she is currently holding her
xeloda. Of note, she recently stopped her diabetes meds several
months ago, which seems to correspond with the worsening of her
weakness/balance. ROS is otherwise unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY: For full Onco history, please see
Atrius records. Briefly: Breast cancer, initially on the right
side in ___ with DCIS on the left with microinvasion. First
metastasis was in ___ to bone and liver. She has had stable
disease now ___ years. She taking the Xeloda and Zometa every
three months.
PAST MEDICAL HISTORY:
Congenital glaucoma and related blindness
HTN
Asthma
GERD
CKD, baseline Cr
Allergic rhinitis
IBS
Depression
Uterine fibroids
+PPD
Social History:
___
Family History:
Father ___ - Type II; Psych - Depression; Stroke
Mother Cancer - ___
Paternal Aunt Cancer
Son ___ - Type I
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VS: BP 108/64 HR 88 RR 20 T 98.5
GENERAL: Pleasant, frail woman. NAD.
HEENT: NC/AT, legally blind with marked saccades at rest. PERLL.
Anicteric. Dry MM.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema. Right foot with 1cm
fissure without surrounding erythema or drainage
NEURO: Oriented to person and place. Answers ___ for month.
Fair attention. Blind. PERLL. Marked saccades at rest. Moves
eyes on command to all four quadrants. Attends to examiner.
Slight right facial droop. Tongue and Pharanyx is midline. 3+/5
strength right shoulder. ___ throughout rest of upper
extremities, although exam limited by patient. Marked intention
tremor bilaterally during FTN and noticeable DDK. Poor HTS,
worse on right. Good antigravity strength throughout both lower
extremities.
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.7 ___ 70 16 97-99RA
GENERAL: Pleasant, frail woman. NAD.
HEENT: NC/AT. Blind with saccades at rest. Anicteric sclera. Dry
MM.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4.
LUNG: Clear to auscultation, no wheezes or rhonchi.
ABD: +BS, soft, NT/ND, no rebound or guarding.
BACK: Small soft hematoma at L3, with dressing coming off but no
bleeding or erythema. Nontender.
EXT: No lower extremity pitting edema. Right foot with 1-cm
fissure without surrounding erythema or drainage.
NEURO: A&Ox3. Blind with marked saccades at rest. Otherwise CN
II-XII intact. 4+/5 strength, overall ___ throughout. Marked
tremor and ataxia, worse on right. Normal finger to nose.
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 01:35PM BLOOD WBC-6.4 RBC-2.61* Hgb-8.3* Hct-25.9*
MCV-99* MCH-31.8 MCHC-32.0 RDW-14.2 RDWSD-51.2* Plt ___
___ 01:35PM BLOOD Neuts-82.6* Lymphs-9.4* Monos-6.6
Eos-0.8* Baso-0.3 Im ___ AbsNeut-5.26 AbsLymp-0.60*
AbsMono-0.42 AbsEos-0.05 AbsBaso-0.02
___:35PM BLOOD ___ PTT-29.3 ___
___ 01:35PM BLOOD Glucose-254* UreaN-18 Creat-0.8 Na-134
K-3.9 Cl-94* HCO3-29 AnGap-15
___ 01:35PM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.7 Mg-2.2
___ 01:35PM BLOOD ALT-17 AST-34 AlkPhos-93 TotBili-0.5
=========
KEY LABS:
=========
___ 09:15AM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 01:35PM BLOOD VitB12-230* Folate-12.5
___ 07:00AM BLOOD Ferritn-713*
___ 09:02AM BLOOD %HbA1c-7.0* eAG-154*
___ 07:55AM BLOOD CEA-2.0 ___
=================
DISCHARGE LABS:
=================
___ 07:33AM BLOOD WBC-5.4 RBC-2.84* Hgb-9.1* Hct-28.0*
MCV-99* MCH-32.0 MCHC-32.5 RDW-14.3 RDWSD-51.9* Plt ___
___ 07:33AM BLOOD Glucose-176* UreaN-23* Creat-0.9 Na-137
K-4.3 Cl-97 HCO3-29 AnGap-15
___ 07:33AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.0
========
IMAGING:
========
___ MRI HEAD: Several T1 hypo intense and enhancing
calvarial lesions worrisome for metastatic disease. No evidence
of intracranial disease involvement.
___ MRI C/T/L SPINE:
1. Diffusely abnormal bone marrow signal in the cervical,
thoracic, and lumbar
spine, as well as included upper sacrum and medial iliac bones,
indicating
diffuse metastatic disease.
2. Mild loss of height involving several cervical and thoracic
vertebral bodies is noted, unchanged in the thoracic spine
compared to the ___ torso CT. No prior cervical spine
imaging for comparison.
3. No evidence for epidural or leptomeningeal metastatic
disease.
4. Multilevel cervical degenerative disease with moderate spinal
canal stenosis and moderate to severe neural foraminal
narrowing.
5. Mild thoracic and lumbar degenerative disease without
evidence for neural impingement.
6. Stable 15 mm oval nodule in the right upper gluteal
subcutaneous soft tissues, of uncertain clinical significance
given partial fat density on the prior CT, but no evidence for
fat on the present MRI on which it is incompletely evaluated.
___ CT ABD PELVIS:
1. Of the 3 previously identified hypodense liver lesions, only
2 are seen, relatively similar in size. Interval stability is
reassuring however not diagnostic for a benign process.
2. Stable thickening of the left adrenal gland.
3. Stable soft tissue mass in the left adnexa, of unclear
etiology.
4. Diffuse osseous metastases. No compression deformities in
the lumbar
spine.
___ CT CHEST 1. No evidence of metastatic disease to the
pleura, mediastinum, or pulmonary parenchyma.
2. Numerous osseous metastases, not significantly changed from ___, and no pathologic compression deformity in the
thoracic spine or acute pathological rib fractures.
3. Previously identified areas of ground-glass in the upper
lobes bilaterally have resolved since the prior study.
Brief Hospital Course:
___ with metastatic breast cancer, blindness ___ congenital
glaucoma, depression, and asthma referred from ___'s office for
subacute mental status decline and increasing falls, confusion,
and dysarthria at home.
# Falls/Instability: Patient presented with poor cerebellar exam
and 'shaking'. CT scan showed no acute lesions. MRI was degraded
by with significant movement artifact but showed no evidence of
direct CNS involvement. ID work-up was negative and she had no
fever or leukocytosis. Repeat MRI head with no clear intraxial
mets but calvarial lesions consistent with bony metastases. MRI
C/T/L spine with and without contrast showed cervical spine
stenosis and e/o bony mets but no intramedullary lesions.
Neurology was consulted given her ataxia and felt that her
symptoms were concerning for a possible paraneoplastic syndrome.
Serologies were sent but did not return until after discharge.
Patient was noted to be B12 deficient as a possible cause and
repleted during hospitalization. Patient worked with physical
therapy daily and had improvement in gait though still was
notable to be a significant fall risk.
- f/u serologies.
- f/u with neurology as an outpatient
- please check B12 and replete as needed.
# Subacute Right Acetebular Fracture: Likely pathological. Seen
by Orthopaedics with no plans for surgery at this time give
patient's frail state. Recommended plan below:
- Activity: Protected weight bearing until further notice - may
weight bear as pt is able but she must do so with a walker.
- ___ as patient can tolerate, encourage ambulation
- Defer R hip surgery until further notice.
- Follow-up with Dr. ___ in ___ ___ clinic in ___ weeks
for reassessment
# DM: Diagnosis of diabetes, previously on medications, no off
for several months after losing weight. Placed on HISS to
control sugars.
- discharged to rehab on ___, recommend transition to oral
medication (metformin)
# Metastatic breast cancer: Patient with numerous bony
metastases and rising ___. Holding chemotherapy at this
time. Will followup with Dr. ___.
# Asthma: continued symbicort
# Depression: Stable. Continue home Buproprion XL 300mg daily
and Sertraline 200mg daily
# HTN: Continued home atenolol
====================
TRANSITIONAL:
=====================
# CODE: Full
# HCP: Husband, ___: ___
[] ___ Blood Glucose elevated during hospitalization.
Recommend initiation of metformin as outpatient.
[] ___ paraneoplastic panel pending at time of discharge.
[] ___: 221 from 153 on ___
[] Activity: may weight bear as pt is able but she must do so
with a walker.
[] acetabular fracture seen on staging CT. No surgery planned.
Should follow-up with Dr. ___ in ___ clinic in ___
weeks for reassessment
[] followup with neurology.
[] please check B12 and replete as needed (repleted during
hospitalization)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 200 mg PO DAILY
2. Lorazepam 0.5 mg PO QHS:PRN insomnia/anxiety
3. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
4. Atenolol 25 mg PO DAILY
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Simvastatin 20 mg PO QPM
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation DAILY
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Atenolol 25 mg PO DAILY
4. BuPROPion (Sustained Release) 300 mg PO QAM
5. Lorazepam 0.5 mg PO QHS:PRN insomnia/anxiety
6. Sertraline 200 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation DAILY
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Breast Cancer, metastatic to bone
- Right acetabular fracture
SECONDARY DIAGNOSIS:
- Blindness secondary to glaucoma
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 has been a pleasure to care for you at ___. You were
admitted due to some confusion at home and difficulty getting
around, causing frequent falls. We performed a lot of imaging
studies that showed some cancer metastatic to your bones but no
clear signs for why you had all of your symptoms. The neurology
team was consulted and recommended testing you for a
paraneoplastic syndrome. Those results are still pending and
will be followed up by your primary oncologist.
There is a small fracture in your right hip. This is probably
due to cancer. You should be careful to also walk with your
weight supported by a walker or similar device. You should
follow up with orthopedics after discharge.
Thank you for letting us participate in your care,
Your ___ team
Followup Instructions:
___
|
10607527-DS-19 | 10,607,527 | 23,045,637 | DS | 19 | 2168-03-29 00:00:00 | 2168-03-30 15:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Latex
Attending: ___
Chief Complaint:
Shortness of breath, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with known pulmonary fibrosis, cervical
cancer ___ years prior, seizure disorder presenting from outside
hospital with concern for dyspnea and hypoxia. Of note, the
patient is on 6 L of oxygen at baseline. She has had 7 days of
gradually increasing shortness of breath, exacerbated by today,
relieved partially with spironolactone and increased oxygen
utilization. Patient was started on CellCept about a month ago
as a measure to try to improve her IPF. She endorses a 21 pound
unintentional weight gain over the past week. She also endorses
some headaches, abdominal pain, which she attributes to the
CellCept. She also says her weight gain correlates with the time
that she started her CellCept; her predominate complaint on
presentation today was mostly her weight gain and fluid
overload.
In the ED, initial VS were 97 68 148/98 24 98% nrb. Labs were
performed which were ntoable for a lactate of 1.9, a U/A with
leuks, WBC, and bacteria, tropinin negative x 1, proBNP 3976,
and INR: 1.2. In the ED she was given written for Nitropaste
0.5in TP Q6H, as well as CeftriaXONE 1g. A CXR was performed
which on my read appeared diffuse to show pulmonary edema. EKG
in the ED showed Twave flatting in V4-V6 as compared to ___.
On transfer, her vitals were 97.5 88 25 146/89 100% BiPAP.
Notably, at OSH she was given 60 mg IV Lasix and put out ~3 L.
She has made 1 L since arrival to our ED.
.
She has been diagnosed with IPF. A rheumatologic panel as well
as a hypersensitivity panel and a careful history did not detail
any obvious etiology for her pulmonary fibrosis and therefore it
was felt that she may have had idiopathic pulmonary fibrosis,
although the upper lobe predominance of her infiltrates is not
classic. An ECHO done ___ showed ___, normal
LVEF, and normal PASP. She also had a right heart
catheterization performed which showed PCWP 14, and a PA 40/16,
read as mild pulmonary hypertenstion on ___ with
elevation of PVR, normal filling pressures and preserved cardiac
output. A CT scan of the chest on that day, which was notable
for subpleural reticular markings that were increased as well
as areas of honeycombing consistent with pulmonary fibrosis. Her
case of IPF had previously been discussed at case conferences,
and given the extensive fibrosis and lack of ground glass or
other abnormalities the consensus was that she was unlikely to
respond to cytotoxic therapy such as azathioprine, cellcept. She
was initiated on Letairis around ___. An attempted to
refer her for a lung transplantation evaluation did not procede
forward given her prohibitive BMI of 38. She had self DC'ed her
Letairis in ___. She is on 6 liters O2 with exertion and has
become quite sedentary.
.
A letter from Dr. ___ on ___ indicated that she had
recently started CellCept, in addition to having been recently
treated for a UTI with Bactrim/Doxycycline.
.
On arrival to the MICU, she is on BiPaP, but is very pleasant,
alert, and oriented.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Hypertension
Pulmonary Hypertension
Osteoarthritis in her ___ with multiple joint replacements
Pulmonary Fibrosis
High cholesterol
Fibromyalgia
GERD
S/p right total knee replacement in ___
L5-S1 disectomy x2 complicated by nerve damage and a foot drop
she uses a brace.
Cholecystectomy
Home 02 @2L turns it up to 3L with exertion
GIB secondary to medication
Hypothyroidism
Cervical Cancer s/p conization at the age of ___
Tubal Ligation
Social History:
___
Family History:
Mother with "arthritis" which does not require treatment. She
does have a brother with lung cancer diagnosed at the age of ___.
He was a heavy smoker. In addition, she also has another
brother age ___ with emphysema. He also was a smoker.
Physical Exam:
Exam on admission:
General: Alert x3
HEENT: Sclera anicteric, EOMI, PERRL
Neck: supple, JVP elevated to the mandible
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles to the midline bilateally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, non-pitting edema in the
thigh
Neuro: CNII-XII intact
Pertinent Results:
Labs on admission:
___ 03:10AM GLUCOSE-109* UREA N-20 CREAT-1.1 SODIUM-142
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-29 ANION GAP-15
___ 03:10AM ALT(SGPT)-24 AST(SGOT)-29 ALK PHOS-72 TOT
BILI-0.4
___ 03:10AM cTropnT-<0.01
___ 03:10AM proBNP-3976*
___ 03:10AM ALBUMIN-4.0
___ 03:10AM WBC-8.8 RBC-4.01* HGB-12.8 HCT-36.1 MCV-90
MCH-31.9 MCHC-35.4* RDW-14.6
___ 03:10AM NEUTS-76.6* LYMPHS-12.8* MONOS-6.6 EOS-2.7
BASOS-1.2
___ 03:10AM PLT COUNT-204
___ 03:10AM ___ PTT-28.0 ___
TRANSTHORACIC ECHOCARDIOGRAM: ___
The left atrium is mildly dilated. The right atrium is markedly
dilated. The estimated right atrial pressure is at least 15
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size. Overall left ventricular systolic function
is low normal (LVEF 50-55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The left ventricular
inflow pattern suggests impaired relaxation. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Borderline left ventricular systolic function with
abnormal systolic septal motion consistent with right
ventricular pressure overload. Moderately dilated right
ventricle with moderate global free wall hypokinesis. Severe
pulmonary hypertension. Mildly dilated aortic arch. Moderate
tricuspid valve regurgitation. Compared with the findings of the
prior study (images reviewed) of ___, there is now severe
pulmonary hypertension, moderate dilation and moderate
dysfunction of the right ventricle, moderate tricuspid
regurgitation, and borderline left ventricular systolic
function.
CXR ___:
IMPRESSION: Probable moderate interstitial pulmonary edema
superimposed upon background pulmonary fibrosis. The ddx could
include fibrosis with superimposed interstital pneumonia, though
this is considered less likely.
Brief Hospital Course:
HOSPITAL SUMMARY: ___ with a history of idopathic pulmonary
fibrosis, recently noted to worsen clinically, who presented
from an outside hospital with worsening hypoxia and dyspnea. She
initially required NRB oxygen and was placed on BiPap and
admitted to the medical ICU. She was started on antibiotics to
cover possible CAP, and placed on a furosemide gtt given volume
overload on exam. Oxygen requirement improved with these
measures, and she was transitioned back to nasal cannula oxygen
and called out to the general medical ward on hospital day #2.
ACTIVE ISSUES:
# HYPOXIA: The patient's worsening hypoxia is likely
multifactorial, but was felt most likely due to worsening
underlying pulmonary fibrosis leading to a spiral effect of
worsening pulmonary hypertension, cor pulmonale, and fluid
retention. Given the degree of fibrosis present at baseline,
her chest x-ray is difficult to interpret (specifically with
regard to excluding infiltrate), so she was started on
ceftriaxone and azithromycin to cover possible CAP despite being
afebrile with no convincing sputum data. She received 5 days of
ceftriaxone/azithro but given her lack of cough or leukocytosis
to suggest pneumonia, antbx were narrowed to ciprofloxacin only
for her UTI when sensitivities returned. In addition, she was
treated with a furosemide gtt to reduce volume overload, with
brisk urine output associated with improvement in her oxygen
requirement. Transthoracic echocardiogram was done shortly
after admission, which demonstrated severe pulmonary
hypertension with pressure estimates of 60-75 mmHg; it should be
noted that the patient was still volume-overloaded at the time
this study was obtained. On the medical floor, she was given
more IV lasix for diuresis and was discharged home on 20mg PO
lasix.
# IPF: Progression of underlying disease is likely, as above.
Her Cellcept was recently increased, and may have contributed to
some of her pulmonary edema and peripheral edema symptoms.
Cellcept was held in-house, though Bactrim prophylaxis was
continued. Steroids were felt unlikely to offer significant
benefit in this clinical scenario, and were therefore not
initiated.
# UTI: Urine culture grew Klebseilla which was Bactrim
resistant. She was treated with IV ceftriaxone concurrent with
CAP treatment as above and transitioned to ciprofloxacin upon
discharge to complete a 7 day course.
# GOALS OF CARE: The patient's primary pulmonary team, fellow
Dr. ___ attending Dr. ___ contacted
regarding this admission and expressed concern for limited
treatment options in the setting of underlying disease. Their
current feeling is that if her disease continues the current
trajectory of rapid progression, the only remaining avenue may
be palliative care. Gentle attempts were made to broach this
topic with the patient; however, it was apparent that she does
not currently feel mentally or emotionally ready for this
discussion. It was explained to her that if her respiratory
status were to deteriorate to the point of intubation, weaning
from the ventillator may not be feasible. Nonetheless, she
elected to remain full code while she continues to think about
her condition and prognosis.
INACTIVE ISSUES:
# HYPOTHYROIDISM: Thyroid studies were checked given her history
of hypothyroidism and worsening lower extremity edema, but
returned unremarkable at TSH 5.2 and free T4 2.8. No changes
were made to her home dose of levothyroxine at 200 mcg PO daily.
# GERD: Continued on omeprazole 20 mg PO BID.
# ARTHRITIS/PAIN CONTROL: Per patient, she has seen two
different specialists who disagree on whether her arthritis is
sero-negative RA or osteoarthritis. She has not had significant
improvement with increased dose of Cellcept, which was held
during this admission. She was restarted on home Tramadol 50 mg
PO BID PRN; NSAIDs were held in the setting of diuresis, but was
started on Nambutone on discharge.
# HYPERTENSION: Continued on lisinopril 20 mg PO daily.
# HYPERLIPIDEMIA: Continued rosuvastatin 5 mg PO daily.
TRANSITION OF CARE:
# Code: Full
# Contact: Husband ___ - ___
___ on Admission:
Confirmed with pharmacy:
Spironolactone 25 mg Daily
Levothyroxine 200 mcg Daily
Mycophenolate Mofetil 1000 mg QAM, 500 mg QPM
Omeprazole 20 mg BID
Tramadol 50 mg BID
Lisinopril 20 mg Daily
Bactrim SS Daily
Rosuvastatin 5 mg Daily
Albuterol 90 mcg Q6H PRN dyspnea
Acetaminphen 500 mg Q6H PNR
CALCIUM CARBONATE-VITAMIN D3 - 500-400 Daily
COENZYME Q10 100 mg BID
FOLIC ACID
MULTIVITAMIN
NIACIN 500 mg BID
OMEGA-3 FATTY ACIDS 1,000 mg Capsule BID
SENNOSIDES Dosage uncertain
Discharge Medications:
1. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet Sig: Two (2) Tablet PO once a day.
11. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. nabumetone 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
18. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
19. Home Oxygen
4L via nasal cannula - titrated to O2 sat >92%
Diagnosis: Pulmonary Fibrosis
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pulmonary Fibrosis
Pulmonary Edema
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital with worsening shortness of
breath, thought to be related to pulmonary fibrosis and fluid in
your lungs. We gave you lasix to reduce the amount of fluid.
Medication Changes
Please START lasix 20mg daily
Please START ciprofloxacin 500mg twice daily for two days for
urinary tract infection
Followup Instructions:
___
|
10607968-DS-11 | 10,607,968 | 24,660,584 | DS | 11 | 2150-01-25 00:00:00 | 2150-02-01 14:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subcutaneous emphysema
Major Surgical or Invasive Procedure:
___
Right anterior blow hole to VAC suction
History of Present Illness:
___ w interstitial lung disease and RUL NSCLC (___) s/p
CT-guided RFA on ___ who presents after waking up w her L
eye swollen shut w massive subcutaneous emphysema that appears
to be emanating from the ablated RUL lesion. Pt has
schizoaffetive disorder and is an extremely poor historian, so
much of her history comes from her chart. She has interstitial
lung disease s/p diagnostic R VATS wedge x2 in ___ and was
found in ___ after a fall to have bilateral lung nodules. The
largest lesion on the right was biopsied and found to be NSCLC
(SCC). She was seen in ___ and discussed in ___ and deemed to
be a poor surgical candidate given her underlying lung disease.
Pt underwent CT-guided ablation of the known SCC on
___. Since that time it appears she is called in a couple of
times for fevers (which she denies). She was also admitted to
___ for 4 days last week for just feeling
"off."
She now presents to the ___ ED after waking up in the middle
of the night with swelling of her left face that has caused her
left eye to be swollen shut. She presented initially to ___
___ and had a CT scan of her head, neck, and chest, which
demonstrated diffuse subcutaneous emphysema that appears to be
originating from the ablated posterior RUL lung lesion. Her lung
appears up on the scan and that the air is just tracking out of
the lesion into her subcutaneous tissue. Pt is well-appearing
and presented with a normal respiratory rate and O2 sat of 94%
on room air. She does not have any increased work of breathing
and
her lungs actually sound clear on auscultation.
Past Medical History:
Interstitial lung disease
NSCLC (SCC) of RUL s/p RFA ___
Schizoaffective disorder
Social History:
___
Family History:
Father's side is unknown.
No lung disease or lung cancer on her mother's side.
Physical Exam:
Discharge Exam
VS: T 98.3, BP 122 / 78, HR 99, RR 18, O2 sat 98% (RA)
Gen: Awake, alert, NAD
HEENT: Left eye swelling resolved
CV: +RRR
Chest: Mild crepitus over R shoulder, chest, lateral neck,
greatly improved from prior exam; R thorax incision closed
primarily with simple interrupted sutures, dressing w/ gauze
c/d/i
Resp: Normal WOB, no distress on RA; +CTAB, no wheezes or
crackles
Abdomen: Soft, non-distended, non-TTP
Ext: Warm, well-perfused
Pertinent Results:
Admission Labs
___ 04:59AM BLOOD WBC-14.6* RBC-3.91 Hgb-13.0 Hct-39.5
MCV-101* MCH-33.2* MCHC-32.9 RDW-14.2 RDWSD-52.1* Plt ___
___ 04:59AM BLOOD Neuts-66.9 ___ Monos-4.5* Eos-6.5
Baso-0.3 Im ___ AbsNeut-9.73* AbsLymp-2.95 AbsMono-0.65
AbsEos-0.95* AbsBaso-0.05
___ 04:59AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-142
K-4.1 Cl-104 HCO3-24 AnGap-14
Discharge Labs
___ 04:45AM BLOOD WBC-11.2* RBC-3.90 Hgb-13.0 Hct-39.7
MCV-102* MCH-33.3* MCHC-32.7 RDW-14.3 RDWSD-53.5* Plt ___
___ 04:45AM BLOOD Glucose-110* UreaN-15 Creat-0.8 Na-145
K-4.2 Cl-105 HCO3-27 AnGap-13
___ 04:45AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.2
Brief Hospital Course:
Patient is a ___ F with PMH of schizoaffective d/o, interstitial
lung disease, and RUL NSCLC (___) s/p CT-guided RFA on ___
who presented as a transfer from ___ after waking up with her L
eye swollen shut with massive subcutaneous emphysema that
appears to be emanating from the ablated RUL lesion. Her lung
appears up on the scan and that the air is just tracking out of
the lesion into her subcutaneous tissue. She was breathing
comfortably on room air with an O2 sat of 94%, with no signs of
respiratory distress. In the ED, a 3 cm incision was made over
the right anterolateral chest wall under local anesthesia, and
was easily dissected down to the chest wall. A wound vac was
placed in the tract to evacuate any subcutaneous air. The
patient tolerated the procedure well with minimal blood loss of
2 CC, and was admitted to the Thoracic Surgery service for
further monitoring of her subcutaneous emphysema.
The patient was seen by ___ on HD 1, who recommended
endobronchial intervention with IP. The patient was also seen by
IP on HD 1, who recommended continuing conservative management
with the wound vac for now. If the patient's clinical condition
worsened, they recommended placing a right surgical chest tube
followed by endobronchial valve placement to the airway leading
to the lesion treated with RFA.
The patient was admitted to the floor, and on HD 2, her
subcutaneous emphysema had improved, with decreased swelling of
her left eye and decreased crepitus over the right shoulder and
chest. She was otherwise without complaints, breathing
comfortably on room air, tolerating a regular diet, voiding
without issue, passing flatus, and ambulating independently. Her
voice was noted to sound slightly congested, but when asked
about it, the patient reported it was not significantly
different from her baseline. Her wound vac remained in place.
Overnight from HD 2 to HD 3, the patient had a desaturation to
the ___ while asleep, and was placed on 3L NC with recovery
of her oxygen saturation. On the morning of HD 3, her
subcutaneous emphysema continued to improve around her right
shoulder, neck, and lateral chest, and her left eye swelling had
completely resolved. She denied any chest pain or shortness of
breath. Her wound vac was discontinued and the incision was
closed primarily with simple interrupted nylon suture under
local anesthetic, which the patient tolerated well. A dry
sterile dressing with gauze and tegederm was placed over the
closed incision.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The closed incision to her right anterolateral chest
wall was clean, dry, and intact with a dry sterile gauze
dressing. The patient was discharged home without services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
___ She was instructed to follow up with Dr. ___ in
clinic on ___ for suture removal, and to go for
pulmonary function testing on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PALIperidone Palmitate 245 mg IM Frequency is Unknown
2. QUEtiapine Fumarate 400 mg PO QHS
3. Ranitidine 150 mg PO BID
4. BuPROPion 300 mg PO DAILY
5. Cyclobenzaprine 10 mg PO TID:PRN spasm
6. Sertraline 200 mg PO QHS
7. ALPRAZolam 0.5 mg PO TID:PRN anxiety
8. Gabapentin 600 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not exceed 4000 mg of acetaminophen in 24 hrs from all
sources
2. Famotidine 20 mg PO Q12H
3. PALIperidone Palmitate 245 mg IM Q1MO (MO)
4. ALPRAZolam 0.5 mg PO TID:PRN anxiety
5. BuPROPion 300 mg PO DAILY
6. Cyclobenzaprine 10 mg PO TID:PRN spasm
7. Gabapentin 600 mg PO BID
8. QUEtiapine Fumarate 400 mg PO QHS
9. Sertraline 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Subcutaneous emphysema
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 treatment of massive
subcutaneous emphysema over your chest and face following your
lung biopsy. A small incision was made in your chest to help
relieve the air that accumulated under your skin and it was
effective. You are now ready for discharge.
* The stitches in your chest will be removed in clinic next
week.
* Check the area for any redness or drainage.
* If you develop any fevers > 101 or chills, recurrent swelling
of face /chest or any new symptoms that concern you call Dr.
___ at ___.
Followup Instructions:
___
|
10607968-DS-12 | 10,607,968 | 29,492,388 | DS | 12 | 2150-02-01 00:00:00 | 2150-02-01 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
swelling of face, eye, neck and chest
Major Surgical or Invasive Procedure:
___
Right anterior chest VAC placement
___
Flexible bronchoscopy, balloon dilatation and endobronchial
valve placement in RUL bronchus
History of Present Illness:
Ms. ___ is a ___ female with interstitial lung disease
and right upper lobe squamous cell carcinoma, who recently
underwent CT-guided RFA on ___, who recently presented
with
severe chest swelling and left eye swelling found to have
massive
subcutaneous emphysema, likely from a broncho-cutaneous fistula
at the biopsy site, on ___. When she presented
initially,
she was stable, but the degree of emphysema was concerning that
the decision was made to place a wound VAC at the site of the
presumed bronchopulmonary fistula. The VAC did improve her
symptoms, and it was removed on ___. Unfortunately, today,
she
reports that suddenly she started feeling more swollen. At this
time, her right eye seems to be affected. This is the reason
for
coming back to the emergency room. She is not short of breath,
not having chest pain. She thinks her voice sounds a little
funny, and this was present last time she came in as well.
Denies any other symptoms.
Briefly, she is interstitial lung disease that was diagnosed
during a right VATS wedge x2 in ___ for nodules that were
found during imaging in ___ of that year to assess for trauma
after a fall. The biopsy of the largest lesion on the right
showed squamous cell carcinoma. She was determined to be poor
surgical candidate due to underlying ILD. She underwent
CT-guided ablation for the known SCC on ___. Although
this
preceded her current symptoms.
Past Medical History:
Interstitial lung disease
___ (___) of RUL s/p RFA ___
Subcutaneous emphysema post RFA required blow hole
Schizoaffective disorder
R VATS wedge biopsy x2 ___ M ___
ankle surgery
tubal ligation
Social History:
___
Family History:
Father's side is unknown.
No lung disease or lung cancer on her mother's side.
Physical Exam:
Vitals: 102 | 101/54 | 14 | 96% 2L NC
GEN: A&Ox3, NAD, appears comfortable, obese
HEENT: No scleral icterus, mucus membranes moist, R eye swollen
nearly shut, scant facial edema, moderate neck edema and no
appreciable crepitus on face or neck (despite known CT findings)
CV: Tachycardic, regular
PULM: Clear to auscultation b/l, normal work of breathing;
crepitus appreciated over anterior chest wall (R>L)
ABD: Soft, obese, nondistended, nontender, no masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 04:54 9.6 3.37* 11.0* 34.3 102* 32.6* 32.1 14.5
53.8* 181
___ 05:59 12.4* 3.52* 11.4 35.9 102* 32.4* 31.8* 14.5
54.6* 222
___ 12:45 14.9* 4.11 13.4 41.5 101* 32.6* 32.3 14.6
53.7* 323
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:54 931 7 0.8 141 4.2 ___
___ 05:59 ___ 143 3.7 ___
___ 12:45 971 9 0.9 142 5.32 ___
___ Chest CT :
1. Redemonstrated is an ablation cavity in the posterior aspect
of the right upper lobe with air locules seen to extend into the
adjacent chest wall which is most likely the area of air leak
with massive subcutaneous emphysema and pneumomediastinum. The
subcutaneous emphysema extends outside of the field of view
superiorly and inferiorly. Compared to CT dated ___, the emphysema appears more widespread.
2. Multifocal fibrosing interstitial lung disease, with
radiographic pattern favoring fibrosing NSIP appears fairly
similar compared to prior imaging.
3. Multiple pulmonary nodules ranging up to 12 mm in the right
upper lobe
appears fairly similar compared to prior imaging and reference
to prior CT
chest report of ___ is made.
___ CXR :
-Slight interval improvement of opacities overlying the mid to
lower right
lung.
-No definite evidence of pneumothorax.
-Stable extensive severe subcutaneous emphysema
Brief Hospital Course:
___ was evaluated by the Thoracic Surgery team in the
Emergency Room and due to her massive subcutaneous emphysema the
sutures from her right anterior chest blow hole were removed and
a wound VAC was placed to help decrease her crepitus. She was
admitted to the hospital for further management and remained NPO
as the Interventional Pulmonary service planned bronchoscopy.
Her subcutaneous emphysema was gradually resolving and she was
taken to the Operating Room on ___ where she underwent
bronchoscopy, fibrin glue placement and endobronchial valve
placement in the posterior segment of the right upper lobe. She
tolerated the procedure well and returned to the PACU in stable
condition. She maintained adequate oxygen saturations with O2
at 2 LPM.
Following transfer to the Surgical floor she progressed well.
Within 24 hours her subcutaneous emphysema around her eyes, face
and neck had resolved and she had just a minimal amount over her
right anterior chest. The VAC remained in place until ___
and was removed to assess the effectiveness of the endobronchial
valve. She never reaccumulated crepitus and a loose packing was
placed in the right chest incision to allow healing from
secondary intention. The skin edges were red but there was no
purulent drainage or cellulitis present. Her oxygen saturations
were generally > 95% on 2 L O2 but she would desaturate on room
air to 82%. She has home O2 but states she only uses it at
night at 2 LPM. She was encouraged to use it continuously
during this period and may be able to get back to her baseline
in a few weeks. As she continued to progress well she was
discharged to home on ___ and will follow up with Dr. ___
in 2 weeks. The Interventional Pulmonary team will also arrange
follow up in their clinic in one week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN spasm
2. Gabapentin 600 mg PO BID
3. QUEtiapine Fumarate 400 mg PO QHS
4. Sertraline 200 mg PO QHS
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
6. ALPRAZolam 0.5 mg PO TID:PRN anxiety
7. BuPROPion 300 mg PO DAILY
8. PALIperidone Palmitate 245 mg IM Q1MO (MO)
9. Famotidine 20 mg PO Q12H
10. Perphenazine 8 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety
3. BuPROPion 300 mg PO DAILY
Extended release
4. Cyclobenzaprine 10 mg PO TID:PRN spasm
5. Famotidine 20 mg PO Q12H
6. Gabapentin 600 mg PO BID
7. PALIperidone Palmitate 245 mg IM Q1MO (MO)
8. Perphenazine 8 mg PO BID
9. QUEtiapine Fumarate 400 mg PO QHS
10. Sertraline 200 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Massive subcutaneous emphysema
RUL bronchocutaneous fistula
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 recurrent subcutaneous
emphysema over your face, neck and chest. The Interventional
Pulmonary doctors put ___ valve in place which
sealed the air leak and another VAC dressing was placed in your
right chest to reduce the air that accumulated under your skin.
You have done well and are now ready for discharge.
* The ___ will be contacted to help with your right chest
dressing so that it heals from inside out.
* Continue to use your oxygen at 2 LPM to maintain saturations >
90%
* Use your incentive spirometer 10 times an hour while awake.
* Resume all of your pre admission medications
* Take Tylenol for any discomfort from the right chest wound.
* Eat well and stay well hydrated.
* You may shower daily with the right chest wound covered,
replace the dressing after your shower.
* Call Dr. ___ if you develop any increased SOB,
fevers > 101, drainage from your right chest wound, recurrent
subcutaneous emphysema or any new symptoms that concern you.
Followup Instructions:
___
|
10608349-DS-5 | 10,608,349 | 21,209,465 | DS | 5 | 2181-11-23 00:00:00 | 2181-11-23 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
naproxen
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: right and left heart catherization
History of Present Illness:
___ year old woman with history of diabetes, hypertension, HLD,
CHF (unknown EF), history of stroke presenting with chest pain
intially to ___ found to have elevated troponin transferred
to ___ for further evaluation.
The patient developed chest pain while doing the dishes at
10:30 ___. She called ___ and was brought to ___
where he was found to have an elevated troponin as well as an
elevated CK-MB. Her pain improved but persisted after receiving
nitroglycerin and morphine and so she was sent to ___
___ for further evaluation. On arrival to ___ ED patient
reports her pain is much improved. She denies any recent fever,
chills, shortness of breath, abdominal pain, nausea, vomiting,
dysuria, or bowel changes. She is on Plavix due to a remote
history of TIA. She is not otherwise anticoagulated.
___ labs showed: Sodium 142, Potassium 2.9, Chloride 97,
Bicarbonate 32, Glucose 303, BUN 22, Creatinine 1.3, CK-MB 6.7,
Troponin 0.04, BNP 1130, WBC 6.7, Hemoglobin 11.4, Hematocrit
36.7. Platelets 141, INR 1.0
EKG at ___ showed sinus rhythm with lateral T wave
flattening but no significant ST elevation. CXR showed baseline
cardiomegaly. Patient was given full dose aspirin prior to
tranfer.
In the ED initial vitals were:
Pain 6 Temp. 97.9 HR 90 BP 133/72 RR 18 SpO2 96% RA
EKG: not done
Labs/studies notable for: WBC 7.2, Hg 10.3, platelets 139.
Troponin of 0.08.
Patient was given: IV Heparin
Vitals on transfer: 98.3 67 142/76 22 98% RA
On the floor the patient notes that her chest pain started this
evening around 10:30 ___ while she was washing her dishes sitting
down. She notes that she called her daughter who recommended she
call ___. She notes that pain was through her midchest and back
without radiation to her arms or jaw. She denies any associated
diaphoresis, SOB, nausea, or vomiting. She notes her pain lasted
for a few hours and improved before she left ___.
She is currently ___ pain free. She denies any prior history of
chest pain. She notes she sleeps with a few pillows under her at
night. She also endorses dyspnea with exertion. She denies any
new lower extremity edema and that she has been taking her Lasix
daily as prescribed.
She lives alone and performs all of her ADL's/IADL's herself.
She uses a walker when she leaves the house. She denies any
recent falls.
ROS: On review of systems positive for prior "mild stroke" per
patient. Denies deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors. Denies exertional buttock or calf pain. All of
the other review of systems were negative. Cardiac review of
systems is notable for absence of palpitations, syncope or
presyncope.
Past Medical History:
DM (on insulin), hypertension, hyperlipidemia, CHF, history of
stroke, anemia, depression, arthritis
Social History:
___
Family History:
Son with colon cancer. Mother died at birth.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.8 BP= 175/89 HR= 74 RR= 18 O2 sat= 95% RA
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP at the earlobe with head of bed at 30
degrees.
CARDIAC: normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild crackles
bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ peripheral pulses bilaterally to the midshins
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
Vitals: 97.6 ___ 105/57 20 96% on ra
Weight on admission 80.4
24 Hour I/O: 1560/1300
8 Hour I/O: ___
Today's weight: 79.7-> 79.5 -> 78.7 -> 77.2 -> 75.7 -> 76.3 ->
76.3-> 76.0--> 75.3
Tele: NSR
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple JVP not appreciated.
CARDIAC: No murmurs/rubs/gallops. No thrills, lifts. Irregular
rate
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema. Skin discoloration on R upper thigh,
nontender.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
==================
___ 03:50AM PLT COUNT-139*
___ 03:50AM NEUTS-74.6* ___ MONOS-3.9* EOS-0.1*
BASOS-0.6 IM ___ AbsNeut-5.40 AbsLymp-1.50 AbsMono-0.28
AbsEos-0.01* AbsBaso-0.04
___ 03:50AM WBC-7.2 RBC-4.64 HGB-10.3* HCT-32.5* MCV-70*
MCH-22.2* MCHC-31.7* RDW-16.2* RDWSD-39.9
___ 03:50AM calTIBC-439 FERRITIN-29 TRF-338
___ 03:50AM IRON-49
___ 03:50AM CK-MB-10 MB INDX-3.5 proBNP-1557*
___ 03:50AM CK(CPK)-286*
___ 03:50AM CK(CPK)-286*
___ 03:50AM estGFR-Using this
___ 03:50AM GLUCOSE-286* UREA N-25* CREAT-1.2* SODIUM-140
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 04:18AM LACTATE-1.4
___ 08:35AM ___ PTT-136.2* ___
___ 08:35AM PLT COUNT-143*
___ 08:35AM WBC-7.3 RBC-4.70 HGB-10.3* HCT-33.1* MCV-70*
MCH-21.9* MCHC-31.1* RDW-16.0* RDWSD-39.8
___ 08:35AM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-1.9
___ 08:35AM CK-MB-21* cTropnT-0.15*
___ 08:35AM GLUCOSE-240* UREA N-23* CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
___ 03:05PM CK-MB-32* cTropnT-0.24*
___ 05:15PM PTT-53.0*
___ 08:50PM CK-MB-32* cTropnT-0.40*
STUDIES:
==================
___: EF 72%, Mild symmetric left ventricular hypertrophy with
preserved regional and global systolic function. Severe
pulmonary artery hypertension. Severe tricuspid regurgitation.
