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10610574-DS-14 | 10,610,574 | 23,104,581 | DS | 14 | 2135-03-28 00:00:00 | 2135-03-29 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Univasc / Shellfish / Mold/Yeast/Dust / Lyrica / Cozaar /
Tegaderm Transparent Dressing
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ female with Crohn's disease
on
mesalamine and metastatic colon cancer complicated by large
bowel
obstruction s/p diverting loop transverse colostomy and GI bleed
___ duodenal ulcer recently started on FOLFOX who presents with
abdominal pain.
Patient reports 2 days of severe ___ periumbilical sharp
abdominal pain. Pain started suddenly on ___ morning. Pain is
constant but worse with PO intake and movement. She did not take
any pain medications (has script for oxycodone but never filled
as wanted to avoid taking narcotics). She denies nausea and
vomiting. Notes no change in ostomy consistency or output. No
bleeding. Notes decreased PO intake. She called her Oncology
team
who recommended presenting to the ED.
On arrival to the ED, initial vitals were 97.7 ___ 20
100% RA. Exam was notable for soft mildly tender abdomen without
rebound or guarding and ostomy with brown stool. Labs were
notable for WBC 3.7, H/H 10.2/31.5, Plt 160, Na 139, K 5.8
(hemolyzed) -> 4.1, BUN/Cr ___, LFTs/lipase wnl, trop T <
0.01, and negative UA. Urine culture was sent. Abdominal CT did
not show bowel obstruction and demonstrated known extensive
omental and peritoneal nodularity. Patient was given morphine
4mg
IV x 2, zofran 4mg IV, Tylenol ___ PO, pantoprazole 40mg PO,
and 1L LR. Colorectal surgery was consulted and recommended GI
consult and admission to OMED. Prior to transfer vitals were
97.8
88 145/81 18 98% RA.
On arrival to the floor, patient reports improved ___ abdominal
pain. Notes headache due to dehydration and tingling in her
right
foot and hand. She denies fevers/chills, vision changes,
dizziness/lightheadedness, weakness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
IPMN
CROHN'S DISEASE
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
PULMONIC REGURGITATION
SHOULDER ARTHRITIS
KNEE ARTHRITIS
DIVERTICULOSIS
INTERNAL HEMORRHOIDS
OSTEOPENIA
PSORIASIS
SEBORRHEIC KERATOSIS
STASIS DERMATITIS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
MERALGIA PARESTHETICA
G-067
LACTOSE INTOLERANCE
FRUCTOSE INTOLERANCE
CHOLELITHIASIS
DIVERTICULITIS
PAST SURGICAL HISTORY
Diagnostic laparoscopy ___ ___ diagnosis of Crohn's disease)
laparoscopic cholecystectomy ___
Both knee, both shoulder replacement
Tonsillectomy
Tubal ligation ___
breast surgery
hemorrhoidectomy ___
Two back surgeries
Social History:
___
Family History:
No known history of gastrointestinal diseases or malignancies.
Physical Exam:
ADMISSION EXAM:
=========================
ADMISSION PHYSICAL EXAM:
VS: Temp 98.6, BP 100/73, HR 86, RR 16, O2 sat 97% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally.
ABD: Soft, non-tender, mildly distended, positive bowel sounds,
ostomy with semiformed brown stool in the bag.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE EXAM:
=========================
VS: 24 HR Data (last updated ___ @ 841)
Temp: 98.7 (Tm 98.7), BP: 112/68 (110-112/68-73), HR: 91
(85-91), RR: 20 (___), O2 sat: 98% (96-98), O2 delivery: room
air
GENERAL: Pleasant woman, in no distress
HEENT: OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally.
ABD: Soft, non-tender, mildly distended, positive bowel sounds,
ostomy with semiformed brown stool in the bag.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
ADMISSION LABS
=========================
___ 10:05AM BLOOD WBC-3.7* RBC-3.36* Hgb-10.2* Hct-31.5*
MCV-94 MCH-30.4 MCHC-32.4 RDW-13.6 RDWSD-46.4* Plt ___
___ 10:05AM BLOOD Neuts-78.4* Lymphs-15.3* Monos-2.5*
Eos-3.0 Baso-0.5 Im ___ AbsNeut-2.88 AbsLymp-0.56*
AbsMono-0.09* AbsEos-0.11 AbsBaso-0.02
___ 10:05AM BLOOD Glucose-106* UreaN-21* Creat-0.9 Na-139
K-5.8* Cl-104 HCO3-21* AnGap-14
___ 10:05AM BLOOD ALT-12 AST-31 AlkPhos-71 TotBili-0.5
___ 10:05AM BLOOD Lipase-21
___ 10:05AM BLOOD cTropnT-<0.01
___ 10:05AM BLOOD Albumin-3.8
___ 03:14PM BLOOD K-4.1
PERTINENT LABS
=========================
NONE
DISCHARGE LABS
=========================
___ 05:00AM BLOOD WBC-2.7* RBC-2.82* Hgb-8.7* Hct-27.0*
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.5 RDWSD-47.5* Plt ___
___ 05:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-142
K-4.2 Cl-108 HCO3-24 AnGap-10
___ 05:00AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7
STUDIES
=========================
___ CT A/P
IMPRESSION:
1. No evidence of bowel obstruction.
2. Status post diverting loop transverse colostomy, with
redemonstration of a focal concentric area of mural thickening
in the mid to distal descending colon measuring approximately
4.6 cm in length, concerning for possible neoplasm.
3. Extensive omental and peritoneal nodularity is more
conspicuous on the
current study, compatible with metastatic disease.
4. Stable appearance of a 5 mm hyperattenuating lesion within
the pancreatic tail, findings which are nonspecific though
possibly representing a neuroendocrine tumor or intrapancreatic
accessory spleen. Metastatic disease is less likely but cannot
be excluded. Consider nonemergent nuclear medicine study such
as tagged red blood scintigraphy to assess for accessory spleen
or PET-CT to assess for neuroendocrine tumor.
5. Stable 11.6 cm minimally complex septated cyst within the
left lower renal pole, better characterized on prior MRI.
6. Stable 3.1 cm hypoattenuating right renal lesion, previously
characterized as a proteinaceous/hemorrhagic cyst.
7. Enlarged, partially calcified fibroid uterus.
MICROBIOLOGY
=========================
___ 1:20 pm URINE Site: NOT SPECIFIED ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
SUMMARY
=========================
Ms. ___ is a ___ female with Crohn's disease
on mesalamine and metastatic colon cancer complicated by large
bowel obstruction s/p diverting loop transverse colostomy and GI
bleed ___ duodenal ulcer recently started on FOLFOX who
presented with severe abdominal pain found to have benign
abdomen on imaging w/ pain that resolved spontaneously thought
to be ___ known extensive peritoneal/omental disease.
TRANSITIONAL ISSUES
=========================
[] There is a drug-drug interaction with mesalamine and
chemo-agents. Enhanced myelosuppressive effects iso mesalamine.
[] She was given small amount of tramadol for pain. Please
continue to assess need for analgesia.
ACTIVE ISSUES
=========================
# Cancer-Related Abdominal Pain
She presented with 3 days of ___ ___ pain that was
worse with eating and movement. Given her known extensive
omental/peritoneal nodules this could have been irritation from
malignancy. She also had a prior hx of obstruction with
diverting colostomy, so another obstruction was high on the
differential. CT on ___ showed no signs of obstruction or
perforation of the bowel. Also considered a flare of Crohn's
disease as the pain was likened to her presenting pain when she
was first diagnosed. This was thought to be unlikely given she
has not had a flare in ___ years and has been stable on her home
mesalamine. Also there was no change in ostomy output or signs
of inflammation on imaging. She was given morphine in ED and her
pain improved. On HD2 she endorsed ___ pain. She was not
requiring any analgesia. She endorsed wanting to have a weaker
opioid pain medication at home if this happens again. She was
discharged with tramadol for use prn.
# Metastatic Colon Cancer
# Secondary Neoplasm of Peritoneum
She recently started palliative FOLFOX C1D1 ___. She was
discharged with follow-up oncology appointment on ___
# Crohn's Disease
The abdominal pain could potentially have been a crohn's disease
flare as it was a similar pain she had felt when she was first
diagnosed ___ years ago. Lending against a flare would be that
she had not had one in ___ years and had been stable on
medication. That being said, she had just started chemotherapy
with FOLFOX and it was conceivable there was drug interaction.
There is a noted enhanced myelosuppressive effect of
___ with mesalamine but no metabolic interactions
that would decrease effectiveness of mesalamine. Her home apriso
was non-formulary so she was continued on mesalamine 500mg TID
as equivalent dosage.
# Anemia in Malignancy
# History of GI Bleed ___ Duodenal Ulcer
She has a known anemia. H/H stable during this admission. No
evidence of bleeding, no hematemesis, melena, bright red blood
per ostomy. This is likely iso myelosuppressive agents. Her home
PPI and iron were continued.
# Hypertension
Her home irbesartan was held as non-formulary (and allergy to
losartan)
and poor PO intake.
# Hypothyroidism
Continued home levothyroxine.
# Hyperlipidemia
Held her statin during this stay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. irbesartan 150 mg oral DAILY
4. Fexofenadine 60 mg PO DAILY:PRN allergies
5. Apriso (mesalamine) 1.5 g oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
9. Amoxicillin ___ mg PO PREOP
10. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN rash
11. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
13. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
14. Align (Bifidobacterium infantis) 4 mg oral DAILY
15. Magnesium Oxide 250 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN Constipation - First Line Duration:
7 Days
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice per day
Disp #*14 Tablet Refills:*0
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*16 Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
4. Align (Bifidobacterium infantis) 4 mg oral DAILY
5. Apriso (mesalamine) 1.5 g oral DAILY
6. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN rash
7. Ferrous Sulfate 325 mg PO DAILY
8. Fexofenadine 60 mg PO DAILY:PRN allergies
9. irbesartan 150 mg oral DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. LORazepam 0.5 mg PO Q8H:PRN
nausea/vomiting/anxiety/insomnia
12. Magnesium Oxide 250 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. Pantoprazole 40 mg PO Q12H
16. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=======================
metastatic colon adenocarcinoma
SECONDARY DIAGNOSIS
=======================
Crohn's disease
HTN
HLD
Hypothyroidism
Anemia of malignancy
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 here at ___
___!
WHY WAS I IN THE HOSPITAL?