Right ventricular cavity dilation with preserved free wall
motion. Moderate aortic regurgitation. Moderate mitral
regurgitation.
___ CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
___ FEMORAL VASCULAR US
2.9 cm pseudoaneurysm with a ___rising anteriorly from
the right
common femoral artery.
___ CT ABD & PELVIS W/O CONTRAST
1. Re- demonstration of 22 mm pseudoaneurysm anterior to the
right SFA/ CFA junction.
2. Mild-to-moderate right thigh hematoma. No abdominal
hematoma.
3. Cardiomegaly.
FEMORAL VASCULAR US ___
1. Minimally decreased size of right common femoral artery
pseudo aneurysm.
2. Sluggish flow is noted in the right common femoral artery.
___ Femoral U/S:
Thrombosed pseudoaneurysm arising anteriorly from the right
common femoral artery.
DISCHARGE LABS:
==================
___ 04:55AM BLOOD WBC-7.9 RBC-4.06 Hgb-9.0* Hct-28.4*
MCV-70* MCH-22.2* MCHC-31.7* RDW-16.5* RDWSD-39.4 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-157* UreaN-29* Creat-0.9 Na-136
K-4.1 Cl-92* HCO3-36* AnGap-12
___ 04:55AM BLOOD ___ PTT-33.2 ___
PENDING LABS:
=================
Final urine culture
Brief Hospital Course:
BRIEF SUMMARY STATEMENT
==============================
___ F w/ h/o dCHF (EF 72%), prior TIA in ___ (on Plavix at
home), T2DM, HTN, and HLD, who presented to ___ with chest
pain, was found to have elevated troponin, and was transferred
to ___ for NSTEMI, likely secondary to severe pulmonary
hypertension. Cardiac cath showed no signs of CAD, but was
consistent with severe pulmonary HTN. She was diuresed with IV
Lasix, and was euvolemic at time of discharge. Course was
complicated by pseudoaneurysm in her R femoral artery, but this
thrombosed spontaneously without any intervention. Of note, she
developed new Afib while in the hospital, and was started on
Warfarin 5mg daily; Metoprolol was continued for rate control.
On ___, she had some dysuria and U/A was positive, so she was
started on CTX; no fevers or leukocytosis.
ACTIVE ISSUES
========================
# TYPE 2 NSTEMI:
Patient initially presented to OSH with chest pain, and was
found to have elevated troponins. She was transferred to ___,
and had no return of chest pain while here. Left heart cath on
___ showed no sign of CAD, but severe pulmonary HTN, which
likely contributed to NSTEMI. She was placed on Metoprolol
Succinate XL 50 mg PO DAILY, Atorvastatin 80 mg PO/NG QPM,
Lisinopril 40 mg PO/NG DAILY, and Aspirin 81 mg PO/NG DAILY. At
time of discharge, she had no chest pain.
# SEVERE PULMONARY HYPERTENSION:
ECHO on admission showed severe pulmonary artery systolic HTN &
severe TR, confirmed by R heart cath on ___. PCWP in low
___, no vasodilator done. CTA on ___ negative for PE. Will
need sleep study as outpatient, but continuous O2 monitoring
overnight showed no desaturations in house. She was diuresed
with Lasix IV, then transitioned to Torsemide 40mg PO daily for
goal net even. She was discharged on Torsemide 40mg PO daily.
#dCHF (EF 72% on ___:
BNP was elevated to BNP 1130 at ___. ___ BNP was
900). On admission exam, patient had mild crackles bilaterally
and elevated JVP. BNP at ___ was 1557. CXR at OSH without
pulmonary edema. Patient does sleep on multiple pillows but says
this is because of habit not SOB. She was diuresed then
transitioned to PO Torsemide, as above. At time of discharge,
she was euvolemic on exam.
# PSEUDOANEURYSM:
After cardiac cath, patient developed 22 mm pseudoaneurysm
anterior to the right SFA/ CFA junction. ___ was consulted, and
planned for U/S guided thrombin injection. However, Doppler on
___ showed complete thrombosis of artery, so no intervention
was performed. H/H stable, Hgb 8.4 at time of discharge.
# UTI:
On ___, patient developed dysuria. U/A positive for bacteria
and leuk esterase, so she was started on Ceftriaxone. This was
transitioned to Keflex ___ PO q8 hours. At time of discharge,
symptoms had improved, and patient was instructed to complete
7-day course of Keflex to be completed on ___.
# AFIB:
On ___, patient developed palpitations on her way back from
U/S. ECG showed new onset atrial fibrillation, with heart rates
in the ___. Metoprolol was continued. She was started on
Warfarin 5mg daily.
# HISTORY OF TIA IN ___:
On admission, patient was on Plavix. Was held in the setting of
H/H drop with hematoma and pseudoaneurysm. At time of discharge,
she was taking Aspirin 81mg daily and Warfarin 5mg daily. Plavix
was discontinued.
# HTN
Patient's home clonidine was discontinued, and she was stable on
Metoprolol Succinate XL 50 mg PO DAILY and Lisinopril 40 mg
PO/NG DAILY.
# THROMBOCYTOPENIA:
Throughout hospitalization, patient had a mild, stable
thrombocytopenia, with no active signs of bleeding.
# Diabetes
Continued home Glargine 22 units with dinner, plus an Insulin
Sliding Scale
# Hyperlipidemia:
Discontinued Simvastatin, started Atorvastatin 80mg daily.
# Neuropathy
Continued home gabapentin 200 mg BID
TRANSITIONAL ISSUES:
======================
Discharge Weight: 75.3kg
Discharge Cr: 0.9
# NEW AFIB: Patient developed symptomatic Afib on ___ with
palpitations. HRs remained <100. She was started on Warfarin 5mg
daily. PLEASE CHECK INR WITHIN ___ DAYS OF HOSPITAL DISCHARGE
AND ADJUST WARFARIN DOSE ACCORDINGLY. Continued on Metoprolol
50mg daily with good rate control.
# UTI: Patient was discharged on 7-day course of Keflex ___ q8
hours PO, to be completed on ___. Follow up on final urine
culture.
# TYPE 2 DEMAND ISCHEMIA: Cath showed no CAD. Patient discharged
on Metoprolol Succinate XL 50 mg PO DAILY, Atorvastatin 80 mg
PO/NG QPM, Lisinopril 40 mg PO/NG DAILY, and Aspirin 81 mg PO/NG
DAILY
# SEVERE PULMONARY HTN: Confirmed by right heart cath on ___.
PCWP in low ___, no vasodilator done. CTA on ___ negative for
PE. Will need sleep study as outpatient, but continuous O2
monitoring overnight showed no desaturations in house. Patient
was transitioned to PO Torsemide 40mg PO daily. Discharge weight
75.3kg standing. Euvolemic on exam.
# PSEUDOANEURYSM: Patient developed PSA in right femoral artery
after cardiac catheterization. ___ and interventional cardiology
were consulted. Repeat U/S showed a thrombosed lesion, so no
intervention performed. Hgb stable at 8.4 at time of discharge.
Please examine thigh & recheck H/H at outpatient visit.
# HISTORY OF TIA IN ___: Patient was discharged on ASA 81mg
daily, and her home Plavix was discontinued in the setting of
stopping Warfarin.
# DM: Patient was discharged on her prior home regimen of Lantus
22 units nightly. Please monitor blood glucose daily as
outpatient.
# Guiac positive stool: Pt had guiac positive stool while in
house. Can consider outpatient colonoscopy if it persists
outside the acute setting.
# CODE: Full
# CONTACT: Name of health care proxy: ___
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Gabapentin 200 mg PO BID
4. Simvastatin 20 mg PO QPM
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
8. CloniDINE 0.2 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Lantus solastar 22 Units Dinner
Discharge Medications:
1. Lantus solastar 22 Units Dinner
2. Lisinopril 40 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Aspirin 81 mg PO DAILY
5. Gabapentin 200 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
9. Torsemide 40 mg PO DAILY
10. Warfarin 5 mg PO DAILY16
11. Cephalexin 250 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
- myocardial infarction (Type 2 NSTEMI)
- diastolic congestive heart failure
- pulmonary hypertension
- atrial fibrillation
- urinary tract infection
SECONDARY DIAGNOSES
- type 2 diabetes mellitus
- hypertension
- hyperlipidemia
- peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
You were admitted because you had chest pain. You underwent
cardiac catheterization which revealed no blockage in your
heart. You did not have any stents placed. However, we did see
that the pressures in your lungs were really high, so we took
some fluid off to relieve the pressure.
While you were here, you also developed an irregular heart
rhythm called atrial fibrillation (Afib). When you go to rehab,
you should STOP TAKING Plavix (Clopidogrel). Instead, you should
START TAKING Aspirin and Warfarin to prevent blood clots. You
will need to have your labs monitored regularly while you are on
Warfarin.
It is very important to take all of your heart healthy
medications.
Weigh yourself every day, and call your doctor if your weight
goes up by more than 3 pounds.
We wish you all the best!
Your ___ Cardiology team
Followup Instructions:
___
|
10608540-DS-11 | 10,608,540 | 26,990,922 | DS | 11 | 2202-12-04 00:00:00 | 2202-12-04 10:54:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Stroke
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
The patient is a ___ yo ambidextrous M PMHx ischemic L
internal capsule posterior limb stroke ___, ___ residual
deficits) and uncontrolled HTN who presents to the ___ ED with
acute onset slurred speech and L facial droop.
Pt reports feeling well this AM. While at work, during an office
meeting, he suddenly developed slurred speech accompanied by
fatigue. He had ___ issues with comprehension or fluency.
Coworkers noted that his left face was drooping. He spoke with
his wife who recommended he come to the ED.
Upon presenation to the ___, vitals notable for BP 223/123. A
code stroke was activated with CTA head revealing a R M1
occlusion (pt had a history of high grade R M1 stensosis). tPA
was not given due to elevated BP and minimal symptoms.
Additionally, both patient's facial droop and slurred speech
started resolving during ED course.
Of note, pt reports not taking his aspirin for >1 wk. He also
last took his BP medications the day prior.
On neurologic review of systems, the patient reports a dull
holocephalic headache. Pt denies lightheadedness, or confusion.
Denies difficulty with comprehending speech. Denies loss of
vision, blurred vision, diplopia, vertigo, or dysphagia. Denies
focal muscle weakness or numbness. Denies bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, cough, nausea, vomiting, diarrhea, constipation, or
abdominal pain.
Past Medical History:
Ischemic L posterior limb internal capsule stroke ___,
presented with dysarthria and R sided weakness, ___ residual
deficits)
?mini-stroke ___ (right arm/leg weakness which lasted 6
weeks but recovered fully with ___ residual deficits
Hypertension
Hyperlipidemia
Severe LVH with probable diastolic dysfunction
+PFO
Aortic dilation
CKD
Social History:
___
Family History:
Mother-HTN, ?seizures
Father-HTN, heart disease
Brother-pulmonary embolism
Sister MS
___ strokes
Physical Exam:
ADMISSION EXAMINATION:
Vitals: ___ 22 99% RA
General: NAD, resting in bed comfortably, obese
HEENT: NCAT, ___ oropharyngeal lesions
Neck: Supple
___: Tachycardic
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, ___ edema
Skin: ___ rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and ___ paraphasias.
Normal
prosody. Mild dysarthria. ___ evidence of hemineglect. ___
left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, ___ nystagmus. V1-V3 without deficits to light touch
bilaterally. +L NLFF. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. ___ drift. ___ tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - ___ deficits to light touch or pin bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1 0
R 2 1 1 1 0
Plantar response flexor bilaterally.
- Coordination - ___ dysmetria with finger to nose testing
bilaterally. Decreased speed and cadence with rapid alternating
movements with the L hand.
- Gait - Deferred.
=
=
=
=
=
=
=
=
================================================================
DISCHARGE EXAMINATION:
????
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:03PM BLOOD WBC-7.4 RBC-4.72 Hgb-14.3 Hct-43.2 MCV-92
MCH-30.3 MCHC-33.1 RDW-12.5 RDWSD-41.6 Plt ___
___ 04:03PM BLOOD ___ PTT-31.9 ___
___ 04:02PM BLOOD Creat-1.6*
___ 04:03PM BLOOD UreaN-21*
___ 03:00AM BLOOD Glucose-131* UreaN-17 Creat-1.3* Na-140
K-4.0 Cl-104 HCO3-25 AnGap-15
___ 04:03PM BLOOD ALT-24 AST-50* AlkPhos-46 TotBili-0.4
___ 03:00AM BLOOD CK(CPK)-308
___ 04:03PM BLOOD cTropnT-<0.01
___ 03:00AM BLOOD CK-MB-5 cTropnT-<0.01
___ 04:03PM BLOOD Albumin-4.6
___ 03:00AM BLOOD Cholest-205*
___ 03:00AM BLOOD %HbA1c-5.5 eAG-111
___ 03:00AM BLOOD Triglyc-77 HDL-61 CHOL/HD-3.4 LDLcalc-129
___ 03:00AM BLOOD TSH-0.76
___ 04:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 07:28AM BLOOD Glucose-137* UreaN-29* Creat-1.2 Na-144
K-4.5 Cl-108 HCO3-25 AnGap-16
___ 05:55AM BLOOD Glucose-113* UreaN-25* Creat-1.1 Na-141
K-3.9 Cl-105 HCO3-24 AnGap-16
___ 04:43PM BLOOD D-Dimer-4343*
___ 03:00AM BLOOD %HbA1c-5.5 eAG-111
___ 03:00AM BLOOD Triglyc-77 HDL-61 CHOL/HD-3.4 LDLcalc-129
___ 03:00AM BLOOD TSH-0.76
___ 12:33PM URINE RBC-98* WBC-13* Bacteri-NONE Yeast-NONE
Epi-0
___ 12:33PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 12:33PM URINE Uric AX-MANY
=======
IMAGING
=======
CTA H&N - ___
1. Abrupt cut off of the proximal right M1 segment of the right
MCA, new since ___. Evidence filling of some of the
distal hemispheric right MCA branches, likely via collaterals.
Ultimately, the M1 cut off is
age-indeterminate, although there was tight stenosis seen on MRA
of ___.
2. Mild narrowing of the cavernous left ICA due to calcific
plaque. The
remainder of the ___ demonstrates multifocal mild luminal
narrowing
compatible with atherosclerotic disease, but is otherwise
patent.
3. Prominent right C5-6 uncovertebral osteophyte narrows the
right transverse foramen and attenuates the adjacent right
vertebral artery at this level, which is patent distally.
4. Mild stenosis of the distal left V4 vertebral artery due to
mixed
atherosclerotic plaque. Otherwise, patent bilateral ICA and
vertebral
arteries. ___ ICA stenosis by NASCET criteria
5. ___ acute intracranial process on unenhanced head CT. ___
hemorrhage.
___ - ___
___ evidence of hemorrhage or infarction. Given the findings on
the CTA,
follow-up with CT or MR may be helpful.
ECHO - ___
The left atrium is mildly dilated. ___ left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). There
is severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. ___ aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is ___ mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
Severe symmetric LVH with normal regional and global systolic
function. Indeterminate indices to assess diastolic function.
Mild mitral regurgitation.
The severity of LVH is beyond that usually seen with
hypertension (unless uncontrolled) and suggests a process such
as hypertrophic cardiomyopathy or an infiltrative process such
as amyloidosis.
Compared with the prior study (images reviewed) of ___, ___
aortic regurgitation was detected. Estimated pulmonary artery
pressures are normal (though may be due to technical differences
of the study).
CXR - ___
NG tube tip is in the stomach. Heart size is mildly enlarged.
Mediastinum is stable. Bibasal areas of atelectasis are noted
in there is minimal amount of pleural effusion. ___
pneumothorax.
MRI BRAIN - ___
Acute/subacute infarcts in the distribution of right middle
cerebral artery with thrombus in the region of right middle
cerebral artery M1 segment and slow or retrograde flow distally
within the sylvian branches of right MCA. ___ signs of acute
hemorrhage. Chronic micro hemorrhage right thalamus unchanged
from previous MRI.
EEG ___
Abnormal portable EEG due to persistent mixed frequency slowing
in the right temporal region. This indicates a focal subcortical
dysfunction in the right hemisphere. There remained normal
background activity posteriorly on the right. There were ___
epileptiform features.
NCHCT ___
Compared with the MRI of 10 days prior, there has been evolution
of the known right MCA territory infarction involving the basal
ganglia in the right periventricular region, as well as the
right posterior temporal region. ___ shift of normally midline
structures or evidence of acute intracranial hemorrhage.
CXR- PORTABLE AP ___
In comparison with the study of ___, there is little
change. Cardiac silhouette is at the upper limits of normal in
size or mildly enlarged, but there is ___ evidence of vascular
congestion or acute focal pneumonia. Elevation of the right
hemidiaphragmatic contour is again seen. The nasogastric tube
is been removed.
Brief Hospital Course:
ICU Course ___ - ___
Mr. ___ is a ___ ambidextrous M with PMHx of ischemic
L internal capsule posterior limb stroke ___, ___ residual
deficits) and poorly controlled HTN who presents to the ___ ED
with acute onset slurred speech and L facial droop. Neurologic
examination notable for mild dysarthria and L NLFF. CTA H/N
revealed a R M1 occlusion in the setting of prior R M1 severe
stenosis.
In ED, received labetolol 200mg PO for significantly elevated
SBP (>260). BP improved but remained above 200. Then received
two more PRN doses of labetolol in the ED with SBP drop to 168
around 11PM. This corresponded with a worsening of his
dysarthria and overall exam, consistent with R MCA syndrome
(hemiplegia, neglect). He was then bolused with fluids and
placed flat with subsequent improvement in his examination.
Arrived in ICU around ___ on ___ with sBP in 210s, HR in
110s. Exam at that time was as follows: Wakens to voice, speaks,
follows commands in extremities. Speech is slow and very
dysarthric but improved, with ___ aphasia. Neglecting left side.
PERRL, BTT on right but not left. Gaze rests slightly to right,
crosses midline to left but does not bury. Profound left facial
droop, eye closure full. Strength was ___ in the LUE, weaker
proximally. Strength was 4+ to 5 in LLE. ___ response to deep
noxious in left arm and leg.
An MRI of the head without contrast was consistent with an
acute/subacute infarcts in the distribution of right middle
cerebral artery with thrombus in the region of right middle
cerebral artery M1 segment and slow or retrograde flow distally
within the sylvian branches of right MCA. ___ signs of acute
hemorrhage.
Through the course of his ICU stay, BP allowed to autoregulate
with treatment only for sBP > 220. HOB remained <30 degrees for
the first 48hrs, before being liberalized to sitting up.
Examination over this period remained largely stable, though he
continued to have a considerable amount of dysarthria and L
motor neglect. An NGT was placed, and after a failed swallow
evaluation TF were started on HD3.
Mr. ___ continued to remains stable over the weekend, and
was called out to the step-down unit on ___, he
received a bed on ___.
===============================================
FLOOR COURSE ___ -
On arrival to the floor, Mr. ___ had slow dysarthric speech
with left sided neglect, left sided UMN weakness, and left
nasiolabial fold flattening.
Our impression was that his presentation was likely a right
watershed stroke in the MCA territory where the M4 branches meet
the lenticulostriates. He received an Echo (TTE), which showed
severe symmetric LVH with normal regional and global systolic
function. His echo is likely consistent with his history of
poorly controlled hypertension. He had an EEG which showed
intermittent R sided slowing and ___ epileptiform discharges.
Overall, Mr. ___ appears to have acutely occluded a
chronically stenosed R M1. Subsequently, hypoperfused tissue at
risk became completely infarcted as he has had significant
worsening of his neurological examination with a complete left
hemiplegia and left sided motor neglect with inability to cross
the midline on left gaze.
He is currently enrolled in the POINT trial with aspirin 81mg +
study drug (Plavix or placebo) ___ subQ heparin). He was also
treated with atorvastatin 80 mg QPM. His stroke work up included
HbA1c = 5.5, LDL = 129, TSH = 0.76. He failed multiple swallow
evaluations and required NGT feeds; ACS then placed a PEG, and
he was started on G tube feeds.
Acute drops in his blood pressure resulted in lethargy and
sluggish pupillary responses. As a result of his perfusion
dependence, hypertension was tolerated, and his HOB restriction
was very slowly lifted. At the time of discharge, his SBP goal
was 160-180, his home lisinopril had been restrated at 10mg
(home dose 40mg), and he was allowed to be OOB to chair and
stand up with ___ and nursing. He was also treated with 100mg TID
of IV labetalol.
On HD ___, while on PEG, he had two episodes of emesis with
loose BM x10. CXR showed ___ aspirations/pneumonia, Abd xray
showed ___ overt signs of SBO. Stool cx and cdiff negative. Given
negative infectious etiology, it seems this episode was tube
feed related. He was given bowel rest, and his symptoms
resolved.
He was initially treated for aspiration PNA with vanc and zosyn;
this was deescalated to augmentin, and he completed a 7 day
course. His leukocytosis and tachycardia improved after
treatment.
He was discharged to rehab at the recommendation of ___.
=
=
=
=
=
=
================================================================
TRANSITIONAL ISSUES:
- Failed swallow evaluations. He required PEG tube placement.
- Liberalize activity restrictions to OOB with assistance
- continue to allow BP to autoregulate (SBP < 160-180/90); will
need to uptitrate lisinopril will ultimate goal of normotension
as tolerated by patient (have been increasing lisinopril by 10mg
daily--home dose prior to admission was 40mg daily; also on
labetalol)
- ___ recommended by ___ will need ___
therapy/nutrition resources at rehab
- Normocytic anemia
- UA on ___ had many uric acid crystals
-___ need ___ once he leaves rehab for medication adherence
-Will need to follow-up with his PCP ___ ___ weeks
-Has an appointment for follow-up in stroke clinic
===============================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () ___
2. DVT Prophylaxis administered? (x) Yes - () ___
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () ___
4. LDL documented? (x) Yes (LDL = 129) - () ___
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () ___ [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) ___ [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 - () ___
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () ___
9. Discharged on statin therapy? (x) Yes - () ___ [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () ___
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () ___ - (x) N/A
Medications on Admission:
Lisinopril 40
Aspirin 81
*Records from ___ state that pt was previously also on
rosuvastatin, amlodipine, and carvedilol but pt does not report
currently taking these medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 80 mg PO QPM
3. Labetalol 100 mg PO TID
4. Aspirin 81 mg PO DAILY
5. Clopidopgrel 75mg/Placebo Study Med 1 tab PO/NG/PEG ONCE
DAILY ON STUDY DAYS ___ AS PER PROTOCL
6. Fluoxetine 20 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right MCA stroke
Left hemiplegia w/ left motor neglect
Discharge Condition:
Mental Status: Somnolent but easily aroused largely A&O x3
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness and
facial droop resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
We are changing your medications as follows:
Aspirin 81mg + study drug
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:
___
|
10608703-DS-23 | 10,608,703 | 29,048,366 | DS | 23 | 2142-02-13 00:00:00 | 2142-02-13 12:19:00 |
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 and drainage from ___ drain site
Major Surgical or Invasive Procedure:
None during this hospitalization
History of Present Illness:
___ presented on ___ to ___ emergency room with
worsening abdominal pain and purulent drainage around his RUQ ___
drain. He also notes a fever to ___ at home. He was started on
meropenam and vancomycin in the ER, and was transferred to ___
for surgical evaluation. In the emergency room, patient was
afebrile, with a WBC 4.4
Of note, he has an extensive past surgical history which
includes a cecal perforation s/p subtotal colectomy and end
ileostomy (___), ileostomy reversal (___) complicated
by pneumoperitoneum s/p ex-lap, drainage of 1L of sucus, repair
of enterotomy and placement of two RUQ ___ drains for fluid
collections.
He recently presented ___ w/ several days of abdominal pain
and distension, feculent leakage around drain sites w/ minimal
drain output, concerning for a clogged drain. At that time, he
was admitted to ___ and went to ___ for drain resizing.
Past Medical History:
1. Hypertension.
2. Bipolar Disorder w/ Depression.
3. Hep C( s/p Harvoni rx)
4. OCD.
5. Multiple episodes of right sided rib fractures ___
all seemingly associated with falls/traumas as well as right
shoulder and leg as well as left shoulder trauma. Multi trauma
approximately ___ years ago. ?Pedestrian accident, primarily
orthopedic knee trauma.
6. Hammer toe, status post repair.
7. BPH.
PSH:
cecal perforation s/p subtotal
colectomy and end ileostomy (___) s/p ileostomy reversal (___)
s/p takeback, repair of enterotomy ___
Social History:
___
Family History:
His mother died of breast cancer. His father is alive and well.
He is not married. Patient is single. No HCP on record. Has 2
grown children in ___. He did not want prior physician to
contact them.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 98.5 HR: 58 BP:158/89 RR: 16 SO299% RA
Constitutional: uncomfortable, Not in acute distress
Head / Eyes: NC/AT
ENT: WNL
Resp: CTAB, non-labored breathing
Cards: RRR. Nl S1/S2, no m/r/g
Abd: Tender in the right quadrant around the drain site;
purulent
drainage from the drain #2 site
Skin: erythema adjacent to right abdominal drain. Wound vac
in place
DISCHARGE PHYSICAL EXAM:
T: 98.1 HR: 62 BP:137/76 RR: 18 SO2 97% RA
Constitutional: comfortable, Not in acute distress
Head / Eyes: NC/AT
ENT: WNL
Resp: CTAB
Cards: RRR. Nl S1/S2, no m/r/g
Abd: mild tenderness around the drain site; , drain #2 stitched
in place
Skin: erythema adjacent to right abdominal drain. Wound vac
in place
Pertinent Results:
___ 04:48AM WBC-4.4 RBC-3.07* HGB-7.5* HCT-25.0* MCV-81*
MCH-24.4* MCHC-30.0* RDW-17.1* RDWSD-50.4*
___ 04:48AM NEUTS-41.8 ___ MONOS-20.0* EOS-5.7
BASOS-0.7 IM ___ AbsNeut-1.93 AbsLymp-1.41 AbsMono-0.92*
AbsEos-0.26 AbsBaso-0.03
___ 04:48AM ALT(SGPT)-13 AST(SGOT)-16 ALK PHOS-97 TOT
BILI-0.3
___ 04:48AM GLUCOSE-87 UREA N-10 CREAT-0.9 SODIUM-139
POTASSIUM-3.3* CHLORIDE-104 TOTAL CO2-21* ANION GAP-14
___ 06:02AM BLOOD WBC-3.9* RBC-3.51* Hgb-8.6* Hct-27.9*
MCV-80* MCH-24.5* MCHC-30.8* RDW-17.1* RDWSD-49.2* Plt ___
___ 06:20AM BLOOD WBC-4.8 RBC-3.63* Hgb-8.9* Hct-29.2*
MCV-80* MCH-24.5* MCHC-30.5* RDW-17.1* RDWSD-49.8* Plt ___
___: CT ABD & PELVIS WITH CONTRAST
1. Perihepatic collection is slightly decreased in size though
contains
fecalized material as well as enteric contrast suggesting patent
communication
with bowel loops. Drainage catheter terminates within this
collection.
2. A second drainage catheter entering the right mid abdominal
wall is
unchanged without residual collection seen near the pigtail.
3. Small right pleural effusion with adjacent compressive
atelectasis.
4. Mild splenomegaly up to 15 cm.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of increased abdominal pain and
drainage from around
___ drain site. He had been transferred from ___ were he
was started on Vanc/ Meropenam and received an abdominal/pelvic
CT scan which revealed one ___ catheter terminating in a
progressively decreasing collection, the other terminating in
the previous collection location, without a residual collection
seen. He was transferred to ___, where his antibiotics were
switched to zosyn and meropenam/ vancomycin were discontinued.
On HD 1, patient's pain was improved, he was hemodynamically
stable, afebrile, and zosyn was discontinued and patient was
advanced to a regular diet. One of the ___ drains, Drain #3, was
removed due to minimal output, and the other ___ drain was
sutured in place to prevent it from dislodging.
On HD2, pain was well controlled. Regular diet was tolerated.
The patient voided without problem. The patient received
subcutaneous heparin and venodyne
boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The 1 ___ drain was patent with minimal leakage
from insertion site. The patient was discharged home with
services for wound care and drain care. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
3. Atenolol 50 mg PO DAILY
4. ClonazePAM 0.5 mg PO BID
5. LamoTRIgine 200 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 200 mg PO DAILY
8. Tamsulosin 0.4 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Please take as needed for mild pain
2. Atenolol 50 mg PO DAILY home med
3. ClonazePAM 0.5 mg PO BID
4. LamoTRIgine 200 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
7. Sertraline 200 mg PO DAILY depression
8. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ drain site infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
worsening abdominal pain and purulent drainage around your ___
drain. You will go home with the drains and a visiting nurse
___ help you monitor the output. The visiting nurse ___ also
assist you with wound vac changes.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Best wishes,
Your ___ Surgery Team
Followup Instructions:
___
|
10608703-DS-27 | 10,608,703 | 26,416,907 | DS | 27 | 2142-08-28 00:00:00 | 2142-08-29 14:09:00 |
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 arm pain
drainage from EC fistula
Major Surgical or Invasive Procedure:
___: left PICC line placed
___: right PICC line removed
History of Present Illness:
___ is a ___ year-old man with a history of bipolar
disorder and sigmoid perforation s/p sigmoid colectomy.
Ultimately, he was reversed and subsequently developed a leak
from the small bowel, which developed into an enterocutaneous
fistula. His fistula has been managed non-operatively with bowel
rest and TPN and previously controlled with ___ drain placement
which has since been removed. He was last seen in clinic on
___, at which point he was reminded to limit his PO intake
while the fistula continues to heal. Over the last 10 days, he
noted increasing right arm discomfort at the site of his PICC
line with reported drainage and localized skin reaction which he
attributes to an allergy to certain adhesives. He also reports
eating more over the holidays with a subsequent increase in
fistula output. He denies fevers, chills, chest pain, abdominal
pain, abdominal redness or general malaise.
Past Medical History:
Past Medical History:
1. Hypertension.
2. Bipolar Disorder w/ Depression.
3. Hep C (s/p Harvoni rx)
4. OCD.
5. Multiple episodes of right sided rib fractures ___
all seemingly associated with falls/traumas as well as right
shoulder and leg as well as left shoulder trauma. Multi trauma
approximately ___ years ago. ?Pedestrian accident, primarily
orthopedic knee trauma.
6. Hammer toe, status post repair.
7. BPH.
Past Surgical History:
___- L Left rotator cuff surgery
___: Ex-Lap, Resection of terminal ileum and ascending
colon. (bowel left in discontinuity). Temporary abdominal
closure with ABThera wound VAC
___: Transverse colectomy, End ileostomy, Abdomen left
open with ABThera wound VAC.
___: Laparoscopic exploratory laparotomy with abdominal
wall closure.
___: Ileostomy reversal, partial enterectomy, extensive
lysis of adhesions with wound closure in layers, incisional VAC.
___: Exploratory laparotomy, suturing of probable
enterotomy and VAC placement
Social History:
___
Family History:
His mother died of breast cancer. His father has stage 4 lung
cancer. He is not married. Patient is single. Has 2 grown
children who are healthy.
Physical Exam:
Physical Exam: upon admission: ___
VS: Afebrile, AVSS
Gen: Comfortable appearing, non-toxic, pleasant, conversant
CV: RRR
Resp: Breathing comfortably on room air
Abd: Soft, non-tender, non-distended. RUQ enterocutaneous
fistula
draining thick tan/yellow secretions, non-foul smelling, no
surrounding erythema. Non-tender, no rebound or gaurding.
Discharge Physical Exam:
VS: 98.3 PO 146 / 71 R Lying 48 18 99 Ra
GEN: Awake, alert, pleasant and interactive.
CV: RRR
RESP: Clear bilaterally.
ABD: Soft, non-tender, non-distended. Active bowel sounds. Scant
amount of drainage on RUQ.
EXT: Warm and dry. No edema.
Pertinent Results:
___ 07:18AM BLOOD WBC-3.7* RBC-3.61* Hgb-8.0* Hct-27.2*
MCV-75* MCH-22.2* MCHC-29.4* RDW-19.0* RDWSD-52.0* Plt ___
___ 10:30AM BLOOD WBC-4.3 RBC-3.93* Hgb-8.7* Hct-30.4*
MCV-77* MCH-22.1* MCHC-28.6* RDW-19.3* RDWSD-52.7* Plt ___
___ 10:30AM BLOOD Neuts-55.1 ___ Monos-11.5
Eos-8.2* Baso-0.5 Im ___ AbsNeut-2.35 AbsLymp-1.03*
AbsMono-0.49 AbsEos-0.35 AbsBaso-0.02
___ 07:18AM BLOOD Plt ___
___ 07:18AM BLOOD ___ PTT-25.2 ___
___ 07:18AM BLOOD Glucose-95 UreaN-8 Creat-1.0 Na-146 K-3.5
Cl-110* HCO3-24 AnGap-12
___ 07:18AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.6
___ 10:30AM BLOOD Lactate-1.5
___: CXR:
1. New right upper extremity PICC terminates in the expected
region of the
distal right brachiocephalic vein.
2. No acute cardiopulmonary process
___: CT abd. and pelvis:
Similar overall appearance of a complex entero-cutaneous fistula
extending from small bowel loops in the right upper quadrant to
the skin surface in the anterolateral mid abdominal wall.
Associated contrast and gas-filled sinus tract are again seen,
most notably along the right hepatic lobe.
2. Stable mild splenomegaly.
___: CXR:
Left PICC line courses along the left internal jugular vein with
the distal tip out of view.
2. Right PICC line likely terminates at the junction of the
right
brachiocephalic and sub-clavian vein.
Brief Hospital Course:
Ms. ___ is a ___ yo M with complex surgical history notable for
a non-healing small bowel fistula who presented to the Emergency
Department on ___ with PICC line malfunction and drainage
from abdominal wound. He was admitted for PICC line replacement
and ___ evaluation of the fistula. On ___ he had a new PICC
line placed in the opposite arm. The patient was taken to
interventional radiology and underwent contrast study through
opening in abdomen which showed intracutaneous fistula to a loop
of small bowel. Given this information, he was kept NPO and TPN
was re-started. There was discussion about future interventions
that may be attempted in interventional radiology to help heel
the fistula.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was discharged
home with visiting nursing services.
Medications on Admission:
LamoTRIgine 200 mg PO DAILY
Sertraline 200 mg PO DAILY
Atenolol 75 mg PO DAILY
Tamsulosin 0.4 mg PO QHS
ClonazePAM 0.5 mg PO BID: PRN anxiety
LOPERamide 4 mg PO DAILY:PRN loose stool
Omeprazole 40 mg PO DAILY
OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Atenolol 100 mg PO DAILY
3. ClonazePAM 0.5 mg PO BID:PRN Anxiety
4. LamoTRIgine 200 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
7. Sertraline 200 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
EC fistula
pruritus around right arm PICC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ year old male admitted to the hospital with drainage from EC
fistula and pruritus around right PICC line. You underwent a cat
scan of the abdomen which showed a fistula extending from the
small bowel to the skin. The right PICC line was removed and a
new left PICC line was placed. You resumed your TPN. You were
discharged home with the following instructions:
Followup Instructions:
___
|
10608703-DS-28 | 10,608,703 | 28,358,900 | DS | 28 | 2142-10-11 00:00:00 | 2142-10-11 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ year-old man with a history of bipolar
disorder and
ischemic bowel with transverse colon perforation, s/p colectomy
and end ileostomy in ___. Ultimately, he was reversed with
extensive adhesiolysis and subsequently developed a leak from
the small bowel, which developed into an enterocutaneous
fistula. His fistula has been managed non-operatively with bowel
rest and TPN and previously controlled with ___ drain placement.
He most recently saw Dr. ___ in clinic on ___, with plan for
strict NPO and CT to re-evaluate EC fistula in two weeks. The
patient reports that he had been maintaining a diet of liquids
(including milk, juice, ice cream) since that time. He reports
last PO intake was ___ evening. ___ AM, he awoke with
abdominal pain, nausea and emesis. He reports three small
episodes of emesis that consistently mostly of saliva, NBNB. He
reports last emesis was yesterday evening. No BM or flatus since
___. At OSH, CT was concerning for SBO and patient was
transferred for further management.
He states that the EC fistula output quantity is not associated
with PO intake, and quantifies output in terms of dressing
changes/day.
In the ED, he is AVSS and labs within normal limits. He denies
fevers/chills, chest pain, shortness of breath, change in
urinary habits.
Past Medical History:
Past Medical History:
1. Hypertension.
2. Bipolar Disorder w/ Depression.
3. Hep C (s/p Harvoni rx)
4. OCD.
5. Multiple episodes of right sided rib fractures ___
all seemingly associated with falls/traumas as well as right
shoulder and leg as well as left shoulder trauma. Multi trauma
approximately ___ years ago. ?Pedestrian accident, primarily
orthopedic knee trauma.
6. Hammer toe, status post repair.
7. BPH.
Past Surgical History:
___- L Left rotator cuff surgery
___: Ex-Lap, Resection of terminal ileum and ascending
colon. (bowel left in discontinuity). Temporary abdominal
closure with ABThera wound VAC
___: Transverse colectomy, End ileostomy, Abdomen left
open with ABThera wound VAC.
___: Laparoscopic exploratory laparotomy with abdominal
wall closure.
___: Ileostomy reversal, partial enterectomy, extensive
lysis of adhesions with wound closure in layers, incisional VAC.
___: Exploratory laparotomy, suturing of probable
enterotomy and VAC placement
Social History:
___
Family History:
His mother died of breast cancer. His father has stage 4 lung
cancer. He is not married. Patient is single. Has 2 grown
children who are healthy.
Physical Exam:
Prior To Discharge:
VS: 98.3, 54, 153/84, 20, 98% RA
GEN: Pleasant with NAD
HEENT: NC/AT, PERRL, EOMI, no scleral icterus
CV: RRR
PULM: CTAB
ABD: Midline scar well healed. RLQ fistula with feculent output
covered with abdominal pad.
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 04:41AM BLOOD WBC-3.5* RBC-4.25* Hgb-9.7* Hct-32.3*
MCV-76* MCH-22.8* MCHC-30.0* RDW-18.2* RDWSD-48.5* Plt ___
___ 04:41AM BLOOD Glucose-121* UreaN-14 Creat-1.0 Na-141
K-3.7 Cl-107 HCO3-23 AnGap-11
___ 05:49AM BLOOD ALT-37 AST-39 AlkPhos-110 TotBili-0.3
___ 04:41AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.1 Mg-2.0
Iron-25*
___ 04:41AM BLOOD calTI___* Ferritn-19* ___*
RADIOLOGY:
___ CT ABD:
IMPRESSION:
Resolution of small bowel obstruction. Persistent
enterocutaneous fistula. Unchanged mild splenomegaly.
Brief Hospital Course:
Mr. ___ is a ___ yo M with history of sigmoid perforation status
post colostomy, end ileostomy complicated by fistula who
presented to and outside hospital with abdominal pain concerning
for a small bowel obstruction. He was therefore transferred to
___. CT scan was obtained and showed resolution of small bowel
obstruction. He was admitted to the surgical floor for ongoing
monitoring.
The patient remained alert and oriented during hospitalization.
Pain was managed with home regimen or oral oxycodone. Vital
signs were routinely monitored and despite home atenolol the
patient was hypertensive to He was maintained strict NPO with
TPN. The patient was evaluated by nutrition who recommended
restarting continuous TPN.The patient had bowel movements and
voided adequate urine. Fistula output remained scant and
contained with a dry gauze dressing.
Psychiatry was consulted for history of bipolar, OCD and
possible binge eating behavior given that the patient is unable
to maintain NPO status at home. They recommended ___ rehab
setting after possible fistula repair intervention to assist
patient with remaining NPO.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating TPN ,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Outpatient TPN was arranged
prior to discharge.
Medications on Admission:
Atenolol 100 mg PO DAILY You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often)
ClonazePAM 0.5 mg PO BID You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often)
LamoTRIgine 200 mg PO DAILY You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often)
Omeprazole 40 mg PO DAILY You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often)
OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet ___ You were taking this medication at
home and you should continue it at the same dose (how much) and
frequency (how often)
Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
Please discuss your need to continue this medication with your
primary care provider.
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atenolol 100 mg PO DAILY
RX *atenolol 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. ClonazePAM 0.5 mg PO BID
4. LamoTRIgine 200 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Partial small bowel obstruction
Entero-cutaneous fistula
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 Acute Care Surgery Service on ___
with abdominal pain and concern for a bowel obstruction. You had
a CT scan that showed your obstruction was resolved. We are
working on making a plan to attempt to fix your fistula. You
were seen by the psychiatry team to help you decrease cravings
to eat. They agreed that it may be helpful to spend some time in
a rehab facility in order to help you refrain from eating.
You are now ready to be discharged to home to continue your
recovery. Please follow up with Dr. ___ in clinic at the
appointment listed below.
Please ___ 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. ___ 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.
Avoid driving or operating heavy machinery while taking pain
medications.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
___
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10608703-DS-29 | 10,608,703 | 25,537,795 | DS | 29 | 2142-11-05 00:00:00 | 2142-11-05 18:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Enterocutaneous fistula
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of bipolar disorder and ischemic
bowel with transverse colon perforation, s/p colectomy and end
ileostomy in ___. Ultimately, he was reversed with extensive
adhesiolysis and subsequently developed a leak from the small
bowel, which developed into an enterocutaneous fistula. His
fistula has been managed non-operatively with bowel rest and TPN
and previously controlled with ___ drain placement.
Of note, he was recently hospitalized with abdominal pain
___ and concern for SBO however this resolved and he as
discharged home on ___. At that time there was discussion for
definitive repair however he chosen to be discharged. Following
his admission, he reports a dramatic increase in the drainage
from his ECF. He reports having to spend several hours per day
cleaning up drainage. He reports not eating and has only had a
singular banana since his discharge. He denies any
fevers/chills, chest pain, or shortness of breath.
Past Medical History:
Past Medical History:
1. Hypertension.
2. Bipolar Disorder w/ Depression.
3. Hep C (s/p Harvoni rx)
4. OCD.
5. Multiple episodes of right sided rib fractures ___
all seemingly associated with falls/traumas as well as right
shoulder and leg as well as left shoulder trauma. Multi trauma
approximately ___ years ago. ?Pedestrian accident, primarily
orthopedic knee trauma.
6. Hammer toe, status post repair.
7. BPH.
Past Surgical History:
___- L Left rotator cuff surgery
___: Ex-Lap, Resection of terminal ileum and ascending
colon. (bowel left in discontinuity). Temporary abdominal
closure with ABThera wound VAC
___: Transverse colectomy, End ileostomy, Abdomen left
open with ABThera wound VAC.
___: Laparoscopic exploratory laparotomy with abdominal
wall closure.
___: Ileostomy reversal, partial enterectomy, extensive
lysis of adhesions with wound closure in layers, incisional VAC.
___: Exploratory laparotomy, suturing of probable
enterotomy and VAC placement
Social History:
___
Family History:
His mother died of breast cancer. His father has stage 4 lung
cancer. He is not married. Patient is single. Has 2 grown
children who are healthy.
Physical Exam:
Admission Physical Exam:
Vital Signs: 98.7 58 148/61 18 96% on RA
GEN: A&Ox3, NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: no respiratory distress, unlabored respirations
ABD: soft, non-distended, healed midline incisions with severe
scarring, RUQ fistula currently drainage yellow bile, there is
severe excoriation of the surrounding skin mostly on the
inferior
aspect, there is mild tenderness in the RUQ with no signs of
rebound or gaurding
PELVIS: deferred
EXT: WWP, no edema
NEURO: A&Ox3, no focal neurologic deficits
Discharge Physical Exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs.
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 06:02AM BLOOD WBC-4.6 RBC-3.58* Hgb-8.3* Hct-29.1*
MCV-81* MCH-23.2* MCHC-28.5* RDW-19.7* RDWSD-57.1* Plt ___
___ 06:02AM BLOOD Glucose-91 UreaN-15 Creat-1.2 Na-139
K-4.8 Cl-107 HCO3-21* AnGap-11
___ 06:02AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
___ 02:40AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE.
Identification and susceptibility testing performed on culture
#___ (___).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
CT ABD & PELVIS WITH CONTRAST on ___:
IMPRESSION:
Persistent enterocutaneous fistula from the small bowel to the
right upper
quadrant abdominal wall with linear extraluminal oral contrast
in the right upper quadrant extending anterior to the liver and
into the gallbladder fossa causing reactive inflammation of the
gallbladder.
LIVER OR GALLBLADDER US (SINGLE ORGAN) on ___:
IMPRESSION:
1. Nondistended gallbladder with wall thickening in trace
pericholecystic
fluid as seen on prior CT. No gallstones visualized.
2. Patent portal vein. No biliary dilation.
CT ABD & PELVIS WITH CONTRAST ON ___:
IMPRESSION:
Compared to ___, there is no change in the appearance
of the
enterocutaneous fistula from the small bowel to the right upper
quadrant
abdominal wall with crescentic extraluminal oral contrast in the
perihepatic region. No new sites of contrast extravasation.
CHEST (PA & LAT) ON ___:
IMPRESSION:
There are old healed right-sided rib fractures. Left-sided PICC
line is
unchanged. Cardiomediastinal silhouette is stable. No
pneumothorax. No no pleural effusions
Brief Hospital Course:
Mr. ___ is a ___ year old male, who is a patient of Dr. ___
and is known to the ___ service. He has a PMH significant for
HTN, Bipolar (w/ depression), Hep C, R-sided rib fractures from
falls/traumas, BPH, ex lap w/ resection of terminal ileum, s/p
colectomy and ileostomy w/ reversal c/b chronic enterocutaneous
fistula. He was admitted on ___ for increased drainage from
his chronic ECF. An abdomen/pelvis CT w/ contrast was obtained,
which showed a decompressed gallbladder with hyperemic wall and
surrounding inflammatory changes suggests cholecystitis, which
may be reactive to the persistent enterocutaneous fistula from
the small bowel to the right upper quadrant abdominal wall.
The patient was admitted to the floor hemodynamically stable
with the intention for bowel rest. He was made NPO and started
on IVF. Wound nurse was consulted for EC fistula management. TPN
was restarted according to nutrition recommendations. TPN was
discontinued on HD#3 (d/t removal of PICC) and PPN was initiated
and ended on HD#5. Patient was advanced to a regular diet on
HD#6, which he tolerated well. EC fistula with high output on
HD#1+2 (> 500mL/day), but since then EC fistula output has
decreased (< 50mL/day).
Patient had positive blood cultures from OSH (___),
which grew gram negative rods. He was started on broad-spectrum
antibiotics on ___ for bacteremia. Additional blood cultures
were obtained daily. Patient's PICC line was removed for 48
hours for a line holiday. After removal, IV catheter tip was
cultured and showed no significant growth. Antibiotics were
narrowed to ceftriaxone after speciation of blood cultures,
which grew Klebsiella pneumoniae and E.coli. Plan for a two-week
course of antibiotics, starting from the last negative blood
culture (___).
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled on PO pain medications. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He will follow
up with Dr. ___ in ___ clinic.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. CefTRIAXone 1 gm IV Q24H
end ___
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 gram IV once a
day Disp #*8 Intravenous Bag Refills:*0
3. Miconazole Powder 2% 1 Appl TP QID:PRN rash
4. amLODIPine 5 mg PO DAILY
5. Atenolol 100 mg PO DAILY
RX *atenolol 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. ClonazePAM 0.5 mg PO TID:PRN anxiety
7. LamoTRIgine 200 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*8 Tablet Refills:*0
10. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Enterocutaneous fistula
Positive blood cutlures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were having increased
output from your abdominal fistula. An abdomen/pelvis CT showed
your persistent enterocutaneous fistula. We placed you on bowel
rest (nothing by mouth and IV fluids) and resumed your TPN for
nutrition. You were eventually advanced back to a regular diet,
which you tolerated. In addition this admission, your blood
cultures grew bacteria suggestive that you had an infection in
your blood. You were treated with antibiotics and had your
central line replaced. You will be going home with your PICC
line in order to finish your antibiotic course. It is very
important that you record the output from your fistula site each
time your empty it.
Please follow the instructions below to continue your recovery:
Please ___ 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. ___ or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid driving or
operating heavy machinery while taking pain medications.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely.
DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES. Please keep
the dressing clean and dry. Contact your ___ Nurse if the
dressing comes undone or is significantly soiled for further
instructions.
Followup Instructions:
___
|
10608802-DS-16 | 10,608,802 | 29,489,718 | DS | 16 | 2192-03-28 00:00:00 | 2192-03-28 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
GI BLEED
Major Surgical or Invasive Procedure:
IVC filter ___
Colonoscopy ___
History of Present Illness:
___ female with history of vascular dementia/amyloid
angiopathy, HTN, recent admission for DVT/PE (on
Coumadin)transferred ___ for GI bleed.
Of note, has had multiple recent admissions, first ___ for
encephalopathy. She was treated for a UTI with CTX/cefpodoxime
and course was also c/f acute agitation treated with various
antipsychotics. She was discharged to a SNF.
She represented from her SNF on ___ with hypoxia, 1 week
after she was found by her PCP to have ___ new RLE DVT for which
she was started on lovenox. She was found on CTA to have massive
saddle PE with acute hypoxic respiratory failure requiring brief
ICU stay. Was started on heparin gtt and transitioned to
Coumadin. MASCOT was consulted due to concern for bleeding risk
given h/o amyloid angiopathy, and felt there there was no
indication for IVC filter. She was discharged back to ___ on
Coumadin w/ lovenox bridge on ___.
At rehabilitation facility today was noted to have onset of
hematochezia with associated abdominal pain. Brought to outside
hospital. She was hemodynamically stable but continued to have
active hematochezia. Found to have supratherapeutic INR of 4.
Hgb 9.4 down from (10.3 on ___. Patient given 2 units of FFP,
10 mg of IV vitamin K, and one unit packed red blood cells.
Patient on arrival is demented but at baseline per daughter.
In the ED, initial vitals were: 97.2 91 134/82 18 98% RA
- Exam notable for: Mild abdominal tenderness
- Labs notable for: WBC 3.5K, Hgb 9.3, Plt 233K, Lactate:1.4,
UA +large leuk, sml blood, moderate bacteria
- Imaging was notable for: CTA A/P: No evidence of active
arterial or venous intraluminal extravasation, bladder wall
thickening
- Patient was given: Pantoprazole 40 mg IV, Acetaminophen IV
1000 mg, CeftriaXONE 1 gm
Upon arrival to the floor, patient reports that she has some
suprapubic pain. Otherwise, she is oriented only to self.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
1. Hypertensive heart disease
2. Hypothyroidism
3. Hyperlipidemia
4. Osteoarthritis
5. Cognitive impairment
6. Amyloid angiopathy
7. Mitral valve prolaps
8. Osteoporosis
9. breast cancer ___, s/p partial mastectomy and
radiation
Social History:
___
Family History:
Son ___ ___ BRAIN TUMOR
Father with colon cancer and esophageal cancer, died of an MI.
Mother had ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: 97.4 PO 133 / 84 R Sitting 89 20 97 Ra
GENERAL: Elderly female, hard of hearing, in NAD
HEENT: Anicteric sclerae, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: somewhat distended but non-tender, +BS, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Warm. Upper right extremity with hematoma and
tender to palpation mass on forearm
NEURO: AAOx1 (knows name only, confused where she is, unable to
state date), perseverates, and has moderate memory loss,
dysarthric
DISCHARGE PHYSICAL EXAM
Vitals: 97.8 PediatricAxillary 116/71 R Lying 75 20 96 Ra
General: Alert, hyper oral- frequent kissing movements w/ mouth
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI sys murmur
___ at LUSB rad to carotids, no rubs, gallops
Abdomen: soft, obese, distended, bowel sounds present, no
guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sleeping this morning, but arousable, otherwise not
oriented
Pertinent Results:
ADMISSION LABS:
==============
___ 06:00PM URINE HOURS-RANDOM
___ 06:00PM URINE UHOLD-HOLD
___ 06:00PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 06:00PM URINE RBC-29* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0 TRANS EPI-3
___ 06:00PM URINE HYALINE-3*
___ 06:00PM URINE WBCCLUMP-MOD MUCOUS-RARE
___ 05:40PM LACTATE-1.4
___ 05:30PM GLUCOSE-106* UREA N-18 CREAT-0.8 SODIUM-142
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17
___ 05:30PM estGFR-Using this
___ 05:30PM ALT(SGPT)-36 AST(SGOT)-32 ALK PHOS-71 TOT
BILI-0.7
___ 05:30PM LIPASE-46
___ 05:30PM ALBUMIN-3.4* CALCIUM-8.5 PHOSPHATE-2.6*
MAGNESIUM-2.3
___ 05:30PM WBC-3.5* RBC-2.75* HGB-9.3* HCT-25.5* MCV-93
MCH-33.8* MCHC-36.5 RDW-16.8* RDWSD-53.9*
___ 05:30PM NEUTS-64.3 ___ MONOS-5.8 EOS-1.2
BASOS-0.0 IM ___ AbsNeut-2.22 AbsLymp-0.97* AbsMono-0.20
AbsEos-0.04 AbsBaso-0.00*
___ 05:30PM PLT COUNT-233
MICRO:
======
___ 6:00 pm URINE CLEAN CATCH.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 4 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
========
+ CTA A/P ___
1. No evidence of active arterial or venous intraluminal
extravasation.
2. Subtle hazy stranding of the fat adjacent to the proximal
rectum may represent a mild proctitis.
3. Apparent bladder wall thickening may be secondary to
underdistention, however infection cannot be excluded. Recommend
correlation with urinalysis.
4. Small bilateral nonhemorrhagic pleural effusion
+ IVC GRAM/FILTER
1. Patent normal sized, non-duplicated IVC with single bilateral
renal veins and no evidence of a clot.
2. Successful deployment of an infra-renal Denali IVC filter.
COLONOSCOPY ___
Diverticulosis of the sigmoid colon and descending colon
Normal mucosa in the whole colon and examined portion of TI
Polyp in the cecum
Otherwise normal colonoscopy to cecum and 10 cms into tI
DISCHARGE LABS
==============
___ 10:30AM BLOOD WBC-7.1 RBC-3.97 Hgb-11.6 Hct-36.0 MCV-91
MCH-29.2 MCHC-32.2 RDW-17.3* RDWSD-56.8* Plt ___
___ 10:30AM BLOOD ___ PTT-41.9* ___
___ 10:30AM BLOOD Glucose-120* UreaN-13 Creat-0.8 Na-137
K-4.4 Cl-100 HCO3-27 AnGap-14
___ 10:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1
Brief Hospital Course:
This is an ___ year old female with past medical history of
vascular dementia, amyloid angiopathy, hypertension, recent
admission for acute pulmonary embolism, discharged ___ on
lovenox bridge to Coumadin, admitted ___ with acute GI
bleed, course complicated by re-bleeding after restarting
anticoagulation, now status post IVC filter, colonoscopy
without identifiable source of bleeding, restarted on
anticoagulation x 4 days without sign of rebleeding, able to be
discharged home with services with daughter.
# Acute blood loss anemia / Lower GI Bleed: Patient presented
with multiple episodes of hematochezia in setting of INR 3.9.
She was transfused 2 units of blood in setting of large volume
of blood loss and was admitted to medicine. CTA showed no
active extravisation. Initially anticoagulation was held, with
resolution of bleeding. Given high risk of pulmonary embolism
complications, patient was trialed on heparin drip, with
bleeding recurrence within 24 hours. Patient had IVC filter
placed as below and was managed over anticoagulation for > 48
hours. Colonoscopy did not reveal source of bleeding--presumed
to be diverticulosis. Restarted on heparin gtt to Coumadin
bridge, without bleeding. Patient then switched to Lovenox
bridge to coumadin without rebleeding. She was monitored for
72 hours given high risk. Discharge Coumadin dose 6 mg,
discharge INR 1.2, discharge Lovenox dose 80 bid. Should
continue Lovenox until INR therapeutic (___) on Coumadin.
2. E coli UTI: patient also was found to have a urinary tract
infection with e coli resistant to ceftriaxone. Patient has
bactrim allergy, so augmentin was used x ___. Recent Saddle PE: found on CTA chest ___ after
presenting w/ hypoxia after diagnosis of DVT one week prior.
As above, her course this admission was notable for bleeding
while on anticoagulation with failure of trial of heparin drip.
Given high risk for pulmonary embolism complications while off
anticoagulation, patient had IVC filter placed this
hospitalization ___ with ___. Given risk that patient
could have re-bleed in the future, IVC filter was left in
place. If remains without bleeding, would consider removal at
3 months.
Transitional Issues:
[]Patient has IVC filter placed with ___ on ___
[]Patient AO x self only at baseline
[]Discharge Coumadin dose 6 mg, discharge INR 1.2, discharge
Lovenox dose 80 bid
[]Polyp seen at cecum - repeat colonoscopy should be discussed
___ PCP and family re goals of care
[]TSH 7.7 on admission, recommend outpatient TFTs
[]Outpatient HCTZ 25 daily stopped on admission, subsequently
discontinued d/t normotension in house
CODE: DNR, ok to intubate (per MOLST)
CONTACT: ___ daughter ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Simvastatin 20 mg PO QPM
8. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO QID:PRN
indigestion
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Warfarin 5 mg PO DAILY16
11. OLANZapine 5 mg PO DAILY:PRN agitation
12. TraZODone 25 mg PO TID:PRN agitation
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
2. Warfarin 6 mg PO ONCE Duration: 1 Dose
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO QID:PRN
indigestion
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Levothyroxine Sodium 25 mcg PO DAILY
8. OLANZapine 5 mg PO DAILY:PRN agitation
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. Simvastatin 20 mg PO QPM
12. TraZODone 25 mg PO TID:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Acute GI Bleed
- Acute blood loss anemia
- Pulmonary embolism with saddle embolism
- Diverticulosis
- Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you at ___.
Why was I in the hospital?
- You were bleeding from your colon
What happened while I was in the hospital?
- You had a filter placed in your vein to prevent blood clots
going to your lungs. This filter is called an "IVC filter".
- You had a colonoscopy which showed "diverticulosis".
Diverticuloses are outpouchings in your colon. Sometimes
diverticulosis can cause bleeding.
What should I do now that I am leaving the hospital?
- Please take your medicine exactly as prescribed
- Please follow-up with your doctors ___ instructions below)
- You are taking a medicine called "coumadin or warfarin" which
can cause bleeding.
- Please notify your doctor immediately if you are bleeding.
- You had a polyp (small mass) in your colon seen during the
colonoscopy. Please discuss follow-up with your primary care
provider.
We Wish You The ___!
- Your ___ Team
Followup Instructions:
___
|
10608802-DS-17 | 10,608,802 | 22,542,278 | DS | 17 | 2192-04-04 00:00:00 | 2192-04-04 14:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ amyloid angiopathy with recent hospitalization for saddle PE
with readmission for GIB in setting of anticoagulation now s/p
IVC filter placement now presents from SNF with progressive
lethargy and altered mental status.
Per patient's daughter, she has been lethargic at baseline
since her discharge on ___. A UA was checked at her SNF which
was positive and the patient was sent to ___. A CT head was
obtained in the ED which showed a 4mm hyperdense focus c/f
micro-bleed vs. contusion. She was seen by neurosurgery and
neurology who recommended holding anticoagulation, starting
keppra and repeating a head CT which was stable.
In the ED, initial vitals were:
T 96.9 HR 93 BP 113/73 R 16 SpO2 94% RA
- Exam notable for:
generalized abdominal ttp, CTAB, rrr, moving all extremities
- Labs notable for:
Trop-T: 0.03
Lactate:1.6
UA w/ Small Leuks, few bacteria, +nitrates
INR: 2.0
Normal CBC, Chem7, LFTs
Patient was given:
___ 21:11 IV Ampicillin-Sulbactam 1.5 g
___ 22:18 IVF NS 500 mL
Upon arrival to the floor, patient was AAOx0, moving all 4
extremities and answering "No" to all questions.
REVIEW OF SYSTEMS: unable to obtain
PAST MEDICAL HISTORY:
Per OMR
Hypertensive heart disease
Hypothyroidism
Hyperlipidemia
Osteoarthritis
Cognitive impairment
Amyloid angiopathy
Mitral valve prolaps
Osteoporosis
breast cancer ___, s/p partial mastectomy and radiation
MEDICATIONS:
The Preadmission Medication list is accurate and complete
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Warfarin 6 mg PO ONCE
7. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO QID:PRN
indigestion
11. TraZODone 25 mg PO TID:PRN agitation
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Past Medical History:
1. Hypertensive heart disease
2. Hypothyroidism
3. Hyperlipidemia
4. Osteoarthritis
5. Cognitive impairment
6. Amyloid angiopathy
7. Mitral valve prolaps
8. Osteoporosis
9. breast cancer ___, s/p partial mastectomy and
radiation
Social History:
___
Family History:
Son ___ ___ brain tumor
Father with colon cancer and esophageal cancer, died of an MI.
Mother had ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: T 100.2 BP 126/80 HR 102 R 20 SpO2 95 RA
GEN: elderly, lying on side in bed, moving in discomfort,
answering "No" to all questions
HEENT: sclerae anicteric, moist mucous membranes
___: Regular, III/VI SEM radiating to back
RESP: No increased WOB, no wheezing, crackles or rhonchi
ABD: suprapubic tenderness, no rebound or guarding
EXT: warm without edema
NEURO: No facial droop, PERRL, moving all 4 extremities, AAOx0
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 98.6 PediatricAxillary 115 / 74 82 18 97 Ra
GEN: no acute distress
HEENT: sclerae anicteric, moist mucous membranes
___: Regular, III/VI SEM radiating to back
RESP: No increased WOB, no wheezing, crackles or rhonchi
ABD: no abd tenderness, no rebound or guarding
EXT: warm without edema
NEURO: No facial droop, PERRL, moving all 4 extremities, Alert
and oriented to person only
Pertinent Results:
ADMISSION LABS:
===============
___ 09:27PM PTT-38.0*
___ 07:11PM ___
___ 02:33PM URINE HOURS-RANDOM
___ 02:33PM URINE UHOLD-HOLD
___ 02:33PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 02:33PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM
___ 02:33PM URINE RBC-<1 WBC-7* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 02:33PM URINE MUCOUS-MANY
___ 01:50PM LACTATE-1.6
___ 01:38PM GLUCOSE-111* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18
___ 01:38PM ALT(SGPT)-25 AST(SGOT)-28 ALK PHOS-74 TOT
BILI-0.8
___ 01:38PM LIPASE-19
___ 01:38PM cTropnT-0.03*
___ 01:38PM ALBUMIN-3.7
___ 01:38PM WBC-5.8 RBC-4.12 HGB-12.2 HCT-38.0 MCV-92
MCH-29.6 MCHC-32.1 RDW-17.8* RDWSD-59.7*
___ 01:38PM NEUTS-76.5* LYMPHS-17.4* MONOS-4.9* EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-4.40# AbsLymp-1.00* AbsMono-0.28
AbsEos-0.03* AbsBaso-0.01
___ 01:38PM PLT COUNT-240
MICRO:
======
___ 11:46 pm STOOL CONSISTENCY: SOFT
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ AT
09:32.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ 2:33 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefepime (>16 MCG/ML).
Cefepime sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
========
+ ___ CT Head W/O Contrast
1. Stable appearance of 4 mm hyperdense focus within the
anterior left
temporal lobe. As mentioned previously, this may reflect a
contusion in the setting of trauma or cerebral microbleed
setting of known amyloid angiopathy. Possibility of an
extra-axial lesion is possible though considered less likely
given timing interval development.
2. Re-demonstrated bilateral medial occipital lobe cortical
laminar necrosis.
3. Stable left frontal meningiomas.
4. Chronic changes, including age-related cortical atrophy and
small vessel ischemic disease.
+ ___ CT Abd & Pelvis With Contrast
1. Mild inferior rectal wall thickening and perirectal fat
stranding, suggesting proctitis.
2. Apparent bladder wall thickening may be secondary to
underdistention, though infection cannot be definitively
excluded. Correlation with urinalysis is advised.
3. Stable left renal angiomyolipoma, measuring up to 2.5 cm.
4. Multiple bilateral renal lesions which are complex and likely
enhancing, specifically a 1.0 x 0.9 cm lesion at the lower pole
the left kidney and heterogeneously enhancing 1.3 cm lesion in
the interpolar region of the right kidney. These are suspicious
for mass lesions. Multiphasic exam is suggested to further
characterize by MRI if no contraindication.
+ Repeat ___ CT Head W/O Contrast
1. A 4 mm hyperdense focus within the anterior left temporal
lobe is new since prior exam and therefore is most concerning
for intraparenchymal hemorrhage. This may be due to contusion in
the setting of trauma or related to patient's known amyloid
angiopathy.
2. Unchanged appearance of cortical laminar necrosis in the
bilateral medial simple lobes.
3. Stable left frontal meningiomas.
4. Chronic changes, including age-related cortical atrophy and
small vessel ischemic disease.
+ ___ Chest (Pa & Lat)
1. Stable mild-to-moderate cardiomegaly with pulmonary vascular
congestion. No overt pulmonary edema.
2. Mild retrocardiac opacification is most consistent with
atelectasis.
3. Stable loss of height of a mid-thoracic vertebral body.
+ ___ CT Head non-con
1. Stable appearance of 4 mm hyperdense focus in the anterior
left temporal lobe. As previously noted, this may reflect a
contusion in the setting of trauma or cerebral micro bleed in
setting of known amyloid angiopathy. Possibility of
extra-axial lesion is possible although considered less likely
given the timing of interval development.
2. Unchanged 2 hyperdense extra-axial left frontal lesions
consistent with
meningiomas.
3. Unchanged cortical laminar necrosis of medial bilateral
occipital lobes.
+ ___ MRI brain
1. Study is extremely limited by patient motion.
2. 0.6 cm focus of intrinsic T1 hyperintensity within the
anterior left temporal lobe with associated low signal on the
susceptibility weighted images, is likely secondary to a focus
of hemorrhage. Although evaluation is extremely limited, no
definite underlying enhancement is seen.
3. Slight interval increase in size of the left frontal lobe
lesions, likely secondary to meningioma compared to the prior
exam from ___, measuring up to 1.1 cm. 4. New 0.5 cm
extra-axial focus of enhancement, series 1100, image 107 within
the left frontal lobe is seen. This can be better assessed on
the follow up study. 5. Multiple foci of low signal on the
susceptibility weighted sequences, consistent with patient's
known amyloid angiopathy. 6. Punctate hemorrhagic focus is seen
in the left occipital lobe (image 10, series 7, image 14, series
3).
RECOMMENDATION(S): A follow up MRI in 3-months is recommended to
evaluate for evolution and to exclude underlying enhancement.
Brief Hospital Course:
___ with PMH cerebral amyloid angiopathy with two recent
admissions for saddle PE c/b GIB in setting of anticoagulation
s/p ICV filter placement presents from SNF with lethargy, found
to have UTI, proctitis and intraparenchymal hemorrhage.
#TOXIC / METABOLIC ENCEPHALOPATHY
Patient presented with progressive lethargy from SNF. Per
daughter, this is has been close to her baseline since her
discharge from ___ on ___. There are multiple etiologies to
explain her encephalopathy including UTI, proctitis and CT head
which showed small intraparenchymal hemorrhage. UCx with e coli
resistant to cefepime, cefazolin and CTX but sensitive to
Bactrim, macrobid and ampicillin-sulbactam. Patient also had
stool positive for C diff. Patient was seen in ED by neurology
and neurosurgery who recommended serial CT, EEG. Serial CT
showed stable IPH. EEG with diffuse slowing but no epileptiform
discharges. Limited MRI (due to patient's movement) showed new
0.5 cm extra-axial focus of enhancement within the left frontal
lobe. She was started on amp-sulbactam (___) for complicated
cystitis. She was started on vencomycin PO 125 mg Q6H (___)
for 14 days post final days post final UTI abx course (vanc to
end ___. Her mental status improved throughout her hospital
course but she remained intermittently lethargic and sometimes
oriented to self, place.
#Complicated Cystitis
UA and culture c/w UTI in setting of altered mental status.
Culture confirmed resistant E. Coli. Plan for 7 day course,
transitioning from ampicillin/sulbactam to
amoxicillin/clauvulonate 875 mg po bid through ___.
#Mild-moderate cdiff
#Proctitis
CT abd/pelvis showed proctitis with abdominal pain on exam. Mild
fevers without hemodynamic instability, elevated lactate or
leukocytosis. Stool returned C diff positive ___. Vancomycin
treatment as above, for 2 weeks after completion of systemic
antibiotics for cystitis.
#Intraparenchymal Hemorrhage
#Cerebral Amyloid Angiopathy
No history of trauma. No focal neurological deficits. CT showed
new hemorrhage located in anterior left temporal lobe. Stable on
serial CT. MRI as above. Seen by neurology and neurosurgery. No
intervention per neurosurgery. SBP goal <150s. Per discussion
with family and outpatient neurologist, the decision was made to
not resume anticoagulation given high risk for bleeding.
#Recent Saddle PE: Presented from ___ on ___ with hypoxia x1
week in setting of new RLE DVT, CTA found massive saddle PE. She
was started on warfarin and lovenox at that time. She
represented ___ with LGIB. She had IVC filter placed during
that admission. She was discharged on ___ on warfarin and
lovenox. Because she represented with possible new IPH, her
anticoagulation was discontinued given that she is high risk for
bleeding.
# Recent Lower GI bleed
Presented from ___ on ___ (last hospitalization) with
hematochezia with INR of 3.9. Heparin gtt initially stopped but
restarted once hematochezia stopped given recent PE. Patient had
a re-bleed on heparin gtt and then had an IVC filter placed on
___. Colonoscopy negative for active bleed. Patient was
discharged on warfarin with lovenox bridge. She has been
hemodynamically stable w/ stable H/H and no recurrent of
hematochezia during this hospitalization.
CHRONIC ISSUES:
===============
#HLD: simvastatin continued.
#Hypothyroidism: levothyroxine continued.
TRANSITIONAL ISSUES:
====================
# NEW MEDICATIONS: Augmentin 875 mg po bid through ___,
Vancomycin 125 mg PO Q6H through ___ (2 weeks from final
day of abx for UTI treatment, ___
# STOPPED MEDICATIONS: warfarin (now has had lower gi bleed and
intracranial hemorrhage), lovenox
[] ANTICOAGULATION IS NOT IN LINE WITH PATIENT'S GOALS OF CARE
(with exception of SQ heparin for DVT prophylaxis)
# IMAGING FINDINGS REQUIRING FOLLOW-UP
[] RENAL LESIONS: Multiple bilateral renal lesions which are
complex and likely enhancing, specifically a 1.0 x 0.9 cm lesion
at the lower pole the left kidney and heterogeneously enhancing
1.3 cm lesion in the interpolar region of the right kidney.
These are suspicious for mass lesions. Multiphasic exam is
suggested to further characterize.
RECOMMENDATION(S): Renal MRI suggested, if no contraindication,
to further assess bilateral complex slightly enhancing lesions.
[] MRI BRAIN:
RECOMMENDATION(S): A follow up MRI in 3-months is recommended
to evaluate for evolution and to exclude underlying enhancement.
[] Baseline mental status: alert and oriented sometimes to
person but usually not place or date, waxes and wanes
[] Patient might need UTI suppression therapy. We are awaiting
fosfomycin sensitivities at time of discharge.
[] Please continue to discuss goals of care with patient and
HCP.
# Code Status: DNR, ok to intubate
# ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Warfarin 6 mg PO ONCE
7. Enoxaparin Sodium 80 mg SC Q12H
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO QID:PRN
indigestion
11. TraZODone 25 mg PO TID:PRN agitation
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
through ___
2. Heparin 5000 UNIT SC BID
3. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 16 Days
through ___
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO QID:PRN
indigestion
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO DAILY:PRN constipation
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. Simvastatin 20 mg PO QPM
13. TraZODone 25 mg PO TID:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Intraparenchymal Hemorrhage
Toxic metabolic encephalopathy
clostridium difficile infection
complicated cystitis
Secondary Diagnosis:
Cerebral Amyloid Angiopathy
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable and at times
alert.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___!
Why was I in the hospital?
- You were more confused and tired so you were brought to the
hospital
What happened while I was in the hospital?
- You had imaging of your brain which showed a small bleed
- You had an "EEG" which showed you were not having seizures
- You had testing of your stool which showed you have an
infection in your bowels
- You were given medicine to treat your stool infection
- You were given medicine to treat your urine infection
What should I do now that I am going home?
- Please take all of you medicines exactly as prescribed
We wish you the best,
- Your ___ Team
Followup Instructions:
___
|
10608802-DS-19 | 10,608,802 | 20,881,149 | DS | 19 | 2193-07-09 00:00:00 | 2193-07-09 14:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central Line Placement: ___
History of Present Illness:
Ms. ___ is an ___ woman with a history of hypothyroidism, OA,
amyloiod angiopathy, MVP, remote breast CA, as well as massive
saddle PE in ___ who presents from her SNF with fever, altered
mental status. The patient was recently diagnosed with and
treated with cefpodoxime for urinary tract infection (___).
On arrival to the ED she was reportedly shaking and not
responsive, thus was given 2 mg Ativan for seizure which
reportedly helped and she then became responsive.
Of note, her baseline blood pressure is ___.
In ED initial VS:
96.6 96 118/50 30 94% RA
Labs significant for:
Lactate 8.1 --> 3.4 --> 1.3
BUN/creatinine 55/1.1
Chemistry panel otherwise within normal limits
WBC 6.4 78% neutrophils
H/H 11.6/36.8
Urinalysis showed large leuks, WBCs greater than assay, few
bacteria, negative nitrites, small blood.
Patient was given:
IV LORazepam 2 mg
IVF NS x total of 2L
IV Acetaminophen IV 1000 mg
IV Piperacillin-Tazobactam 4.5g
IV Vancomycin 1000 mg
IV DRIP Norepinephrine
Imaging notable for:
___ non con head ct
C/w ct dated ___ and MRI dated ___. No acute hemorrhage.
Similar pattern of laminar necrosis in the bilat occipital
lobes. Small left frontal meningioma unchanged. Small vessel
disease. Fluid level in left sphenoid sinus.
___ CXR: Mild vascular congestion. No pleural effusion. No
consolidations to suspect pneumonia.
Consults:
Neurology was consulted when the patient arrived in questionable
seizure however this consult was deferred due to hypotension and
pressor requirement.
VS prior to transfer:
98.0 74 99/49 23 98% RA
On arrival to the ___, the patient was yelling "help me" with
her daughter at the bedside. She was unable to answer any
questions or review of systems.
Past Medical History:
-Hypertensive heart disease
-Hypothyroidism
-Hyperlipidemia
-Osteoarthritis
-Cognitive impairment
-Amyloid angiopathy
-Mitral valve prolapse
-Osteoporosis
-Breast cancer ___, s/p partial mastectomy and radiation
-Saddle PE with readmission for GIB in setting of
anticoagulation now s/p IVC filter, also subsequently c/b small
intraventicular hemorrhage
-C.diff ___
Social History:
___
Family History:
Son ___ ___ brain astrocytoma.
Father with colon cancer and esophageal cancer, died of an MI.
Mother had ___.
Physical Exam:
ADMISISON PHYSICAL EXAM:
=========================
VITALS: Reviewed in metavision
GENERAL: Elderly woman, appears distressed, not responding to
commands, clenching to the bed rails with both hands.
HEENT: Sclera anicteric, MMM, oropharynx clear. Mucous membranes
appear slightly dry.
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, no m/r/g.
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: Scattered ecchymoses, otherwise no obvious rashes.
NEURO: Not following commands.
DISCHARGE PHYSICAL EXAM:
=========================
Pertinent Results:
ADMISSION LABS
===============
___ 08:05AM BLOOD WBC-6.4 RBC-3.95 Hgb-11.6 Hct-36.8 MCV-93
MCH-29.4 MCHC-31.5* RDW-16.8* RDWSD-56.5* Plt ___
___ 08:05AM BLOOD Neuts-78* Bands-0 Lymphs-16* Monos-3*
Eos-0 Baso-1 ___ Metas-2* Myelos-0 AbsNeut-4.99
AbsLymp-1.02* AbsMono-0.19* AbsEos-0.00* AbsBaso-0.06
___ 08:05AM BLOOD Plt Smr-NORMAL Plt ___
___ 08:05AM BLOOD Glucose-136* UreaN-55* Creat-1.1 Na-144
K-4.4 Cl-97 HCO3-23 AnGap-24*
___ 08:05AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1
___ 08:15AM BLOOD Lactate-8.1*
___ 08:27AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 08:27AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 08:27AM URINE RBC-7* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-1
___ 08:27AM URINE CastHy-9*
___ 08:27AM URINE WBC Clm-OCC* Mucous-RARE*
INTERVAL LABS
===============
___ 11:14AM BLOOD Lactate-3.4*
___ 02:45PM BLOOD Lactate-1.3
___ 02:30AM BLOOD Lactate-1.1
MICRO/PATH
===============
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ BCx x1: Pending, no growth to date
___ BCx x2:
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Total metanephrines
TOTAL, FREE (MN+NMN) 211 H <=205 pg/mL
IMAGING
===============
___ CXR IMPRESSION: Pulmonary vascular congestion with mild
edema
___ CT HEAD w/o Contrast IMPRESION:
1. Stable pattern of gyriform hyperdensity in the bilateral
occipital cortex is most consistent with chronic laminar
necrosis.
2. Small meningioma adjacent to the left frontal lobe.
3. Left sphenoid sinus fluid level, may represent acute sinus
disease in the correct clinical setting.
MRI:
1. Late acute to subacute infarcts within the right centrum
semiovale and left occipital lobe, without evidence of
hemorrhagic transformation.
2. Probable amyloid angiopathy.
3. Probable moderate chronic small vessel disease and an old
infarct within the isthmus of the right cingulate gyrus.
4. Several small meningiomas, with mild interval growth from ___, however negligible mass effect and no associated
vasogenic edema.
5. Normal MRA brain and neck.
EEG: Slowing consistent with encephalopathy.
TTE: Moderate AS, EF 75%
DISCHARGE LABS
===============
___ 06:40AM BLOOD WBC-3.1* RBC-3.39* Hgb-10.0* Hct-32.7*
MCV-97 MCH-29.5 MCHC-30.6* RDW-17.1* RDWSD-60.5* Plt ___
___ 06:35AM BLOOD Glucose-96 UreaN-31* Creat-0.7 Na-145
K-4.9 Cl-105 HCO3-27 AnGap-13
___ 01:20PM BLOOD CK(CPK)-164
___ 05:10AM BLOOD ALT-38 AST-40 LD(___)-214 AlkPhos-72
TotBili-1.0
___ 09:30AM BLOOD Triglyc-153* HDL-50 CHOL/HD-4.0
LDLcalc-118
___ 09:30AM BLOOD %HbA1c-5.3 eAG-105
___ 03:58PM BLOOD CRP-2.5 Anti-Tg-LESS THAN antiTPO-LESS
THAN
___ 08:27AM URINE WBCCLUMP-OCC* MUCOUS-RARE*
Brief Hospital Course:
===============================
FICU COURSE ___ - ___
===============================
Ms. ___ is an ___ woman with a history of hypothyroidism,
amyloiod angiopathy, remote breast CA, as well as massive saddle
PE in early ___ who presents with fever, altered mental status,
hypotension, and sepsis likely secondary to UTI.
# Hypotension
# Fever
# Sepsis ___ UTI
Of note, patient has a history of recurrent UTIs. Broad
infectious workup was initiated in the ED; CXR was reassuring,
UA was intermediate/dirty. Pt was started on cefpodoxime 1 week
ago (on ___ and was supposed to end treatment today ___.
Given UA, favor partially treated UTI as the cause for her
fever, hypotension, sepsis, and altered mental status. Prior
cultures from ___ grew E. coli that was CTX resistant. For her
hypotension (of note, baseline BPs 90/50s), feel this is related
to urosepsis as she was fluid responsive. She was started on
Zosyn, which her prior cultures have been sensitive to, and
completed 5 day course. Required Norepinephrine briefly during
her ICU stay, however was quickly weaned off. Urine culture grew
<10,000 CFUs. On ___ she spiked a fever again to 102 degrees;
she was recultured at this time and has not had fevers since
then.
#Altered Mental Status
#Shaking episodes - ultimately felt to be vestibular in nature.