==============================
- You came to the hospital because you were experiencing severe
abdominal pains.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given fluids and pain medications.
- Imaging was obtained of your abdomen. It did not show any
signs of an obstruction or perforation of the bowel.
- You were given a diet and observed for worsening abdominal
pain. It was thought that your pain was from the known cancer in
your abdomen.
WHAT SHOULD I DO WHEN I LEAVE?
==============================
- You have a follow-up appointment with your oncologist on
___. Please attend this appointment.
- You will have a new prescription for pain, tramadol. Please
use for severe breakthrough pain.
- If you notice a change in your ostomy output, or have
worsening pain please reach out to your healthcare provider.
We wish you all the best!
Your ___ care team
Followup Instructions:
___
|
10610574-DS-16 | 10,610,574 | 25,568,156 | DS | 16 | 2135-06-01 00:00:00 | 2135-06-01 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Univasc / Shellfish / Mold/Yeast/Dust / Lyrica / Cozaar /
Tegaderm Transparent Dressing
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old female with a past medical
history notable for Crohn's disease, metastatic colon cancer s/p
resection and ostomy on FOLFOX, duodenal ulcer, hypertension,
and
hyperlipidemia presenting with shortness of breath likely
consistent with delayed laryngeal reaction to oxaliplatin.
The patient was recently admitted from ___ to ___
for
increased ostomy output and weakness. Colorectal surgery
service
was consulted and recommended starting a large number of
antidiarrheal medications including Lomotil, loperamide and
psyllium. She was also started empirically on Cipro and Flagyl
for 7-day course. Largely, her diarrhea has resolved and she is
no longer taking her antidiarrheal medications.
She presented today for cycle 2-day 15 of FOLFOX, and she
initially tolerated this well. As she was leaving the ___
building, she began to experience hoarseness and shortness of
breath. She was taken to the emergency department for further
evaluation. She was treated with epinephrine, IV steroids,
famotidine and fluids with significant improvement in her
respiratory status though with continued tachycardia. Her
oncologist Dr. ___ was contacted and felt that it was unclear
that this was a true anaphylactic reaction though she would
require allergy testing for all components of the regimen. Of
note, even though her symptoms had rapidly resolved she had a
elevated lactate that did not resolve with fluids. She was
admitted to oncology for further evaluation.
On evaluation, patient states that she is feeling much
improved and essentially back to her baseline. She has no
complaints at this time. Her ___ chemotherapy pump has removed
by the emergency department. She is worried that because of
this
reaction her chemotherapy schedule will be delayed.
REVIEW OF SYSTEMS: Pertinent positives and negatives as noted in
the HPI. All other systems were reviewed and are negative.
Past Medical History:
IPMN
CROHN'S DISEASE
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
PULMONIC REGURGITATION
SHOULDER ARTHRITIS
KNEE ARTHRITIS
DIVERTICULOSIS
INTERNAL HEMORRHOIDS
OSTEOPENIA
PSORIASIS
SEBORRHEIC KERATOSIS
STASIS DERMATITIS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
MERALGIA PARESTHETICA
G-067
LACTOSE INTOLERANCE
FRUCTOSE INTOLERANCE
CHOLELITHIASIS
DIVERTICULITIS
COLON CANCER
Social History:
Country of Origin: US
Marital status: Divorced
Children: Yes: two sons
Lives with: Alone
Lives in: House
Work: ___
Sexual Abuse: Denies
Domestic violence: Denies
Tobacco use: Former smoker
Alcohol use: Past and Present
drinks per week: ___
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Seat belt/vehicle Always
restraint use:
Bike helmet use: N/A
Family History:
Relative Status Age Problem Onset Comments
Mother ___ ___ ABDOMINAL AORTIC
ANEURYSM
STROKE
HYPERCHOLESTEROLEMIA
Father ___ ___ CEREBRAL ANEURYSM
Brother Living ___ PROSTATE CANCER
TRANSIENT ISCHEMIC
ATTACK
MGM Deceased DEMENTIA
PGF Deceased ___ PROSTATE CANCER
PGM Deceased ___ CHRONIC KIDNEY
DISEASE
MGF Deceased ___ PNEUMONIA
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
___ 2215 Temp: 98.4 PO BP: 173/94 HR: 119 RR: 20 O2 sat:
99%
O2 delivery: RA
General: well appearing, pleasant, in no acute distress.
HEENT: sclerae anicteric, mucous membranes moist
NECK: jugular venous pulsations seen at 3 cm above the sternal
angle, carotid upstrokes full without bruit
CHEST: Lungs clear to auscultation bilaterally, no wheezes,
rales
or rhonchi, no dullness to percussion, port in place without
erythema
CARDIAC: tachycardic, normal S1/S2, flow murmur appreciated at
right upper sternal border, no RV heave, non-displaced PMI
ABDOMEN: Soft, nontender, nondistended
EXT/VASC: warm and well perfused, no clubbing, cyanosis or edema
NEURO: grossly non focal. AOx3
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ ___ Temp: 98.2 PO BP: 139/78 HR: 107 RR: 20 O2
sat: 100% O2 delivery: RA
GENERAL: NAD, Sitting up in bed, pleasant and conversant.
HEENT: AT/NC, anicteric sclera, MMM
NECK: Supple
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: Non-labored breaths, CTAB, no wheezes, rales, rhonchi
ABD: Ostomy in place, bag with content and gas. Bowel sounds
appreciated. Abdomen soft, nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly.
EXT: WWP, no cyanosis, clubbing, or edema, peripheral pulses
appreciated in four limbs.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: AOx3, moving all 4 extremities with purpose, face
symmetric, CN II-XII grossly intact
ACCESS: Port, non-erythematous, non-tender, no collection
appreciated, dressing C/D/I.
Pertinent Results:
IMAGING
=======
CXR (___) impression: No acute cardiopulmonary process.
MICROBIOLOGY
============
None.
LABS
====
___ 08:30AM BLOOD WBC-2.3* RBC-2.82* Hgb-8.9* Hct-28.1*
MCV-100* MCH-31.6 MCHC-31.7* RDW-22.2* RDWSD-78.7* Plt Ct-92*
___ 02:10PM BLOOD WBC-2.1* RBC-2.84* Hgb-9.1* Hct-27.9*
MCV-98 MCH-32.0 MCHC-32.6 RDW-21.7* RDWSD-75.7* Plt Ct-99*
___ 05:19AM BLOOD WBC-2.3* RBC-2.53* Hgb-8.0* Hct-24.8*
MCV-98 MCH-31.6 MCHC-32.3 RDW-21.9* RDWSD-76.2* Plt ___
___ 02:10PM BLOOD Neuts-55.2 ___ Monos-5.8 Eos-0.0*
Baso-0.5 AbsNeut-1.15* AbsLymp-0.80* AbsMono-0.12* AbsEos-0.00*
AbsBaso-0.01
___ 05:19AM BLOOD Neuts-63.3 Lymphs-16.0* Monos-20.3*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-1.46* AbsLymp-0.37*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.00*
___ 05:19AM BLOOD Poiklo-1+* Ovalocy-1+* Tear Dr-1+* RBC
Mor-SLIDE REVI
___ 08:30AM BLOOD UreaN-20 Creat-1.0 Na-138 K-3.9 Cl-101
HCO3-21* AnGap-16
___ 02:10PM BLOOD Glucose-153* UreaN-18 Creat-1.0 Na-138
K-3.6 Cl-102 HCO3-16* AnGap-20*
___ 11:56PM BLOOD Glucose-136* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-21* AnGap-16
___ 05:19AM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-22 AnGap-15
___ 08:30AM BLOOD ALT-14 AST-27 AlkPhos-98 TotBili-0.4
___ 02:10PM BLOOD ALT-16 AST-30 AlkPhos-102 TotBili-0.3
___ 05:19AM BLOOD ALT-15 AST-28 LD(LDH)-231 AlkPhos-88
TotBili-0.4
___ 02:10PM BLOOD Lipase-90*
___ 02:10PM BLOOD proBNP-97
___ 02:10PM BLOOD cTropnT-<0.01
___ 08:30AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.5*
___ 02:10PM BLOOD Albumin-3.8 Calcium-9.5 Phos-2.0* Mg-1.3*
___ 11:56PM BLOOD Calcium-9.5 Phos-3.1 Mg-1.8
___ 05:19AM BLOOD Albumin-3.4* Calcium-9.4 Phos-3.7 Mg-1.7
Iron-98
___ 05:19AM BLOOD calTIBC-330 Ferritn-858* TRF-254
___ 08:30AM BLOOD TSH-5.6*
___ 08:30AM BLOOD Free T4-1.7
___ 08:30AM BLOOD CEA-67.5*
___ 12:44AM BLOOD Type-CENTRAL VE pH-7.40
___ 02:33PM BLOOD Lactate-5.0*
___ 04:46PM BLOOD Lactate-3.4*
___ 06:58PM BLOOD Lactate-4.0*
___ 12:44AM BLOOD Lactate-2.6*
___ 12:44AM BLOOD freeCa-1.26
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] Will need Neulasta on ___: Spoke with Dr. ___ the
patient will be contacted for an appointment for this
[ ] Will need allergy testing prior to next round of FOLFOX
which will be arranged by primary oncology team
ASSESSMENT & PLAN:
___ is a ___ year old female with a past medical
history notable for Crohn's disease, metastatic colon cancer s/p
resection and ostomy on FOLFOX, duodenal ulcer, hypertension,
and
hyperlipidemia presenting with shortness of breath likely
consistent with delayed respiratory reaction to oxaliplatin, or
less likely an allergic reaction.
ACUTE ISSUES:
# Delayed laryngeal reaction vs anaphylaxis:
Was treated in the ED with presumed anaphylaxis with good
response. Quick resolution of symptoms and labs within normal
limits, including CXR, make other pulmonary etiology unlikely
(PE, PNA). Also tachycardic, however given rapid improvement
with treatment as above, PE less likely. On the day after
admission her symptoms improved significantly and she returned
quickly to her baseline. She will need outpatient allergy
testing prior to her next round of FOLFOX.
# Lactic acidosis: likely Type B in the setting of Epi
administration. Rapidly downtrended. Low concern for infectious
etiology, pt was never hypotensive, and lactate cleared wuickly
within 12 hours of presentation to the ED.
CHRONIC ISSUES:
# Metastatic colon cancer: will need to formulate a plan for
continued protocol with Dr. ___. As above will need allergy
testing prior to next round of FOLFOX.
# HTN: irbesartan was previously held at her last admission
given
poor PO intake. Will continue to hold at this time.
# Hypothyroidism: continued home synthroid
# CKD: creatinine at baseline on admission
# Crohn's: continued home mesalamine
#HCP/CONTACT: TBD
#CODE STATUS: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. Pantoprazole 40 mg PO Q12H
5. Vitamin D 1000 UNIT PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Potassium Chloride 60 mEq PO DAILY
8. Align (Bifidobacterium infantis) 4 mg oral DAILY
9. Apriso (mesalamine) 1.5 g oral DAILY
10. Magnesium Oxide 250 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
13. Pseudoephedrine Dose is Unknown PO Q6H:PRN after chemo days
Discharge Medications:
1. Pseudoephedrine 30 mg PO Q6H:PRN after chemo days
2. Align (Bifidobacterium infantis) 4 mg oral DAILY
3. Apriso (mesalamine) 1.5 g oral DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
7. Magnesium Oxide 250 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
10. Pantoprazole 40 mg PO Q12H
11. Potassium Chloride 60 mEq PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Metastatic colon cancer
- Shortness of breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED:
- You were having difficulty breathing after your chemotherapy
infusion on ___
WHAT HAPPENED WHILE I WAS HERE:
- You had some medications to treat any allergic reaction to the
chemotherapy
- Your breathing improved greatly while you were here
- You will have allergy testing as guided by Dr. ___ as an
outpatient
WHAT SHOULD I DO WHEN I LEAVE:
- Please take all of your medications as prescribed
- Please attend all of your follow up appointments as scheduled
Followup Instructions:
___
|
10610587-DS-21 | 10,610,587 | 23,083,121 | DS | 21 | 2132-04-20 00:00:00 | 2132-04-20 10:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R knee pain
Major Surgical or Invasive Procedure:
ORIF medial tibial plateau fracture
History of Present Illness:
___ with acute R knee pain while riding his bike, tried to stop
himself by placing outstretched leg in front of him. No other
trauma or pain.
Past Medical History:
PMH/PSH:
Hx R ankle ORIF
Social History:
___
Family History:
non- contributory
Physical Exam:
PHYSICAL EXAMINATION:
General: nad aox3
Vitals: af vss
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- R knee with painful, limited ROM. Varus instability at R knee.
- Full, painless AROM/PROM R ankle and hip
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Exam on Discharge:
AVSS
NAD, A&Ox3
RLE
Incision well approximated. Fires
___. SITLT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally. in unlocked bledso
splint
Pertinent Results:
IMAGING:
XR R knee and CT R knee with comminuted tibial plateau fx
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R. tibial plateau fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF medial R tibial plateau fx, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to Rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB, ROMAT in unlocked ___ brace in the Right lower
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB
RX *albuterol sulfate [Ventolin HFA] 90 mcg 1 puff every six (6)
hours Disp #*3 Inhaler Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Col-Rite] 100 mg 1 capsule(s) by mouth
twice a day Disp #*40 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc once a day Disp #*21
Syringe Refills:*0
5. Ferrous Sulfate 325 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*70 Tablet Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
9. Crutches
Long Crutches
Dx: R tibial platue fx
Px: good
Duration: 13 months
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch Down Weight Bearing, Range of Motion as Tolerated in
unlocked ___ brace (hinged knee brace)
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Your ___ (hinged knee) brace must be left on until follow
up appointment unless otherwise instructed
- Do NOT get your ___ brace wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
TDWB, ROMAT in unlocked ___ brace
Treatments Frequency:
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.
Followup Instructions:
___
|
10610599-DS-9 | 10,610,599 | 25,421,251 | DS | 9 | 2161-06-18 00:00:00 | 2161-06-18 14:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
atorvastatin / simvastatin / Crestor
Attending: ___
Chief Complaint:
disequilibrium, possible headache, and subjective vision
changes.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ man with a history of coronary artery
disease status post CABG in ___, hyperlipidemia the patient is
not taking a statin medication due to side effects and gout who
presented to the emergency room with a sensation of
disequilibrium, possible headache, and subjective vision
changes.
Patient refused interpreter for interview. Patient says that he
was in her usual state of health when he went to bed last night
without any complaints. He has not had some increased stress at
home but otherwise has been feeling well. He woke up this
morning when he went to the bathroom to brush his teeth he
noticed that he felt very unsteady on his feet. He denies any
room spinning vertigo or sensation of movement but just says
that
when he walked he feels he is not steady. He decided to try to
go to work but still felt too unsteady and unwell and advised to
come to the emergency room. In addition to the sensation of
disequilibrium he also endorses a "weird sensation" in his head.
He denies there being a headache or pressure in his head says
his
head just feels "weird" he also endorses some very mild neck
discomfort. In addition he feels like his vision is off though
again this is vague in the denies blurry vision, cuts in his
vision, double vision. But says that he has to focus more to be
able to see and his vision is "off". He has never had any
symptoms like this before.
He denies any upper respiratory infections, cough, chest pain,
shortness of breath, palpitations, fevers, ear pain, tinnitus,
changes in hearing. He denies any change in eating or drinking
recently, denies any abdominal pain nausea vomiting diarrhea.
He
also denies any weakness, sensory changes, difficulty speaking,
difficulty understanding what other people are saying to him,
changes in bowel or bladder function specifically urinary
incontinence or fecal incontinence. He has been able to walk
without an issue just feels mildly unsteady. Overall he thinks
his symptoms are getting better since he is coming to the
emergency room but they have not subsided all the way.
He recently had a gout flare which she treated with Motrin and
colchicine. He says that he is no longer taking the colchicine.
He says his primary care doctor prescribed ___ new medication for
the gout but he has not started taking this yet. He denies any
new medications otherwise.
Past Medical History:
Gout
HYPERCHOLESTEROLEMIA
IMPAIRED FASTING GLUCOSE
OSTEOARTHRITIS ___
knee right, hx menisectomy ___, left knee ___ chrondoplasty,
microfracture, menisectomies
ANGIOMA
TELENGECTASIA
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
stenting of the right coronary artery ___
4V CABG ___
Removal of bullet fragments from left foot
HERNIA REPAIR
Social History:
___
Family History:
Grandmother and Father both died of MIs in ___ per patient. No
family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Vitals:T: 98.1 BP: 152/87 HR: 60 RR: 18 SaO2:99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, no murmurs appreciated, warm, well-perfused
Abdomen: non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects, other
than says and other than glove and is unable to name ___ but
this may be because ___ as a second language for him,. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Right pupil 3 to 2mm and brisk, left is
slightly
larger 3.5 to 2 mm briskly reactive. EOMI without nystagmus. No
corrective saccade with head impulse test, no skew
Normal saccades. VFF to confrontation. Visual acuity, OD ___
does not correct with pinhole, OS ___ corrects to ___ with
pinhole. Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 5 5 *5- ___ 5 5 5 5
DISCHARGE
Awake, alert, responding appropriately to questions.
PERRL, EOM full with right-beating nysgtagmus on rightward gaze
and some rotary upwards nystagmus on right gaze that
extinguishes, face symmetric, palate elevates symmetrically.
Tone is normal, strength is full throughout.
SILT.
No dysmetria or intention tremor on FNF and heel-shin.
Gait is narrow based and smooth without incoordination. Romberg
absent.
Pertinent Results:
___ 08:01AM BLOOD WBC-4.3 RBC-5.21 Hgb-13.9 Hct-44.4 MCV-85
MCH-26.7 MCHC-31.3* RDW-14.6 RDWSD-44.4 Plt ___
___ 08:01AM BLOOD Neuts-59.4 ___ Monos-12.3 Eos-3.2
Baso-1.9* Im ___ AbsNeut-2.56 AbsLymp-0.98* AbsMono-0.53
AbsEos-0.14 AbsBaso-0.08
___ 08:01AM BLOOD ___ PTT-28.1 ___
___ 08:01AM BLOOD Glucose-124* UreaN-13 Creat-0.9 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-11
___ 08:01AM BLOOD cTropnT-<0.01
___ 08:01AM BLOOD Calcium-9.5 Phos-2.4* Mg-2.0 Cholest-204*
___ 08:37AM BLOOD %HbA1c-5.8 eAG-120
___ 08:01AM BLOOD Triglyc-160* HDL-45 CHOL/HD-4.5
LDLcalc-127
___ 08:01AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ Imaging STROKE PROTOCOL (BRAIN
-No acute intracranial abnormality is identified.
-High riding right-sided jugular bulb.
___ Imaging CTA HEAD AND CTA NECK
CT head:
There is no evidence of large territory infarction, edema,
hemorrhage or mass
effect. The ventricles and sulci are normal in size and
configuration.