Per daughter, pt has baseline dementia (detailed below) and is
at times oriented x ___. On presentation she was
shaking/rigoring, however after talking with daughter and
reassuring patient, it was understood that she shakes at
baseline and clings on to her bed rails as she is afraid of
falling out of the bed. This increases at times of transfer.
Her daughter reports that these shaking episodes increased on
the day prior to admission and she could see that her mother was
off from her baseline. As per above, was treated for her
infection and started to improve by the time of transfer.
Throughout her FICU stay, she had several more of these shaking
episodes which again appeared to be driven by delirium/dementia.
Initially, during these episodes, zydis was given which was
effective in calming her down and the shaking episode stopped.
Neurology was consulted and recommended MRI, LP, EEG, and workup
with TSH, anti TPO, ___, 5CK, lactate, ESR, CRP, urine
5HIAA, urine serotonin, plasma metanephrines. This work-up was
discussed with the patient's daughter, who decided not to pursue
LP at this time. Neurology recommended discontinuing home
Risperdal. Total metanephrines mildly elevated but her
presentation is not consistent with pheochromocytoma. W/u
negative
MRI was done, which showed new punctate infarcts, but was not
felt sufficient to explain the shaking episodes, which were
ultimately felt to be secondary to inner ear pathology. TTE
showed moderate aortic stenosis, EF of 75%, and HbA1c and lipid
panel risk stratification showed LDL 118. Neurology recommended
against statin or antiplatelet agent for this patient.
Meclizine was started pre-movement and her shaking episodes
improved dramatically. When RNs attempted small movements of
the patient, they would reposition her very slowly.
#Lactic acidosis, resolved
Presented to the ED with a lactate of 8, decreased to 3 and
resolved to 1.3 by arrival to the FICU. Likely dehydration +
infection/sepsis. Treated her infection as per above.
#Dementia with behavioral disturbances
#History of delirium
Pt is on risperidone 0.25mg daily. Has become delirious in prior
hospitalizations - Zydis has been used but daughter would prefer
that risperidone be tried first as pt has been stabilized on
this regimen. The patient's home risperidone was discontinued
per neurology recommendations due to shaking movements as
mentioned above.
#Hypothyroidism: Continued home levothyroxine 88mcg daily
#History of saddle PE
Diagnosed in ___. Was initially treated with anticoagulation
however patient had subsequent massive GI bleed/also had small
ICH discovered at the time. IVC filter was placed. Patient
remains on twice daily SQ heparin as her only treatment for
this. Continued home heparin SQ BID.
# Elevated Prolactin: Likely due to Risperdal dose. Outpatient
providers can consider recheck.
#Hypernatremia: Pt had hyperNa likely secondary to poor PO
intake, which improved after IV D5W.
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES BID
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Heparin 5000 UNIT SC BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. RisperiDONE 0.25 mg PO DAILY
6. Miconazole Powder 2% 1 Appl TP BID
7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
8. Levothyroxine Sodium 88 mcg PO DAILY
9. morphine 5 mg/mL oral Q6H:PRN
10. GuaiFENesin ___ mL PO Q6H:PRN cough
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Vestibular dysfunction causing shaking episodes
UTI
Delirium
H/O PE
Advanced Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
We admitted you to the hospital for shaking episodes. We did
multiple tests, including a MRI, and determined that your
shaking episodes are likely due to problems with your inner ear,
and these improved with a medication called meclizine.
We are now discharging you back to your facility. Please make
sure to follow up with your doctors and take ___ medications as
listed below.
We wish you the best with your health.
___ Medicine
Followup Instructions:
___
|
10608802-DS-20 | 10,608,802 | 21,573,514 | DS | 20 | 2193-11-25 00:00:00 | 2193-11-26 18:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ h/o HTN, HLD, hypothyroidism, vascular dementia w/o
behavioral disturbance, FTT, UTIs, dysphagia who presents for
evaluation ___ and altered mental status.
History is obtained from the medical record and the patient's
daughter. Per report, the patient is normally alert, says a few
words, and can make simple conversation despite her dementia.
However, a few weeks ago, she became less verbal and was just
saying words. She was still able to answer yes and no questions
by head nodding appropriately. The patient was eating/drinking
normally (for her this means 5 ensures a day, 4 glasses of
water,
and a glass of apple juice). However, about 2 days ago, the
patient began having shaking movement demonstrated by the
daughter that appears to be consistent with rigors. The daughter
says that this is the same phenomenon she observed when her
mother previously presented with sepsis from a urinary source.
Based on these findings, she asked the hospice team to obtain
labs and a urine sample; urinalysis was reportedly positive, and
the patient was given a dose of IM ceftriaxone last night.
However, she was very somnolent today, and could not answer
simple yes or no questions, so the daughter asked her to be
transferred to the emergency department for further evaluation.
Due to altered mental status, she underwent a workup at her
nursing facility. It showed the following:
-CBC 5.3, 12.3/38, 175
-Chemistry: 143, 3.7, 92, 38, 55/1.0, 114
-UA reportedly positive; urine culture with greater than 100,000
colony-forming units of E. coli
-cxr reportedly negative
In the ED, initial vital signs were notable for: 98.4 81 100/62
21 94% RA
Exam notable for: unremarkable. other than nonverbal.
Labs were notable for: Urine c/w UTI (nitrite pos, WBC>182, many
bacteria, no epi). Nl WBC. HCO3 34 and BUN 52 (normally 32), Cr
1.0 baseline 0.7
Studies performed include:
CXR: unremarkable
Patient was given:
1g IV CFTX, 1 L NS
Consults: None
Vitals on transfer: 97.6 78 109/60 17 96% RA
Upon arrival to the floor, patient is nonverbal and unable to
answer questions. Patient's daughter and HCP ___ is at the
bedside and confirms the above story.
Past Medical History:
-Hypertensive heart disease
-Hypothyroidism
-Hyperlipidemia
-Osteoarthritis
-Cognitive impairment
-Amyloid angiopathy
-Mitral valve prolapse
-Osteoporosis
-Breast cancer ___, s/p partial mastectomy and radiation
-Saddle PE with readmission for GIB in setting of
anticoagulation now s/p IVC filter, also subsequently c/b small
intraventicular hemorrhage
-C.diff ___
Social History:
___
Family History:
Son ___ ___ brain astrocytoma.
Father with colon cancer and esophageal cancer, died of an MI.
Mother had ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS:97.9 PO 96/67 R Lying HR77 18 95%Ra
GENERAL: Somnolent, responsive to painful stimuli, verbalizes
pain
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
dry MM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
RUSB
systolic murmur, no gallops or rubs
LUNGS: Clear to auscultation, no wheezes, rhonchi or rales in
anterior lung fields. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, TTP over
subrapubic
area only. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. ecchymoses over lower extremities
NEUROLOGIC: PERRL, moves upper extremities against gravity when
withdrawing, symmetric facies, responds only to pain.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Somnolent, but opens eyes to voice
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
dry MM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
RUSB
systolic murmur, no gallops or rubs
LUNGS: Clear to auscultation, no wheezes, rhonchi or rales in
anterior lung fields. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, TTP over
subrapubic
area only. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Ecchymoses over lower extremities
NEUROLOGIC: PERRL, moves upper extremities against gravity when
withdrawing, symmetric facies, responds to voice but not
verbalizing, withdraws from pain.
Pertinent Results:
ADMISSION LABS
==============
___ 04:40PM BLOOD WBC-5.7 RBC-3.70* Hgb-12.6 Hct-35.0
MCV-95 MCH-34.1* MCHC-36.0 RDW-17.8* RDWSD-55.1* Plt ___
___ 04:40PM BLOOD Glucose-99 UreaN-52* Creat-1.0 Na-142
K-3.5 Cl-91* HCO3-34* AnGap-17
___ 04:40PM BLOOD Calcium-10.9* Phos-3.9 Mg-2.5
DISCHARGE LABS
==============
___ 04:55AM BLOOD WBC-4.8 RBC-4.03 Hgb-12.2 Hct-38.5 MCV-96
MCH-30.3 MCHC-31.7* RDW-16.8* RDWSD-58.6* Plt ___
___ 04:55AM BLOOD Glucose-132* UreaN-35* Creat-0.9 Na-150*
K-3.8 Cl-103 HCO3-31 AnGap-16
MICROBIOLOGY
============
___ 8:44 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:31 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 4:37 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
Ms. ___ is an ___ h/o HTN, HLD, hypothyroidism, vascular
dementia w/o behavioral disturbance, FTT, recurrent UTIs, and
dysphagia who presents with a UTI c/b ___ and ___. Urine culture
from outside facility grew E.coli susceptible to augmentin.
Patient was initially treated with unasyn, and then transitioned
to augmentin, with marked improvement in her mental status.
ACUTE ISSUES:
=============
# Bacterial UTI:
History of recurrent UTIs in the past, consistently growing E.
coli resistant to ceftriaxone, but sensitive to
ceftaz, unasyn, zosyn, meropenem. Patient was initially given
ceftriaxone in the ED, but switched to unasyn once she reached
the floor. Cultures at the nursing home grew E.coli, with
similar sensitivities to what was previously noted, however
cultures here grew E.coli with intermediate resistance to
augmentin raising concern for induced resistance. She was thus
transitioned to nitrofurantoin to complete a 5 day course of
antibiotics (___)
# Acute Toxic metabolic encephalopathy:
Presented quite somnolent, only responsive to painful stimuli.
Improved following initiation of antibiotics as patient was
alert, but still non-verbal. Discussion with patient's daughter
indicated patient was close to baseline. There was low suspicion
for other etiologies, given no recent falls, electrolyte
abnormalities, or other clear sources of infection besides the
UTI.
# Dehydration:
# ___:
Prior to presentation, patient's daughter endorses poor PO
intake. Received 1L IVF in the ED, followed by 1L of IVF on the
floor. The morning following admission, patient was able to
tolerate PO intake, and thus further IVF were held. Her ___
continued to improve and resolved by time of discharge.
CHRONIC ISSUES:
===============
#Dementia with behavioral disturbances
#History of delirium
Not on any antipsychotics at nursing home as no further
behavioral disturbance. Did not require medications or other
interventions during hospitalization.
#Hypothyroidism:
Continued home levothyroxine 88mcg daily
#History of saddle PE
Diagnosed in ___. Continued on home heparin SQ BID and TEDs
TRANSITIONAL ISSUES
===================
[] Please ensure patient completes 5 day course of antibiotics
with nitrofurantoin (___)
[] Continue to encourage adequate water intake in addition to
ensure given hypernatremia
[] Patient should have repeat BMP in the next week to ensure
normalization of her Na and Cr
#CODE: DNR/DNI (ok for noninvasive ventilation)
#CONTACT: Proxy name: ___ Daughter Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Heparin 5000 UNIT SC BID
3. Ensure MAX Protein (food supplemt, lactose-reduced) oral
5X/DAY
4. Bisacodyl ___X/WEEK (___)
5. Meclizine 12.5 mg PO Q6H:PRN dizziness
6. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*10 Capsule Refills:*0
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
3. Bisacodyl ___X/WEEK (___)
4. Ensure MAX Protein (food supplemt, lactose-reduced) oral
5X/DAY
5. Heparin 5000 UNIT SC BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Meclizine 12.5 mg PO Q6H:PRN dizziness
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Urinary tract infection
Toxic Metabolic Encephalopathy
Acute Kidney Injury
SECONDARY
=========
Dementia
Hypothyroidism
History of saddle PE
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital after being found to be more confused
and sleepy at home.
- You were admitted due to concerns for a urinary tract
infection.
What did you receive in the hospital?
- While in the hospital, we started you on an intravenous
antibiotic to help treat your infection. Once we identified the
type of organism that was growing in your urine, we started you
on the appropriate oral medication. Following this, your mental
status seemed to improve.
What should you do once you leave the hospital?
- Please continue to try to eat and drink normally.
- You are being discharge on an antibiotic called
nitrofurantoin. Finish the course of antibiotics as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10608802-DS-21 | 10,608,802 | 27,563,359 | DS | 21 | 2194-01-05 00:00:00 | 2194-01-05 17:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o vascular dementia w/o behavioral disturbance, saddle PE
c/b GI bleed, HTN, hypothyroidism,recurrent UTIs, and dysphagia
presenting with fever, rigors, and new cough with concern for
pneumonia.
History is obtained from patient's daughter, ___. Patient
lives
at a nursing home with caretaker during the day and ___ stays
with her after 4pm and on weekend. She notes that she's been
febrile to 101 over the past few days and has had a new
productive cough for 2 days. She has been on nectar thick liquid
and Ensure for ___ years now without history of pneumonia or
recent
aspiration. At baseline patient is able to recognize ___ and
___ a few words though is bedbound and incontinent. Her mental
status change and fever prompted ED visit.
Of note, patient was recently admitted for recurrent E. Coli UTI
and discharge on ___ with plan to complete treatment with
Macrobid for UTI. She completed the course with return of mental
status to baseline. She was then started on suppressive Macrobid
about 1.5 weeks ago for 5 days before changes in mental status
prompted repeat UA and culture showing Klebsiella and Ecoli that
were resistant to Macrobid per ___. She was started on
Augmentin for 7 days with last day of treatment on day of
admission. Her mental status improved in the ED with fluids and
antibiotics and she is opening eyes more now.
In the ED, initial vitals were:
T 98.5 HR 91 BP 99/62 RR 26 Sat 92% RA
Exam notable for:
Gen: Elderly woman awake without good eye contact
Pulm: Tachypnea, no focal lung abnormalities on anterior chest
wall auscultation
CV: Tachycardic no murmurs rubs gallops
HEENT: Dry mucous membranes, PERRLA, EOMI, no scleral icterus
Abdomen: Rotund mildly distended no obvious tenderness to
palpation several bruises consistent with injection
Extremities: Tremulous and stiff extremities 2+ pulses distally
Skin: Hot moist and intact
Neuro: No obvious facial abnormalities not alert oriented or
able
to respond to yes or no questions
Rectal: Loose rectal tone guaiac negative brown stool in the
vault
Labs notable for:
CBC 5 > 10.5/___ < 202
82% PMN
148/103/50
----------
4.5/___/1.0
LFT wnl
Trop: 0.06 x2
Lactate 1.0
Flu-negative
UA: Neg leuk, nitrite, ket, bacteria, 11 WBC
Patient Given:
___ 11:42 IVF NS 1000ml
___ 11:42 IV Acetaminophen IV 1000 mg
___ 11:44 IV Piperacillin-Tazobactam
___ 12:21 IV Vancomycin
___ 15:04 IVF NS ( 1000 mL ordered) ___
Started
Vitals on Transfer:
T 97.4 HR 99 BP 102/59 RR 25 Sat 99% NC
On the floor, patient is lying in bed comfortably on oxygen.
Opens eyes to command but otherwise non-communicative.
Past Medical History:
-Hypertensive heart disease
-Hypothyroidism
-Hyperlipidemia
-Osteoarthritis
-Cognitive impairment
-Amyloid angiopathy
-Mitral valve prolapse
-Osteoporosis
-Breast cancer ___, s/p partial mastectomy and radiation
-Saddle PE with readmission for GIB in setting of
anticoagulation now s/p IVC filter, also subsequently c/b small
intraventicular hemorrhage
-C.diff ___
Social History:
___
Family History:
Son ___ ___ brain astrocytoma.
Father with colon cancer and esophageal cancer, died of an MI.
Mother had ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
___ 1721 Temp: 98.5 PO BP: 98/58 R Lying HR: 98 RR: 22 O2
sat: 95% O2 delivery: 2L
General: lying in bed comfortably, non-communicative, opens eyes
intermittently, breathing with mouth open
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL
CV: Regular rate and rhythm, III/VII systolic ejection murmur
throughout precordium radiating to the neck
Lungs: Clear to auscultation on anterior fields with upper
airway
sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no ___ edema
Neuro: does not follow commands, symmetrical face without droop
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 338)
Temp: 98.4 (Tm 99.0), BP: 120/72 (113-120/63-72), HR: 75
(73-80), RR: 18 (___), O2 sat: 96% (92-96), O2 delivery: Ra
General: lying in bed comfortably, non-communicative, opens eyes
intermittently, breathing with mouth open
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL
CV: Regular rate and rhythm, III/VII systolic ejection murmur
throughout precordium radiating to the neck
Lungs: Clear to auscultation on anterior fields with upper
airway
sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no ___ edema
Neuro: tracking around the room, does not follow commands,
symmetrical face without droop
Pertinent Results:
ADMISSION LABS:
=============
___ 11:31AM BLOOD WBC-5.0 RBC-3.59* Hgb-10.5* Hct-34.0
MCV-95 MCH-29.2 MCHC-30.9* RDW-17.6* RDWSD-60.8* Plt ___
___ 11:31AM BLOOD Glucose-118* UreaN-50* Creat-1.0 Na-148*
K-4.5 Cl-103 HCO3-31 AnGap-14
___ 11:31AM BLOOD ALT-20 AST-26 AlkPhos-70 TotBili-0.9
___ 11:31AM BLOOD cTropnT-0.06*
___ 03:00PM BLOOD cTropnT-0.06*
___ 06:40AM BLOOD CK-MB-1 cTropnT-0.04* proBNP-1459*
___ 11:31AM BLOOD Albumin-4.0 Calcium-10.9* Phos-3.2 Mg-2.5
___ 07:46AM BLOOD VitB12-654
___ 06:40AM BLOOD TSH-3.7
DISCHARGE LABS:
==============
___ 09:35AM BLOOD WBC-3.1* RBC-2.89* Hgb-9.6* Hct-27.9*
MCV-97 MCH-33.2* MCHC-34.4 RDW-19.5* RDWSD-58.9* Plt ___
___ 09:35AM BLOOD Neuts-70 Bands-2 ___ Monos-3*
Eos-0* Baso-0 AbsNeut-2.23 AbsLymp-0.78* AbsMono-0.09*
AbsEos-0.00* AbsBaso-0.00*
___ 09:35AM BLOOD Glucose-114* UreaN-20 Creat-0.7 Na-140
K-4.8 Cl-103 HCO3-25 AnGap-12
___ 09:35AM BLOOD Calcium-9.9 Phos-2.8 Mg-1.9
MICRO:
======
___ 2:41 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___: BLOOD CULTURE NO GROWTH TO DATE
___ 5:37 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING:
========
CXR ___: Findings concerning for pulmonary vascular
congestion and mild pulmonary edema. Retrocardiac opacity could
represent a left lower pneumonia.
KUB ___: Air distended structure in the right upper
quadrant could represent distended stomach or dilated loop of
bowel.
Brief Hospital Course:
___ h/o vascular dementia w/o behavioral disturbance, saddle PE
c/b GI bleed, HTN, hypothyroidism, recurrent UTIs, and dysphagia
presenting with fever, rigors, and new cough with concern for
pneumonia.
#Hospital Acquired Pneumonia
#Sepsis
Febrile with new cough, hypoxemia, and LLL retrocardiac opacity
concerning for pneumonia with mental status off from baseline.
Potentially aspiration event given high aspiration risk, however
infiltration on the left sided. Urine legionella and strep
pneumo antigen negative. MRSA negative. Other sources of
infection less likely given UA/Urine culture unremarkable and
LFTs unremarkable. She had significant improvement in mental
status after treatment with antibiotics and was at her baseline
prior to discharge. She required ___ L of O2 during
hospitalization that was weaned prior to discharge. She was
given albuterol for upper airway wheezing that was noted. For
antibiotics she received Vancomycin/Cefepime (___),
Ceftriaxone (___) and Doxycycline (___) to
compete a 7 day course.
#Toxic metabolic encephalopathy
Mental status has been worsening over the past week in the
setting of infection and pneumonia as above. Slight improvement
in mental status with antibiotic therapy, at baseline per
daughter. Patient received ___ for vestibular disturbances
which may have contributed to somnolence.
#Hypernatremia
Patient with Na elevation to 152 in setting of decreased PO
intake/altered mental status. She required free water in order
to normalize her sodium. Prior to discharge her sodium remained
normal without any IV fluids the day prior. Can recheck
chemistry panel in one week to ensure her sodium remains within
normal limits.
#Leukopenia
#Low lymphocyte count
Patient with WBC count of 2.6-3.1 with low absolute lymphocyte
count. This has been intermittently low during prior
hospitalizations. She clinically appears to be improving.
Differential for low lymphocyte count includes infection,
underlying malignancy, malnutrition, vitamin deficiency. Her
zinc level and CD4/CD8 ratio pending at time of discharge. Can
recheck CBC in one week to ensure stable.
#Lactic acidosis
Patient with slight lactate elevation to 2.4. Likely this
represents reduced clearance of lactate rather than worsening
sepsis. Have noted that with previous episodes of shaking she
has also had elevated lactate.
#Type II NSTEMI
Elevated troponin, downtrended. Twave inversion in V2, otherwise
nonischemic EKG. Patient unable to report symptoms. Likely in
the setting of demand with sepsis and pneumonia.
#Vestibular shaking spells
Known to have intermittent rigor/shaking with changes in
positions that can last for 20 minutes at times. Previously
evaluated by neurology with extensive neurologic workup that was
negative with the exception of punctate infarcts on MRI.
Ultimately thought to be related to inner ear pathology. Shaking
improves with Ativan 0.25mg and repositioning slowly. Has
stopped using meclizine. The frequency of the shaking episodes
decreased as her infection improved.
#GOC
Per discussion with healthcare proxy it is within her goals of
care to continue to treat her acute infections even if that
requires hospitalizations. Documented DNR/DNI code status.
Chronic Issues:
====================
#Dysphagia
#Nutrition
Has been on 5 Ensure Enlive daily with thickened liquids.
Daughter has thickener with her that she would add to water and
thin liquid but pt able to tolerate enlive without thickening
#Hypothyroidism
Home Levothyroxine 88mcg daily. TSH within normal limits
#H/o stroke
#Amyloid angiopathy
Evaluated by neurology in ___ with decision to forgo
anti-platelet or anti-coagulation given risk of intracranial
bleeding with cerebral amyloid angiopathy. Low LDL and statins
were withheld as well.
#Dementia
No behavioral disturbance currently. Has not required
anti-psychotics before.
#History of saddle PE
Diagnosed in ___. GI bleed while on AC. Has been SC heparin BID
while at nursing home.
# CODE: DNR/DNI
# CONTACT: Proxy name: ___ Daughter Phone: ___
TRANSITIONAL ISSUES:
===================
TRANSITIONAL ISSUES:
===================
[] *** Please start fosfomycin 3gm once weekly for UTI
prophylaxis (did not start in house since she is still on PNA
antibiotics)
[] Can recheck chemistry panel in one week to ensure her sodium
remains within normal limits.
[] Can recheck CBC in one week to ensure stable.
[] Please continue to treat shaking episodes with Ativan 0.25mg
and turn her carefully.
[] Patient was given PPSV 23 on ___.
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
2. Bisacodyl ___X/WEEK (___)
3. Heparin 5000 UNIT SC BID
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Ensure MAX Protein (food supplemt, lactose-reduced) oral
5X/DAY
6. Meclizine 12.5 mg PO Q6H:PRN dizziness
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
3. Bisacodyl ___X/WEEK (___)
4. Ensure MAX Protein (food supplemt, lactose-reduced) oral
5X/DAY
5. Heparin 5000 UNIT SC BID
6. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnosis: Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was pleasure taking care of you at ___.
Why you were here?
-You came to the hospital because you had pneumonia and your
became more confused.
What we did while you were here?
- We gave you antibiotics to treat your pneumonia.
- We gave you IV fluids until you were able to drink enough on
your own.
What you should do when you go home?
- You have completed your antibiotics.
- Please do your best to stay hydrated.
Your ___ Team
Followup Instructions:
___
|
10608839-DS-10 | 10,608,839 | 25,259,277 | DS | 10 | 2149-03-26 00:00:00 | 2149-03-27 23:07:00 |
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:
Percutaneous cholecystostomy tube placement
PICC line placement
History of Present Illness:
Per admission H&P:
___ w/ recently diagnosed borderline resectable
periampullary adenocarcinoma with two recent admissions who
presents back to the ED with back pain and vomiting x1.
Oncologic history is notable for a recent diagnosis
periampullary
adenocarcinoma. He originally noticed a darkening of his urine
and occasional steatorrhea. He initially did not pursue work-up
but then presented to his PCP's office with syncope last week
after going to bathroom. Labs were notable for elevated LFTs
(ALT/AST 248/126 AP 268 TBili 2.4). Abdominal US showed
pancreatic mass with CBD dilation. CT showed a 4.3x4.1x3.5cm
uncinate mass. Around the same time as his workup began he was
began to have increasing epigastric pain, nausea, PO
intolerance,
and emesis. He was referral to ERCP which was done ___ and
demonstrated an ampullary mass causing partial obstruction of
D3/D4. Sphincterotomy was performed and brushings stent. A ___
x 7cm straight plastic stent was placed. Cold forceps biopsies
taken of the ampullary mass.
He has lost about 30 lbs over the last year which per patient
was
intentional and not unusually easy. Patient is currently being
followed by Dr. ___ Port placement and starting
neoadjuvant chemotherapy with the goal of surgical resection.
As it relates to his current presentation, patient notes that he
starting having back pain that radiates to his RUQ which got
worse the night before presenting to the ED. Pain was unrelated
to food consumption and there were no exacerbating or relieving
factors. He also notes mild nausea and 1x emesis that was
bilious
in nature. Prior to presenting to the ED he denies any fever or
chills, denies any change to his BM, and reports good nutrition
saying that he was finally getting back to his baseline appetite
and oral intake.
Past Medical History:
- overweight
- Aflutter s/p ablation of R-sided isthmus dependent
counterclockwise aflutter ___
- RLE DVT (superficial femoral vein thrombosis) ___
- chronic RLE venous insufficiency
- Anxiety
- Pulmonary Embolus
- Pancreatic adenocarcinoma
- Biliary obstruction s/p CBD stent
- Duodenal obstruction s/p duodenal stent
- Upper GI bleed
Social History:
___
Family History:
Father ___, passed away from gastric CA. Mother ___. Parkinsons
Physical Exam:
VITALS:
___ 1218 Temp: 97.9 PO BP: 100/67 HR: 60 RR: 18 O2 sat: 97%
O2 delivery: RA
GENERAL: Alert and interactive. NAD
HEENT: NCAT. Sclera anicteric and without injection.
NECK: No JVD. supple.
CARDIAC: RRR. +S1/S2, no m/r/g
LUNGS: CTAB. No wheezes, rhonchi or crackles. No increased work
of breathing.
ABDOMEN: soft, +BS, non distended, nontender. RUQ abdominal
drain
with clear yellow, blood tinged fluid.
EXTREMITIES: warm, well perfused, no edema.
SKIN: Warm. No rashes appreciated
NEUROLOGIC: AOx3. Moving all extremities spontaneously
ACCESS: RUE ___
Pertinent Results:
ADMISSION LABS:
================
___ 09:44AM BLOOD WBC-13.3* RBC-3.23* Hgb-9.1* Hct-28.7*
MCV-89 MCH-28.2 MCHC-31.7* RDW-12.9 RDWSD-41.7 Plt ___
___ 09:44AM BLOOD Neuts-90.0* Lymphs-4.7* Monos-4.4*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.98* AbsLymp-0.63*
AbsMono-0.58 AbsEos-0.03* AbsBaso-0.03
___ 09:44AM BLOOD Glucose-131* UreaN-7 Creat-0.8 Na-134*
K-5.2 Cl-98 HCO3-22 AnGap-14
___ 09:44AM BLOOD Plt ___
___ 11:00AM BLOOD ___ PTT-27.3 ___
___ 11:00AM BLOOD ALT-27 AST-38 AlkPhos-74 TotBili-0.5
___ 03:24AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6
IMAGING:
========
___ CTA chest and CT abdomen:
1. Interval decrease in overall clot burden with near complete
resolution of the right main pulmonary artery thrombus. The
segmental and subsegmental
levels are poorly assessed given suboptimal contrast timing and
patient
motion.
2. Distended gallbladder with wall edema though no surrounding
inflammation.
This may be secondary to third spacing though clinical
correlation is
suggested.
3. Redemonstration of a 4.2 cm pancreatic lesion abutting the
duodenum. The lesion margins are less distinct compared to prior
examination.
___: liver or gallbladder US
1. Distended gallbladder with gallstones, wall edema, and trace
pericholecystic fluid could reflect acute cholecystitis in the
appropriate
clinical setting, as described on the same day CT. Correlate
with physical examination and right upper quadrant tenderness.
2. Common bile duct stent in place with pneumobilia.
3. The known pancreatic head mass is much better appreciated on
same day CT.
___ TTE:
No 2D echocardiographic evidence for endocarditis. EF >55%.
DISCHARGE LABS:
===============
___ 05:48AM BLOOD WBC-5.5 RBC-2.83* Hgb-7.6* Hct-24.7*
MCV-87 MCH-26.9 MCHC-30.8* RDW-14.1 RDWSD-45.1 Plt ___
___ 05:48AM BLOOD Neuts-59.9 ___ Monos-8.1 Eos-4.9
Baso-0.5 Im ___ AbsNeut-3.32 AbsLymp-1.45 AbsMono-0.45
AbsEos-0.27 AbsBaso-0.03
___ 05:48AM BLOOD Glucose-100 UreaN-4* Creat-0.6 Na-144
K-4.0 Cl-107 HCO3-26 AnGap-11
___ 05:35AM BLOOD ALT-19 AST-18 LD(LDH)-158 AlkPhos-55
TotBili-0.3
___ 05:48AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ yo M with newly diagnosed localized duodenal
adenocarcinoma, recent admission for GIB, PE on apixaban who
presented to the ED for ___ days of worsening sharp back pain
that radiates to front of torso/RUQ with nausea/vomiting.
Initial presentation was concerning for biliary obstruction vs.
acute cholecystitis. ERCP was done and noted that his CBD stent
and duodenal stent were both patent making obstruction much less
likely. Imaging and clinical signs was consistent with acute
cholecystitis. ___ placed a percutaneous cholecystostomy tube on
___. ___ hospital course was complicated with AF with
RVR. EP was consulted who recommended increasing metoprolol for
improved rate control and continued amiodarone therapy.
Patient's rhythm converted to sinus by time of discharge.
Hospital course was also notable for Streptococcus bacteremia
and patient was discharged with PICC line to complete a total of
14 days of IV abx (ceftriaxone 2gm qday to finish on ___
# Sepsis
# Acute cholecystitis ___ Klebsiella
# Strep bacteremia
Now s/p cholecystostomy for acute cholecystitis with improvement
of abdominal pain. After procedure, pt became febrile,
hypotensive,
went back into Afib with RVR. Most likely ___ manipulation of
infected gallbladder.
- Continue ceftriaxone (___)
- TTE with no vegetations
- seen by surgery, will d/c home with drain to be followed up at
___ clinic
#Afib with RVR
Patient converted to sinus rhythm by time of discharge.
Recent episodes likely secondary to combination of sepsis,
hypovolemia, and intermittently holding BB
- Continue Toprol 125mg qday
- Continue amiodarone 200mg qday
- c/w therapeutic lovenox for AC in setting of b/l PE and pAF
- f/u with EP/cardiology as outpatient, will require outpatient
CXR, TFTs,
LFTs in 2 weeks given amiodarone therapy
#bilateral PE dx on CT ___
- Continue therapeutic lovenox
#Duodenal/Periampullary adenocarcinoma
- treatment on hold pending resolution of infection
- PICC line place ___ for both IV abx x ___s
possible chemotherapy in near future
#Anxiety
- Continue home Effexor
#Hx of GIB
- c/w PPI BID for now in setting of recent GIB in ___
TRANSITIONAL ISSUES:
======================
[] patient will require repeat TFTs, LFTs, and CXR in 2 weeks
prior to follow up with cardiology
[] patient to be followed up in ___
___ clinic for management of percutaneous biliary
drain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 100 mg SC Q12H
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Pantoprazole 40 mg PO Q12H
6. Venlafaxine XR 150 mg PO DAILY
7. Amiodarone 200 mg PO BID
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
2. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 125 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Enoxaparin Sodium 100 mg SC Q12H
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
7. Pantoprazole 40 mg PO Q12H
8. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Sepsis
Acute cholecystitis
Strep bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to care for you at ___.
You came to the hospital because of abdominal pain and was found
to have an infection of the gallbladder and infection of the
blood.
WHAT HAPPENED IN THE HOSPITAL?
- you were treated with IV antibiotics and fluids
- you had a procedure to drain the gallbladder
- your heart rate was elevated in the setting of the infection
and were noted to be in atrial fibrillation; cardiology
evaluated you and recommended increasing your home medications
- Infectious disease specialists saw you and recommended
treatment with continued IV antibiotics until ___
- you had a PICC line placed for continued IV antibiotic
treatment
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with your PCP, ___, cardiologist, and
surgery team
- Continue taking your heart medications as directed
- Continue your antibiotic therapy until ___ (to be arranged by
___ agency)
We wish you all the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10608839-DS-9 | 10,608,839 | 21,703,356 | DS | 9 | 2149-03-10 00:00:00 | 2149-03-10 20:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with known PE, afib on metoprolol and lovenox,
status post discharge day 1 for ERCP and new diagnosis of
pancreatic cancer presents status post syncope at ___
___.
He reports he was going to clinic to follow up with his
physician
about his recent hospital stay and while walking began to feel
weak. Per the patient the next thing he remembers is waking up
on
the ground. He admits to LOC and fall but denies hitting his
head. Denies pain in his body. He reports that dehydration
triggers his afib. Notably he has been having trouble with PO
intake since this past admission. He has had 3 vomiting episodes
since 3AM, all non bloody and non bilious. His last dose of
metoprolol was this morning.
His prior hospital course was reviewed in his most recent
discharge summary. He was found to have a GI bleed, with the
tumor eroding into the duodenum, however, given stable H/H, he
was discharged on lovenox for pulmonary embolus. His hospital
course was notable for multiple episodes of atrial fibrillation
with RVR, which improved with IV fluids. He was trailed off of
metoprolol, with a recurrence of his RVR, with hypotension, and
required an esmolol drip. He was subsequently placed on
metoprolol.
In the ED, initial VS were 98.5 ___ 136/99 98% RA. Mostly in
the ED, his HRs were in the 130s-150s in atrial fibrillation
with
RVR.
Exam was notable for no acute distress.
Labs were notable for H/H of 10.8/34.6. proBNP 907. Lipase 758.
Lactate 2.9 which improved to 1.0. INR of 1.4.
CTA redemonstrated pulmonary emboli with decreased in clot
burden. CXR should mild atelectasis without acute
cardiopulmonary
process.
He received 2L IV saline.
Upon arrival to the floor, the patient tells the story as
follows. He reports that he went home last night and ate a
___
sandwich. He feels that this may have been "too much too
quickly." He woke up in the middle of the night feeling queasy,
vomiting food without blood, then went back to bed. This
morning,
he had repeat episodes of vomiting. He called his PCP who
prescribed him Zofran, for which he took one dose. He was going
to his appointment at ___, when he felt lightheaded and as
if
he was going to pass out. He denies chest pain, shortness of
breath, or palpitations at that time. His wife broke his fall
and
lowered him to the ground. He feels that he was very dehydrated
at this time. He otherwise denies abdominal pain, diarrhea, or
localized weakness.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- overweight
- Aflutter s/p ablation of R-sided isthmus dependent
counterclockwise aflutter ___
- RLE DVT (superficial femoral vein thrombosis) ___
- chronic RLE venous insufficiency
- Anxiety
- Pulmonary Embolus
- Pancreatic adenocarcinoma
- Biliary obstruction s/p CBD stent
- Duodenal obstruction s/p duodenal stent
- Upper GI bleed
Social History:
___
Family History:
Father ___, passed away from gastric CA. Mother ___. Parkinsons
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, CN II-XII intact, moves all limbs, ___ strength
in
grip and biceps bilaterally, ___ hip flexion strength
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: ___ 0713 Temp: 98.2 PO BP: 98/60 L Lying HR: 62 RR:
17 O2 sat: 100% O2 delivery: Ra
___ 0714 BP: 102/61 L Sitting HR: 74 RR: 17 O2 sat: 100% O2
delivery: Ra
___ 0715 BP: 96/61 L Standing HR: 89 RR: 18 O2 sat: 98% O2
delivery: Ra
Constitutional: no apparent distress, lying in bed, awake,
alert, bright
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR no MRG, no JVD
Resp: CTAB
GI: no tenderness to palpation, normoactive bowel sounds
GU: no foley
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: A&O grossly, MAEE, no facial droop
Psych: normal affect, pleasant
Pertinent Results:
ADMISSION RESULTS
___ 02:17PM BLOOD WBC: 7.7 RBC: 3.76* Hgb: 10.8* Hct: 34.6*
MCV: 92 MCH: 28.7 MCHC: 31.2* RDW: 13.2 RDWSD: 45.___
___ 02:17PM BLOOD Neuts: 91.2* Lymphs: 4.3* Monos: 3.8*
Eos:
0.0* Baso: 0.3 Im ___: 0.4 AbsNeut: 7.06* AbsLymp: 0.33*
AbsMono: 0.29 AbsEos: 0.00* AbsBaso: 0.02
___ 03:16PM BLOOD ___: 15.4* PTT: 29.9 ___: 1.4*
___ 02:17PM BLOOD Glucose: 133* UreaN: 13 Creat: 1.0 Na:
138
K: 5.1 Cl: 105 HCO3: 21* AnGap: 12
___ 02:17PM BLOOD ALT: 92* AST: 51* AlkPhos: 87 TotBili:
1.0
___ 02:17PM BLOOD cTropnT: <0.01 proBNP: 907*
___ 02:17PM BLOOD Lipase: 758*
CT HEAD ___:
No acute intracranial process.
CTA ___
1. Pulmonary emboli again seen, as above, but with significant
decrease in overall clot burden compared to ___. No CT
evidence of right heart strain.
2. Again seen subtle scattered small areas of ground-glass
opacities
bilaterally, which are nonspecific and less conspicuous than on
the prior study, but may relate to bronchiolitis of an
infectious
or inflammatory etiology.
3. Partially imaged pneumobilia in this patient with a biliary
stent. Mild prominence of the partially imaged pancreatic duct.
CXR ___
Mild atelectasis in the lung bases. Otherwise, no acute
cardiopulmonary process.
PRIOR HOSPITAL STUDIES
Abdominal Ultrasound ___
1. 5.8 cm periampullary/pancreatic mass with biliary dilatation
is suggestive of pancreatic neoplasm, obstructing the distal
common bile duct.
2. Cholelithiasis without acute cholecystitis. No stone is
appreciated within the dilated common bile duct.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
No focal liver lesion.
CTA Abdomen ___:
1. Irregular heterogeneously hypoattenuating
mass centered in the uncinate process of the pancreas measuring
4.3 x 4.1 x 3.5 cm, abutting the distal common bile duct
resulting in moderate biliary ductal dilatation.
2. No encasement of the adjacent major vasculature.
3. No lymphadenopathy.
ERCP ___:
Successful ERCP with sphincterotomy. Limited exam with side view
showed an ampullary mass resulting in partial obstruction of
D3-D4. Cholangiogram showed distal CBD stricture with cutoff at
ampulla. Sphincterotomy, brushings, and stent placement
performed. There was good drainage of bile
after stent deployed. Biopsies were obtained of the ampullary
mass at the conculsion of the case. Path: Adenocarcinoma,
moderately differentiated with ulceration, present in duodenal
mucosa; possible precursor adenoma with high grade dysplasia
identified. -Changes suggestive of lymphovascular invasion
identified.
ERCP ___
Uncovered duodenal stent placed across duodenal stricture
EGD ___
Normal mucosa in the whole esophagus. Normal mucosa in the whole
stomach. Previously placed duodenal stent was found. The
pancreatic mass was eroding into the duodenal stent along with
mild oozing. Two blood clots were seen. But no overt bleeding
was seen except of overall oozing from the mass.
CT chest with contrast ___:
1. Likely subacute bilateral pulmonary emboli with large
thrombus in the right pulmonary artery which appears partially
canalized, and scattered emboli at the segmental levels
bilaterally. Enlarged bronchial arteries.
2. Scattered very small patchy opacities, mostly ground glass,
suggesting small foci of aspiration pneumonitis.
3. Pulmonary nodules measuring up to 4 mm and a number of
calcified granulomas. Metastatic disease is unlikely but
followup surveillance could be considered.
4. Persistent moderate distension of the stomach suggesting
obstruction.
Path: Adenocarcinoma, moderately differentiated with ulceration,
present in duodenal mucosa; possible precursor adenoma with high
grade dysplasia identified.