There is no gross evidence of acute fracture. The ethmoid,
sphenoid, frontal
and maxillary sinuses are clear. The middle air cavities are
unremarkable. The
visualized portion of the orbits are unremarkable.
CTA neck:
Conventional 3 vessel arch with mild calcifications of the
aortic arch.
Minimal calcification of the carotid bifurcations bilaterally.
No significant
stenosis of the internal carotid arteries by NASCET criteria. CT
angiography
of the neck shows normal appearance of the carotid and vertebral
arteries
without stenosis or occlusion or dissection.
CTA head:
Mild calcification of the carotid siphons. CT angiography of the
head shows
normal appearance of the arteries of the anterior and posterior
circulation
without stenosis or occlusion or aneurysm greater than 3 mm in
size. Dural
venous sinuses are patent. Incidentally noted high riding
internal jugular
bulb on the right (3:232).
Other: Partially visualized lung apices and thyroid gland appear
unremarkable.
Mild multilevel degenerative changes visualized spine without
canal narrowing.
Brief Hospital Course:
___ man with a history of CAD s/p CABG in ___ who
presented to ED with complaints of disequilibrium, headache,
neck discomfort along with blurry visions and difficulty
focusing.
His neurologic exam was only notable for a few beats of
nystagmus, predominately on rightward gaze. He had a CT/CTA that
did not show evidence of hemorrhage or vascular
occlusion/stenosis. There was no dissection. He had an MRI of
the head that did not show any acute infarction.
His dysequilibrium may be secondary to cervicogenic vertigo. He
did complain of increased stress and neck pain/stiffness at the
time. Alternative etiologies include vestibular neuritis and
vestibular migraine. The patient was counseled regarding the
above possibilities.
Additionally, he was noted to have an elevated LDL (127). He
states that he has not been taking his statin due to side
effects. Since he has had intolerance to multiple trials of
statin medications, we initiated ezetimide 10 mg daily for
secondary prevention of coronary events and primary prevention
of stroke. Ultimately, we feel that he may benefit from a PCSK-9
inhibitor.
TRANSITIONAL ISSUES
- Started on ezetimibe. Please consider referral to ___ clinic
for consideration of a PCSK-9 inhibitor for cardiovascular and
stroke risk reduction.
- If symptoms do not resolve, consider referral to ___ for
vestibular/ocular therapy.
- Follow up with PCP for blood pressure managment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Ezetimibe 10 mg PO DAILY
RX *ezetimibe 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cervicogenic vertigo
hyperlipidemia
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 because you were feeling
off-balance, had blurry vision, and had head and neck pain.
Initially, there was some concern that you may have had a
stroke. You had a CT scan and MRI of the brain, which did not
show any signs of stroke. Your symptoms may be related to neck
stiffness, which can sometimes cause problems with balance and
blurry vision.
When you go home:
- Follow up with your primary care doctor regarding your
concerns about blood pressure. As your doctor about physical
therapy (specifically, vestibular and ocular physical therapy)
if your symptoms persist.
- You should ask your primary care doctor about ___ referral to a
___ clinic to consider a lipid-lowering drug, called a PCSK-9
inhibitor.
- We started you on a medication called ezetimibe to help lower
your cholesterol
It was a pleasure taking care of you,
Your ___ care team
Followup Instructions:
___
|
10610628-DS-26 | 10,610,628 | 26,037,851 | DS | 26 | 2186-12-12 00:00:00 | 2186-12-07 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Rifampin / Levofloxacin / Pyrazinamide / ampicillin-sulbactam /
Infant's Tylenol / Benadryl / Ceftriaxone / Azithromycin /
Quinolones / Vancomycin / Sulfa (Sulfonamide Antibiotics) /
Trazodone
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo M with history of TB, prostate cancer and recent
UTI who presents with mental status changes. When the patient
woke up this morning he was fine but remained in bed. When his
wife went up to see him around 11am he was not responding. His
daughter also noted a facial droop which has since resolved. The
patient's wife called ___ and he was brought into the ED with
concerns for stroke. His wife does report that he has not been
eating or drinking well over the past few days but has otherwise
been feeling well.
Of note the patient has had 1 month of hematuria. He has been
treated by his PCP/ID doctor for ___ UTI, first with a 10 day
course of doxycycline followed by a 2 week course of macrobid
(prescribed ___ which he is still taking. He has urinary
incontinence at baseline but denies dysuria or increased
frequency. His only symptom is hematuria. He has a history of
prostate cancer in ___ treated with radiation and is currently
being worked up for his hematuria by Dr. ___ urology.
His wife reports he is scheduled for a cystoscopy this week. At
baseline he is incontient of urine.
On arrival to ED a code stroke was called due to facial droop,
dysarthria and pin point pupils. Sx due to lack of dentures.
Neuro with low concern for CVA. Pt found to have ___,
leukocytosis and dirty UA. Sx likely due to UTI. Given
gentamicin 1.5mg/kg given multiple antibiotic allergies.
On arrival to floor the patient is awake and alert. He is very
HOH, but he specifically denies dysuria. Denies fever or chills.
Denies nausea, vomiting, chest pain or shortness of breath.
+bladder incontinence, unchanged. No stool incontinence.
ROS: +per HPI, otherwise reviewed and negative
Past Medical History:
- Hx of pulm TB as a teenager, s/p 18 months TB therapy
- Pott's dz s/p 18 months of TB therapy and L1-L2 removal with
rod placement (___)
- Stage III CKD - baseline Cr 1.2 (CrCl 30cc/hr), ___ rapidly
progressive glomerulonephritis and allergic interstitial
nephritis ___ rifampin.
- HTN
- Hypothyroid
- Prostate CA s/p XRT, radiation proctitis
- H/o cellulitis of right foot, tx with minocycline
- H/o UTIs
- Chronic peripheral neuropathy of unknown etiology
- ___ syndrome ___ Tylenol
- Benign pancreatic mass (calcified adenoma of pancreatic head)
Social History:
___
Family History:
Mom: TB
Sister: ?pathologic fracture
Physical Exam:
VS:98.0 BP: 117/63 HR: 80 R: 24 O2: 100% RA
PAIN:Denies
GEN: Elderly man, in NAD. Very hard of hearing.
HEENT: membranes dry, poor dentition. tongue midline. No LAD.
CHEST: Coarse crackes at bases. Good air entry,
CV: RRR, S1, S2 present, No murmurs appreciated
ABD: NABS, Non-tender, no- distended. Outpouching on left, below
ribs. Healed gastrostomy tube scar.
EXT: No clubbing, Right foot colder then left with dopplerable
DP pulse on right, palpable on left. Sensation/motor intact b/l
feet. B/L pinpoint red, nonblanching lesions on b/l shins.
NEURO:AAOx3, CN II- XII grossly intact. Moving all extremities.
Answers appropriately.
Discharge:
Pertinent Results:
CXR Impression: Regions of scarring and pleural califications at
the right lung base and apex, as on prior. More conspicuous
opacities at the left lung apex and at the costophrenic angle
may be due to progression of underlying lung disease and
scarring, although infection cannot be excluded
______________________________________________
CT HEAD preliminary Report: No evidence of acute intracranial
process.
______________________________________________
___ GU Ultrasound IMPRESSION:
1. No evidence of renal hydronephrosis, stones or worrisome
renal masses.
Bilaterally slightly echogenic kidneys which can be seen with
medical renal pathology.
2. Postvoid residual of over 300 cc.
3. Bladder debris and stones.
______________________________________________
___ 4:53 pm
URINE TAKEN FROM 62672T.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| PROTEUS MIRABILIS
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 8 S <=2 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ 8 I 8 I
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 4 S 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
______________________________________________
___ blood cultures pending x 2
______________________________________________
___ 02:35PM BLOOD WBC-13.8*# RBC-3.77* Hgb-9.7* Hct-31.0*
MCV-82 MCH-25.6* MCHC-31.1 RDW-15.6* Plt ___
___ 06:30AM BLOOD WBC-8.3 RBC-3.29* Hgb-8.8* Hct-27.4*
MCV-83 MCH-26.8* MCHC-32.3 RDW-15.6* Plt ___
___ 06:21AM BLOOD WBC-10.1 RBC-3.61* Hgb-9.7* Hct-29.3*
MCV-81* MCH-27.0 MCHC-33.2 RDW-15.8* Plt ___
___ 02:35PM BLOOD Neuts-83.4* Lymphs-8.6* Monos-6.7 Eos-1.2
Baso-0.1
___ 02:35PM BLOOD Glucose-115* UreaN-36* Creat-1.4* Na-137
K-4.2 Cl-100 HCO3-27 AnGap-14
___ 06:30AM BLOOD Glucose-110* UreaN-43* Creat-1.1 Na-139
K-3.8 Cl-108 HCO3-25 AnGap-10
___ 06:21AM BLOOD Glucose-133* UreaN-30* Creat-1.1 Na-140
K-4.2 Cl-106 HCO3-25 AnGap-13
___ 02:35PM BLOOD ALT-15 AST-24 AlkPhos-67 TotBili-0.5
___ 02:35PM BLOOD Lipase-295*
___ 06:21AM BLOOD Calcium-8.5 Phos-1.8*# Mg-1.9
___ 06:30AM BLOOD Iron-33*
___ 06:30AM BLOOD calTIBC-125* Ferritn-763* TRF-96*
___ 02:35PM BLOOD Albumin-3.6
___ 02:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:46PM BLOOD ___ pO2-67* pCO2-49* pH-7.37
calTCO2-29 Base XS-1 Comment-GREEN TOP
___ 02:46PM BLOOD Lactate-1.4
___ 02:35PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:35PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 02:35PM URINE RBC-23* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
___ 02:35PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
ASSESSEMENT & PLAN: ___ yo with history of prostate cancer and
recurrent UTIs presented with metabolic encephalopathy and ___
due to UTI.
# Urinary tract infection, Proteus
# Multiple antibiotic allergies
# Hematuria
# Urinary retention
Hematuria likely related to UTI given improvement with
antibiotics, however may be second component contributing
(prostatitis, bladder malignancy).
Pt initially given gentamicin 75mg IV q24 based on renal
clearance given multiple antibiotic allergies. On discussion
with PCP, pt tolerates meropenem and due to CKD gentamicin was
changed to meropenem. Urine cultures subsequently grew 2 strains
of proteus, sensitive to meropenem. ___ PCP and ID MD, Dr.
___ through the hospitalization. Pt will complete at
least 2 weeks of antibiotics (meropenem or ertapenem). On ___,
pt developed new fever of uncertain etiology. CXR did not show
pneumonia, BCx pending, repeat UCx negative. There are no rashes
to suggest drug allergy. The patient's meropenem was redosed to
reflect his improved renal function. We are continuing to
monitor his temperature curve, however, at this time he appears
to be afebrile.
Pt had urinary retention, with retention 300 cc noted on abd
ultrasound, and post-void bladder scan noted 500 cc urine. A
foley catheter was placed. Pt is noted to have bladder debris
and stones on ultrasound. ___ urologist Dr. ___ was also
notified of admission, and pt has a scheduled appointment for
cystoscopy on the day following discharge.
#Confusion/Metabolic encephalopathy: resolved w/UTI treatment.
Pt also had some likely sundowning as well.
#Stage III CKD - baseline Cr 1.2 (CrCl 30cc/hr), due to rapidly
progressive glomerulonephritis and allergic interstitial
nephritis due to rifampin.
Cr 1.4 on admission, given gentle IVF. His renal function
improved. His antibiotics were dosed for GFR of 30 cc/hr.
#Poor appetite
Pt has complained of decreased appetite, some of which pt states
is due to not liking the hospital food. Pt slightly tachycardic
currently, due to insufficient po fluids. Pt is able to drink
fluids, and encouraged pt to drink more fluids. Pt was given NS
500 cc on day of discharge, with instructions to drink more.
# Possible periperhal vascular disease
Right foot colder than left on exam, without pallor, paresthesis
and +pulses. His exam remained stable.
Chronic issues:
Hypertension, Benign: continued low dose metoprolol
Hypothyroid: continued synthroid
Gout: continue allopurinol
Prostate CA: s/p XRT, radiation proctitis
ACCESS: PICC ___ R arm.
DISPO: Planning for discharge to rehab.
TRANSITIONAL ISSUES:
- follow temp curve and WBC. If remains afebrile and doing
well, can be discharged to rehab with outpatient Urology follow
up. (It appears that Dr. ___ PCP and ID MD, may have
consulted Urology in ___.
- Pt has stones and debris in bladder that is likely infected.
Would plan for close Urology follow up with cystoscopy, before
antibiotics complete.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. risedronate 35 mg Oral qweek
5. calcium citrate-vitamin D3 315-200 mg-unit Oral BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Folbic (folic acid-vit B6-vit B12) 2.5-25-2 mg Oral daily
8. ALPRAZolam 1 mg PO QHS:PRN insomnia
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
4. Allopurinol ___ mg PO DAILY
5. risedronate 35 mg Oral qweek
6. Folbic (folic acid-vit B6-vit B12) 2.5-25-2 mg Oral daily
7. Fish Oil (Omega 3) 1000 mg PO BID
8. calcium citrate-vitamin D3 315-200 mg-unit Oral BID
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
10. Meropenem 1000 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI, proteus
Hx multiple antibiotic allergies
Hematuria
Confusion/Metabolic encephalopathy
Secondary:
#Stage III CKD
# Anemia, chronic 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:
You were admitted with confusion. This was due to a urinary
infection. This was treated with antibiotics and your symptoms
improved. You have had difficulty urinating, and a catheter was
placed to drain your urine. You will see Urology tomorrow for
further evaluation.
Followup Instructions:
___
|
10610928-DS-7 | 10,610,928 | 20,920,127 | DS | 7 | 2168-11-23 00:00:00 | 2168-11-23 17:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Lithium / alcohol / sorbitan / red dye / yellow dye / CI pigment
blue 63 / opiod analgesics / polysorbate 80 / Depakote
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
___ M with a history of ESRD ___ lithium exposure), bipolar
disorder, alcohol
dependence (sober ___ years), and recently-diagnosed subacute
SDH (___) who is transported to our ED after being intubated
at an OSH following what sounds like a prolonged generalized
convulsion.
His story begins yesterday (___), when he was driving home
after dialysis and was the restrainder driver in an ___. He
apparently hit a parked car at a low speed. Beyond this, the
circumstances are unclear, and there is question of whether this
was a possible syncopal episode. His wife reports that in the
past six weeks, he has had five such car accidents with similar
circumstances (he is never able to give much information as to
how the accidents occurred. No further investigations were done.
.
Following his MVC yesterday, he was brought to our hospital
where CT scan showed left-sided subacute SDH (the density of the
hemorrhage was isodense to surrounding brain). Also had C5/C6
vertebral body fractures for which hard collar was placed. He
was seen by Neurosurgery who felt the subdural hemorrhage was
thought to be not acute, and may have been related to prior
accidents. They recommended starting Keppra 500mg BID but this
was not done during hospitalization. His serum sodium also
dropped from 140 to 126 overnight on ___, for unclear reasons:
his wife reports he was not placed on renal diet during
hospitalization and she recalls he asked for ginger ale from a
nurse and got it without any problems. He was discharged home
today with rx for oxycodone and instructions to seek outpatient
carotid U/S for syncope workup.
.
He did fine this afternoon, and was having dinner with his
family and watching the ___ game. While at dinner, he
suddenly started to develop some rapid eye blinking and then
rhythmic facial twitching of the right face. This progressed to
bilateral arm and leg rhythmic jerking with tonic extension of
his trunk. It continued for several minutes (wife estimates ___
minutes),
and EMS was called. She reports that it continued in the
ambulance, the exact duration of the seizure is not known. In
the outside ED, he was noted to be somnolent, so was intubated
for airway protection. He received one dose of IV
levetiracetam (500mg). The CT scan at OSH showed the presence of
a hyperdensity in the region of the old SDH on the left
frontoparietal convexity without midline shift. He was
transported to ___ on a propofol drip.
Of note, review of records shows that patient was hospitalized
at ___ in ___ for global encephalopathy which was
felt to be secondary to hyponatremia.
Past Medical History:
Bipolar disorder, has been hospitalized in past
ESRD ___ Lithium toxicity) on ___ HD
Hospitalized in ___ for global encephalopathy ___ hyponatremia
COPD
H/O EtOH abuse (sober ___ years)
Social History:
___
Family History:
Negative for neurologic illness
Physical Exam:
Admission Exam:
Physical Exam:
Vitals: HR 60, BP 128/87, ___, 18, 100% on CMV ___
General: Sedated intubated with hard c-collar.
HEENT: NC/AT, no conjunctival icterus noted, MMM, no lesions
noted in
oropharynx. + Hard c-collar
Pulmonary: Coarse breath sounds anteriorly
Cardiac: Regular, no murmurs
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: Left AVF
Skin: no rashes or lesions noted.
Neurologic (limited examination)
- When propofol was held for several minutes, the patient did
make some spontaneous symmetric movements of his upper
extremities that were not purposeful. He did not make any
attempts to communicate. He could not follow commands.
- Both pupils were 2mm and sluggishly reactive. No abnormal eye
movements were noted. No facial asymmetry. Gag/cough were not
assessed.
- 3+ symmetric reflexes throughout with bilateral ankle clonus
and upgoing toes bilaterally.
- Mild paratonia throughout.
Physical Exam on Discharge:
Vitals: T 97.8, BP 136/80, P 65, RR 18, 98% RA
General: NAD
HEENT: NC/AT, no conjunctival icterus noted, MMM, oropharynx
clear.
Neck: + Hard c-collar
Pulmonary: Coarse breath sounds with crackles at lung bases b/l,
otherwise moving air well
Cardiac: RRR, normal S1, S2, no murmurs
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: WWP, DP 2+
Skin: no rashes or lesions noted.