-Changes suggestive of lymphovascular invasion identified.
==========
PERTINENT INTERVAL RESULTS
___ 07:55AM BLOOD WBC-3.8* RBC-2.92* Hgb-8.6* Hct-27.1*
MCV-93 MCH-29.5 MCHC-31.7* RDW-13.0 RDWSD-44.2 Plt ___
___ 07:55AM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-26 AnGap-10
___ 07:55AM BLOOD ALT-62* AST-29 AlkPhos-64 TotBili-0.6
==========
DISCHARGE RESULTS
___ 05:38AM BLOOD WBC-4.8 RBC-2.96* Hgb-8.5* Hct-27.4*
MCV-93 MCH-28.7 MCHC-31.0* RDW-12.9 RDWSD-44.0 Plt ___
___ 05:38AM BLOOD Neuts-55.5 ___ Monos-12.4 Eos-5.9
Baso-0.4 Im ___ AbsNeut-2.65 AbsLymp-1.21 AbsMono-0.59
AbsEos-0.28 AbsBaso-0.02
___ 05:38AM BLOOD ___ PTT-29.7 ___
___ 05:55AM BLOOD ALT-60* AST-29 AlkPhos-67 TotBili-0.6
___ 05:55AM BLOOD Glucose-99 UreaN-5* Creat-0.7 Na-145
K-4.2 Cl-106 HCO3-27 AnGap-12
Brief Hospital Course:
Mr. ___ is a ___ male with afib/aflutter s/p
ablation, anxiety, hx of DVT with new bilateral PEs and newly
diagnosed pancreatic adenocarcinoma s/p duodenal stenting and
ERCP with CBP metal stent placement and duodenal stent placement
with hospital course complicated by recurrent afib w/ RVR and
hypotension requiring ICU admissions, now more recently slow GIB
from tumor eroding into stent, readmitted with syncope
presumably from hypovolemia +/- RVR.
ACUTE/ACTIVE PROBLEMS:
# Syncope: Episode most c/w hypovolemia in setting of PEs and
preload dependence with poor PO after emesis. Possible that also
had RVR at the same time (he does not feel his RVR), either as a
primary or secondary phenomenon at that time. Prior to admission
had cessation of dark stools/emesis (which he had had on last
admission), and hgb roughly stable throughout here. Continued
home metoprolol. Received several liters of IVF in ED and also
on floor, with persistent positive orthostatics. Was taking
excellent PO and not requiring IVF with negative orthostatics on
discharge (met criteria still by HR, however was asymptomatic
and no longer dropping his BPs). He was discharged with a 30-day
heart rate event monitor.
# Acute anemia, UGIB, tumor erosion into duodenal stent: On
previous admission, he had episodes of dark stools and dark
emesis during his ICU, never requiring transfusion. He underwent
EGD on previous admit and was noted to have a tumor mass eroding
into duodenal stent. His Hb was stable and due to the need for
anticoagulation, he was discharged with a plan for observation.
As above, dark stools/emesis resolved prior to this admission,
and hgb roughly stable (accounting for possible diluational
effects). Continued home BID PPI. Discharge hgb 8.5.
# Atrial fibrillation with RVR: His prior hospital course
involved multiple episodes of atrial fibrillation with RVR,
which improved with IV fluids. He was trailed off of metoprolol,
with a recurrence of his RVR, with hypotension, and required an
esmolol drip. He was discharged on metop 25mg po qd. When in
hospital on this regimen the last time he had no fib at all over
the last 4 or so days of his hospitalization, so we suspect that
the recurrence on this admission in the ED is more secondary (ie
hypovolemia) rather than due to failure of the rate regimen.
With IVF in the ED, his RVR spontaneously converted to NSR. He
converted back to a fib with RVR (rates up to 140s) overnight on
___, for which he received IV fluids and IV metoprolol and
converted back to sinus by the morning of ___ (was in a fib for
around 8 hours). Due to limitations on increasing metoprolol due
to relatively slow sinus heart rate (60s) and low BP in the ___
mostly at baseline, cardiology was consulted for another
possibility. He was started on oral amiodarone loading per their
recommendations, and continued on prior dose of metoprolol
succinate 25 daily. Anticoagulation continued (for both a fib
and PEs).
# Bilateral pulmonary emboli: CT this admission shows decreased
clot burden compared to last admission. BNP elevated, however,
no CT evidence of right heart strain. Is likely causing a degree
of preload dependence as above. We continued home enoxaparin.
# CBD obstruction, jaundice
# Pancreatic adenocarcincoma
# Duodenal obstruction
# Malnutrition
# Vomiting, poor oral intake: As discussed above, patient
underwent duodenal stent placement on last admission (___) due
to inability to tolerate PO, with a successful advancement of
diet. Patient has had significant difficulty tolerating a diet,
which was leading to dehydration. Tolerating POs well now and
taking adequate PO (low residue diet). Has outpatient
appointment to discuss initiating treatment for malignancy.
CHRONIC/STABLE PROBLEMS:
# Anxiety: Continued home Effexor.
==========
TRANSITIONAL ISSUES
- will see pancreatic cancer team this ___
- being discharged with 30-day event recorder, and will have
cardiology follow-up scheduled
-amiodarone load plan: 400 BID x7 days (___) then 200
BID x7 days (___) then continue maintenance at 200
daily until seeing cardiology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 150 mg PO DAILY
2. Enoxaparin Sodium 100 mg SC Q12H
3. Pantoprazole 40 mg PO Q12H
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Amiodarone 400 mg PO BID Duration: 1 Week
Tapered dose to maintenance 200 daily, see instructions on
prescriptions
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
2. Amiodarone 200 mg PO BID Duration: 1 Week
To begin after you complete week of 400 twice daily
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
To begin after finish 2 weeks of loading; this is your
maintenance dose
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Enoxaparin Sodium 100 mg SC Q12H
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Pantoprazole 40 mg PO Q12H
9. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
syncope
orthostasis
pulmonary embolism
pancreatic adenocarcinoma
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 caring for you. You were admitted because you
passed out. This was likely caused by a dehydration
("hypovolemia") which may or may not have led to atrial
fibrillation with rapid heart rate.
You got better with IV fluids and better oral intake, and
controlling your heart rate.
We wish you the best in your recovery!
Sincerely, your ___ Team
Followup Instructions:
___
|
10608904-DS-10 | 10,608,904 | 21,646,110 | DS | 10 | 2165-11-13 00:00:00 | 2165-11-13 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex / Penicillins / Cipro / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Decreased vision
Major Surgical or Invasive Procedure:
Ocular Biopsy
History of Present Illness:
___ with history of myotonic dystrophy and cutaneous B-cell
lymphoma and PET-avid adenopathy without evidence of
lymphomatous
nodal infiltration who is admitted for further management of
lymphomatous infiltration of his bilateral orbits.
The patient has a history of decreased vision over the past
three
months. He was last seen by his oncologist on ___ with plans for
6 month follow-up. He went to see his optometrist on ___ given
worsened visual acuity, and this was confirmed (OD ___, OS
___. He therefore saw an ophthalmologist, who noted proptosis
with periorbital edema, dilated temporal episcleral veins and
decreased vision. An MRI of the orbits was ordered given concern
for retro-orbital mass. This came back positive for findings
consistent with bilateral lymphomatous infiltration of his
orbits, and he was therefore sent to the ___ ED.
In the ED, initial VS were: 96.5 90 139/91 19 96% RA
Labs were notable for: no acute changes from prior
Imaging included: None
Consults called: rad/onc and neuro-onc
Recommendations: 6 mg IV dexamethasone q6h, formal consults to
follow but will likely need systemic chemo and radiation
Treatments received: 6 mg IV dex, 20 mg omeprazole, 4 mg IV
morphine
On arrival to the floor, patient endorses the above story as
well
as sinus pressure that is not particularly bothersome. He thinks
his vision, especially in his right eye, is improving.
Past Medical History:
- B cell lymphoma, cutaneous, as above
- chronic pain
- tobacco dependence
- pulmonary emphysema
- dysplipidemia
- ventricular premature contractions
- prehypertension
- myotonic dystrophy
- low testosterone
- chronic prostatitis
- BPH
Social History:
___
Family History:
- mother's sister with colon cancer
- sister with unknown type of gynecologic cancer
Physical Exam:
GENERAL: NAD
HEENT: EOMI, no pain with extraocular movements, visual fields
appear grossly intact, no oropharyngeal lesions, anicteric
sclera, some periocular edema greater on the right.
CARDIAC: RRR
LUNG: CTAB
ABD: NT/ND, no organomegaly appreciated
EXT: WWP, no edema.
NEURO: Alert and oriented, CN except visual acuity intact,
sensation intact to light touch throughout, moves all four
extremities with purpose, strength intact
SKIN: no rash
Pertinent Results:
___
WBC: 7.0. RBC: 4.88. HGB: 15.8. HCT: 45.9. MCV: 94. RDW: 12.3.
Plt Count: 255.
Na: 135. K: 4.3. Cl: 98. BUN: 20. Creat: 0.7.
Brief Hospital Course:
___ with history of myotonic dystrophy and cutaneous B-cell
lymphoma with PET-avid nodes without evidence of lymphoma in
these nodes who is admitted for management of lymphomatous
infiltration of his bilateral orbits.
# Lymphomatous infiltration of orbits: Vision improved with IV
steroids.
- dexamethasone 6 mg IV q6h, will switch to PO on discharge.
- omeprazole 20 mg daily
- artificial tears (home med)
- neuro-onc and rad-onc consulted; s/p mapping and radiation.
- For pain, continued on PRN oxycodone and Tylenol for
headaches.
- CT torso with pre-meds due to contrast allergy ordered for
staging.
- Ophthalmology consulted for biopsy as this is possibly a
different and more aggressive type of lymphoma than his previous
cutaneous. He was transferred to mass eye and ear ___ for biopsy
due to lack of necessary equipment being available here and
returned later in the day.
- Erythromycin ointment to eye per optho.
- Ice packs to eye that had biopsy.
- Follow up on biopsy pathology, preliminary read unclear.
# Myotonic dystrophy: Continued home meds
# Insomnia: Trazodone at home dose
# Dyslipidemia: Continued atorvastatin
# Depression: Continued venlafaxine
# Emphysema: Continued flovent, albuterol
# EMERGENCY CONTACT HCP: Patient stated that his mother was
previously his proxy but he does not wish for this to be the
case
given her frailty. He has no other family or friends that he can
identify as HCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clomiPHENE citrate 50 mg oral 3X/WEEK
2. Atorvastatin 40 mg PO QPM
3. Mexiletine 150 mg PO Q8H
4. Gabapentin 300 mg PO TID
5. Nabumetone 500 mg PO BID
6. TraZODone 200 mg PO QHS
7. Venlafaxine XR 150 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
2. Atorvastatin 40 mg PO QPM
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Gabapentin 300 mg PO TID
6. Mexiletine 150 mg PO Q8H
7. TraZODone 200 mg PO QHS
8. Venlafaxine XR 150 mg PO DAILY
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Acetaminophen 1000 mg PO Q8H:PRN Pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
11. Docusate Sodium 100 mg PO BID Constipation
RX *docusate sodium [Stool Softener] 50 mg 2 capsule(s) by mouth
twice a day Disp #*30 Capsule Refills:*0
12. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 capsule(s) by mouth Q4 hour Disp #*12
Capsule Refills:*0
14. Polyethylene Glycol 17 g PO BID:PRN Constipation
RX *polyethylene glycol 3350 17 gram/dose 17gm gm by mouth twice
a day Refills:*0
15. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides 8.6 mg 8.6 mg by mouth twice a day Disp #*30
Tablet Refills:*0
16. clomiPHENE citrate 50 mg oral 3X/WEEK
17. Nabumetone 500 mg PO BID
18. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID
RX *erythromycin 5 mg/gram (0.5 %) 5 mg in the right eye three
times a day Refills:*0
19. Dexamethasone 6 mg PO Q6H
RX *dexamethasone 6 mg 1 tablet(s) by mouth four times a day
Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ocular Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with decreased vision and were
evaluated by opthamology and oncology, and started radiation for
ocular lymphoma. You were sent home on pain medications, oral
steroids, and a bowel regimen and will have close follow up with
those services.
Followup Instructions:
___
|
10609078-DS-4 | 10,609,078 | 24,404,421 | DS | 4 | 2198-03-28 00:00:00 | 2198-03-29 14:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
HMED Admission Note
___
cc: abdominal pain
Major Surgical or Invasive Procedure:
Findings: 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: Evidence of a previous sphincterotomy was noted
in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep using a free-hand technique. Contrast medium was injected
resulting in complete opacification. The procedure was not
difficult.
Biliary Tree: A single stricture that was 10 mm long was seen at
the upper third of the common bile duct [1 cm below the
bifurcation]. There was no post-obstructive dilation. Otherwise
normal biliary tree.
Procedures: Cytology samples were obtained using a brush in the
upper third of the common bile duct.
A 9cm by ___ ___ biliary stent was placed successfully
using a Oasis system stent introducer kit.
Impression: S/P sphincterotomy at the major papilla - this was
patent.
A single stricture that was 10 mm long was seen at the upper
third of the common bile duct [1 cm below the bifurcation].
Otherwise normal biliary tree.
Cytology samples were obtained using a brush in the upper third
of the common bile duct.
A biliary stent was placed successfully.
(cytology, stent placement)
Otherwise normal ercp to third part of the duodenum
Recommendations: Return patient to hospital ward
Await cytology results.
Pancreas protocol CT scan
Check CA ___
Watch for complications - bleeding , perforation, pancreatitis.
Clear liquids today and then advance diet per primary team's
instructions
History of Present Illness:
___ yo M with history of cholecystitis s/p CCY in ___ who
presents with abdominal pain and jaundice. Pt has had
intermittent epigastric abdominal pain, particularly with fatty
foods since his surgery in ___. On ___ morning, pt
developed severe epigastric non-radiating abdominal pain. He had
fevers to 100.4. No associated nausea or vomiting. He was able
to continue eating, however. No diarreha or constipation. He saw
his PMD on ___ who noticed he was jaundiced and ordered labs
which showed Tbili of 4.2 and transaminitis. He had u/s done
this evening which showed dilatation of CBD to 8mm with
stone/sludge in the mid CBD. Pt sent to ED for admission and
ERCP.
In the ED, pt was afebrile and hemodynamically stable. He was
leukopenic with mild decrease in his plt. T bili decreased to
3.3. Pt admitted for further care. On admission to floor, pt
pain free. Denies nausea.
ROS: negative except as above
Past Medical History:
#cholecystitis s/p lap to open cholecystectomy in ___
#IPMN in body of pancreas
#HTN
#GERD
Social History:
___
Family History:
Father with CAD. No history of gallstones or GI malignancy.
Physical Exam:
Vitals: 97.6 149/51 86 16 96%RA
Gen: NAD
HEENT: scleral icterus
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, nt/nd, +BS
Ext: no edema
Neuro: alert and oriented x 3
Pertinent Results:
Labs on Admission:
___ 03:30PM GLUCOSE-99 UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25
___ 03:30PM ALT(SGPT)-245* AST(SGOT)-46* ALK PHOS-126 TOT
BILI-3.3*
___ 03:30PM LIPASE-91*
___ 03:30PM ALBUMIN-4.1
___ 03:30PM WBC-3.2* RBC-4.61 HGB-14.8 HCT-42.6 MCV-92
MCH-32.1* MCHC-34.7 RDW-12.8
___:30PM NEUTS-43.7* ___ MONOS-18.6* EOS-3.7
BASOS-0.6 IM ___
___ 03:30PM PLT COUNT-142*
RUQ U/S:
1. Mild common bile duct dilatation up to 8 mm with apparent
echogenic
material in the mid common bile duct concerning for retained
stone and/or
sludge. Further assessment with MRCP is recommended. No
intrahepatic biliary
duct dilatation is seen.
2. Echogenic lesion with distal shadowing in the region of the
gallbladder
fossa. This correlates to an area of scarring seen on the prior
MRI, and could
reflect calcification within remnant gallbladder tissue or
stone.
3. Simple bilateral renal cysts. 7 mm nonobstructing stone
within the lower
pole of the left kidney.
4. Pancreatic body cyst re-demonstrated, previously
characterized on MRI.
Brief Hospital Course:
___ yo M with h/o cholecystitis s/p cholecystectomy who presents
with abdominal pain, jaundice and fevers. Pt with
choledocholithiasis and potential cholangitis.
# Choledocholithiasis/cholangitis
Pt was treated with cipro and flagyl and had no fevers, chills.
He underwent ERCP which revealed bile duct stricture. This was
treated with a stent. No stones were found. Brushings were
taken to eval for malignancy. CT pancreas was also performed.
Post-procedure pt's LFTs showed improvement and he was
discharged to home.
The ERCP team will call the patient with his brushing results
and plan for stent removal in 4 weeks.
Medications on Admission:
No meds.
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
biliary stenting due to stenosis
Discharge Condition:
alert, ambulatory
Discharge Instructions:
You underwent a procedure call ERCP with a stent placed in the
bile duct. You will need to have the stent changed out in 4
weeks. You will also need to continue to follow up with the GI
team about your pancreas. Brushings were taken of the area of
stenosis. The results from pathology will not be back until
later this week. ___ his team will contact you for
the results.
Followup Instructions:
___
|
10609078-DS-7 | 10,609,078 | 24,805,338 | DS | 7 | 2199-05-13 00:00:00 | 2199-05-15 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ paracentesis
___ PTBD and liverbx
___ cholangiogram and metal stent placement; paracentesis
History of Present Illness:
___ with cholangiocarcinoma and cryptogenic cirrhosis who is
undergoing work up for possible recurrent disease with a biopsy
planned for next week. Over the past several weeks he has been
experiencing lethargy, low grade fevers, and enlarging stomach
girth. He reports that his stomach really grew rapidly in size
over the past two or three days. He also reports some shortness
of breath and abdominal pain which is diffuse but worse on the
RLQ. Given his lethargy and low grade fevers, he thought he was
having a UTI so started taking Bactrim today. Was seen in
___ clinic several days prior to this admission and noted
to have ascities, but not to the degree reported by the patient
and has interval worsening.
In the ED, initial VS were: stable and patient afebrile
A diagnostic paracentesis was performed.
Imaging included: RUQUS with dopplers which was negative for PV
or hepatic artery thrombosis.
Treatments received: Given ceftriaxone
On arrival to the floor, patient appears comfortable
ROS, as per HPI, otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR
Extrahepatic cholangiocarcinoma stage II (T2a N0 M0) LVI+, PNI+
- ___ Developed epigastric pain. Evaluated and felt to be
related to cholecystitis.
- ___ Underwent uncomplicated cholecystectomy. Pathology
demonstrated acute on chronic cholecystitis, but no dysplasia.
- ___ Presented with clinical evidence of biliary cholic,
fever, and jaundice.
- ___ Seen in Urgent Care. Labs showed Tbili of 3.3 with
an AST of 46 and an ALT of 245. RUQ US showed CBD dilation and
an
echogenic lesion in the biliary tree at the level of the
resected
gallbladder.
- ___ Underwent ERCP and spincterotomy. A stricture was
noted in the bile duct. Brushings were atypical but
nondiagnostic.
- ___ Repeat ERCP was performed. The biliary stricture
was
re-demonstrated. Biopsies were again nondiagnostic.
- ___ Seen in the Hepatobiliary and Pancreatic Cancer
Clinic. Recommended resection given high risk of cancer at the
site of stricture.
- ___ Underwent resection of the area of concern with LN
dissection. Final pathology showed a distal cholangiocarcinoma
with extension into the biliary connective tissue, T2a, node
negative N0. LVI and PNI were present. Margins were negative.
Course complicated by UTI and possible wound infection.
- ___ C1D1 gemcitabine 1000 mg/m2
- ___ C1D8,17 gemcitabine 750 mg/m2 reduced for
thrombocytopenia
- ___ Start XRT with capecitabine 1000 mg PO BID on
treatment days
- ___ Completed XRT. Course complicated by
thrombocytopenia which led to a hold of capecitabine
#Cholecystitis s/p lap to open cholecystectomy in ___
#IPMN in body of pancreas
#HTN
#GERD
Social History:
___
Family History:
Father with CAD. No history of gallstones or GI malignancy.
Physical Exam:
#Cholecystitis s/p lap to open cholecystectomy in ___
#IPMN in body of pancreas
#HTN
#GERD
Pertinent Results:
ADMISSION LABS
==============
___ 04:15AM BLOOD WBC-5.0 RBC-3.60* Hgb-11.9* Hct-36.0*
MCV-100* MCH-33.1* MCHC-33.1 RDW-13.1 RDWSD-48.1* Plt ___
___ 04:15AM BLOOD Neuts-73.8* Lymphs-10.2* Monos-11.4
Eos-3.2 Baso-0.8 Im ___ AbsNeut-3.69 AbsLymp-0.51*
AbsMono-0.57 AbsEos-0.16 AbsBaso-0.04
___ 04:15AM BLOOD ___ PTT-26.6 ___
___ 04:15AM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-136
K-5.2* Cl-105 HCO3-21* AnGap-15
___ 04:15AM BLOOD ALT-63* AST-75* AlkPhos-321* TotBili-4.9*
___ 10:30AM BLOOD ALT-54* AST-55* LD(LDH)-199 AlkPhos-326*
Amylase-129* TotBili-5.4* DirBili-4.1* IndBili-1.3
___ 04:15AM BLOOD Albumin-3.1*
___ 10:30AM BLOOD calTIBC-322 Ferritn-65 TRF-248
___ 04:42AM BLOOD Lactate-1.7
DISCHARGE LABS
==============
IMAGING
=======
MICROBIOLOGY
============
PATHOLOGY
=========
OTHER PERTINENT FINDINGS
========================
Brief Hospital Course:
___ with cryptogenic cirrhosis and cholangiocarcinoma stage II
(T2a, N0, M0) with extensive lymphovascular and perineural
invasion and possible liver and pulmonary spread based on recent
CT, who p/w with 3 days of increasing abdominal distension and
pain.
#Ascites: History of cryptogenic cirrhosis. On admission,
ascites was found to have progressed since last outpatient
appointment on ___. He has a mass in Lobe II, but this has
been stable. The Doppler study was negative for flow reversal
in the portal vein. His ascitic fluid was notable for WBC of
450 with 9% PMNs arguing against SBP and a SAAG of 3.1
suggestive of cirrhosis. Patient underwent several peritoneal
taps for removal of ascites; studies conducted were mostly
negative except for 1 colony on 1 plate of ___ growth on
___ peritoneal culture. Patient was treated with micafungin
prior to being switched to fluconazole at discharge. As
suspicion of hepatosplenic candidiasis was relatively low,
patient received an abdominal pleurX prior to discharge, for
continued low-volume taps at home.
#LFT elevation: Had obstructive pattern LFTs with a marked
elevation in the Tbili since one week prior which continued to
display an upward trend throughout hospitalization. No gall
stone obstruction on Doppler. MRCP showing multiple enlarged
liver lesions. Concern for cholangitis given abdominal pain and
low grade temperatures; Zosyn was given ___ then switched
to cipro/flagyl ___. Switched back to Zosyn ___ for subjective
symptoms of fever and overall worsening clinical/laboratory
picture. Underwent PTBD and bx ___ which showed adenocarcinoma
c/w prior dx. T. bili initially decreased then increased again,
so patient underwent cholangiogram and stent placement ___.
Patient was then switched to meropenem on ___ after cultures
grew E. coli sensitive only to meroenem, ertapenem, and
gentamicin. Despite appropriate coverage, patient continued to
have elevated LFTs; this was thought to be ___ decompensated
cirrhosis. At discharge, patient's bilirubin persisted around
~17; patient remained neurologically intact throughout
hospitalization.
#Dyspnea: Complained once during hospitalization of dyspnea,
likely related to his ascites, as he appeared to derive some
symptomatic relief s/p para. He was noted, however, to also
have vascular engorgement on CXR. ECHO was normal in ___.
Lungs continued to sound clear throughout hospitalization and
patient had no further episodes of dyspnea.
#UTI: found to have cipro-resistant UTI on ___, started on DS
Bactrim ___. When IV zosyn was started, as aforementioned,
Bactrim was held. Full course of zosyn as detailed above.
#Cholangiocarcinoma: Cholangiocarcinoma stage II (T2a, N0, M0)
with extensive lymphovascular and perineural invasion up to the
level of the capsule without true lymph node involvement, status
post primary resection on ___, followed by
adjuvant gemcitabine with chemoradiation with capecitabine and
then ultimately ___. ___ be metastatic given liver lesion and
pulmonary nodules, though these have not been sampled. S/p Cycle
2 of Fluorouracil in ___. Liver biopsy taken during this
hospitalization showing adeno c/w cholangiocarcinoma dx.
===================
TRANSITIONAL ISSUES
===================
-Will need labs drawn on ___: CBC, Chem 10, LFTs
-Drain 1L from PleurX ___
NEW MEDICATIONS
-Ciprofloxacin HCl 500 mg PO/NG Q12H
-Docusate Sodium 100 mg PO BID:PRN constipation
-Fluconazole 200 mg PO Q24H
-Furosemide 40 mg PO DAILY
-OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
-Polyethylene Glycol 17 g PO DAILY:PRN constipation
-Senna 8.6 mg PO BID:PRN constipation
-Spironolactone 25 mg PO DAILY
CHANGED MEDICATIONS: none
DISCONTINUED MEDICATIONS: none
CODE: Full (confirmed)
CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO QHS
2. Ursodiol 500 mg PO BID
3. Tamsulosin 0.4 mg PO BID
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. Mirtazapine 15 mg PO QHS
2. Tamsulosin 0.4 mg PO BID
3. Ursodiol 500 mg PO BID
4. Ciprofloxacin HCl 500 mg PO/NG Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. 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
6. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Multivitamins W/minerals 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please stop taking this if you have diarrhea or more than 3
bowel movements a day.
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
12. Simethicone 40-80 mg PO TID:PRN gas pain
RX *simethicone 80 mg 1 tablet by mouth three times a day Disp
#*50 Tablet Refills:*0
13. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
15. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
UTI
acute cholangitis
biliary duct obstruction
cholangiocarcinoma
hepatosplenic candidiasis
SECONDARY:
recurrent ascites
cirrhosis
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 ___ with abdominal pain and low grade
fevers. Your liver function tests were found to be abnormally
high and you were diagnosed with acute cholangitis, or infection
of the bile ducts. You were begun on IV antibiotics and
underwent several tests which showed you had lesions in your
liver which were preventing your bile ducts to properly empty.
You underwent several procedures to help drain the bile ducts.
You were also found to have significant abdominal distension.
You underwent several drainage procedures to help remove the
fluid from your abdomen. One of these taps showed possible
fungal infection; you were started on an antifungal which you
should continue to take until directed to stop by your doctor.
Prior to discharge, you received an indwelling catheter so you
can continue to drain the abdominal fluid at home.
On admission, you were also found to have a urinary tract
infection. You were appropriately treated for this infection
with a course of antibiotics. Please notify your doctor if you
have increased frequency or pain/burning upon urination as this
may be a sign of infection.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10609277-DS-6 | 10,609,277 | 29,454,833 | DS | 6 | 2174-07-01 00:00:00 | 2174-07-11 02:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bleeding scalp lac, R clavicle fx, T12 chance Fx, R 5th rib Fx,
small R PTX
Major Surgical or Invasive Procedure:
1. Open treatment, thoracic fracture dislocation.
2. Posterior arthrodesis T10-T11, T11-T12, T12-L1.
3. Posterior instrumentation T10 through L1.
4. Allograft, morcellized.
5. Autograft, same incision.
History of Present Illness:
his is a ___ female presenting status post pedestrian
struck with a T12 Chance fracture. Patient was in the crosswalk
and hit by a car. Had a large laceration to the occipital
portion of her head and brought to the ED for evaluation. On
exam she was tender in the T-spine and C-spine as well as right
clavicle. She was taken to the CT scanner with a negative CT of
her C-spine for acute fracture and a positive CT for a T12
Chance
fracture as well as a 5th rib and distal clavicle. On
evaluation
patient complained of subjective numbness/tingling in her right
lower leg and her right distal arm. Patient denied any
nausea,
vomiting, weakness, bowel incontinence, bladder incontinence,
shortness of breath, or numbness tingling in perineal area.
Tetanus not up-to-date.
Past Medical History:
None
Family History:
NC
Physical Exam:
Constitutional: Boarded and collared
Head / Eyes: Large occipital laceration
ENT / Neck: C-collar in place
Chest/Resp: Right chest wall tenderness
Cardiovascular: Regular Rate and Rhythm
GI / Abdominal: Soft
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: Pain with range of motion of the right upper
extremity, T-spine tenderness to
palpation
Skin: Multiple abrasions including a flank abrasion
Pertinent Results:
ADMISSION
___ 08:50PM BLOOD WBC-7.0 RBC-4.82 Hgb-14.6 Hct-43.5 MCV-90
MCH-30.3 MCHC-33.6 RDW-11.9 RDWSD-38.9 Plt ___
___ 08:50PM BLOOD ___ PTT-28.4 ___
___ 08:50PM BLOOD ___ 09:52AM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-140 K-3.8
Cl-105 HCO3-23 AnGap-12
___ 09:52AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.9
___ 08:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:50PM BLOOD ___ pO2-44* pCO2-45 pH-7.36
calTCO2-26 Base XS-0
___ 08:50PM BLOOD Glucose-131* Lactate-2.1* Na-136 K-6.9*
Cl-98
___ 09:01PM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-99
___ 09:01PM BLOOD freeCa-1.08*
IMAGING:
CT Head Impression:
Large scalp laceration with blood products and gas underneath
the
scalp. No fracture or intracranial hemorrhage.
CT C-spine Impression:
1. No acute fracture or malalignment of the cervical spine.
2. Small right apical pneumothorax is partially imaged.
CT Torso Impression:
1. Acute Chance fracture of T12 with TLICS score of 7.
DISCHARGE
___ 12:50PM BLOOD WBC-5.2 RBC-3.38* Hgb-10.3* Hct-31.1*
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.2 RDWSD-43.8 Plt ___
___ 06:40AM BLOOD Glucose-77 UreaN-6 Creat-0.5 Na-142 K-4.1
Cl-105 HCO3-28 AnGap-9*
___ 06:40AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ female presenting status post
pedestrian struck. Patient was in the crosswalk and hit by a
car. Had a large laceration to the occipital
portion of her head and brought to the ED for evaluation. At a
On exam she was tender in the T-spine and C-spine. She was
taken to the CT scanner with a negative CT of her C-spine for
acute fracture and a positive CT for a T12 Chance fracture.
Additionally the patient has multiple injuries including a
clavicle fracture,
and apical pneumothorax and rib fracture. Head laceration was
repaired in the ED and the patient was admitted to the ACS
service for pain control and monitoring. The spine service was
consulted and she underwent a T10-L1 instrumented posterior
fusion with Dr. ___ on ___. There were no adverse events
in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation. Patient was evaluated
and treated by physical therapy who recommended physical therapy
as an outpatient upon discharge.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV
medications and then transitioned to oral.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored.
Patient tolerated regular diet.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay and was encouraged to
get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth Every 8 hours Disp #*45 Tablet Refills:*0
2.Straight Cane
Dx: Spine fracture
Px: Undetermined
___: 13 months
3.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
-Scalp laceration
-Right clavicle fracture
-T12 chance Fracture
-Right 5th rib Fracture
-Small Right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted the hospital after you were struck by a
vehicle on while walking the street. In the hospital, we found
that you had clavicle fracture, an apical pneumothorax, rib
fractures and a fracture of your thoracic spine. Your were
admitted for inpatient management. While in the hospital, we
monitor your blood levels, gave you medications to control your
pain and received physical therapy. Additionally, the orthopedic
spine team did a surgery to repair your thoracic fracture.
You are now getting better and we think that you are safe for
being discharge to your home. Please follow up in the Spine
Clinic (see details about follow up appointment below) and make
an appointment with a primary care doctor (___). Your PCP ___
be able to arrange follow up with the cognitive neurology clinic
for your concussion. We are also giving you scripts for
outpatient physical therapy and for pain medications.
* 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.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* 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 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.
Your ___ team
Followup Instructions:
___
|
10609532-DS-11 | 10,609,532 | 20,748,885 | DS | 11 | 2175-10-31 00:00:00 | 2175-11-01 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lamictal
Attending: ___
___ Complaint:
Fatigue
Anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with PMH of anxiety/depression and GERD
presenting with fatigue, ___, and anemia.
The patient was seen at his PCP's office on ___. At this visit,
he was noted to have anemia with a hemoglobin of 10 from a
baseline of 14.7. He was also noted to have an increase in
creatinine to 2.0 from a baseline of approximately 1.0. Patient
was also noted to be hyperkalemic to 5.9. He was referred by his
PCP to the ___ ED for further work-up.
He has been experiencing weakness, dizziness, fatigue, and
general malaise for the last 2 months. He also has a ___ pound
weight loss over the last 6 months, which was initially
intentional but has far exceeded what he would expect for the
amount of caloric restriction he has adhered to. He had a fall
on ice in ___, which resulted in back pain which he
began taking ibuprofen for. He took about 800 mg ___ times a day
for about 6 weeks starting in ___ and ending sometime in
___. He has not had any NSAIDs in the last 3 weeks. He denies
bright red blood per rectum, dark tarry stools, hematemesis, or
abdominal pain. He has some intermittent nausea which is what
prompted him to stop taking the NSAIDs a few weeks ago. He
drinks about 1 alcoholic beverage or less per day. Denies bone
pain or pain any where other than ___ pain at site of fall (mid
R thoracic back).
He had an EGD for ___ esophagus screening in ___,
which showed normal mucosa throughout. He had a colonoscopy at
the same time which showed small grade 1 internal hemorrhoids
but otherwise normal colonoscopy to the cecum.
Patient has a past medical history significant for depression,
anxiety, and GERD. He has no significant past surgical history.
He drinks approximately 1 alcoholic beverage a day.
- In the ED, initial vitals were: Temp 96.9 HR 97 BP 145/88 RR
18 100% RA
- Exam was notable for: non-Tachycardic, non toxic appearing,
abdomen benign, no blood in vault, hemoccult negative, no lower
extremity edema
- Labs were notable for: WBC 8.8, Hgb 9.8, Hct 31.3, MCV 99,
Plt 377, Abs-Ret 0.05, Hapto 285, AP 160, Na 132, K 5.1, BUN 46,
Cr 1.9, Calcium 9.5, Phos 4.1, TSH 5.4
- Studies were notable for:
Renal ultrasound: Normal renal ultrasound.
CRX: No acute cardiopulmonary process.
- The patient was given: 2L Liter NS, IV PPI
Past Medical History:
-Depression
-Obstructive sleep apnea
-Constipation
-GERD
-Lower thoracic muscle strain/back pain
-Right-sided TMJ
-HSV
Social History:
___
Family History:
No family history of ulcerative colitis, Crohn's, malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
___ 2330 Temp: 97.5 PO BP: 144/86 HR: 86 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Mildly tachycardic. Regular rhythm. 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.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
=========================
24 HR Data (last updated ___ @ 2314)
Temp: 98.4 (Tm 98.4), BP: 144/81 (119-154/73-86), HR: 78
(78-88), RR: 18, O2 sat: 96% (96-99), O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing on room air.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non-distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS
================
___ 04:30PM BLOOD WBC-8.8 RBC-3.16* Hgb-9.8* Hct-31.3*
MCV-99* MCH-31.0 MCHC-31.3* RDW-14.4 RDWSD-52.0* Plt ___
___ 04:30PM BLOOD Neuts-48.6 ___ Monos-11.1 Eos-3.4
Baso-0.5 Im ___ AbsNeut-4.29 AbsLymp-3.20 AbsMono-0.98*
AbsEos-0.30 AbsBaso-0.04
___ 04:30PM BLOOD Glucose-88 UreaN-46* Creat-1.9* Na-132*
K-5.1 Cl-102 HCO3-23 AnGap-7*
___ 04:30PM BLOOD ALT-19 AST-17 LD(LDH)-147 AlkPhos-160*
TotBili-0.3
INTERVAL LABS
===============
___ 04:30PM BLOOD Lipase-76*
___ 04:30PM BLOOD Albumin-3.6 Calcium-9.5 Phos-4.1 Mg-2.0
___ 08:41AM BLOOD AlkPhos-142*
___ 08:02AM BLOOD GGT-85*
___ 04:30PM BLOOD Hapto-285*
___ 08:02AM BLOOD calTIBC-280 VitB12-508 Folate-4
Ferritn-358 TRF-215
___ 04:30PM BLOOD TSH-5.4*
___ 08:41AM BLOOD CRP-8.3*
___ 08:02AM BLOOD PEP-POLYCLONAL FreeKap-161.3*
FreeLam-148.9* Fr K/L-1.1
___ 07:15AM BLOOD HIV Ab-NEG
___ 12:18AM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
Osmolal-240
___ 07:15AM BLOOD HIV Ab-NEG
___ 08:02AM BLOOD PEP-POLYCLONAL FreeKap-161.3*
FreeLam-148.9* Fr K/L-1.1
___ 12:18AM URINE Hours-RANDOM Creat-26 Na-49 TotProt-14
Prot/Cr-0.5* Albumin-5.6 Alb/Cre-215*
___ 06:26PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
DISCHARGE LABS
=================
___ 07:15AM BLOOD WBC-8.8 RBC-2.81* Hgb-8.8* Hct-27.4*
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.6 RDWSD-52.1* Plt ___
___ 07:15AM BLOOD Glucose-88 UreaN-25* Creat-1.6* Na-140
K-4.5 Cl-107 HCO3-25 AnGap-8*
___ 07:15AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.7
___ 07:15AM BLOOD ALT-13 AST-13 AlkPhos-125
IMAGING/STUDIES
================
CXR ___
No acute cardiopulmonary process.
RENAL US ___
1. Normal renal ultrasound. No hydronephrosis.
2. Postvoid residual of 85 cc.
RUQUS ___
IMPRESSION:
No acute findings or sonographic correlate for the patient's
symptoms.
Brief Hospital Course:
PATIENT SUMMARY
=================
Dr. ___ is a ___ male who presented with newly
identified normocytic anemia and kidney injury of unclear
chronicity with symptoms of fatigue, weakness, and dizziness.
ACUTE/ACTIVE ISSUES:
====================
# Normocytic/macrocytic anemia
Hgb 10.0 is decreased from baseline of 14.7 (one year prior)
with inappropriate reticulocyte response (0.05). MCV is 98-102.
Iron studies, B12, Folate were normal and haptoglobin was
elevated. Ddx includes GI bleed (heme positive stools, possible
ulcers from 3 months of taking 800 mg ibuprofen TID), production
(aplastic anemia from a virus). Less likely destruction (hapto
high, tbili normal). Primary heme malignancy is less likely in
setting of normal smear and lack of M spike on SPEP and UPEP.
Since no signs of active GI bleed, will defer scope to
outpatient since he was hemodynamically unstable.
# Kidney Injury of unclear chronicity
FeNa with intrinsic renal. Ddx NSAIDs plus valacyclovir use,
myeloma kidney (though SPEP and UPEP unremarkable). Renal
ultrasound was without hydronephrosis. UA with 2 granular casts.
He was intermittently given IVF. Cr improved to 1.6 on
discharge. Patient should avoid any further use of NSAIDS.
# Hyperkalemia (improved)
With potassium 5.9 on outpatient testing on ___, EKG normal.
Improved with fluids.
# Elevated alk phos: Alk phos elevated to 140-160s during
admission, with elevated GGT. RUQUS unremarkable.
CHRONIC/STABLE/RESOLVED ISSUES:
===============================
# Hyponatremia (resolved)
Hyponatremia to 132 on presentation. Resolved with IVF.
# Hypothyroidism
History of fatigue, cold intolerance, but also with weight loss.
Thyroid appears normal on exam. TSH was elevated to 5.4 with
decreased free T4 of 0.8. TSH was previously normal in ___.
Differential diagnosis also includes sick euthyroid. Plan to
repeat thyroid studies as an outpatient.
# Anxiety/depression
Patient was maintained on home Lorazepam 1 mg PO Q8H:PRN
anxiety, BuPROPion XL (Once Daily) 300 mg PO DAILY, Venlafaxine
XR 300 mg PO DAILY (brought in home med). His home lamictal was
held as he has been introducing this at a very low dose for the
last 2 weeks despite concern in the past for rash under the
guidance of his psychiatrist. He felt that holding it at this
time was reasonable.