Neurological exam:
Mental status: awake, alert, oriented to name, ___, ___ backwards, mild dysarthria, names stethoscope and
knuckles, follows 3 step-command
Cranial Nerve: PERRL (3.5 mm --> 2 mm), EOMI, several beats of
nystagmus on R lateral gaze but non-sustained, VFF, intact
sensation to light touch, tongue midline
Motor: full strength in RUE, RLE, LLE; LUE not tested as the
limb was connected to HD machine at the time of exam
Reflexes: Brisk and symmetric in ___
Sensory: intact to light touch, no extinction to DSS
Coordination: normal FNF
Pertinent Results:
Admission labs:
___ 07:08AM GLUCOSE-115* UREA N-20 CREAT-5.6*#
SODIUM-126* POTASSIUM-3.8 CHLORIDE-87* TOTAL CO2-28 ANION GAP-15
___ 07:08AM ALBUMIN-3.6 CALCIUM-8.3* PHOSPHATE-5.7*
MAGNESIUM-1.8
___ 09:52PM ___ 09:52PM PLT COUNT-185
___:52PM ___ PTT-32.3 ___
___ 09:52PM WBC-14.0* RBC-3.56* HGB-11.9* HCT-35.8*
MCV-101* MCH-33.3* MCHC-33.2 RDW-15.1
___ 09:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:52PM OSMOLAL-263*
___ 09:52PM LIPASE-15
___ 09:52PM UREA N-25* CREAT-6.7*
___ 10:00PM freeCa-0.94*
___ 10:00PM HGB-12.1* calcHCT-36 O2 SAT-96 CARBOXYHB-2.2
MET HGB-0.4
___ 10:00PM GLUCOSE-132* LACTATE-0.8 NA+-121* K+-3.7
CL--86* TCO2-26
___ 10:00PM ___ PH-7.34* COMMENTS-GREEN TOP
___ 11:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 11:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:00PM URINE OSMOLAL-155
___ 11:00PM URINE HOURS-RANDOM CREAT-11 SODIUM-53
POTASSIUM-6 CHLORIDE-28
___ 11:05PM LACTATE-0.5
___ 11:05PM TYPE-ART RATES-14/ TIDAL VOL-500 PEEP-5
O2-100 PO2-314* PCO2-66* PH-7.26* TOTAL CO2-31* BASE XS-0
AADO2-338 REQ O2-61 INTUBATED-INTUBATED VENT-CONTROLLED\
___ 05:15AM BLOOD VitB12-636 Folate-3.1
___ 09:51AM BLOOD Vanco-9.9*
___ 06:19AM BLOOD Vanco-13.0
___ 04:36AM BLOOD WBC-9.4 RBC-3.11* Hgb-10.7* Hct-31.0*
MCV-100* MCH-34.3* MCHC-34.4 RDW-14.8 Plt ___
___ 12:49AM BLOOD WBC-9.1 RBC-3.29* Hgb-11.2* Hct-33.8*
MCV-103* MCH-33.9* MCHC-33.0 RDW-14.9 Plt ___
___ 02:17AM BLOOD WBC-10.8 RBC-3.33* Hgb-11.3* Hct-33.4*
MCV-100* MCH-33.8* MCHC-33.7 RDW-14.9 Plt ___
___ 04:00AM BLOOD WBC-13.5* RBC-3.48* Hgb-11.7* Hct-35.0*
MCV-101* MCH-33.6* MCHC-33.4 RDW-14.9 Plt ___
___ 09:51AM BLOOD WBC-11.8* RBC-3.27* Hgb-10.9* Hct-33.2*
MCV-102* MCH-33.2* MCHC-32.7 RDW-15.3 Plt ___
___ 05:15AM BLOOD WBC-9.8 RBC-3.43* Hgb-11.6* Hct-34.8*
MCV-102* MCH-33.7* MCHC-33.2 RDW-15.2 Plt ___
___ 04:23AM BLOOD WBC-10.9 RBC-3.09* Hgb-10.5* Hct-31.3*
MCV-101* MCH-34.1* MCHC-33.6 RDW-14.7 Plt ___
___ 05:15AM BLOOD WBC-10.1 RBC-3.47* Hgb-11.6* Hct-35.5*
MCV-102* MCH-33.5* MCHC-32.7 RDW-15.0 Plt ___
___ 08:30AM SODIUM-124* POTASSIUM-3.9 CHLORIDE-86*
___ 07:03PM SODIUM-130* POTASSIUM-5.3* CHLORIDE-92*
___ 06:39AM Na-130* K-5.5* Cl-93* HCO3-26 AnGap-17
___ 09:00PM Na-131* K-4.6 Cl-94* HCO3-23 AnGap-19
___ 02:17AM Na-135 K-4.6 Cl-96 HCO3-21* AnGap-23*
___ 09:00AM Na-137 K-4.7 Cl-98 HCO3-22 AnGap-22*
___ 06:00PM Na-136 K-3.7 Cl-98 HCO3-27 AnGap-15
___ 09:51AM Na-134 K-4.1 Cl-96 HCO3-23 AnGap-19
___ 05:15AM Na-134 K-4.5 Cl-95* HCO3-23 AnGap-21*
___ 10:50AM Na-137 K-4.5 Cl-99
___ 06:19AM BLOOD WBC-9.2 RBC-3.20* Hgb-10.8* Hct-33.1*
MCV-103* MCH-33.7* MCHC-32.6 RDW-14.6 Plt ___
___ 06:19AM BLOOD Glucose-87 UreaN-78* Creat-8.7* Na-133
K-5.0 Cl-95* HCO3-19* AnGap-24*
Imaging:
CT head w/o contrast ___
COMPARISON: Multiple prior NECTs of the head from ___.
MR head
___.
FINDINGS: Compared to most recent NECT of the head from
___, there is no significant interval change. Again seen
is a thin left frontoparietal subdural hematoma without
significant mass effect. No new area of hemorrhage is seen.
The ventricles and sulci are normal in size and configuration.
The basal cisterns are patent. The gray-white matter
differentiation is preserved. There is no fracture. There is
mild mucosal thickening in the left maxillary and right sphenoid
sinuses. The remaining visualized paranasal sinuses, mastoid
air cells and middle ear cavities are clear.
IMPRESSION: Stable left frontoparietal subdural hematoma.
CT head w/o contrast ___
FINDINGS: There is a left frontoparietal subdural hematoma of
relatively high density, measuring up to 7 mm from the inner
table of the skull. This mildly effaces the frontoparietal
sulci, but there is no shift of usually midline structures.
Incidental note is made of cavum septum pellucidum, and of a rim
calcified pineal cyst which measures 1.3 cm. The ventricles are
normal in size. Gray matter/white matter differentiation
remains intact, without evidence of territorial infarction.
There is mucosal thickening within the left greater than right
maxillary sinuses, with mucosal thickening of frontoethmoidal
sinuses and sphenoid sinuses to a lesser degree. The soft
tissues are unremarkable. The mastoid air cells are clear
bilaterally. There is no fracture.
IMPRESSION: Minimal increase in size of the left frontoparietal
subdural
hematoma, without significant mass effect.
Chest x-ray ___
Increase in both heart size and the caliber of mediastinal and
pulmonary
vessels between ___ and ___ is due to cardiac
decompensation and/or volume overload. Since ___, there
is new focal consolidation in the left lower lung and
progression of consolidation in the anterior segment of the
right upper lobe and in the right lower lobe, probably worsening
multifocal pneumonia. Heart size top normal. Right PIC line
ends in the SVC.
TTE ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The number
of aortic valve leaflets cannot be determined. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. No structural cardiac
cause of syncope identified. Left ventricular function is
probably normal, a focal wall motion abnormality cannot be fully
excluded. No significant valvular abnormality seen. No resting
outflow tract obstruction.
EEG ___ (final report pending)
No epileptiform activity
Labs on Discharge:
___ 06:19AM BLOOD WBC-9.2 RBC-3.20* Hgb-10.8* Hct-33.1*
MCV-103* MCH-33.7* MCHC-32.6 RDW-14.6 Plt ___
___ 06:19AM BLOOD Glucose-87 UreaN-78* Creat-8.7* Na-133
K-5.0 Cl-95* HCO3-19* AnGap-24*
Brief Hospital Course:
___ M with a history of ESRD ___ Lithium toxicity) on ___ HD,
bipolar disorder, COPD, tobacco abuse, alcohol dependence and
recent MVCs who presents after a right facial twitching/eye
blinking followed by generalized convulsion in the setting of a
SDH.
# Neuro: Patient was recently hospitalized at ___ on the
trauma service after a low speed motor vehicle accident where he
sustained minor C-spine injuries that have been conservatively
managed. A ___ at the time showed the presence of a subacute
left SDH. Of note, his wife says he has had 5 low-speed car
crashes like this over the past 6 weeks. He was initially
intubated and sedated at OSH, transferred to our neuro ICU,
subsequently extubated, now called out to the floor. While on
the floor, he showed symptoms/signs of delirium including some
visual hallucination, but no localizing exam findings. Head CT
on ___ showed stable SDH. On ___, he was noted to be a bit
more dysarthric. A repeat head CT showed again stable SDH.
(1) SEIZURE: Semiology sounds like partial with secondary
generalization. Given presence of left subacute temporal SDH
(not on seizure ppx after car accident), this was probably the
seizure focus that caused the event. Acute hyponatremia may also
have been contributing. Repeat NCHCT on ___ was stable. Now
sodium level is normalized. EEG for 24 hours showed NO seizures
(only left posterior delta slowing, and occasional sharp
transients over C3/P3 and T3/T5 areas). We continued to hold
anti platelet agents. We started Keppra 500mg PO BID with
additional 250mg after HD.
(2) DELIRIUM: Patient's mental status returned to baseline.
Likely multifactorial etiology: hyponatremia (had similar
presentation at ___ in ___, ___, hospital delirium (has
h/o this per wife). ___ (see below) also likely
contributing to fluctuating mental status. Also, has history of
EtOH dependence so could be withdrawing, but CIWA scale has been
zero so we discontinued it.
# CARDIAC: Patient was hypertensive to the 180s during hospital
course. TTE this admission was suboptimal quality and showed a
low normal EF of 50-55%. No clear LV dysfunction. h/o angina.
Cath on ___ showed no signs of coronary disease.
(1) HTN: Found to be hypertensive to 180s in ICU. Now stable
(130s-140s) on labetalol 100 mg TID and lisinopril 5 mg daily.
(2) POSSIBLE SYNCOPE: multiple car crashes over the past 6
weeks, unclear circumstances. Per wife, not all of these
episodes happen after HD. Needs further workup for orthostatic
vs. vasovagal vs. cardiac syncope. Of note, has somewhat
prolonged QTc (500). Seizure is obviously also on DDx.
# PULM: intubated for airway protection at OSH. Extubated here
without issues. BAL showed 1+ PMNs. CXR on ___ showed
multiple opacity (RUQ, RLQ, LLQ), concerning for multifocal
pneumonia. Started Cefepime/Vancomycin for HCAP and Flagyl to
cover anaerobes on ___. Cefepime was switched to
ceftazidime 1mg per HD on ___ for easier administration.
Swallow eval was unremarkable. Day 8 of antibiotic course is
___.
# RENAL: ESRD secondary to Lithium toxicity on HD MWF. Was
hyponatremic on admission to 121. Sodium back to normal via HD.
Euvolemic on exam. His initial hyponatremia likely ___ excess
free water. Osm shifts less likely given serum osm was
low/normal. SIADH is unlikely given urine lytes showed diluted
urine. He was on Trileptal (300mg PO qHS) at home which could
also have been contributing. Fluid restriction < 1000 cc.