# Insomnia
Continued trazodone 100 mg and zolpidem 10 mg at night.
# HSV PPx
Held home valcyclovir in setting of ___. Restarted on discharge
to daily instead of BID adjusted for renal function.
# OSA
Maintained on CPAP.
TRANSITIONAL ISSUES:
==================
- Please consider outpatient hematology follow-up for further
work-up of anemia as well as repeat outpatient EGD/colonoscopy.
- Repeat CBC and BMP within the next 5 days. Consider renal
follow-up if Cr persistently elevated.
- Restarted on daily valacylovir instead of BID adjusted for
renal function.
- Repeat TFTs in 4 weeks and if persistently abnormal, please
start on supplementation as may be contributing to patient's
symptoms.
# CODE: Full (presumed)
# CONTACT: Husband ___ ___
Dr. ___ is clinically stable for discharge today. The
total time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 1 mg PO Q8H:PRN anxiety
2. ValACYclovir 1000 mg PO QPM
3. TraZODone 100 mg PO QPM
4. Zolpidem Tartrate 10 mg PO QHS
5. Omeprazole 40 mg PO BID
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Venlafaxine XR 300 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. LORazepam 1 mg PO Q8H:PRN anxiety
4. Omeprazole 40 mg PO BID
5. TraZODone 100 mg PO QPM
6. ValACYclovir 1000 mg PO QPM
7. Venlafaxine XR 300 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia
Kidney Injury of unclear duration
Hyperkalemia
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 at the ___
___.
Why did you come to the hospital?
- You came to the hospital because your primary care doctor
noticed that you had a high potassium and that your kidney
function had worsened. Your red blood cell count was also lower
than it had been in the past.
- You also had been feeling tired and had weight loss.
What happened while you were in the hospital?
- We did imaging and blood tests to examine why you had the lab
abnormalities.
- Common causes for anemia (low iron, Vitamin B12, folate, red
cell destruction) showed no abnormalities.
- Your reticulocyte count (new red blood cells) was low, meaning
your bone marrow was not making enough cells.
- Since you had anemia and kidney injury, we tested for multiple
myeloma. This came back as negative.
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:
___
|
10609725-DS-16 | 10,609,725 | 20,922,219 | DS | 16 | 2138-01-30 00:00:00 | 2138-01-30 18:55:00 |
Name: ___. Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Tetanus / Bactrim DS / Zinc / sulfa drugs
Attending: ___
Chief Complaint:
Facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ male with a PMHx of ___
disease s/p two DBS devices (followed by Dr. ___, HTN (per
OMR, patient's wife denies), HL, and prediabetes who presents
with increased falls, urinary incontinence, and confusion since
right pulse generator replacement yesterday morning at 10:00am
(Dr. ___. In the ED, he was incidentally noted to have a
new left facial droop, and a subsequent MRI DBS protocol
revealed right basal ganglia ischemia involving the right
caudate head, portion of internal capsule anterior limb, and
possibly putamen for which neurology was consulted.
The patient is unable to explain why he is in the ED; he does
note that he presented because his wife asked him to and also
that his wife was upset with him at his brother-in-law's house
(his wife clarifies that she was upset because patient got out
of car despite instructions and then fell). The remainder of the
history is obtained from his wife.
He was in his USOH until yesterday morning at which time he had
the right pulse generator replacement as mentioned above. It was
an ambulatory procedure, and he left the hospital by noon.
Subsequently, he and his wife went to her sister's house at
which time the patient was told to stay in the car while his
wife went in the house. When his wife went back outside, the
patient was found out of the car and on the ground on his left
side. His wife lifted him up, and they went home. Since then, he
has had multiple falls while using his walker wherein "his body
goes forward but his legs don't" and he falls forward or to
either side. He hit his face on one of the falls; he has not
lost consciousness. This is a change from baseline.
Additionally, the patient has been confused since the procedure
wherein his speech is inappropriate to the situation, or he is
not following directions like he normally does (e.g., car as
above). For example, in the ED, he started pressing all the
buttons on the remote. Also, he mentioned that his father (who
is deceased) was going to come by to the ED. His wife does not
think the confusion has been fluctuating; there have been ___
changes in his level of arousal. His wife says he has some
cognitive impairment at baseline; his wife gave an example of
failing to remember reminders (e.g., to push in a chair).
Additionally, he has been having frequent episodes of urinary
incontinence since yesterday (not his baseline); his wife is not
sure whether it is because the patient can't get to the bathroom
in time. His wife called neurosurgery, and they were asked to go
to the ED for battery evaluation.
During the neurosurgical evaluation, a plan was made to evaluate
the battery by Dr. ___ pending at the time of
this note). An incidental left facial droop was noted, and an
MRI brain DBS protocol was done with findings as above (DBS was
shut off for this).
Otherwise, his speech is at baseline (baseline dysarthria not
worse per wife). He has not complained of headaches, focal
weakness, or sensory changes. With regard to his parkinsonian
symptoms, his wife wonders whether his resting tremor is worse
since yesterday's procedure when the patient rests his hands on
his chest. Denies any worsening bradykinesia, bradyphrenia, or
rigidity. There have been ___ recent medication changes.
Past Medical History:
HYPERLIPIDEMIA
HYPERTENSION (per OMR, patient's wife denies)
___ DISEASE s/p DBS bilaterally
DYSPHAGIA
FOOT PAIN
BONE SPUR
GOUT
PREDIABETES
Social History:
___
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___
Father ___ ___ ATHEROSCLEROTIC
CARDIOVASCULAR
DISEASE
Not in OMR: mother with CHF, paternal GM with tremor, ___ history
of strokes, clots, MI, or neurologic diseases not mentioned
above
Physical Exam:
ON ADMISSION
============
Vitals: T: ___ P: 63 R: 18 BP: 127/113-->126/83 SaO2: 96RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, ___ scleral icterus noted, MMM, ___ lesions noted in
oropharynx, hypomimia
Neck: Supple. ___ nuchal rigidity.
Pulmonary: ___ work of breathing
Cardiac: RRR
Abdomen: non-distended
Extremities: ___ C/C/E bilaterally
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, oriented to person, place, and date but
not situation. Unable to relate a history (was unable to offer
reason for presentation). Language is fluent with intact
repetition and comprehension. Normal prosody. There were ___
paraphasic errors. Pt was able to name both high and low
frequency objects (although called "hammock" a "moccasin" (or
similar sounding word) initially and then self-corrected to
hammock. Able to read without difficulty. Speech was dysarthric
(baseline). Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. There was ___ evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus except doesn't fully bury sclera of right eye when
depressing and abducting. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. ___ rigidity including with
augmentation of arms, mild lower extremity rigidity bilaterally.
___ cogwheeling. ___ pronation, ___ drift. ___ orbiting with arm
roll. +Resting tremor L>R with 2cm amplitude. +Action tremor
bilaterally. Left postural tremor. ___ asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: ___ deficits to light touch, cold sensation,
proprioception throughout. ___ extinction to DSS.
-DTRs: brisk in ___ with slight asymmetry L>R (3+ at left
triceps), 2 at patellas, absent at Achilles. Plantar response
was flexor bilaterally.
-Coordination: ___ dysmetria on FNF or HKS bilaterally on left,
mild dysmetria in RUE (noted previously).
-Gait: Patient did not have walker at bedside. Able to sit up by
pulling himself up with both rails. Unable to remain sitting up
without back support. Could not stand him up to assess gait.
====================================
DISCHARGE PHYSICAL EXAM
General: Awake, cooperative, NAD.
HEENT: NC/AT, ___ scleral icterus noted, MMM, ___ lesions noted in
oropharynx
Neck: Supple. ___ nuchal rigidity.
Pulmonary: normal work of breathing
Cardiac: RRR
Abdomen: non-distended
Extremities: ___ C/C/E bilaterally
Neurologic:
-Mental Status: Alert, oriented to person, place, month and
year.
Language is sparse and halting but with intact repetition and
comprehension. Normal prosody. There were ___ paraphasic errors.
Speech was dysarthric. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left facial droop
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: Mildly increased tone in both legs. ___ rigidity
including
with augmentation of arms. ___ cogwheeling. ___ pronation, ___
drift. Resting tremor in R>L feet. +Action tremor bilaterally.
___
asterixis noted. Strength is full throughout with the exception
of the left hamstring which is 4+/5.
-Sensory: ___ extinction to DSS.
-DTRs: ___ response was flexor bilaterally.
-Coordination: ___ dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 12:25PM BLOOD WBC-10.3* RBC-4.59* Hgb-14.5 Hct-43.6
MCV-95 MCH-31.6 MCHC-33.3 RDW-13.3 RDWSD-46.5* Plt ___
___ 12:25PM BLOOD Neuts-69.8 Lymphs-13.7* Monos-14.9*
Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.20*# AbsLymp-1.41
AbsMono-1.54* AbsEos-0.08 AbsBaso-0.03
___ 12:25PM BLOOD ___ PTT-25.9 ___
___ 12:25PM BLOOD Glucose-120* UreaN-13 Creat-0.9 Na-144
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 12:25PM BLOOD ALT-9 AST-24 AlkPhos-68 TotBili-0.8
___ 05:15AM BLOOD GGT-19
___ 12:25PM BLOOD cTropnT-<0.01
___ 05:15AM BLOOD CK-MB-4 cTropnT-<0.01
___ 12:25PM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.0 Mg-2.0
Cholest-159
___ 05:15AM BLOOD %HbA1c-6.0 eAG-126
___ 12:25PM BLOOD Triglyc-162* HDL-42 CHOL/HD-3.8
LDLcalc-85
___ 12:25PM BLOOD TSH-0.89
___ 05:15AM BLOOD CRP-11.6*
___ 12:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___:
1. ___ acute intracranial abnormalities, specifically ___ evidence
of
intracranial hemorrhage.
2. Stable appearance of bilateral trans frontal deep brain
stimulator
electrodes that appear unchanged in position when compared to
the prior study.
CXR ___:
Low lung volumes with bibasilar atelectasis.
MRI HEAD ___:
1. Abnormal signal in the right basal ganglia is consistent with
late acute or subacute infarct.
2. Technically limited, incomplete exam.
CTA HEAD AND NECK ___:
Previously noted acute/subacute right basal ganglia infarct is
better
appreciated on most recent MR.
___ intracranial artery occlusion or aneurysm. ___ ICA
dissection. ___
intracranial hemorrhage.
___ internal carotid artery stenosis by NASCET criteria.
TTE ___: PENDING
Brief Hospital Course:
Mr. ___ is a ___ year old man with ___ disease
s/p DBS placement who is admitted to the Neurology stroke
service with left facial droop and dysarthria secondary to an
acute ischemic stroke in the right basal ganglia. His stroke was
most likely secondary to small vessel disease event given its
location and his risk factors. Telemetry did not show afib. CTA
without intracranial artery occlusion, aneurysm or dissection.
He will continue rehab at a rehab center.
Of note, this event occurred the day after he presented for DBS
battery replacement, but this surgery was in the chest and was
unlikely to cause the stroke.
Her stroke risk factors include the following:
1) pre-DM: A1c 6.0%
2) Hyperlipidemia: well controlled on Simvastatin with LDL 85
3) Obesity
TTE was done, preliminarily normal. If there is an abnormality,
we will contact facility for further management.
Transitional issues:
-He will need ___ of Hearts monitor to evaluate for atrial
fibrillation once he leaves rehab (can be ordered at outpatient
neurology appointment).
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () ___
2. DVT Prophylaxis administered? (x) Yes - () ___
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () ___
4. LDL documented? (x) Yes (LDL = ) - () ___
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - () ___ [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () ___ [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () ___
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () ___
9. Discharged on statin therapy? (x) Yes - () ___ [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () ___
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () ___ - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amantadine 100 mg PO BID
2. Carbidopa-Levodopa (___) 1 TAB PO BID
3. Escitalopram Oxalate 10 mg PO DAILY
4. mometasone 220 mcg (120 doses) inhalation BID
5. Nadolol 20 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Pramipexole 0.25 mg PO QHS
8. Simvastatin 20 mg PO QPM
9. tadalafil 5 mg oral QHS:PRN
10. Trihexyphenidyl 2 mg PO BID
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amantadine 100 mg PO BID
3. Carbidopa-Levodopa (___) 1 TAB PO BID
4. Escitalopram Oxalate 10 mg PO DAILY
5. mometasone 220 mcg (120 doses) inhalation BID
6. Multivitamins 1 TAB PO DAILY
7. Nadolol 20 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Pramipexole 0.25 mg PO QHS
10. Simvastatin 20 mg PO QPM
11. tadalafil 5 mg oral QHS:PRN
12. Trihexyphenidyl 2 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute right basal ganglia ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of facial droop and
trouble speaking resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Pre-diabetes
High cholesterol
Obesity
We are changing your medications as follows:
Start Aspirin 81mg daily
You will need to be on a monitor to look for an abnormal heart
rhythm called atrial fibrillation. We will arrange for this with
your PCP.
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:
___
|
10609750-DS-6 | 10,609,750 | 22,240,755 | DS | 6 | 2124-01-19 00:00:00 | 2124-01-19 12:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R olecranon fracture
Major Surgical or Invasive Procedure:
___ - R olecranon ORIF
History of Present Illness:
Patient is a ___ transferred from ___ for evaluation of
reported right olecranon fracture. States she was riding her
bicycle earlier today when she hit a patch of sand or gravel,
causing her to lose control and fall, landing on her right side
with immediate right elbow pain and difficulty moving her arm.
Also reports mild right hip pain and bruising but retained
ability to ambulate without difficulty. No HS/LOC and no other
injuries. Was wearing helmet. Denies numbness/tingling in
extremities or change in motor/sensory function of her right
arm/hand. States she sustained some superficial abrasions to
her
right elbow but denies oozing wound or sight of exposed bone.
No
other complaints.
Past Medical History:
Tourette's syndrome, not on medication
Seasonal allergies
Right breast lumpectomy ___
Appendectomy ___
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD
RUE: splint c/d/i, SILT s/s/sp/dp/t, Fires EPL, FPL, DIO,
fingers 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 R olecranon fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R olecranon ORIF, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with OT who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the RUE extremity, and will be discharged on ASA 325mg
for DVT prophylaxis. The patient will follow up with Dr. <<<>>>
per routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
Loratidine PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN moderate pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q3h prn
Disp #*80 Tablet Refills:*0
4. Senna 8.6 mg PO BID
5. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R olecranon fracture
Discharge Condition:
Stable
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing R upper extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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
Followup Instructions:
___
|
10609936-DS-9 | 10,609,936 | 26,844,006 | DS | 9 | 2137-12-11 00:00:00 | 2137-12-11 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
eye pain
Major Surgical or Invasive Procedure:
vitreal tap and inject ___
History of Present Illness:
Mr ___ is a ___ w/hx of AFib, HTN, Bechet's disease with
bilateral ocular involvement resulting in poor vision at
baseline, who presents with right eye pain and drainage that
began this morning.
Pt has a history of prior filtering glaucoma surgery and chronic
blepharitis of the right eyelids for which he uses tobradex
drops OD PRN. Had similar pain to this several years ago and
used dexamethasone drops at that time but they have not provided
relief today. Has worsening eye pain w/ eye movement and a right
sided headache. Developed nausea as well though has not vomited.
No fever. No other recent illness.
In the ED, initial vitals: T97.6 61 166/74 16 100% RA. Labs were
significant for: WBC 13.2, and Lactate 2.7. Ophtho was consulted
and recommended Vigamox OD, vanc/unasyn, and admission for
continued therapy. The patient was admitted to the MICU.
Past Medical History:
1. Atrial fibrillation.
2. Hypercholesterolemia.
3. Hypertension.
4. Benign prostatic hypertrophy.
5. Aortic regurgitation.
6. Behcet's disease with ocular involvement.
9. Benign prostatic hypertrophy.
10. Colon polyps.
Social History:
___
Family History:
Colon cancer, migraines, and high blood pressure.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:97.8 BP:154/62 P:64 R:14 O2:98% RA
GENERAL: Alert, oriented, no acute distress
HEENT: +Rt scleral erythema/pus, dried pus/swelling around Rt
eyelid, orbital ttp, MMM, oropharynx clear
NECK: supple, mild JVD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, II/VI RUSB sys murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema SKIN: No lesions.
NEURO: A&O x3. no vision Lt eye, little vision in Rt eye.
Sensation, strength grossly intact
DISCHARGE PHYSICAL EXAM
GENERAL: Alert, oriented, no acute distress
EYE: R eye covered with shield. L eye without erythema or
exudates.
ENT: MMM, oropharynx clear
NECK: supple, no JVD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, II/VI RUSB sys murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
SKIN: No lesions. Slightly decreased skin turgor.
Pertinent Results:
ADMISSION LABS
=============
___ 12:58AM WBC-13.2*# RBC-4.84 HGB-14.7 HCT-42.7 MCV-88
MCH-30.4 MCHC-34.4 RDW-13.3 RDWSD-43.3
___ 12:58AM NEUTS-90.2* LYMPHS-6.4* MONOS-2.7* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-11.91* AbsLymp-0.85* AbsMono-0.35
AbsEos-0.00* AbsBaso-0.03
___ 12:58AM GLUCOSE-167* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
___ 01:16AM LACTATE-2.7*
MICRO LABS:
==========
___ 4:23 am SWAB Source: right eye.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BETA STREPTOCOCCUS GROUP G. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH. WORK UP PER
___ ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 3:30 pm FLUID,OTHER Source: Vitreous fluid.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ 15:55.
BETA STREPTOCOCCUS GROUP G. SPARSE GROWTH.
Sensitivity testing per ___ ___.
CLINDAMYCIN sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP G
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
IMAGING
=======
MRI ___: Please note, there is mild motion degradation limiting
evaluation of the postcontrast images. Within the confines of
the study, findings are as follows: There is right orbital
preseptal soft tissue thickening and enhancement. There is
enhancement of the right optic nerve with induration of the
adjacent fat (06:12). The right lateral rectus muscle appears
enlarged and demonstrates mild diffuse enhancement. The globes
appear intact without definite intraorbital fat infiltration.
The left orbit appears unremarkable. There is partial bilateral
ethmoid sinus mucosal thickening. The visualized brain
parenchyma appears unremarkable. There is no definite fluid
collection or abscess.
DISCHARGE LABS:
==============
WBC-9.8 RBC-4.42* Hgb-13.6* Hct-40.1 MCV-91 RDW-13.7 Plt ___
Na-137 K-3.5 Cl-106 HCO3-23 UreaN-21* Creat-1.2 Glucose-105*
Brief Hospital Course:
___ year old male with history of atrial fibrillation,
hypertension, Bechet's disease with bilateral ocular involvement
resulting in poor vision at baseline, who presents with right
eye pain and drainage, concerning for endophthalmitis. He was
admitted to the ICU for frequent eye drops.
#Endophthalmitis:
#Blebitis:
Bleb associated endophthalmitis with surrounding associated
cellulitis following surgery. Vitreous cultures grew Group G
strep and MSSA. He is s/p intravitreal injections of
vanc/ceftaz. She was also treated with IV vanc/unasyn,
subsequently narrowed to Unasyn alone. He was also being treated
with vancomycin, atropine, Neomycin, Brimonidine and
Prednisolone drops.
His plan of treatment will be:
-Atropine 1% ophthalmic gtts OD Qday
-PredForte OD QID
-Fortified Vancomycin topical OD QID (if this is not available,
Bacitracin ophthal ointment OD TID).
-Ampicillin 500 mg TID PO
-Other home meds as prior to admission (however, NO TOBRADEX OPH
OINTMENT)
-Continue shield use OD when not applying drops.
-Patient to follow-up with Dr. ___ ___ at
___ at 10:00am.
___
The patient developed ___ with increase in creatinine from 0.9
to 1.3. On exam he appeared dehydrated, likely from being NPO
for surgery and having decreased access to ad lib fluids being
in a hospital where he does not speak the language. He was given
IVF and creatinine improved slightly to 1.2. He was not kept in
house for this to normalize, since it seemed to be going in the
right direction.
#HTN: continued home amlodipine
#HLD: continued home pravastatin
#Hypothyroidism: continued home synthroid
#Afib: continued home rivaroxaban
#BPH: continued home Flomax, Finasteride
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Rivaroxaban 15 mg PO DAILY
4. Pravastatin 20 mg PO QPM
5. Tamsulosin 0.8 mg PO QHS
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Tobramycin-Dexamethasone Ophth Susp 1 DROP RIGHT EYE QID
8. Vitamin D ___ UNIT PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*20 Tablet Refills:*0
3. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE Q24H
RX *atropine 1 % 1 drop in the right eye daily Refills:*0
4. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE TID
RX *bacitracin 500 unit/gram 1 appl OD three times a day
Refills:*0
5. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
RX *prednisolone acetate 1 % 1 drop OD four times a day
Refills:*0
7. amLODIPine 5 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Pravastatin 20 mg PO QPM
12. Rivaroxaban 15 mg PO DAILY
13. Tamsulosin 0.8 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right eye endophthalmitis
Acute kidney injury
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
came for further evaluation of eye pain and discharge. It was
determined that you had an infection of your eye called
endophthalmitis. You were seen by our eye doctors, underwent a
surgery called a vitrectomy, and several antibiotics were given.
You are now doing better and will be discharged home.
It is important that you continue to take your medications as
prescribed and follow up with your appointments as listed below.
Good luck!
Followup Instructions:
___
|
10610033-DS-20 | 10,610,033 | 25,071,131 | DS | 20 | 2158-01-17 00:00:00 | 2158-01-19 20:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lithium / Phenobarbital / Morphine / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Knee Pain, Mechanical Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male with multiple orthopedic problems in his legs,
walks with a cane, presents with knee pain after ___t home. He has trouble getting around in general, and is
out on disability, several days prior to admission he slipped
and fell down a flight of stairs injuring his left knee and left
ankle. He states he heard a pop in his ankle, and has been
unstable on his feet since then. Since that fall he was seen by
his orthopedist where he had an MRI of the left ankle which by
report showed achilles tendonitis.
He is currently doing outpatient ___ and is planned for a MRI of
the knee on ___ with ortho follow up. However, has been having
difficulty ambulating due to left leg pain with several recent
falls including one involving a head strike with reported LOC.
He was evaluated at ___ with a negative CT head
per the patient. He was prescribed oxycodone 10mg Q3h which is
not adequately controlling the pain.
Has also has a history of chronic LBP which is unchanged. No
bowel incontinence or urinary retention. Of note the patient has
had 7 ED visits since ___ to ___, all for assorted pain
complaints, mostly leaving with prescriptions for oxycodone. And
in a masshare query he has had 134 prescriptions (of all types)
since ___.
In the ED, initial VS: 98.4 84 151/82 18 97% c/o ___ pain. He
underwent head CT which was negative, and was attempted to be
observed overnight in the ED for a ___ evaluation in the morning,
however stated he was in "too much pain to go home." He was
given 3mg of IV dilaudid, 2mg of PO dilaudid, 10mg of oxycodone,
valium 5mg, tylenol, ___ of gabapentin, and alprazolam.
Past Medical History:
- Benign Hypertension
- GI bleed (hematochezia), ___. Diverticulosis and
hemorrhoids on colonoscopy. CT's negative
- GERD
- Asthma
- Chronic back pain, since a work injury in ___, takes
oxycodone/acetaminophen routinely. Hospitalized twice at ___.
___. MRI reportedly with disc protrusion.
- Bipolar disorder.
- Right knee surgery, years ago, for a benign tumor.
ALLEGIES/RXNS:
morphine, lithium, NSAIDS, phenobarbital
Social History:
___
Family History:
Unknown as he was adopted.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, + Arthralgia, + Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.3, 135/79, 78, 18, 95%
GEN: NAD, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, scar on R medial knee, left knee no major effusion,
no erythema, no warmth
NEURO: CAOx3, Non-Focal
EXAM ON DC:
VS - Temp 98.3 ___ 95% on RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, R. Knee with
a no echymoses or effusion - ve drawer and ___ tests. TTP
over bilateral tibial plateaus. Unable to perform apply grind.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
PERTINENT LABS:
___ 03:00AM BLOOD WBC-6.2 RBC-4.73 Hgb-13.7* Hct-42.5
MCV-90 MCH-29.1 MCHC-32.4 RDW-13.8 Plt ___
___ 03:00AM BLOOD Neuts-61.5 ___ Monos-6.1 Eos-5.5*
Baso-0.8
___ 03:00AM BLOOD Glucose-143* UreaN-13 Creat-0.8 Na-140
K-3.5 Cl-99 HCO3-32 AnGap-13
CT HEAD W/O CONTRAST Study Date of ___ 10:21 ___
There is no evidence of acute hemorrhage, edema, large vessel
territorial infarction, or shift of the normally midline
structures. The
ventricles and sulci are normal in size and configuration. No
acute fractures are identified. Ethmoidal and bilateral
maxillary mucosal thickening is noted. Otherwise, the remainder
of the visualized paranasal sinuses and the mastoid air cells
are clear. IMPRESSION: No acute intracranial process.
Brief Hospital Course:
HOSPITAL COURSE: ___ w/ recent fall ___ 'knee buckling' who
presented a few days after the fall for pain managment. Dc/ed on
home pain meds as has MRI and outpt followup with Orthopedics as
outpt.
Monoarticular Arthralgia:
The patient's pain is well out of proportion to this exam.
Likely traumatic injury, and given his ability to ambulate he
does not have a tibial plateu fracture or other major bone
injury, and while he may have ligamentous or tendon injury these
are not likely to be serious given the benign exam. It is
possible that his falls are related to instability which might
indicate a ligament tear or meniscal injury, however, the pt is
back to baseline on his home pain regimen. Physical therapy was
called to see him who cleared him for home d/c. He already has
an outpatient MRI of his knee arranged from prior to the
admission on in 3 days.
Benign Hypertension:
stable.
We continued HCTZ 25mg QD, atenolol 25mg QD and lisinopril 40mg
QD,
Bipolar Disorder:
stable.
We continued buspirone 30mg TID prn, alprazolam 2mg ___,
Chronic Lumbar Back Pain:
stable.
We continued gabapentin 600mg TID and restarted home oxycodone
10mg Q3h prn pain.
Insomnia:
stable
# CODE: Full
Medications on Admission:
HCTZ 25mg QD,
atenolol 50mg QD,
lisinopril 40mg QD,
buspirone 30mg TID prn,
alprazolam 2mg ___,
trazodone 300mg QHS,
gabapentin 600mg TID,
prazosin 2mg QD,
oxycodone 10mg Q3h prn pain (prescribed by orthopedist)
omeprazole 20 qd
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. buspirone 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety: as prescribe by your doctor.
4. alprazolam 2 mg Tablet Sig: ___ Tablets PO once a day as
needed for anxiety.
5. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. prazosin 2 mg Capsule Sig: One (1) Capsule PO once a day.
8. oxycodone 10 mg Tablet Sig: One (1) Tablet PO q3h as needed
for pain: Do not drive or operate on machinery when you take
this medication in order to prevent accidents.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12 hours and off for 12 hours.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
11. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Left knee pain
Secondary diagnoses:
- Hypertension
- Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It is a pleasure to take care of you at ___
___. You were admitted to the hospital for
evaluation of your left knee pain after a fall. You said you
hit your head after the fall. The CT of your head does not show
any bleeding. Physical therapy evaluated you and thought that
it is safe for you to return home. Your pain is better
controlled. You will need to have further outpatient work-up
for your knee pain as it is already arranged for you.
Please note the following changes to your medications:
- START tylenol ___ mg, every 8 hours as needed for pain
- START lidocaine patch, 1 patch to the affected area, on for 12
hours and off for 12 hours.
- You can take stool softener such as colace and laxative such
as senna if you experience constipation.
- You can use ice pack to help with the discomfort in your knee
You should not drink, drive, or operate machinery while taking
oxycodone. This can make you drowsy and can potentially lead to
accidents.
Followup Instructions:
___
|
10610033-DS-21 | 10,610,033 | 22,432,120 | DS | 21 | 2158-07-13 00:00:00 | 2158-07-14 19:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lithium / Phenobarbital / Morphine / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
LLQ pain and BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
c/o abdominal pain BRBPR. states that it started this am. states
4 episodes of brbpr with LLQ pain. Also endorses one episode of
coffee ground emesis. He was brought to the ___ ED for
evaluation from ___ where he was "cooling off" after an
argument with his father. He arrived in the ED and initially
refused a CT and NG lavage. After meeting with psych they were
able to convince him to get his CT scan which showed
diverticulosis but no diverticulitis. His rectal exam showed
blood with stool mixed into it. He denies fevers and chills. He
has had no further bleeding.
.
On the floor he is comfortable and in NAD.
.
Per PSYCH he is secontioin 21 and cannot leave AMA. If he wishes
to leave they shoudl be contacted. If he is to be discharged
they need to be contacted first.
Past Medical History:
- Benign Hypertension
- GI bleed (hematochezia), ___. Diverticulosis and
hemorrhoids on colonoscopy. CT's negative
- GERD
- Asthma
- Chronic back pain, since a work injury in ___, takes
oxycodone/acetaminophen routinely. Hospitalized twice at ___.
___. MRI reportedly with disc protrusion.
- Bipolar disorder.
- Right knee surgery, years ago, for a benign tumor.
ALLEGIES/RXNS:
morphine, lithium, NSAIDS, phenobarbital
Social History:
___
Family History:
Unknown as he was adopted.
Physical Exam:
Admission Exam:
Vitals: 98.6 158/97 82 16 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese. Focal TTP in LLQ
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact.
.
Discharge Exam:
GEN Alert, oriented x3, 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. Mild TTP in LLQ. ND hypoactive 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 ulcers or lesions
Pertinent Results:
Admission Labs:
___ 11:35AM BLOOD WBC-9.3 RBC-4.77 Hgb-14.3 Hct-42.0 MCV-88
MCH-29.9 MCHC-33.9 RDW-13.5 Plt ___
___ 11:35AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-143
K-4.2 Cl-106 HCO3-27 AnGap-14
___ 11:35AM BLOOD Calcium-9.6 Phos-3.1 Mg-2.1
.
Discharge Labs:
___ 11:30AM BLOOD WBC-8.9 RBC-4.63 Hgb-14.0 Hct-41.4 MCV-90
MCH-30.4 MCHC-33.9 RDW-13.7 Plt ___
___ 08:00AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-145
K-4.9 Cl-106 HCO3-30 AnGap-14
___ 08:00AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1
.
Micro:
___ 02:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
.
Studies:
___ EKG: Sinus rhythm. Early anterior R wave transition.
Compared to the previous tracing of ___, accounting for
differences in precordial electrode placement, no diagnostic
differences.
.
___ CT Abd/Pelvis: Diverticulosis without diverticulitis.
No acute intra-abdominal process
.
Brief Hospital Course:
___ yo M with underlying psych and past addiction history in
addition to diverticulitis that presented to BID from ___
___ with 24 hour h/o bloody diarrhea, and LLQ pain that
resolved on admission. Originally at ___ under ___ for
SI/HI. Initially concerned for diverticulitis given past
history, but CT negative, and no leukocytosis, fever, or chills.
Hct with mild drop, so monitored overnight. Remained HD stable
with normal BM during hospitalization. Cleared by psychiatry to
be discharged to home after speaking with parents.
.
Acitve Issues:
#BRBPR: Admitted from ___ for 1 day h/o blood
in the toilet bowel. Pt remained HD stable and VSS throughout
stay. Likely source was bleeding diverticula, as he is known to
have them, and blood in bowel has happened on multiple
occassions. Pt hct slightly decreased from admission so
monitored overnight. H&H stable in afternoon. No additional
episodes of BRBPR or melena during stay.
.
#LLQ pain: Initially concerned for diverticulitis, however, none
seen on CT and no fever, leukocytosis or other signs of illness.
Unclear of exact etiology, but it appears this may be a chronic
process per the pt. Pt had normal BMs and was passing gas at
discharge. Tolerated full diet. Because of patient history of
substance abuse, narcotic analgesics were given sparingly.
.
#Coffee ground emesis: Pt describes single episode of coffee
ground emesis at ___, however, NG lavage was negative. No
episodes of emesis while in-hospital.
.
#SI/HI: Pt was in ___ for SI/HI after getting
into fight with parents about giving him his alprazolam.
Evaluated by psych and deemed safe to go back home with mother,
after speaking with her. ___ was notified of this decision.
.
Chronic Issues:
# HTN: Continued anti-HTN meds
.
# Anxiety: Continued buspirone, but held alprazolam per psych
note.
.
Transitional Issues:
#Scheduled to see his therapist on ___
#Will need to see psychiatry within ___ week for med adjustment
after holding alprazolam
#F/u blood cultures
Medications on Admission:
1. BusPIRone 30 mg PO TID
2. Hydrochlorothiazide 25 mg PO DAILY hold for sbp<100
3. Lisinopril 40 mg PO DAILY hold for sbp<100
4. traZODONE 300 mg PO HS:PRN insomnia
5. Prazosin 2 mg PO QHS nightmares
6. Omeprazole 40 mg PO DAILY
7. Atenolol 50 mg PO DAILY
Discharge Medications:
1. BusPIRone 30 mg PO TID
2. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp<100
3. Lisinopril 40 mg PO DAILY
hold for sbp<100
4. traZODONE 300 mg PO HS:PRN insomnia
5. Prazosin 2 mg PO QHS nightmares
6. Omeprazole 40 mg PO DAILY
7. Atenolol 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
diverticulosis
diverticular bleed
Secodary Diagnosis:
hyertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___. You were admitted
from ___ with a one day history of bright red blood in the
toilet bowel. You also had abdominal pain in your lower left
side. We were initially concerned that you may have an
inflammation of your colon referred to as diverticulitis. We
took an image of your stomach (CT scan), to make sure that you
did not have this illness. The image showed tiny pouches along
your colon (diverticulosis), but no obstruction or inflammation
of these puches (diverticulitis).
You were monitored overnight to make sure that your blood count
(hematocrit) was stable after your bleed. It did not decrease,
and you did not have any blood in your stool during your stay at
___.
Your abdominal pain was low grade, and intermittent. You
described this as ongoing. You may take tylenol or ibuprofen for
this pain.
There have been no medication changes during this stay.
Followup Instructions:
___
|
10610163-DS-11 | 10,610,163 | 23,744,663 | DS | 11 | 2117-12-26 00:00:00 | 2117-12-26 16:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L hand cellulitis
Major Surgical or Invasive Procedure:
I&D of L hand cellulitis/abscess on ___
History of Present Illness:
Mr ___ is a ___ year old man who is admitted for left hand
swelling and erythema. He reports he injected cocaine into his
hand 3 days ago. Since then, he reports progressive redness,
swelling, and pain of the hand. Denies fevers, chills,
lightheadedhess, dizziness, nausea, emesis, abdominal pain,
dyspnea, chest pain, palpitations, back pain, numbness/tingling
or weakness. He presented to ___ but was referred to ___
for hand surgery evaluation.
In the ED, initial vitals were:
Temp 98.1 | HR 100 | BP 124/86 | RR 16 | SpO2 99% RA
Exam was notable for swelling, warmth, erythema to left hand
extending just distal to elbow. Labs from ___ were
unremarkable.
The patient was given Vancomycin and ceftriaxone, but then
switched to piperacillin-tazobactam for better anaerobic
coverage.
Patient was evaluated by hand surgery. A bedside I&D of the
dorsum of the left hand was performed without encountering any
purulence. The surgical service recommended admission to
medicine
for IV antibiotic administration given ongoing significant pain
and erythema.
On arrival to the floor, patient reports the pain in his hand is
slowly improving, although it hurts to make a fist.
Past Medical History:
HCV, untreated
Schizophrenia
Cocaine Use Disorder
Social History:
___
Family History:
Non contributory.
Physical Exam:
ADMISSION EXAM:
General: disheveled appearing young man sleeping in bed in no
apparent distress
HEENT: sclerae anicteric, no injection, normal pupil size, MMM.
No axillary LAD.
Lungs: CTAB, normal WOB
CV: RRR, normal S1/S2, no M/R/G
GI: soft, non-tender to palpation, no organomegaly
UE: L hand wrapped in clean dressing. Improving tenderness to
palpation across
dorsum of L hand with. L hand is edematous but without
fluctuance. I&D site clean and intact. Area of erythema across L
dorsolateral forearm (outlined in blue) improving. No splinter
hemorrhages, no ___ nodes.
___: WWP, no edema
Neuro: Grossly alert and oriented, no focal deficits. ___
strength on L digital flexion/extension. Intact sensation across
L hand and arm. Kanavel sign negative
Psych: flat affect
DISCHARGE EXAM:
Vitals: ___ 0712 Temp: 98.2 PO BP: 99/65 R Lying HR: 91 RR:
16 O2 sat: 96% O2 delivery: RA
General: disheveled appearing young man sleeping in bed in no
apparent distress
HEENT: sclerae anicteric, no injection, normal pupil size, MMM.
No axillary LAD.
Lungs: CTAB, normal WOB
CV: RRR, normal S1/S2, no M/R/G
GI: soft, non-tender to palpation, no organomegaly
UE: L hand wrapped in clean dressing. Improving tenderness to
palpation and erythema across dorsum of L hand. I&D site clean,
dry, and intact. Area of erythema across L dorsolateral forearm
(outlined in blue) improving.
___: bilateral abrasions covered with gauze but with healthy
appearing granulation tissue. No purulence.
Neuro: Grossly alert and oriented, no focal deficits. ___
strength on L digital flexion/extension. Intact sensation across
L hand and arm. Kanavel sign negative
Psych: flat affect
Pertinent Results:
ADMISSION LABS:
===============
___ 08:00PM BLOOD WBC-5.8 RBC-4.88 Hgb-13.3* Hct-39.5*
MCV-81* MCH-27.3 MCHC-33.7 RDW-13.2 RDWSD-37.6 Plt ___
___ 06:08AM BLOOD Neuts-68.8 Lymphs-16.1* Monos-12.0
Eos-2.5 Baso-0.3 Im ___ AbsNeut-4.06 AbsLymp-0.95*
AbsMono-0.71 AbsEos-0.15 AbsBaso-0.02
___ 08:00PM BLOOD Glucose-94 UreaN-7 Creat-1.2 Na-142 K-4.1
Cl-103 HCO3-26 AnGap-13
___ 08:00PM BLOOD ALT-47* AST-89* AlkPhos-73 TotBili-0.5
___ 06:12AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8
___ 08:00PM BLOOD HCV VL-6.5*
___ 08:00PM BLOOD HCV Ab-POS*
___ 08:00PM BLOOD HIV Ab-NEG
___ 08:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:12AM BLOOD Osmolal-288
DISCHARGE LABS:
================
___ 06:20AM BLOOD WBC-5.7 RBC-4.34* Hgb-12.1* Hct-35.1*
MCV-81* MCH-27.9 MCHC-34.5 RDW-13.0 RDWSD-37.4 Plt ___
___ 06:20AM BLOOD Neuts-63.0 ___ Monos-10.5 Eos-3.7
Baso-0.4 Im ___ AbsNeut-3.60 AbsLymp-1.25 AbsMono-0.60
AbsEos-0.21 AbsBaso-0.02
___ 06:20AM BLOOD Glucose-81 UreaN-12 Creat-1.6* Na-143
K-4.1 Cl-104 HCO3-25 AnGap-14
MICRO:
======
___: Blood cultures and urine cultures with no growth to
date
IMAGING:
========-=
RENAL US ___: Normal renal ultrasound.
TTE ___: No 2D echocardiographic evidence for endocarditis. If
clinically suggested, the absence of a discrete vegetation on
echocardiography does not exclude the diagnosis of endocarditis.
Brief Hospital Course:
Mr. ___ is a ___ with substance use disorder, HCV not on
treatment, transferred to ___ from ___ for treatment
left hand cellulitis after injection with a non-sterile needle.
#Left hand cellulitis:
The patient underwent bedside I&D on ___ with hand surgery
without any evidence of abscess or purulence. He was initially
started on vancomycin and Zosyn (___), Augmentin
(___) but given continued fevers he was transitioned to
Clindamycin and Keflex (___) with plan for 7 day course.
The patient remained without signs of systemic infection and
with decreasing erythema and edema and no signs of neurovascular
or tendon compromise. Blood cultures were negative (at ___ and
___. TTE with no evidence of vegetation. He received TDaP
vaccine prior to transfer from ___. He will follow up with
hand surgery after discharge.
#Intravenous cocaine use
#Schizophrenia v. Mood Disorder
The patient reported a history of anxiety. He currently uses IV
cocaine and reports a prior history of heroin use. He currently
smokes ___ pack per day. According to outpatient providers, he
has a diagnosis of schizophrenia and was recently hospitalized
at ___ ___ for psychosis and suicidal ideation in the
context of substance use, after which he was discharged on
buproprion and olanzapine. These medications were continued
during this admission. He was seen by social work and was
provided information on safe needle use. He was also seen by
addition psychiatry but stated that he did not believe that his
substance use or nicotine dependence were a problem because he
is not a daily user (patient has a limited income and can only
purchase cocaine ~monthly). He has an outpatient psychiatrist
with plan for outpatient treatment.
___:
During admission, creatinine bumped from 1.2 on admission ->
1.8. Urine electrolytes were consistent with intrinsic renal
pathology. The patient was given IV fluids given low PO intake
from fatigue. It was suspected that the ___ may have been due to
toxicity from vancomycin/Zosyn. Urine microscopic evaluation was
bland. Renal ultrasound unremarkable. Cr downtrending prior to
discharge to Cr 1.6. Patient will need repeat chemistry panel to
monitor renal function within one week.
#HCV:
Patient reported history of HCV, for which he has not received
treatment or seen a gastroenterology or ID specialist. HCV viral
load was 6.5. He was given HBV vaccine given lack of immunity.
He will follow up with GI upon discharge.
#Nicotine Dependence:
The patient received nicotine replacement with a patch.
Name of health care proxy: ___.
Relationship: FATHER
Phone number: ___
___ Issues:
[] Ensure patient completes Clindamycin and Keflex (___)
with plan for 7 day course.
[] Ensure patient follow up with hand surgery
[] Please follow up BMP in one week, given ___ that developed
during admission. Discharge Cr 1.6
[] Please continue to assess patient's willingness to engage in
substance use counseling and services. The patient demonstrated
poor insight into his substance use and maintained a flat affect
throughout admission. He has follow up scheduled on ___ through
Aspire Psych.
[] Patient has HCV, not on treatment with VL 6.5. Please
evaluate for appropriateness of HCV treatment. Scheduled for
follow up appointment GI for consideration of treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 450 mg PO DAILY
2. OLANZapine 30 mg PO QHS
Discharge Medications:
1. Cephalexin 500 mg PO QID
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*6 Capsule Refills:*0
2. Clindamycin 300 mg PO QID
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*6 Capsule Refills:*0
3. BuPROPion XL (Once Daily) 450 mg PO DAILY
4. OLANZapine 30 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis of the left hand
Acute kidney injury
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 pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had an infection in your left hand and arm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- The infection was drained by hand surgery, and you were given
antibiotics.
- Your kidney function slightly decreased but got better with
some hydration.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10610191-DS-19 | 10,610,191 | 22,670,679 | DS | 19 | 2168-01-01 00:00:00 | 2168-01-01 18:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hallucinations and bizarre behavior
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman without significant PMH who presents
for bizarre behavior. (Collateral interviews are documented in
the psychiatry note from ___ According to the patient, she
moved back to ___ on ___. She is a student at
___.
___ night she was at a party, drinking and smoking marijuana.
She reports that she smoked "way too much" but suddenly realized
that she had undergone a terrible trauma as a child. Since that
time she reports that she has not been sleeping well. She
reports
that "I know I haven't slept in days". the patient works at this
___ as part of her coop and was at work ___ night.
She
reports that she remembers seeing blood all over her cloths -
but
it wasn't really there. She doesn't recall much else since that
time.
The patient is currently complaining of trouble thinking and
concentrating. She reports feeling very fatigued and her
thoughts
are disorganized. She admits that when she arrived in the ED she
had ___ and was very overwhelmed by all of the noise. She
then saw her grandmother walking by and was upset that she
wouldn't come and say hello to her. "no one comes over to say
hi!" She again thought that she saw blood on her shorts today.
Based on the collateral information gathered prior. The patient
has been exhibiting unusual behavior on and off for the past
week. She admitted to "hearing voices". She had episodes of
"rambling" speech for hours. She sent strange text messages and
was asking strange, out of context questions. The patient has no
prior history of depression or psychiatric disease. No history
of
depressive or unusual behavior. She was a good student and had
no
significant issues until this past week.
The patient was treated for a rash with PO steroids recently.
On neuro ROS: The patient reports a right frontal/temporal
headache with some associated right sided neck pain. She denies
neck stiffness, photophobia, nausea or vomiting. The headache is
a constant pressure. mild to moderate in intensity. This is
similar to prior headaches.
the pt denies loss of vision, blurred vision, diplopia,
oscilopsia, dysarthria, dysphagia, lightheadedness, vertigo,
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 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:
None
Social History:
___
Family History:
No significant family history of psychiatric illness.
Physical Exam:
===========================================
ADMISSION PHYSICAL EXAMINATION:
===========================================
T: 97.2 HR: 109 BP: 131/67 RR: 16 Sat: 100% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress
HEENT: Neck is supple. Full ROM. cervical paraspinal muscles are
tense and tender. deep palpation recreates/worsens her right
sided headache.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures. No
Edema.
Skin: No visible rashes. Warm and well perfused.
Negative ___ sign
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and time.
History is very tangential. Patient is grossly inattentive in
conversation requiring frequent redirection. She was unable to
give MOYB but could give DOWB slowly. Language is fluent and
appropriate with intact comprehension, repetition and naming of
both high and low frequency objects. Normal prosody. 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.
Rare out of context statements such as "it wasn't a gun was it?"
Cranial Nerves:
I: not tested
II: pupils equally round and briskly reactive to light, both
directly and consensually. Visual fields full to finger
counting.
Funduscopic exam revealed no papilledema.
III-IV-VI: Normal conjugated, extra-ocular eye movements in all
directions of gaze. No nystagmus or diplopia. Normal saccades.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound. No asterixis noted. Occasional whole body myoclonus
was noted upper body>lower body.
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:
Bi 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 light touch and
temperature.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were symmetric with regard to cadence and
speed, no dysdiadochokinesia noted.
Gait: Unable to test
===================================================
DISCHARGE PHYSICAL EXAMINATION:
===================================================
Unchanged from admission except as noted below:
Mental status: awake, alert, interactive. Fully oriented to
person, place, time and situation. Attention intact to serial
subtraction. Speech fluent with normal grammar and syntax.
Speech is fully linear and logical without tangentiality,
circumstantiality or any phrases which are inappropriate to the
conversational context. Denies hallucinations. Comprehension
intact to complex cross-body commands. Naming intact to very low
frequency objects. No paraphasic errors.
Motor: Myoclonus is now resolved. Other motor exam is as
documented on admission.
Pertinent Results:
___ 08:36PM BLOOD WBC-7.9 RBC-4.77 Hgb-13.2 Hct-40.4 MCV-85
MCH-27.7 MCHC-32.7 RDW-13.3 RDWSD-41.1 Plt ___
___ 03:30PM BLOOD WBC-7.1 RBC-4.73 Hgb-12.8 Hct-40.2 MCV-85
MCH-27.1 MCHC-31.8* RDW-13.0 RDWSD-40.3 Plt ___
___ 08:36PM BLOOD Neuts-56.1 ___ Monos-12.6 Eos-1.1
Baso-0.8 Im ___ AbsNeut-4.40 AbsLymp-2.28 AbsMono-0.99*
AbsEos-0.09 AbsBaso-0.06
___ 08:36PM BLOOD Glucose-127* UreaN-7 Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-24 AnGap-15
___ 03:30PM BLOOD UreaN-18 Creat-1.0 Na-139 K-4.0 Cl-103
HCO3-25 AnGap-15
___ 07:00AM BLOOD ALT-16 AST-16 LD(LDH)-168 AlkPhos-55
TotBili-0.5
___ 03:30PM BLOOD ALT-16 AST-16 LD(LDH)-138 AlkPhos-62
TotBili-0.3
___ 03:30PM BLOOD Lipase-29
___ 07:00AM BLOOD TSH-1.2
___ 07:00AM BLOOD antiTPO-14
___ 05:46PM BLOOD ___
___ 08:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:00AM BLOOD ENCEPHALOPATHY, AUTOIMMUNE EVALUATION,
SERUM-PND
___ 07:00AM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-PND
___ 08:30PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:27AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM
___ 08:30PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
___ 02:27AM URINE RBC-4* WBC-7* Bacteri-FEW Yeast-NONE
Epi-9
___ 08:30PM URINE UCG-NEGATIVE
___ 08:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 05:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
Bands-0 ___ Macroph-4
___ 05:00PM CEREBROSPINAL FLUID (CSF) TotProt-LESS THAN
Glucose-75
___ 05:00PM CEREBROSPINAL FLUID (CSF) ENCEPHALOPATHY,
AUTOIMMUNE EVALUATION, SPINAL FLUID-PND
___ 05:00PM CEREBROSPINAL FLUID (CSF) PARANEOPLASTIC
AUTOANTIBODY EVALUATION, CSF-PND
___ 05:00PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
___: RPR NONREACTIVE.
___: CSF enterovirus culture, Preliminary result No
Enterovirus isolated.
___ CSF culture: NO GROWTH.
Imaging:
NCHCT: no acute or chronic pathology seen
CXR: Normal chest radiographs.
cvEEG ___: This is an abnormal video-EEG monitoring session
because of
several clinical episodes of irregular jerking or tremulousness
of the limbs and/or head. Clinically, these did not appear to be
consistent with epileptic seizures, as they affected
noncontiguous body parts, had variable amplitude and direction
of tremor, and had on-off characteristics. There was no ictal
EEG correlate during any of these episodes. Interictal EEG was
normal, without focal slowing or epileptiform activity. These
clinical episodes are most consistent with nonepileptic events,
probably psychogenic in origin.
MRI brain ___: 1. Normal brain MRI.
2. Cerumen within the external auditory canals bilaterally.
Brief Hospital Course:
Ms. ___ was admitted to the Neurology service for workup of
possible neurologic etiologies of her abnormal behavior,
hallucinations and disorganized thinking. Initial differential
diagnosis included autoimmune encephalitis, post-ictal psychosis
is possible however highly unlikely given the lack of any ictal
events. Substance induced psychosis is also very possible given
recent substance use. These changes (including from marijuana)
can last for weeks to months. Primary psychiatric diagnosis is
also a strong possibility.
She also had jerking movements which were thought possibly
myoclonus on examination, and for evaluation of this she was
placed on continuous video EEG monitoring, which showed that
these movements had no electrographic correlate, also showing
normal background and no epileptiform discharges. Other workup
including serologies were normal, MRI brain normal, systemic
infectious workup normal, CSF basic studies normal, and at the
time of discharge, CSF paraneoplastic and autoimmune
encephalitis panels are still pending.
Psychiatry was consulted from the ED, and followed throughout
her admission. They recommended ___ and inpatient
psychiatric placement, as well as starting scheduled olanzapine,
with prn PO or IM olanzapine. IM olanzapine was never required.
She also began to voice numerous somatic complants, of which she
was not able to give any chronicity or detailed history, and the
complaints changed over the span of seconds.
Throughout her admission, her myoclonus resolved, and her
hallucinations and disorganized thinking resolved. On the day of
discharge her thinking was linear and logical and she denied
hallucinations. In consultation with Psychiatry, given her
marked improvement, it was determined that she was safe for
discharge with close outpatient psychiatric follow up, which was
subsequently arranged for 5 days post-discharge.
===============================================
Transitional Issues
[ ] Neurology to follow up CSF paraneoplastic and autoimmune
encephalitis panels in clinic.
[ ] f/u need for continued zyprexa at outpatient psychiatric
follow-up.
[ ] if substance abuse is not problematic in the future,
recommend reevaluating whether or not thiamine and folate
supplementation are required.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
5. OLANZapine 2.5 mg PO BID:PRN anxiety, agitation, psychosis
6. OLANZapine 2.5 mg PO QHS Duration: 7 Days
Take each night for next ___ days, and then take as needed.
RX *olanzapine 2.5 mg 1 tablet(s) by mouth nightly or as needed
Disp #*15 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN headache or nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*15 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO BID:PRN no bowel movement past
24 hours
Take this or another over the counter stool softener as directed
on the bottle.
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Psychosis NOS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with bizarre behavior. We did tests to look
for neurologic causes of this, and all the tests that came back
during your admission were normal. There were some tests sent on
your spinal fluid which won't be back for another several weeks.
We will see you in clinic to follow up these results. If all of
this testing is normal, it is most likely that these changes are
due to either substance induced psychosis or primary psychiatric
disorder. Please avoid any and all intoxicating substances. You
will follow up with Neurology and Psychiatry as listed below.
Followup Instructions:
___
|
10610275-DS-12 | 10,610,275 | 28,574,811 | DS | 12 | 2121-05-02 00:00:00 | 2121-05-02 22:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left arm and face numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old high-functioning man with a
history notable for bilateral glaucoma (s/p L-eye surgery and
profound loss of visual acuity), hypertension, "borderline high
cholesterol" (unmedicated), and AAA (s/p repair ___ in ___.
He was in his USOH until ___ evening), when he first
noticed a numb sensation in his left face and left hand/forearm,
which he describes as "like you got a Novacaine injection." He
denies any weakness or hand clumsiness, and there was no
dysarthria or language abnormality. There may have been a mild
facial droop on the left, unclear. It did not get any better or
worse. There was no pain. He slept overnight, and it was still
present in the morning, so he drove himself to the ___ ED hoping that they would "tell me it's just a virus."
He was admitted, a ?partial workup was conducted (see below)
over
1.5d, but he left AMA this morning due to impatience with delays
in communication of test results.
We have no records from ___, but his wife did just
bring in a CD from the OSH containing a few sets of images and
radiology reports (MRI brain, MRA head and neck, and NCHCT
performed there yesterday, ___. I reviewed these studies and
the OSH hospital course (only per verbal recollection from
pt/wife), and the highlights seem to be the following:
- MRI brain shows (1) three punctate diffusion abnormalities in
R-posterior thalamus and thalamic-midbrain transition zone, (2)
many spots and confluent white matter FLAIR/T2 hyperintensities
involving the hemispheres and pons, and (3) a ~3mm
top-of-basilar
likely aneurysm on MRA (incidental). (4) All major vessels are
patent, with mild ICA stenosis on the Left (~50%), not right.
- NCHCT (ordered to look for SAH, which was not seen on MRI)
which appears unremarkable except for periventricular
hypodensities c/w microvascular ischemic disease.
- Cardotid U/S, results unknown
- TTE w/bubble, results unknown
- They started Plavix and possibly a statin (wife says yes, pt
says no).
The patient left ___ this morning, frustrated with
the slow pace of their workup. He knows he has an aneurysm, and
he was told to f/u with Dr. ___ (?neurosurgeon) and given a
phone #. He says he was told he "maybe had a microstroke." He
came to our ED, possibly on the advice of his son, who is an OR
nurse here at ___.
Review of Systems: negative except as above
Denies headache, change in vision (chronic poor acuity in Left
eye ___ severe glaucoma s/p op years ago, here), blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. 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. +chronic sinus disease, unchanged. 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:
1. 2d-old stroke, as above
2. top-of-basliar aneurysm, as above
3. bilateral glaucoma (s/p L-eye surgery and profound loss of
visual acuity)
4. hypertension on thiazide and BB
5. "borderline high cholesterol" (unmedicated)
6. AAA (s/p repair ___ in ___.
7. recurrent sinusitis s/p multiple ENT procedures; takes
acetaminophen PRN to reduce his sinus congestion
8. ?migraine headaches (endorses occasional scintillating
scotoma, sometimes followed by headache; no formal Dx or
ppx-Tx),
for which he sometimes takes ___ at night or coffee
during the day.
9. on-going tobacco abuse, 60+ pk-yr cigarette history
10. ?Raynaud's phenomenon
11. ?chronic kidney disease (Cr currently 1.6 --> GFR ~40-45 -->
CKD-stage III if chronic); patient denies any knowledge of
kidney
disease... prior Cr here in ___ were 0.5-0.8, never
elevated
12. chronic LBP
Social History:
___
Family History:
no known migraines or early strokes or seizures
Physical Exam:
Vital signs:
T: 97.9F
P/HR: 52
BP: 169/81
RR: 18
SaO2: 100% RA
General: sitting up in ED stretcher, awake, cooperative, NAD.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx.
Neck: Supple, with full range of motion and no nuchal rigidity.
No bruits. No lymphadenopathy.
Pulmonary: Lungs CTA bilaterally. Non-labored breathing.
Cardiac: RRR.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Left hand/wrist becomes mottled and purpuric every
time the BP cuff compresses his brachial artery, and then for a
minute or two after. Radial pulses 2+. No edema. 2+ DP pulses
bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to ___, ___. Grossly attentive, and able
to
name ___ backward without difficulty (refuses serial 7s and
MOYbw). Speech was not dysarthric. Language is fluent with
intact
repetition and comprehension, normal prosody. Affect is
sarcastic
/ annoyed (with being in hospital), tangential but
re-directable.
There were no paraphasic errors. Able to read and write without
difficulty with Right eye. Naming is intact. Memory - registers
4
objects and recalls ___ at 5 minutes, ___ with multiple choice.
Mediocre knowledge of recent events ___ elections/riots,
runaway kids found in ___). Calculation intact (answers seven
quarters in $1.75). There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 3 to 2mm and brisk. Visual fields are full to red-pin
testing each eye separately. The left eye acuity is poor, not
even able to count fingers, but is able to discriminate large
shapes/light/colors.
III, IV, VI: EOMs full and conjugate; no nystagmus. Normal
saccades.
V: Facial sensation intact to light touch V1-V2-V3. Subjectively
diminished pinprick on left side of face from forehead/temple
down to just past the jawline.
VII: No ptosis. Mild flattening of the Left nasolabial fold; son
agrees and patient says he's not sure. Facial elevation with
smile is normal, full, and symmetric, with no lag on either
side.
Brow elevation is symmetric. Eye closure is strong and
symmetric.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii, which elevate symmetrically.
XII: Tongue protrusion is midline.
-Motor:
No drift. No asterixis. No tremor or fasciculations. Normal
muscle bulk and tone; no flaccidity, hypertonicity, or
spasticity
noted.
Delt Bic Tri WE FF FE IO | IP Q Ham TA ___
L ___ ___ 5 4+ 5 5 5 5 5
R ___ ___ 5 5 5 5 5 5 5
-Sensory:
Left forearm and hand/fingers has only "20%" pinprick intensity
as compared to the right. Cold sensation somewhat less in both
ankles/feet, symmetric. No gross proprioceptive deficits on
eyes-closed Finger-to-nose testing or great toes up/down.
* No agraphesthesia (0/3/5) or astereoagnosia
(___) in either hand.
-Reflexes (left; right):
Pec/delt (++;++)
Biceps (++;++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;+)
___ / achilles (++;tr)
Plantar response was extensor on the Left, mute on the right.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. No dysdiadochokinesia.
-Gait:
Stands without difficulty. Good initiation. Narrow-based, normal
stride and arm swing. Turns normally. Able to walk on heels,
toes. Tandem gait with minimal difficulty. Romberg absent.
Physical Exam on Discharge:
Vitals: ****
General: sitting up in bed, awake, cooperative, NAD.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx.
Neck: Supple, with full range of motion and no nuchal rigidity.
No bruits. No lymphadenopathy.
Pulmonary: Lungs CTA bilaterally. Non-labored breathing.
Cardiac: RRR.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Left hand/wrist becomes mottled and purpuric every
time the BP cuff compresses his brachial artery, and then for a
minute or two after. Radial pulses 2+. No edema. 2+ DP pulses
bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to ___, ___. Grossly attentive, and able
to
name ___ backward without difficulty (refuses serial 7s and
MOYbw). Speech was not dysarthric. Language is fluent with
intact
repetition and comprehension, normal prosody. Affect is
sarcastic
/ annoyed (with being in hospital), tangential but
re-directable.
There were no paraphasic errors. Able to read and write without
difficulty with Right eye. Naming is intact. Memory - registers
4
objects and recalls ___ at 5 minutes, ___ with multiple choice.
Mediocre knowledge of recent events ___ elections/riots,
runaway kids found in ___). Calculation intact (answers seven
quarters in $1.75). There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 3 to 2mm and brisk. Visual fields are full to red-pin
testing each eye separately. The left eye acuity is poor, not
even able to count fingers, but is able to discriminate large
shapes/light/colors.
III, IV, VI: EOMs full and conjugate; no nystagmus. Normal
saccades.
V: Facial sensation intact to light touch V1-V2-V3. Subjectively
diminished pinprick on left side of face from forehead/temple
down to just past the jawline.
VII: No ptosis. Mild flattening of the Left nasolabial fold; son
agrees and patient says he's not sure. Facial elevation with
smile is normal, full, and symmetric, with no lag on either
side.
Brow elevation is symmetric. Eye closure is strong and
symmetric.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii, which elevate symmetrically.
XII: Tongue protrusion is midline.
-Motor:
No drift. No asterixis. No tremor or fasciculations. Normal
muscle bulk and tone; no flaccidity, hypertonicity, or
spasticity
noted.
Delt Bic Tri WE FF FE IO | IP Q Ham TA ___
L ___ ___ 5 4+ 5 5 5 5 5
R ___ ___ 5 5 5 5 5 5 5
-Sensory:
Left forearm and hand/fingers has only "20%" pinprick intensity
as compared to the right. Cold sensation somewhat less in both
ankles/feet, symmetric. No gross proprioceptive deficits on
eyes-closed Finger-to-nose testing or great toes up/down.
* No agraphesthesia (0/3/5) or astereoagnosia
(___) in either hand.
-Reflexes (left; right):
Pec/delt (++;++)
Biceps (++;++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;+)
___ / achilles (++;tr)
Plantar response was extensor on the Left, mute on the right.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. No dysdiadochokinesia.
-Gait:
Stands without difficulty. Good initiation. Narrow-based, normal
stride and arm swing. Turns normally. Able to walk on heels,
toes. Tandem gait with minimal difficulty. Romberg absent.
Pertinent Results:
___ 09:04PM %HbA1c-5.6 eAG-114
___ 04:45PM GLUCOSE-91 UREA N-30* CREAT-1.6* SODIUM-142
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-32 ANION GAP-12
___ 04:45PM estGFR-Using this
___ 04:45PM WBC-13.4* RBC-4.87 HGB-15.6 HCT-46.4 MCV-95
MCH-32.0 MCHC-33.6 RDW-13.3
___ 04:45PM NEUTS-70.5* ___ MONOS-5.4 EOS-2.4
BASOS-0.5
___ 04:45PM PLT COUNT-303
___ 04:45PM ___ PTT-34.4 ___
MRI/A:
****
___ dopplers: No evidence of DVT
CXR: No acute cardiopulmonary process.
Transthoracic echo:
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). 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) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
Brief Hospital Course:
Mr. ___ was admitted to the neurology service on ___
with left face and arm numbness and tingling.
Neuro:
A repeat MRI/A was performed to better evaluate his infarcts and
basilar aneurysm. This study again showed several small acute
infarcts in the R thalamus as well as posterior limb of the
internal capsule. A basilar tip aneurysm measuring about 3mm was
again seen. He was started on aspirin 81mg daily (as pt has hx
of bleeding on 325mg) He was continued on his home
antihypertensives (HCTZ 50mg daily, Metoprolol XL 12.5mg daily).
Metoprolol was increased to 25mg XL daily for persistent
hypertension. HbA1c was 5.6%. Lipid panel revealed Cholesterol
153 Triglyc 145 HDL 37 LDL 87. He was started on Simvastatin
20mg daily. A TTE with bubble study showed no evidence of
cardioembolic source. Due to the appearance of his infarcts he
will be scheduled for a TEE as an outpatient as well to rule out
any embolic source.
Neurosurgery was consulted regarding his basilar aneurysm. They
recommended follow up with Dr. ___ with repeat MRI/A in 6
months.
Patient was counseled regarding smoking cessation given his high
risk of future strokes as well as life-threatening aneurysmal
bleeding.
CV:
Pt was maintained on tele monitoring with no events. His home
antihypertensives were continued. Metoprolol was increased to
25mg XL daily. He was started on simvastatin 20mg daily.
Renal:
His creatinine was found to be elevated at 1.6 on admission. He
has no known history of chronic kidney disease. UA was negative.
Urine protein/Cr ratio less than 0.2. His renal function and
electrolytes were monitored throughout his admission and
remained stable.
ID:
Pt's WBC was elevated to 13.4 on admission of unclear etiology.
UA and CXR were clear. Lower extremity dopplers were negative
for DVT. He remained afebrile with no signs of infection. WBC
was trended during his admission and remained stable between
___. He was advised to follow up with his PCP for ___ repeat CBC
in 1 week.
Ophtho:
Pt was continued on his home Xalatan and Timolol gtt for his
glaucoma.
Prophylaxis:
Pt was maintained on subQ heparin and pneumoboots for DVT
prophylaxis
Mr. ___ was discharged home in good condition on ___. He
will follow up with Dr. ___ in stroke clinic, as well as
Dr. ___ in ___ clinic.
Medications on Admission:
1. HCTZ 50 daily
2. metoprolol succinate (XL) 12.5 daily
3. Xalatan one gtt to OD qhs
4. timolol 0.5% one gtt to OD tid
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic TID
(3 times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
R thalamic infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on
___ with left face and arm numbness. An MRI showed
a stroke in the right side of your brain that is likely the
cause of your symptoms.
You were also incidentally found to have an aneurysm at the tip
of your basilar artery. You should follow up with Dr. ___ in
neurosurgery in 6 months regarding this (see information below).
You are strongly encouraged to quit smoking.
We made the following changes to your medications:
Started Aspirin 81mg daily
Started Simvastatin 20mg daily
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10610387-DS-5 | 10,610,387 | 22,388,745 | DS | 5 | 2124-09-11 00:00:00 | 2124-09-11 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / Lactulose
Attending: ___.
Chief Complaint:
S/p seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a pmhx. significant for
metastatic RCC with mets to skull on pazopanib, HTN,
hyperlipidemia and depression, who is admitted from the ED with
change in mental status and ___ activity.
Patient states that for the last 3 days she has felt slightly
off: she has noticed ___ difficulty and that sometimes
she "moves her lips and no words come out." She also reports
myoclonic jerkings in her extremities, which subside on their
own. On day of admission to the hospital, patient's social
worker was visitng. Ms. ___ lost consciousness and apparently
had a seizure (unknown duration or clinical manifestations).
Social worker called ___, and the next thing patient remembers
was waking up in the back of an ambulance. She was taken to
___ where a CT scan showed: in comparison to
study in ___, stable L craiotomy changes presnet w/
underlying encephalomalacia of the L frontal and parietal lobe.
inc CSF is noted at the surgical site. no evidence of acute ICH.
no midline shift. no masses. no evidence of acute territorial
infarct. bony calvarium is otherwise intact."
Patient was transferred to ___ for further evaluation. In
___ ED, initial vitals were: 98.1 68 109/66 21 96%. Neuro
oncology was contacted who recommended Keppra load of 1000mg and
admit to OMED. On admission, vitals were: 68 108/68 20 97%.
ROS: Patient endorses ___ difficulties. Says memory
has gotten worse over the past ___ days. Has chills but no
documented fevers. Nausea, which she relates to anxiety.
Denies vision change, shortness of breath, chest pain, change in
stools, dysuria, or other concerning signs or symptoms.
Past Medical History:
--Metastatic renal cancer
--Hypertension
--Hyperlipidemia
--Ostomy for incontinence
--Depression
--COPD
Social History:
___
Family History:
No family history of malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 68 108/68 20 97%
GENERAL: No acute distress, lying in bed, pale
HEENT: Mucous membranes slightly dry
NECK: No cervical, submandibular, or supraclavicular LAD
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, light brown stool in ostomy, ___,
___
EXTREMITIES: No edema bilaterally
NEURO: Alert and oriented, forgetful about some parts of her
medical history (she says this is not normal), CN ___ grossly
intact, strength ___ in upper and lower extremities, cerebellar
signs not done, gait deferred
Pertinent Results:
___ 05:45PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 05:45PM ___ this
___ 05:45PM ALT(SGPT)-23 AST(SGOT)-36 ALK ___ TOT
___
___ 05:45PM ___
___ 05:45PM ___
___
___ 05:45PM ___
___
___ 05:45PM ___
___
___ 05:45PM ___
___
___ 05:45PM PLT ___
___ 05:45PM ___ ___
CXR ___: FINDINGS: Frontal and lateral views of the chest
were obtained. There is persistent blunting of the costophrenic
angles and possible minimal pleural thickening bilaterally,
which is unchanged in appearance since the prior study. Chain
sutures are again seen overlying the right ___
hemithorax. Slight upper lobe patchy opacity are seen which
could be due to aspiration or infection and are of indeterminate
acuity. No pleural effusion is seen. There is no evidence of
pneumothorax. The cardiac and mediastinal silhouettes are
stable. Surgical clips are partially seen in the upper
abdomen.
.
___ read:
Preliminary ReportNo infarct or hemorrhage. No evidence of
abnormal enhancement or masses
Preliminary Reportwithin the confines of the study.
.
Head CT:
IMPRESSION:
Interval development of a small ___ hemorrhage at the
cranioplasty site, without mass effect on the adjacent brain.
.
Micro
___ flora
Brief Hospital Course:
Pt is a ___ y.o female with h.o metastatic RCC to the skull s/p
cyberknife on chemo, HTN, HL, s/p ostomy for incontinence,
depression, COPD who was admitted with suspicion of new seizure,
c/b possible encephalopathy.
.
#Seizure, convulsive: No clear suggestion of infection or
metabolic cause. Pt was on tramadol as an outpatient which can
decrease the seizure threshold. This was discontinued. Primary
concern remained for metastasis. OSH CT was without acute
findings. However, CT at ___ concern for small hemorrhage near
craniotomy site. Unclear if this could precipitate seizure. The
patient was loaded on keppra and started on this medication.
Given, no fever, leukocytosis, or signs of meningitis, there was
no current indication for LP. Given, pt's history of depression,
there was some consideration of changing keppra to an
alternative AED and it was decided on ___ to transition over to
depakote. Pt was given a final dose of keppra on ___ and a
depakote load of 1500mg. Depakote was started at 750mg BID on
___. Neurosurgical did not think there was anything to do
regarding the possible small intracranial hemorrhage. ___
recommended transitioning to depakote and checking a level on
___ AM, and the ___ will draw this and fax to Dr. ___
(___) and Dr. ___. She has follow up with oncology
at ___, ___ in 2 weeks. She is discharged home with a
walker.
.
#chronic headache/intracranial ___ has a h.o
headaches. She is s/p cyberknife therapy for frontal skull vs.
frontal lobe metastasis, details unclear. Headache and possible
small bleed were felt to be due to fall after seizure. As
above, initial OSH CT unrevealing for acute process. No fever or
leukocytosis or signs of meningitis. However, CT at ___
revealed small extraaxial hemorrhage which was very small and
possibly related to trauma from fall. The neurosurgical service
was consulted and did not have further recommendations. The
neurooncology service recommended transition to depakote for
seizure prophylaxis. Her tramadol was discontinued and she was
started on PO oxycodone and acetaminophen therapy.
-headache is semiacute, on chronic (was taking meds at home)
.
#Encephalopathy, NOS vs. mood ___ exhibited some frontal
disinhibition as well as mood lability during admission. Per her
home SW, and PCP she has exhibited lability in the past and has
had some cognitive impairments after her prior surgery. Seemed
as though disinhibition and emotional lability were increased
during this admission, though decreased prior to discharge. It
is theoretical that this could be atypical manifestation of
concussion, or from keppra (was discontinued), vs. acute
exacerbation of her depression/stress related to her current
medical and social condition (finances, divorce). Social work
was consulted as well as ___ and OT who recommended rehab, but
patient refused, so will go home with increased services. Pt was
given PO ativan with good effect. Pt has ___ TIWK, home health
aids who help her clean weekly and help with her finances, and
home Soc worker. She will get ___ services too.. She has a
friend who helps with her cat. Her husband according to SW,
appears agreeable by phone, but patient reports he's not that
helpful to the patient. Pt does have a therapist, but stated
that she has been unable to see her therapist due to financial
concerns (of note, it appears that her finances are helped by
social worker, but pt has some cognitive deficits and forgets
her PINs and then reports having difficulty with fiances. She
has insurance. She is discharged to home with increased
services and will follow up with neurooncology ___.
.
#metastatic ___ on pazopanib as outpt, held during admission.
OK to restart upon discharge. follow up with oncologist ___
.
#adrenal ___ hydrocortisone and
fludricortisone at home doses.
.
#HTN, ___ home meds
.
#depression- Continued outpt sertraline and remeron. Social work
was consulted. Pt expressed that she has a therapist in the
outpatient setting and that financial concerns have been a
barrier in the outpatient setting. She will benefit from
continued support by social work and therapist.
.
DVT PPx:hep SC TID
.
CODE: DNR/DNI
.
Transitional (external):
-continued SW and therapist support for ongoing depression and
social situation
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of breath
2. Atenolol 100 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
Please hold for SBP <100.
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Hydrocortisone 15 mg PO BID
6. Mirtazapine 15 mg PO HS
7. Sertraline 200 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. pazopanib *NF* 400 mg Oral QD
10. TraMADOL (Ultram) 50 mg PO Q8H:PRN Headache
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Fludrocortisone Acetate 0.05 mg PO DAILY
4. Hydrocortisone 15 mg PO QAM
5. Hydrocortisone 10 mg PO QPM
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Mirtazapine 15 mg PO HS
8. Sertraline 200 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. pazopanib *NF* 400 mg Oral QD
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Acetaminophen 1000 mg PO Q8H:PRN headache
available over the counter
13. Divalproex (DELayed Release) 750 mg PO BID
RX *divalproex [Depakote] 250 mg 3 tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*0
14. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN severe
pain
RX *oxycodone 5 mg ___ to1 tablet(s) by mouth q6hr; prn Disp
#*60 Tablet Refills:*0
15. Outpatient Lab Work
Dx = Convulsive Seizure ICD 345.10. Please draw "depakote"
level on ___ and fax result to Dr. ___
and Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure w/ fall, small head bleed
metastatic renal cell carcinoma
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted for evaluation of a seizure. For this, you
were started on a new medication called depakote to help prevent
further seizures. In addition, you had a head imaging (CT scan)
that showed concern for a possible small bleed and you were
evaluated by the neurosurgical service. In addition, you
underwent an MRI that showed which did not show anyhing further
though was limited by motion artifact. You were evaluated by the
physical therapists as well as occupational therapists who felt
that you wouild be ideally served in rehab. You declined to go
to rehab so services are being increased for you at home.
Please take acetaminophen and oxycodone for any residual
headache. Please follow up with your physicians.
Followup Instructions:
___
|
10610402-DS-13 | 10,610,402 | 26,618,763 | DS | 13 | 2146-04-27 00:00:00 | 2146-04-27 14:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ first year college student from ___ who presents
with 2 days of abdominal pain that started ___ and
over time progressed most to RLQ but also has pain in LLQ. He
has
been able to eat without nausea or vomiting. He has no urinary
symptoms or tenesmus. He reports chills but no fevers. He has
never had pain like this before and no bowel irregularity in
past.
Past Medical History:
Past Medical History: denies
Past Surgical History: tooth extraction
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: T 98.4 HR 78 BP 126/64 RR 18 100% RA
GEN: A&O, NAD
CV: RRR
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, non distended, TTP most in RLQ but also in LLQ and
___, guarding in RLQ
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.2 PO 95/47 72 16 98 RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 04:00PM BLOOD WBC-16.3* RBC-5.14 Hgb-14.6 Hct-44.9
MCV-87 MCH-28.4 MCHC-32.5 RDW-12.7 RDWSD-40.0 Plt ___
___ 04:00PM BLOOD Glucose-115* UreaN-13 Creat-1.0 Na-136
K-4.4 Cl-97 HCO3-26 AnGap-17
___ 04:00PM BLOOD ALT-8 AST-18 AlkPhos-75 TotBili-1.1
Imaging:
CT abd: Acute uncomplicated appendicitis
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT revealed acute uncomplicated appendicitis.
WBC was elevated at 16. The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
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:
Dear Mr. ___,
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 at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10610424-DS-9 | 10,610,424 | 23,750,968 | DS | 9 | 2165-12-07 00:00:00 | 2165-12-10 22:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
testicular pain/fever and cough
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
The pt is a ___ previously healthy presenting in the ED with
week long episode of cough and fever which progressed from runny
nose and sneezing. He reports cough productive of green sputum.
Denies any fevers prior to today. Also denies dyspnea. No
history of asthma, but does smoke. Since developing cough he has
cut back on cigarette use since it makes his breathing worse. No
sick contacts. He had pneumonia once as a child but never since
then.
In addition, yesterday he started developing ___
sharp,nonradiating, testicular pain aggravated with movement or
coughing. He also noticed scrotal pain and swelling. His
testicular pain is what brought him to the ED. He reports one
episode of diarrhea yesterday and has not had a bowel movement
today. No N/V, no dysuria.
He also reports one sexual encounter one two weeks ago. Initial
referral noted that encounter was unprotected, but he reports
condom use. He received yearly HIV testing, with most recent
testing in ___ or ___.
In the ED, initial vitals were: 100.4 109 112/66 18 97% RA
- Labs were significant for leukocytosis of 11.8, lactate 1.0,
UA with 98 WBCs and negative nitrites
- Imaging revealed:
CT Abd/Pelvis:
Right inguinal hernia containing vessels and fat with
associated fat
stranding. No evidence of upstream small bowel abnormality.
Scrotal US:
1. Asymmetrically increased fat in the right inguinal canal may
represent a right inguinal hernia.
2. Normal appearance of bilateral testes and epididymides.
CXR:
Right middle lobe and left lower lobe regions of consolidation
which may represent pneumonia given patient's history. Repeat
after treatment suggested to document resolution.
He was seen by surgery, who felt that hernia was not
strangulated or incarcerated, and that he could have outpatient
follow up.
- The patient was given 1g CTX, 500mg azithromycin, 2L NS, 5mg
IV morphine, and 1g tylenol
Vitals prior to transfer were: 98.7 86 101/57 18 94% RA
Upon arrival to the floor, initial vitals were 98.5 101/58 77
20 95% RA.
Past Medical History:
None.
Social History:
___
Family History:
Mother died of amyloidosis. Two brothers with inguinal hernias
Physical Exam:
=== ADMISSION PHYSICAL EXAM ===
Vitals: 98.5 101/58 77 20 95% 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, R groin and scrotum warm, erythematous, and
tender to palpation
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact
=== DISCHARGE PHYSICAL EXAM ===
Vitals: T 98.4 111/63 73 18 95% RA General: Alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM. PERRLA.
Lungs: Bilateral lower lungs with wheeze. Scattered crackles in
RML.
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
Genital: R inguinal area with pain to palpation. R testicle with
pain to palpation, slight erythema on overlying scrotum, slight
swelling. L testicle and groin area without pain. No rash.
Ext: Warm, well perfused, no edema.
Skin: No rash noted.
Neuro: Alert, moving all extremities. CN II-XII intact. ___
strength in bilateral upper and lower extremities.
Pertinent Results:
=== ADMISSION LABS ===
___ 03:03PM BLOOD Lactate-1.0
___ 03:03PM BLOOD Lactate-1.0
___ 02:48PM BLOOD Glucose-107* UreaN-11 Creat-0.9 Na-135
K-4.2 Cl-99 HCO3-26 AnGap-14
___ 02:48PM BLOOD Neuts-76.1* Lymphs-11.0* Monos-11.9
Eos-0.3* Baso-0.1 Im ___ AbsNeut-8.99* AbsLymp-1.30
AbsMono-1.41* AbsEos-0.03* AbsBaso-0.01
___ 02:48PM BLOOD WBC-11.8* RBC-4.11* Hgb-13.8 Hct-37.2*
MCV-91 MCH-33.6* MCHC-37.1* RDW-11.3 RDWSD-37.2 Plt ___
=== IMAGING ====
___ Scrotal Ultrasound
IMPRESSION:
1. Asymmetrically increased fat in the right inguinal canal may
represent a right inguinal hernia.
2. Normal appearance of bilateral testes and epididymides.
___ CXR
IMPRESSION:
Right middle lobe and left lower lobe regions of consolidation
which may
represent pneumonia given patient's history. Repeat after
treatment suggested to document resolution.
___ CTAP
IMPRESSION:
1. Asymmetric thickening within the right inguinal canal
suggests inflammation
or infection involving the spermatic cord, in the setting of
UTI.