# ID: ___ blood culture positive for GPCs, and eventually grew
coag negative staph. PICC was DCed. A new PICC was placed he was
afebrile for 24 hours. Follow-up surveillance blood cultures
were negative. His CXR on ___ showed consolidation in RUQ,
RLQ and LLQ concerning for multi-focal pneumonia, which likely
was HCAP and also likely aspect of aspiration pneumonia. Started
Cefepime/Vancomycin for HCAP and Flagyl to cover anaerobes on
___. Fever curve trended down and leukocytosis resolved.
Switched Cefepime to Ceftazidime per renal recs on ___.
Last day of Cettazidime/Vancomycin/Flagyl is ___. New PICC
line was removed on ___ and he would get ceftazidime and
vancomycine at HD.
# Musculoskeletal. Known C-SPINE FRACTURE (C5-C6 vertebral body
fracture). In hard C-collar until further directed by spinal
surgery. Per ACS discharge summary, will f/u with ortho as
outpatient. Continue C-collar per ortho recs, F/u with Dr.
___ attending as outpatient at 11 AM on ___.
# Psych: H/O BIPOLAR DISORDER: We continued home olanzapine
(monitor daily EKG for QTc prolongation) and citalpram. We held
home trileptal 300mg qHS due to hyponatremia. Instead,
lamotrigine was started. He will follow up his PCP, ___
___ (who managed his psych meds) regarding continuing
lamotrigine vs restarting trileptal. He was started on
lamotrigine 25 mg BID on ___, with the uptitration plan
of 25 mg BID for two weeks, 50 mg BID for two weeks, 75 mg BID
for two weeks and 100 mg BID from then on. Informed patient that
if he develops a rash to stop lamictal and call his doctor.
TRANSITIONS OF CARE:
- will complete vancomycin/ceftazidime/flagyl course on ___
for aspiration and hospital acquired pneumonia
- will follow up with Dr. ___ in stroke clinic and Dr.
___ in orthopedics
- will follow up with his PCP, ___, as trileptal was
discontinued and we started him on lamotrigine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Citalopram 60 mg PO DAILY
3. OLANZapine 15 mg PO QPM
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
hold for sedation or RR<10
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
7. Terazosin 4 mg PO HS
Discharge Medications:
1. Citalopram 60 mg PO DAILY
2. OLANZapine 15 mg PO QPM
3. Terazosin 4 mg PO HS
4. Vancomycin 1000 mg IV HD PROTOCOL bacteremia
day ___
RX *vancomycin 1 gram on HD days Disp #*2 Vial Refills:*0
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
6. sevelamer CARBONATE 1600 mg PO TID
7. Thiamine 100 mg PO DAILY
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last day ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
9. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
10. LeVETiracetam 250 mg PO ASDIR
take after each dialysis session
RX *levetiracetam 250 mg 1 tablet(s) by mouth ASDIR Disp #*30
Tablet Refills:*0
11. CefTAZidime 1 g IV Q24H
RX *ceftazidime-dextrose (iso-osm) [Fortaz in D5W] 1 gram/50 mL
on HD days Disp #*2 Vial Refills:*0
12. Labetalol 100 mg PO TID
RX *labetalol 100 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*2
13. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
14. LaMOTrigine 25 mg PO QHS
take 25mg twice per day for 2 weeks, then 50mg twice per day for
2 weeks, then 75mg twice per day for 2 weeks, then up to 100mg
twice per day
RX *lamotrigine [Lamictal ODT] 25 mg 1 tablet(s) by mouth twice
a day Disp #*100 Tablet Refills:*2
15. Outpatient Occupational Therapy
16. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
tonic-clonic seizure in setting of subdural hematoma
Hyponatremia (likely related to trileptal use)
hospital acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital because you had a seizure. We thought that this
episode were triggered by your subdural hematoma (some previous
bleeding in the brain) in addition to your low sodium level.
Your sodium level were subsequently corrected. You were started
on a medication (Keppra) to prevent another seizure episode. We
monitored your brain signals for 24 hours and did not find any
further seizure activity. Your mental status were subsequently
improved. Please continue to take Keppra until you see Dr.
___ in stroke clinic.
While you were here, you were also found to have a pneumonia,
and your blood culture grew some bacteria. You were treated with
antibiotics (vancomycin, flagyl and cefepime). Please continue
these antibiotics until ___.
You have a neck bone fracture due to your previous car accident.
Please continue to wear your hard collar until your appointment
with Dr. ___ of our orthopedics surgeon on ___.
We have made the following changes to your medications:
STOP
Trileptal
DECREASE
Renelva to 1600mg three times per day
START
Labetalol for blood pressure control
Lisinopril for blood pressure control
Keppra for seizures
Lamictal to replace trileptal (take 25mg twice per day for 2
weeks, then 50mg twice per day for 2 weeks, then 75mg twice per
day for 2 weeks, then up to 100mg twicer per day)
Vancomycin, Ceftazidime, Flagyl for pneumonia (last day is
___
As we discussed with you prior to discharge, lamictal can cause
a serious allergic reaction which is initially manifested as a
rash. We start at low doses and increase slowly to avoid this
reaction. However, if you DO develop a rash, stop taking the
medication and call your doctor immediately.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10611071-DS-18 | 10,611,071 | 27,575,952 | DS | 18 | 2190-12-27 00:00:00 | 2190-12-27 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ ___ with h/o Pulmonary MAC not
on active treatment, DM, HTN, HLD, ovarian and breast cancer who
presents with BRBPR. She reports having diarrhea on ___ with
bright red blood noted on her toilet paper and in the toilet.
She denies any history of hemorrhoids or straining with bowel
movements. At the time she noted lower abdominal pain. On the
morning of admission she had another bloody bowel movement, this
time with a mix of lighter and darker blood. She endorses
epigastric discomfort which is mild. She denies lightheadedness,
dizziness, SOB, recent falls, history of ulcers, history of GI
bleeds, use of blood thinners or aspirin, recent use of NSAIDS
(occasional Ibuprofen, none in past week). Denies current rectal
itching (had seen urologist in ___, given steroid cream for
rectum and vagina, resolved).
She also complains of chest pressure that occurred last week.
She denies cardiac history including MI, angina or any prior
diagnoses. She is not able to quantify how often this occurs,
but most recently it happened last week, lasted two hours with
laying down, and was +/- responsive to Validol (Menthyl
isovalerate), a menthol derivative that is common in ___
communities and used for cardiac chest pain and nausea (per
Wikipedia). She denies associated radiation to back, arms, jaw,
nausea, weakness, sweats, chills, fevers, dizziness.
Exam in ED: Mild epigastric tenderness w/o guarding, rebound.
Guaiac (+) BRB in rectum w/o stool. No visible external
hemorrhoids. Neuro-exam: Oriented and attentive, sensation,
strength intact in UE and ___, Babinski (-), No cerebellar signs,
CNII-XII intact.
In the ED, initial vitals were: 97.4 86 151/83 18 98% RA
On the floor, patient denies any abdominal or chest discomfort.
Reports she feels wells. Of note she reports her last Colonscopy
was done at ___ she believes in ___ and was normal as
far as she knows.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Breast cancer
Osteporosis
Ovarian cancer
IBS
Mycobacterium Avium Intracellular
GERD
HTN
Insomnia
Vit B12 deficiency
Depression
Social History:
___
Family History:
Relative Status Age Problem
Mother ___ ___ GASTRIC CANCER
OSTEOARTHRITIS
CONGESTIVE HEART
FAILURE
Father ___ KILLED IN ___
PEPTIC ULCER DISEASE
Physical Exam:
EXAM ON ADMISSION:
==================
Vitals: 98.2, 174/77, HR 75, RR 18, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Rectal: no evidence of hemorrhoids, Guiac positive stool. no
evidence of skin irritiation or excoriations
EXAM ON DISCHARGE:
===================
Vitals: 98.2, BP 150/64, HR 62, RR 16, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait normal.
Pertinent Results:
LABS ON ADMISSION:
===================
___ 09:15AM BLOOD WBC-13.5*# RBC-5.10 Hgb-14.7 Hct-41.8
MCV-82 MCH-28.9 MCHC-35.3*# RDW-14.3 Plt ___
___ 09:15AM BLOOD Neuts-81.5* Lymphs-12.4* Monos-5.2
Eos-0.8 Baso-0.1
___ 10:00AM BLOOD ___ PTT-29.5 ___
___ 09:15AM BLOOD Glucose-169* UreaN-16 Creat-0.7 Na-138
K-3.3 Cl-98 HCO3-23 AnGap-20
___ 09:15AM BLOOD ALT-17 AST-20 AlkPhos-89 TotBili-1.1
___ 09:15AM BLOOD Albumin-4.8 Calcium-9.8 Phos-2.9 Mg-1.7
___ 10:21AM BLOOD Lactate-2.0
LABS ON DISCHARGE:
==================
___ 07:15AM BLOOD WBC-9.4 RBC-4.85 Hgb-13.8 Hct-39.8 MCV-82
MCH-28.5 MCHC-34.7 RDW-14.5 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-140
K-3.3 Cl-102 HCO3-26 AnGap-15
___ 07:15AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ ___ with h/o mild Pulmonary MAC
not on active treatment, DM, HTN, HLD, ovarian and breast cancer
who presented with bright red blood per rectum.
ACTIVE:
=======
# Bright red blood per rectum
Patient with history of bright red blood per rectum associated
with bowel movements and initial lower abdominal crampy pain
with no history of melena per history making upper GI bleed less
likely source. Patient noted to have guaic positive brown stool
on admission. Lower GI bleeding thought to be more likely given
history of bright red blood per rectum and considerations for
etiology included internal hemorrhoids, diverticulosis, and
possible skin breakdown secondary to clobetasol treatment of
pruritis ani recently. Patient remained without abdominal pain,
further diarrhea, or blood noted in stool throughout hospital
course. Per patient's report last colonscopy in ___ was
unremarkable. Patient remained completely hemodynamically stable
throughout hospital course with normal Hg/Hct. As such GI was
consulted and felt that patient was clinically stable and would
thus be best evaluated by outpatient colonscopy. Colonscopy
scheduled for follow up with Dr. ___ in 2 weeks following
discharge. Patient informed she would be sent prep with
instructions in ___ in the next week for colonscopy. Patient
was educated about danger signs including increased bright red
blood per rectum and dizziness for which she should return to
Emergency Department.