2. Scattered areas of consolidation within bilateral lung bases
suggests an atypical pulmonary infection.
NOTIFICATION: The updated impression above was discussed by Dr.
___
___ with Dr. ___ on the telephone on
___ at 22:34, 8 minutes after the discovery of the
findings.
=== MICROBIOLOGY ===
___ Sputum Cx: ___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
___ Serology RPR: Non-Reactive.
___ BCx pending
___ UCx: <10,000 organisms/ml.
___ Urine chlamydia and gonorrhea: Negative for Chlamydia
trachomatis by PANTHER System, APTIMA COMBO 2 Assay. Negative
for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2
Assay.
___ BCx pending
=== DISCHARGE LABS ===
___ 06:40AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-140 K-4.3
Cl-103 HCO3-28 AnGap-13
___ 06:40AM BLOOD WBC-9.5 RBC-4.01* Hgb-13.0* Hct-37.2*
MCV-93 MCH-32.4* MCHC-34.9 RDW-11.5 RDWSD-39.0 Plt ___
___ 06:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
Brief Hospital Course:
=== SUMMARY ===
___ with no significant PMH who presented with fever, testicular
pain, and cough.
=== ACUTE ISSUES ===
# Pneumonia: Patient presented with one week of productive cough
and one day of fevers. In ED patient was tachycardic (109) and
febrile (100.4). CXR performed was consistent with atypical
pneumonia and patient was started on azithromycin and
ceftriaxone. Patient was discharged on levofloxacin 10 day
course to treat both pneumonia and vasitis.
# Vasitis: Patient presented with 1 week of discomfort with
urinating that evolved into dysuria and hematuria. Came into ED
yesterday due to acute onset non-radiating groin pain. Reported
sexual encounter prior week (MSM). Scrotal ultrasound performed
in ED ruled out testicular torsion. CTAP did not show evidence
of hernia but did show asymmetric thickening within the right
inguinal canal suggests inflammation or infection involving the
spermatic cord. UA with 98 WBC, 13 RBC, few bacteria, and
negative nitrites. Patient received IV ceftriaxone and
azithromycin per above. Additionally received IM ceftriaxone
dose in hospital and was discharged on 10 day course of
levofloxacin to treat pneumonia, possible chlamydia infection,
and vasitis in an MSM patient.
=== CHRONIC ISSUES ===
None.
=== TRANSITIONAL ISSUES ===
#Pneumonia: Patient diagnosed with atypical pneumonia and
discharged on 10d levofloxacin. Please follow up for resolution
of symptoms.
#Vasitis: Patient presented with acute onset groin pain that was
ruled out for testicular torsion and incarcerated hernia. Was
treated for inflammation of spermatic cord seen on CT-AP with IM
CTX and discharged on 10 day levofloxacin course. Was
additionally prescribed 10 pills oxycodone 5mg for pain. Please
follow up and assess for resolution of symptoms.
#Hernia: Scrotal ultrasound showed increased fat in the right
inguinal canal may represent a right inguinal hernia but no
herniation was noted on CTAP. Patient advised to avoid heavy
lifting for next ___ days at least. Please follow up and assess
for evidence of hernia.
#HIV Testing: Patient reports sexual encounter week prior. HIV
testing was not performed in hospital. Please follow up and
consider HIV testing if clinically appropriate.
Code Status: Full
HCP: None Selected
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 10 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
1. Atypical pneumonia
2. Vasitis
SECONDARY DIAGNOSIS:
====================
None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted due to cough, fever, and pain in your groin. A
chest xray was performed and your cough and fever were
determined to be due to a pneumonia. The pain in your groin was
felt to be due to an infection of one of the structures in your
scrotum, the "spermatic cord." You were evaluated by surgery in
the emergency room and they did not feel that you needed any
surgical intervention at this time. We treated your pneumonia
and groin infection with antibiotics that you will continue
after you are discharged. Please avoid lifting heavy objects for
at least the next ___ days.
We wish you a speedy recovery!
- Your ___ Care Team
Followup Instructions:
___
|
10610461-DS-27 | 10,610,461 | 29,561,102 | DS | 27 | 2151-10-15 00:00:00 | 2151-10-18 17:28:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Shellfish Derived / Ciprofloxacin / Infliximab /
Optiray 350 / Remicade
Attending: ___.
Chief Complaint:
Bloody diarrhea
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
___ with hx of inseterminate colitis on Cimzia and also with
irritable bowel syndrome presenting with increasing bloody bowel
movements for 4 days. She reports > 10 episodes of bloody
diarrhea associated with diffuse abdominal pain. She denies
fever, chest pain, shortness of breath. She reports nausea but
no vomiting. She was referred to the ED by her
gastroenterologist, Dr. ___. In the ED, her initial VS were
98.7 91 131/90 16 100%. Pain was ___ and was minimally
improved with IV narcotics. A CT scan was non-specific. Stool
was negative for OB. Vitals on transfer: 126/89 74 18 RA 98.2PO
.
Currently, she complains of ___ pain. She states that her
symptoms began on ___ and are charachterized by crampy
abdominal pain associated with loose stools and increased stool
frequency with bright red blood that is around the stool, in the
toilet and on the toilet paper. She has urgency and has almost
had fecal incontinence. She reports tenesmus. Her pain is
partially releived by passage of stool but she feels a sensation
of incomplete evacuation. Her stool is not greasy or high
volume. She has had nausea and two episodes of emesis on ___,
non-bloody. It is not associated with eating though her appetite
has been poor. She has had no significant changes in diet though
she did eat steak fajitas on ___ night. She had minimal
alcohol consumption (a sip of wine) and did not have excessively
greasy food. She has had no sick contacts or recent travel. Her
children have not had diarrheal illnesses. No NSAIDS. No recent
antibiotics. No other medication changes. She had been
prescribed vicodin and flexeril for back pain but has not needed
these recently. She has lost a few pounds. Her last menstrual
period was ___ (ending on the day her symptoms began). She
has had increased stress as her children were with their father
for the holidays and she missed them. She was also at a party on
the day of her symptom onset and someone brought shellfish into
the room and this led to nearly a panic attack due to her
allergy, though she denied allergic symptoms.
.
In comparison to her prior flares, she states this seems
similar. The only atypical aspect is that her last cimzia dose
was on the ___ prior to her symptoms onset and she usually
feels well after the cimzia.
.
REVIEW OF SYSTEMS:
Denies fever though has felt "clammy", headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, dysuria, hematuria.
Past Medical History:
BD: indeterminate colitis: ANCA- and ASCA IgA-positive. First
diagnosed in ___. S/p sulfasalazine, mesalamine, prednisone,
infliximab, then bimonthly certolizumab since ___.
Congenital hypothyroidism
Depression
Functional bowel disorder.
C. diff in ___.
ADHD.
Anxiety.
Menstrual-related ocular migraines.
Preeclampsia.
Rhinoplasty in the past.
Gastroesophageal reflux disease
h/o Bells palsy
back pain
Social History:
___
Family History:
No family history of inflammatory bowel disease or irritable
bowel syndrome. Maternal grandmother had colon cancer and died
of pancreatic and ovarian cancer. Mother had breast cancer.
Physical Exam:
VS - Temp 96.7 F, BP 112/82, HR 88, R 18, O2-sat 97% RA
GEN: NAD
HEENT: no oral lesions, MMM
NECK: supple
LUNGS: CTAB, no w/r/r
CV: rrr no m/g/r
ABD: s/nd, tender throughout, normoactive bowel sounds
EXT: wwp, no c/c/e
SKIN: no rash
MSE: tearful
DRE: external hemmorhoids, no stool, no blood
.
Pertinent Results:
ADMISSION:
___ 02:30PM BLOOD WBC-5.4 RBC-4.70 Hgb-11.8* Hct-36.4
MCV-78* MCH-25.1* MCHC-32.4 RDW-14.5 Plt ___
___ 02:30PM BLOOD Neuts-43.3* Lymphs-51.9* Monos-3.9
Eos-0.5 Baso-0.3
___ 07:45AM BLOOD ___ PTT-34.7 ___
___ 07:45AM BLOOD ESR-15
___ 07:45AM BLOOD CRP-0.5
___ 02:30PM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-28 AnGap-13
___ 07:45AM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.4 Mg-2.1
___ 07:45AM BLOOD ALT-13 AST-17 AlkPhos-58 TotBili-0.7
DISCHARGE:
___ 09:40AM BLOOD WBC-4.2 RBC-4.48 Hgb-11.2* Hct-34.2*
MCV-76* MCH-24.9* MCHC-32.6 RDW-14.2 Plt ___
___ 09:40AM BLOOD Glucose-105* UreaN-15 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-27 AnGap-11
___ 09:40AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.0
MICROBIOLOGY:
___ 11:47 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
VIRAL CULTURE (Pending):
REPORTS
CT ABD & PELVIS W/O CONTRASTStudy Date of ___ 6:33 ___
1. Distal loops of the descending and sigmoid colon show mildly
thickened
walls which likely represent chronic changes related to the
patient's
inflammatory bowel disease. No acute Crohn's flare or bowel
obstruction.
2. No secondary signs of appendicitis.
3. Epigastric fat containg hernia.
4. Bilateral sacroiliac disease noted.
SIGMOIDOSCOPY:
Impression: Abnormal vascularity in the sigmoid colon (biopsy)
Erythema in the rectum (biopsy). Otherwise normal sigmoidoscopy
to splenic flexure
Recommendations: Await biopsy results. No evidence of active
colitis or etiology of diarrhea and bleeding could be seen.
Symptomatic management now, f/u with inpatient GI consult team.
PATHOLOGY
Pathology ReportTissue: GI BX'S (2 JARS)Study Date of ___
PENDING
Brief Hospital Course:
___ with h/o IBD and coexisting IBS with recurrent flares of
abdominal pain / loose stools without concurrent endoscopic
pathology presenting with abdominal pain and bloody diarrhea.
.
# abdominal pain, bloody diarrhea, h/o colitis:
The patient was worked up extensively and remained afebrile,
normal white count, normal exam and was guiac negative twice.
Her CT abdomen was negative for any acute findings as was her
CRP, ESR. Her stool cultures including c diff toxin were also
negative. GI was consulted for a sigmoidoscopy, which revealed
normal mucosa, although biopsy results are pending. GI and the
primary team's assessment was that IBD flare, infection were
ruled out and that her symptoms were most consistent with an IBS
flare. The patient took some comfort in this reassurance and was
started on dicyclomine; unfortunately this caused throat
tightness and was discontinued. SW was consulted to provide some
support as it seemed marital pressures with her ex-husband
triggered some of her IBS symptoms. She was discharged on her
home hyocyamine which she was not taking due to misunderstanding
its use (this was reexplained to her), and given a script for
lomotil to address acute IBS flare in the future. Follow up was
arranged with her primary gastroenterologist Dr. ___
the following week after discharge.
.
# Depression, Anxiety
tearful
-continued celexa, Ativan
-social work consulted who provided emotional support
.
# IBD
See above under abdominal pain
.
# hypothyroidism
Continued home synthroid
.
# GERD
-continued Prilosec
.
Medications on Admission:
citalopram 40 mg Tab 1 Tablet(s) by mouth once a day
Cimzia 400 mg (200 mg x 2) Sub-Q Kit 400 mg Twice monthly
lorazepam 1 mg Tab ___ Tablet(s) by mouth at bedtime as needed
Omeprazole 20 mg Cap, BID
Synthroid ___ mcg Tab 1 tablet by mouth daily
Hyoscyamine SR 0.375 mg 12 hr Tab 1 Tablet(s) by mouth twice a
day
Flovent 2 puffs inh BID prn excercise induced wheezing
diphenhydramine 25 mg once a day prn allergy
Epinephrine 0.3 mg/0.3 mL (1:1,000) IM Pen Injector
.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: Two (2) Capsule,Extended Release 12 hr PO BID (2 times a
day).
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomina.
6. Lomotil 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Exacerbation of Irritable Bowel Syndrome (IBS)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you at ___ today. You were
admitted for abdominal pain and bloody diarrhea, most likely due
to a flare of your Irritable Bowel Syndrome (IBS). The blood in
your stools were most likely secondary to excessive bowel
movements, frequent wiping, and hemorrhoids. This was confirmed
by CT scan and colonoscopy which showed no features to suggest
this was a flare of your Inflammatory Bowel Disease, which is
very good news. We have worked closely with the Gastroenterology
team here and have discharged you with the following plan:
1) Early appointment with Dr. ___ Gastroenterologist
for follow-up.
2) To continue your Hyoscyamine which well help with your
abdominal discomfort and diarrhea.
3) In addition, we will start you on Lomotil, a drug that will
also help prevent diarrhea as needed.
Followup Instructions:
___
|
10610461-DS-30 | 10,610,461 | 24,287,795 | DS | 30 | 2153-12-26 00:00:00 | 2153-12-26 22:38:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Shellfish Derived / Ciprofloxacin / Infliximab /
Optiray 350 / Remicade / Feraheme
Attending: ___.
Chief Complaint:
increased diarrhea and abdominal pain x weeks
Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
History of Present Illness:
___ with hx of IBD, depression, anxiety, GERD presenting with
increase in diarrhea, unable to tolerate PO steroids ___ nausea
and vomiting. Pt reports that she has a long history of IBD,
indeterminate colitis, with last significant flare in ___. She
and her boyfriend describe 1 month history of increased BMs,
with bright red blood mixed in with stool, ___ watery BMs
daily. She endorses night sweats, subjective fevers, chills, and
insomnia at home, and wonders if some of these symptoms are
related to perimenopause. She has had abdominal pain associated
with her diarrhea, which is intermittently spasming, stabbing,
and a constant ache. The spasms and stabbing pain reaches ___
at its worst, and is very transiently relieved with defecation.
She describes oral intake exacerbating her diarrhea. Dr ___,
___ primary gastroenterologist, prescribed prednisone 20 mg
daily on ___ for IBD flare, without improvement in her
symptoms. The day prior to presentation, she spoke to her
gastroenterogist, who advised admission to hospital for IV
steroids and evaluation for remicaide, but pt declined. On the
evening prior to presentation, she developed nausea with
nonbloody bilious emesis, increased frequency of stools, and
presented to ED on ___. She endorses lightheadedness on the
evening prior to presentation, without syncope or LOC. She
denies CP, SOB, cough, rhinorrhea, rash. No sick contacts.
In the ___ ED:
99.1 HR 70, BP 126/92, RR 19, SaO2 100% RA
Received:
NS 1L x2
Ondansetron 4 mg IV x1
Morphine sulfate 5 mg IV x3
Methylprednisone 20 mg IV x1
10 pt ROS reviewed and negative except as otherwise noted above.
Past Medical History:
Inflammatory bowel disease, indeterminate colitis, last dose
Cimzia early ___, plan to consider transition to IV
remicaide, to which she has previously had allergic reaction
Congenital hypothyroidism
Depression
Functional bowel disorder
C. difficile colitis in ___
ADHD
Anxiety
Menstrual-related ocular migraines
Preeclampsia
S/p rhinoplasty
Gastroesophageal reflux disease
H/o Bells palsy
Chronic low back pain
Social History:
___
Family History:
No family history of inflammatory bowel disease or irritable
bowel syndrome. Maternal grandmother had colon cancer and died
of pancreatic and ovarian cancer. Mother had breast cancer.
Physical Exam:
Admission Physical Exam:
VS: 99.4, HR 59, BP 122/85, RR 16, 99% RA
Gen: Pleasant female, lying in bed, alert, interactive, NAD
HEENT: PERRL, EOMI, oropharynx clear without ulcers, MMM
CV: RRR, no m/r/g
Pulm: CTAB, bibasilar crackles clear with cough
Abd: soft, nondistended, hyperactive bowel sounds. Tender to
palpation throughout, endorses rebound tenderness, with
intermittent guarding. Maximal TTP at periumbilical region.
Ext: WWP, trace bilateral nonpitting edema, no clubbing or
cyanosis
Skin: No rash or lesions
Neuro: grossly intact
Discharge Physical Exam:
Vital Signs: 98.5 ___ 18 98%RA
Glucose: 92 87 161 108 94
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
RESP: CTA B
ABD: S/ND, BS present, TTP throughout without any rebound or
guarding
EXT: trace pitting BLE edema, mild bilaterally TTP in the calves
and the shins
Pertinent Results:
Admission Labs:
___ 09:44AM BLOOD WBC-6.0 RBC-4.79 Hgb-12.9 Hct-41.0 MCV-86
MCH-26.9* MCHC-31.4 RDW-13.6 Plt ___
___ 09:00AM BLOOD Neuts-53.2 ___ Monos-4.3 Eos-0.8
Baso-1.6
___ 09:44AM BLOOD UreaN-17 Creat-1.0 Na-136 K-4.5 Cl-98
___ 09:44AM BLOOD ALT-13 AST-19 AlkPhos-71 TotBili-0.6
___ 09:44AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 09:44AM BLOOD ESR-12
___ 09:44AM BLOOD CRP-0.2
___ 09:15AM BLOOD Lactate-1.3
___ 09:00AM BLOOD Lipase-33
QUANTIFERON(R)-TB GOLD NEGATIVE
___ 09:10AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:10AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 09:10AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
Discharge Labs:
___ 07:40AM BLOOD WBC-8.3 RBC-4.27 Hgb-11.7* Hct-35.8*
MCV-84 MCH-27.3 MCHC-32.5 RDW-14.2 Plt ___
___ 07:40AM BLOOD Glucose-87 UreaN-24* Creat-0.9 Na-138
K-3.4 Cl-101 HCO3-30 AnGap-10
___ 07:40AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.3
====================================
MICROBIOLOGY:
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Stool Viral Cx PENDING
Blood cx PENDING
====================================
IMAGING:
KUB - FINDINGS:
Air seen within the non-dilated loops of small bowel and colon.
There is no obstruction or ileus. There is no intraperitoneal
free air. L4-L5 fusion hardware is noted without complication
evident.
IMPRESSION: Non-obstructive bowel gas pattern without ileus or
obstruction.
Flex Sig - Impression:
Normal mucosa in the to 40cm (biopsy)
Otherwise normal sigmoidoscopy to 40cm
PATHOLOGIC DIAGNOSIS:
Colon biopsies (see note):
1A. Sigmoid: No diagnostic abnormalities recognized.
2A. Rectum: Active cryptitis, minimal.
Note: No dysplasia or granuloma identified; stains for CMV are
negative; control satisfactory.
Brief Hospital Course:
___ with hx of IBD, depression, anxiety, GERD presenting with
increase in diarrhea, unable to tolerate PO steroids ___ nausea
and vomiting, admitted for IV steroids in setting of IBD flare.
# Indeterminate Colitis: The patient presented and was
clinically stable. Stool cx were negative. Per pt, consistent
with prior episodes of IBD flares. Unable to tolerate PO
steroids which have previously worked for her. Recent
colonoscopy with active colitis. GI was consulted and the
patient was placed on IV solumedrol. Flex sig, however, showed
Flex no active disease, indicating healing from recent
colonoscopy showing colitis. At that point, she was transitioned
back to PO steroids. Current symptoms were felt likely related
to IBS superimposed on healing IBD. She was scheduled for
outpatient Remicade infusions for maintenance therapy. She was
discharged on slow prednisone taper as well as dicyclomine for
symptomatic relief. Please see GI OMR note dated ___ for
full details of GI discharge plan.
Chronic Issues:
# Anxiety:
- Continue home lorazepam
# Hypothyroidism:
- Continue home levothyroxine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Levothyroxine Sodium 175 mcg PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
5. Vitamin D 400 UNIT PO DAILY
6. Calcium Carbonate 500 mg PO Frequency is Unknown
7. Lorazepam ___ mg PO HS:PRN insomnia
8. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Lorazepam ___ mg PO HS:PRN insomnia
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. Calcium Carbonate 500 mg PO Frequency is Unknown
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Vitamin D 400 UNIT PO DAILY
8. DiCYCLOmine 10 mg PO BID
RX *dicyclomine 10 mg 1 capsule(s) by mouth two times a day Disp
#*60 Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY
Please follow taper as listed in discharge paperwork.
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*140
Tablet Refills:*0
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Do not take more than prescribed. Use caution with this
medication, as it may cause drowsiness.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4 -
6 hours as needed Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for evaluation of your colitis. You
were given IV steroids for several days. You had a flexible
sigmoidoscopy, which fortunately showed improvement in your
colitis. You will follow-up as below for further treatment for
your colitis (Remicade).
You will use the following prednisone taper:
First take 40 mg (4 tablets) for 2 weeks
Then take 30 mg (3 tablets) for 2 weeks
Then take 20 mg (2 tablets) for 2 weeks
Then take 10 mg (1 tablets) for 2 weeks
Then discuss further prednisone dosing with Dr. ___.
You can take over-the-counter Colace (docusate) and Senna for
constipation as needed.
It was a pleasure taking part in your medical care.
Followup Instructions:
___
|
10610461-DS-32 | 10,610,461 | 29,423,037 | DS | 32 | 2156-03-06 00:00:00 | 2156-03-06 18:13:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Shellfish Derived / Ciprofloxacin / Infliximab /
Optiray 350 / Remicade / Feraheme / Celexa / Iodinated Contrast
Media - IV Dye / propofol
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of Crohn's colitis
(on vedolizumab), IBS and anxiety who presents with fever and
vomiting after recent colonoscopy.
Two days prior to admission, she started taking magnesium
citrate for routine colonoscopy prep. She had two episodes of
emesis within 10 minutes of drinking the solution, but then she
was able to finish the prep. Yesterday she had her colonoscopy
and received propofol for sedation. She notes she has not had
propofol before. The procedure went well with no issues. Upon
returning home, she had acute onset of chills (with temp to 103)
and intractable emesis (7 episodes in 15 minutes). After several
bouts of emesis she noted small amounts of blood in her vomit.
Given these symptoms she decided to present to the ED. En route,
her emesis turned to dry heaves. She noted some headaches which
she associated with dehydration.
The patient notes she has chronic cold-like symptoms that she
attributes to working at a daycare. These worsened over the last
five days to include sore throat, sinus congestion and nasal
congestion.
In the ED, initial vitals: 99.4 88 129/85 16 96% RA
Labs were significant for lactate 1.0, no leukocytosis,
electrolytes wnl.
CXR and CT abdomen & pelvis showed no acute pathology.
She developed hives after receiving CT contrast.
In the ED, she received diphenhydramine 50mg (for hives),
morphine IV 4mg x3, 1L NS, ondansetron 4mg IVx2.
She was admitted for uncontrolled symptoms and inability to
tolerate PO.
Vitals prior to transfer: 99.2 86 108/68 16 95% RA
Currently, she has sore throat, nausea and abdominal pain. Last
emesis was when drinking contrast at 3am for CT.
ROS:
As per HPI. Additionally, denies visual changes, chest pain,
shortness of breath, dysuria, arthralgias, myalgias.
Past Medical History:
1. hypothyroidism
2. Crohn's disease
3. irritable bowel syndrome
4. anxiety
5 depression
6. lumbar radiculopathy
7. status post hernia repair in ___
8. asthma
9 lower back pain
Social History:
___
Family History:
No family history of inflammatory bowel disease or irritable
bowel syndrome. Maternal grandmother had colon cancer and died
of pancreatic and ovarian cancer. Mother had breast cancer.
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
VS: 98.4 90 114/84 20 93% RA
GEN: Alert, lying in bed, no acute distress, voice hoarse
HEENT: Dry MM, several ~0.5cm superficial ulcers on tongue,
anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l with occasional wheeze
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended. TTP in RUQ > LUQ, no rebound or
guarding.
EXTREM: Warm, well-perfused, no edema
NEURO: CN III-XII intact, strength ___, sensation intact
throughout
.
>> DISCHARGE PHYSICAL EXAM:
VS: 98.2 ___ 20 97-100% RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, ~0.5cm ulcers on edges of tongue
NECK: Supple without LAD
PULM: CTAB, good air movement throughout
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended. Mildly TTP diffusely, no rebound or
guarding.
EXTREM: Warm, well-perfused, no edema
NEURO: CN III-XII intact, strength ___, sensation intact
throughout
Pertinent Results:
RELEVANT LABS:
___ 04:50AM BLOOD WBC-8.0 RBC-4.73 Hgb-11.6 Hct-37.2
MCV-79* MCH-24.5* MCHC-31.2* RDW-17.6* RDWSD-50.3* Plt ___
___ 01:50AM BLOOD WBC-9.2 RBC-5.03# Hgb-12.3 Hct-38.6
MCV-77* MCH-24.5* MCHC-31.9* RDW-17.9* RDWSD-49.5* Plt ___
___ 01:50AM BLOOD Neuts-75.8* Lymphs-15.9* Monos-7.3
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.93* AbsLymp-1.46
AbsMono-0.67 AbsEos-0.04 AbsBaso-0.02
___ 04:50AM BLOOD Glucose-101* UreaN-5* Creat-0.8 Na-138
K-3.9 Cl-98 HCO3-29 AnGap-15
___ 01:50AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-138
K-3.9 Cl-99 HCO3-27 AnGap-16
___ 01:50AM BLOOD ALT-15 AST-16 AlkPhos-93 TotBili-0.3
___ 01:50AM BLOOD Lipase-29
___ 04:50AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
___ 01:50AM BLOOD Albumin-4.3
___ 01:50AM BLOOD TSH-9.9*
___ 01:50AM BLOOD Free T4-1.4
___ 02:03AM BLOOD Lactate-1.0
.
IMAGING:
CXR ___: No acute cardiopulmonary process.
CT Abd/Pelvis with PO/IV contrast ___:
1. No acute pathology in the abdomen or pelvis. Specifically,
no free air, and no acute splenic injury.
2. Chronic changes related to Crohn's disease along the terminal
ileum.
3. Small hiatal hernia and tiny umbilical hernia with minimal
subcutaneous fat stranding.
4. No evidence of bowel obstruction.
Brief Hospital Course:
___ with Crohn's disease on vedolizumab q6 weeks, anxiety, IBS,
hypothyroidism, who is admitted with vomiting, abdominal pain
and episode of fever.
.
ACUTE ISSUES:
# Abdominal pain, vomiting, fever: Time course of symptoms
suggests this was a reaction to colonoscopy sedation. Notably,
this is the first time she has had propofol. Perforation was
considered but abdominal exam was reassuring and was not
consistent with rapid symptomatic improvement. Gastroenteritis
was unlikely given no diarrhea. Patient's status improved with
pain control, IV fluids, and antiemetics. Did not have any
episodes of emesis on the floor. Diet was advanced from clear
liquids to regular. Was discharged with minimal nausea and
abdominal pain.
# Crohn's disease: Last vedolizumab infusion ___, gets Q6week
infusions. Unlikely to have contributed to this presentation.
.
STABLE ISSUES:
# Benign migratory glossitis/"geographic tongue": Patient's
ulcers are consistent with benign migratory glossitis. Viscous
lidocaine was given with symptomatic improvement.
# Hypothyroidism: continued home levothyroxine
# Asthma: continued home fluticasone, albuterol
.
TRANSITIONAL ISSUES:
# Allergies: CONSIDER ADDING PROPOFOL on allergy list
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (father) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Diazepam 10 mg PO DAILY:PRN pain, spasm
3. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 severe allergic
reaction
4. Vitamin D 400 UNIT PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Levothyroxine Sodium 250 mcg PO DAILY
7. vedolizumab unknown injection Q6weeks
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Diazepam 10 mg PO DAILY:PRN pain, spasm
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Levothyroxine Sodium 250 mcg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 severe allergic
reaction
RX *epinephrine [EpiPen 2-Pak] 0.3 mg/0.3 mL 0.3 mg IM ONCE Disp
#*1 Packet Refills:*0
8. Vedolizumab 300 mg INJECTION Q6WEEKS
9. Vitamin D 400 UNIT PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 2 sprays nasal daily Disp #*1
Bottle Refills:*0
11. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
RX *lidocaine HCl 2 % 15ml by mouth three times a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Nausea/Vomiting
2. Abdominal pain
SECONDARY:
Benign migratory glossitis
Crohn's disease
IBS
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___, it was a privilege caring for you here at
___.
1. Why was I here?
-You came in because of nausea, vomiting and pain after your
recent colonoscopy.
2. What was done while I was here?
-We took a CAT scan of your belly which did not show any acute
changes.
-We gave you medications to control your nausea, vomiting and
pain.
-Your symptoms may have been a reaction to the medicines you
took for your colonoscopy preparation or anesthesia.
3. What should I do when I get home?
-You should make an appointment to see your primary care doctor
in the next ___
-Avoid foods that irritate your tongue, including hot, spicy,
and acidic foods.
-You should take all your medications as prescribed.
Followup Instructions:
___
|
10610461-DS-34 | 10,610,461 | 20,998,907 | DS | 34 | 2158-11-30 00:00:00 | 2158-12-01 15:21:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Shellfish Derived / Ciprofloxacin / Infliximab /
Optiray 350 / Remicade / Feraheme / Celexa / Iodinated Contrast
Media - IV Dye / propofol / Toradol / Gadavist
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o F with history of Crohn's on
Entyvio, hypothyroidism, and asthma, presenting now with
worsening dyspnea, cough, and new n/v, abdominal pain, and
diarrhea.
Of note, patient states she works for a daycare, where she notes
most children/families have been sick over the past few weeks
with both diarrheal and respiratory illnesses. At baseline, her
asthma is mild, requiring only an albuterol inhaler when
suffering from viral URIs. She has never had an asthma
exacerbation requiring hospitalization.
On ___ patient notes she developed a dry cough. She presented
to
an urgent care on ___ for worsening cough, muscle aches, and
subjective fevers. Given her Crohn's disease, she was
empirically
started on Tamiflu without influenza testing. Unfortunately, she
could not tolerate the medication due to vomiting with the
medication. Starting ___, she reports fevers as high as 101 at
home. On ___, patient notes significant episodes of coughing
and
wheezing, and despite the use of her home albuterol inhaler, was
unable to catch her breath, prompting her to call an ambulance.
With EMS, she received nebulizers, which seemed to improve her
symptoms.
Has also had persistent nausea over the past two days, even
after
vomiting up the Tamiflu. She has also had abdominal pain,
accompanied by ___ non-bloody loose BMs daily. Her last Entyvio
infusion was 3.5 weeks ago. Typically, her symptoms are well
controlled for up to 4 weeks afterwards, and usually she can go
6
weeks until receiving another infusion.
In the ED:
- Initial vital signs were notable for:
- T 98.4, HR 104, BP 131/91, RR 18, Sat 95% RA
- Exam notable for:
- Lying in bed, no acute distress. No lesions of oral
mucosa, MMM. Lungs CTAB, no wheezes, rhonchi, or rales.
Good air exchange, no increased work of breathing. RRR,
mildly tachycardic, no murmurs. Abd soft, NTND.
- Labs were notable for:
- CBC: WBC 10.7 Hgb 12.7 Hct 40.5 Plt 370
- BMP: Na 139 K 4.3 Cl 107, HCO3 19, BUN 9, Cr 0.7
- LFTs - WNL
- Trop-T <0.01
- Flu A/B - Negative
- Studies performed include:
- CXR: No acute cardiopulmonary process.
- Patient was given:
- Resp: Ipratropium-Albuterol Neb 1 NEB x4, prednisone 60mg
x1
- Fluids: IVF 5L total
- Pain: IV Morphine 4mg x2
Upon arrival to the floor, patient reiterates story as above.
She
feels her breathing is back to baseline. She has not had any
further diarrhea since yesterday. She continues to have
abdominal
pain, which is mostly located in the upper abdomen. She also
feels slightly more bloated.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
Anxiety
Crohn's disease
Hypothyroidism
Lumbosacral radiculopathy
Asthma
Social History:
___
Family History:
No family history of inflammatory bowel disease or irritable
bowel syndrome. Maternal grandmother had colon cancer and died
of
pancreatic and ovarian cancer. Mother had breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ ___
Temp: 98.2 (Tm 98.2), BP: 123/78 (123-133/78-88), HR: 85
(85-106), RR: 18 (___), O2 sat: 94%, O2 delivery: Ra, Wt:
176.4
lb/80.02 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: MMM. No cervical lymphadenopathy.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft, non-distended, mildly tender to soft palpation
throughout upper abdomen.
EXTREMITIES: Trace lower extremity edema
NEUROLOGIC: CN2-12 grossly intact. Normal strength and sensation
throughout.
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1321)
Temp: 98.6 (Tm 98.6), BP: 110/76 (103-133/70-88), HR: 67
(67-106), RR: 18 (___), O2 sat: 97% (94-97), O2 delivery: Ra,
Wt: 176.4 lb/80.02 kg
GENERAL: Lying in bed comfortably
HEENT: NCAT, mucous membranes moist, oropharynx clear. Neck
supple to palpation.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops.
LUNG: In no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft. Diffusely tender to light
palpation, no rebund or guarding
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ radial pulses
NEURO: Alert, oriented, palate elevates symmetrically, tongue
protrudes midline, motor and sensory function grossly intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 09:37PM BLOOD WBC-10.7* RBC-5.15 Hgb-13.1 Hct-41.7
MCV-81* MCH-25.4* MCHC-31.4* RDW-15.3 RDWSD-45.3 Plt ___
___ 09:37PM BLOOD Neuts-65.0 ___ Monos-5.9 Eos-2.3
Baso-0.2 Im ___ AbsNeut-6.94* AbsLymp-2.80 AbsMono-0.63
AbsEos-0.25 AbsBaso-0.02
___ 09:37PM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-25 AnGap-11
___ 09:37PM BLOOD CRP-3.0
DISCHARGE LABS:
===============
___ 07:35AM BLOOD Glucose-87 UreaN-10 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-22 AnGap-12
___ 07:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0
MICROBIOLOGY:
=============
___ 11:01PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
IMAGING/STUDIES:
================
CXR ___:
IMPRESSION:
No acute cardiopulmonary process.
___ CT Abd/Pelvis w/o Contrast:
FINDINGS:
Minor atelectasis is found in each lower lobe. Small portion of
the hepatic dome is excluded.
Within the limitations of a non-contrast examination, no focal
liver lesions are identified in the visualized portion of the
liver. There is no biliary dilatation. Gallbladder appears
normal. Pancreas spleen and adrenals are unremarkable. No
hydronephrosis involving either kidney. Tiny calcification in
the right mid to upper pole measuring only 2 mm in diameter,
unchanged.
Small to medium-sized hiatal hernia noted. Medium-sized
diverticulum noted along the third portion of the duodenum.
Large bowel is also unremarkable. Short appendix appears normal.
Dominant uterine fibroid measures 44 mm in diameter, decreased
from 53 mm on the prior CT in association with interval uterine
fibroid embolization.
Adnexa appear normal. Bladder appears normal. No free fluid,
free air or
lymphadenopathy.
Moderate degenerative changes affect the sacroiliac joints.
Patient is status post posterior L4-L5 fusion. Mild
spondylolisthesis of L4 on L5 is unchanged. L5-S1 interspace is
moderately narrowed. There are no suspicious bone lesions.
IMPRESSION:
No evidence of acute abnormality involving the abdomen or
pelvis. Decrease in dominant uterine fibroid.
Brief Hospital Course:
Ms. ___ is a ___ y/o F with asthma, Crohn's Disease
on Entyvio, and hypothyroidism, who presented to ___ with
dyspnea, n/v, abdominal pain, and diarrhea, concerning for an
asthma exacerbation and diarrheal illness vs Crohn's Flare in
the setting of a likely viral URI
ACUTE ISSUES:
=============
# Dyspnea
# Asthma Exacerbation
# Viral URI
# Upper Airway Cough Syndrome
Symptoms and history concerning for possible viral URI. Viral
URI likely acted as trigger for patient's underlying asthma
resulting in an asthma exacerbation. Patient returned to
baseline respiratory status following one dose of prednisone
while in emergency department, without wheezing at time of
presentation in the ED or throughout admission, decreasing
suspicion for asthma exacerbation. Flu test negative. Low
concern for PNA based off CXR and CT Chest. Cardiac etiology
also felt to be unlikely in setting of stable EKG, negative
trops. Some suspicion that original trigger for dyspnea may have
been tachycardia iso albuterol use and anxiety. Patient
continuing to endorse cough and congestion with subjective
wheezing while admitted. Patient stating that cough is worst in
the morning and at night before bed with associated sore throat
in the morning raising suspicion for upper airway cough syndrome
as an additional contributor. She was provided with
guifenacin-dextromethorphan for her cough, Tylenol for pain,
albuterol nebs for dyspnea, and was discharged on a course of
inhaled fluticasone and intranasal fluticasone for asthma
complicated by upper airway cough syndrome.
# Diarrhea,
# Nausea/Vomiting
# Crohn's Disease
Patient presented with several days of increased bowel movent
frequency with softer consistency than baseline for her.
endorsed ___ bowel movements per day until presentation in ED.
Differential included infection vs Crohn's flare. However
symptoms were not typical of her Crohn's flares as there was no
blood in her stool, pain was different in character, and her
diarrhea resolved on admission. More likely viral
gastroenteritis +/- Tamiflu GI upset. CT A/P without colitis or
Crohn's. At time of discharge patient was encouraged to
discontinue ibuprofen use in the setting of her Crohn's.
# Sinus Tachycardia
Tachycardia felt to be most likely secondary to dehydration,
possibly worsened in
setting of multiple nebulizer treatments. In addition, suspect
patient's anxiety likely contributing partially to tachycardia.
HR downtrended to wnl over course of hospitalization.
# Hypothyroidism
Patient receives once weekly Levothyroxine infusions due to
concerns for malabsorption of medication in setting of her
Crohn's. Per a letter from her Endocrinologist ___
___, she needed to be seen in ___ clinic for
further dosage adjustment of her medication given her normal
TSH, however she has not yet followed up. Patient care connected
to Endocrinology upon discharge to further discuss dosing.
Patient due for infusion on day of discharge and had outpatient
appointment scheduled. She felt extremely uncomfortable
attending infusion appointment after discharge out of concern
that she could affect other patient's at ___ with illness she
picked up while admitted. She was provided with her scheduled
infusion of 800mcg levothyroxine before discharge so that she
could be discharged directly home.
CHRONIC ISSUES:
===============
#. Anxiety
Continued diazepam 5mg PO daily PRN
NEW MEDICATIONS: Inhaled Fluticasone
TRANSITIONAL ISSUES
===================
[] f/u ibuprofen use
[] Endocrine follow up Scheduled
[] PCP, GI appointments
[] f/u asthma control, to consider DC inhaled fluticasone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 800 mcg IV 1X/WEEK (TH)
2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR
3. Iron Sucrose 200 mg iron/10 mL injection ASDIR
4. vedolizumab 300 mg injection INFUSION
5. Viactiv (calcium-vitamin D3-vitamin K) 650 mg-12.5 mcg-40 mcg
oral DAILY
6. Diazepam 5 mg PO DAILY:PRN anxiety
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
8. fluticasone 44 mcg/actuation inhalation BID:PRN URI
9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
10. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff IH twice
a day Disp #*1 Inhaler Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. Diazepam 5 mg PO DAILY:PRN anxiety
5. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR
6. fluticasone 44 mcg/actuation inhalation BID:PRN URI
7. Iron Sucrose 200 mg iron/10 mL injection ASDIR
8. Levothyroxine Sodium 800 mcg IV 1X/WEEK (TH)
9. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. vedolizumab 300 mg injection INFUSION
11. Viactiv (calcium-vitamin D3-vitamin K) 650 mg-12.5 mcg-40
mcg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Asthma Exacerbation
URI
Upper Airway Cough Syndrome
Sinus Tachycardia
Abdominal Pain
Chron's Disease
Diarrhea
Nausea/Vomiting
Hypothyroidism
Secondary Diagnosis:
====================
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were admitted to the hospital because there was concern
surrounding your elevated heart rates when you came to the
emergency department for wheezing and shortness of breath
What did you receive in the hospital?
- When you were feeling short of breath we gave you nebulizer
treatments to help with this
- We provided you with cough medicine and pain medication to
help with the symptoms of your illness
- We monitored your heart rates and oxygen to make sure they
remained normal while you were in the hospital with us
- In order to help prevent more shortness of breath at home we
started you on a new inhaler and a nose spray
- Since you were due for your levothyroxine dose as an
outpatient on the day you were being discharged we gave that to
you while you were with us in the hospital
What should you do once you leave the hospital?
- Continue to take all your medications as prescribed
- Please follow up with your primary care, GI, and Endocrine
physicians as an outpatient as detailed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
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