#Leukocytosis with neutrophil predominance on admission that
resolved prior to discharge. UA without evidence of infection
and patient without symptoms of dysuria or frequency. CXR also
without evidence of infection as well. Patient remained afebrile
throughout entirety of hospital course.
#Chest pain
Patient with noted chest pain in ED and at that time was EKG
obtained that was not notable for any ischemic changes. In
addition troponins X 2 obtained that were negative. The patient
remained without chest pain throughout the course of her
admission.
CHRONIC
========
#MAC
Unclear if this is an acitive issue. Per pulm note patient has
mild pulmonary MAC infection and mild reactive airways.
-no treatment at this time
# HTN
Patient intially hypertensive to systolic of 170 on admission
however noted in setting of her not receiving her evening dose
of metoprolol at time of admission. Antihypertensives including
losartan, amlodipine, hydrochlorothiazide and metoprolol
continued and patient remained in normotensive range prior to
discharge.
#Depression
Patient denied history of depression or taking escitalopram on
admission though recent OMR notes noted pscyhiatric visits with
this medication administered. Escitalopram continued and patient
counseled on importance of taking her medications as prescribed.
#Ovarian and Breast Cancer
Patient with history of both ovarian and breast cancer. On
review of OMR patient noted to need follow up for ovarian ca;
last seen ___, supposed to get 6 month f/u, oncologist
(___) retired. Patient instructed of importance of
following up with upcoming hem/onc appointment that was provided
on her discharge paper work.
#Insomnia
Patient with noted history of insomnia. Per OMR review recently
instructed to cut back on lorazepam use at night to help with
sleep. Patient continued on melatonin QHS for sleep and 0.5 mg
lorazepam PRN for sleep during hospital course.
# GERD
Omeprazole continued
TRANSITONAL ISSUES:
=====================
-follow up colonscopy results
-needs f/u for hx of ovarian ca; last seen ___, supposed to
get 6 month f/u, oncologist (___) retired,
upcoming hem/onc appointment on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
3. Escitalopram Oxalate 5 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Hydrocortisone (Rectal) 2.5% Cream ___ID
6. Lorazepam 0.5 mg PO HS:PRN insomnia
7. Losartan Potassium 50 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. melatonin 3 mg oral QHS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Escitalopram Oxalate 5 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN insomnia
5. Losartan Potassium 50 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. melatonin 3 mg oral QHS
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
10. Hydrocortisone (Rectal) 2.5% Cream ___ID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
GI Bleed
Secondary Diagnosis
Breast cancer
Osteporosis
Ovarian cancer
IBS
Mycobacterium Avium Intracellular
GERD
HTN
Insomnia
Vit B12 deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___. You were admitted
because you were found to have blood in your stool. We recommend
that you be seen by a Gastroentorologist Dr. ___ on follow up
to have a colonscopy. It has been scheduled for you on ___
___. Please arrive at 8 AM. You will receive instructions in
the mail for how to prep before the colonoscopy.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10611307-DS-4 | 10,611,307 | 21,389,158 | DS | 4 | 2115-09-27 00:00:00 | 2115-09-27 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Ibuprofen
Attending: ___
Chief Complaint:
acute change in mental status, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is am ___ M with atrial fibrillation (on aspirin) and a
prior left thalamic hemorrhage (per chart history) who presents
with his wife as she noted a somewhat acute change in mentation.
A code stroke was activated.
She explains that ___ at baseline is quite physically able: he
does not need a wheelchair or walker and he can go up and down
stairs without difficulty. He has been having a somewhat gradual
decline in cognitive functioning over the past ___ years. She
explained that he has not been able to process complex questions
as fast. He sustained a number of falls, and while on warfarin,
one fall that is described as a syncopal event resulted in a
NCHCT that identified a left thalamic hemorrhage (noted on
Atrius
records). After that hemorrhage, his warfarin was discontinued
and he at that time developed a step wise decline in overall
cognitive dysfunction.
His health has otherwise been fine lately; no new medication
changes, dietary supplements. She explains that his oral intake
is chronically poor, particularly fluids. Today morning he
appeared to be fine at 9AM or so. Wife was downstairs and noted
that he was taking a particularly long time to get down for
breakfast. When she went up to get him, he just explained that
he
"was getting dressed". He then came down and made a completely
overcooked bowl of cereal, which is unlike him. Then, he
proceeded to eat it with his bare hands. He is a usually very
meticulous neat and clean person, so this was completely out of
character.
Review of systems is negative for headaches, fevers, double
vision, dysarthria, hallucinations, delusions, mood changes,
crying spells or episodes of LOC. He has not had any asymmetric
weakness, jerking or twitching or numbness.
Past Medical History:
Past medical history includes atrial fibrillation, which was
discovered just ___ years prior. He was started on warfarin
therapy. He sustained a left thalamic hemorrhage in ___ -
he had a syncopal spell and fall following which a ___
identified this hemorrhage. His warfarin was switched to aspirin
at that time, and he has since not had any acute events. He has
since that time developed a little right sided facial
tremor/tic. His history is otherwise notable for hypertension,
hyperlipidemia, cervical spondylosis (per chart), arthritis,
GERD. He had a surgery to fix a cataract in the left eye.
Social History:
___
Family History:
H/o pacemaker implantation in brother at age of ___
h/o amyloidosis - mother and sister
h/o breast cancer - sister
h/o colonic polyp/mass in brother
No family history of early MI, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
V/s were 97.8, HR 115, BP 132/85 and RR 20,99%.
He is awake, alert and looking around the room. He appeared
younger than his stated age. His neck was with limited excursion
but not meningismic. Chest examination identified irregular
heart
sounds with clear lungs. Abdomen was soft. Lower extremities
were
dry and without edema.
In terms of his mental status, he struggled with the month but
knew the year. He could tell us his name. He knew that he was in
"hospital". He answered in full sentences that were fluent, but
he often provided longwinded responses around the specific
answer. When asked about his profession, he replied "My
profession was a person who was very clear, who was very clear
..
". Naming of the stroke objects was intact except for "hammock".
Finally, he came up with ___ priest. He knew his date of
birth. He could not name the ___ teams without
considerable prompting. He was easily distractable for tasks
such
as checking visual fields. His responses were quick, and he had
difficulty with calculations. He could read. His repetition was
intact for simple but not complex phrases.
Pupils were asymmetric: left eye was 4-3mm and right was 3-1mm
(s/p surgery on the left). Both reacted to light. Visual fields
were grossly full. Eye movements were with saccadic intrusions
and he had limited upgaze. Facial sensation was symmetric to
pinprick and smile was symmetric. Tongue was strong and midline,
and palate elevated symmetrically. Motor examination identified
full strength throughout without asterixis or myoclonus.
Reflexes
were 2+ and symmetric. S1 jerks were at 1+ and I found the toes
to be downgoing.
There was quite notable gegenhalten, particularly of the lower
extremities. He had a low amplitude low frequency tremor of the
left > right arm, worse with intention.
Sensation was intact to light touch and pinprick throughout.
Finger-nose testing identified no dysmetria. Gait and romberg
testing was deferred.
Pertinent Results:
___ 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 01:06PM GLUCOSE-117* NA+-144 K+-4.9 CL--100 TCO2-31*
___ 01:00PM UREA N-26*
___ 01:00PM CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.2
___ 01:00PM WBC-6.8 RBC-4.63 HGB-14.5 HCT-41.3 MCV-89#
MCH-31.4 MCHC-35.1*# RDW-14.0
___ 01:00PM NEUTS-63.2 ___ MONOS-7.4 EOS-4.7*
BASOS-0.6
___ 01:00PM PLT COUNT-219
___ 01:00PM ___ PTT-30.2 ___
CSF: 1WBC, 1RBC, 87Lymphs, 60Protein, 59Glucose
CSF HSV PCR: Negative
EKG (___): Atrial fibrillation with moderate ventricular
response. Occasional ventricular premature contractions.
Compared to the previous tracing of ___ ventricular
premature contractions are new, but otherwise, no other
significant diagnostic change.
CT head (___): There is no evidence of acute intracranial
hemorrhage, edema, mass effect, or large vascular territory
infarction. The ventricles and sulci are prominent, indicative
of age-related involutional changes. Extensive periventricular
and subcortical white matter hypodensities are nonspecific but
suggestive of chronic small vessel ischemic changes. The basal
cisterns appear patent, and there is preservation of gray-white
matter differentiation.
CTA head and neck (___): CTA of the head demonstrates
patency of the major vessels with no evidence of stenosis or
aneurysms larger than 3 mm in size.
The CTA of the neck demonstrates dominance of the left vertebral
artery. The carotid arteries are widely patent with no
significant stenosis, dissection or hematoma.
EEG (___): This EEG telemetry demonstrated a slow and poorly
organized background with bursts of generalized slowing
consistent with a mild encephalopathy. Also, periods of slow
wave sleep appear to occur in the daytime hours, and are not
strictly confined to the overnight recording period. No
interictal epileptiform activity was seen. Note is made of an
irregularly irregular cardiac rhythm.
Brief Hospital Course:
___ right handed man with a history of atrial fibrillation on
aspirin/metoprolol therapy, also with a history of a left
thalamic hemorrhage (at OSH, per Atrius records) while on
warfarin, who presented with his wife today when he started to
act strange.
NEURO: Patient underwent NCHCT which showed extensive
periventricular white matter hypoatenuation suggestive of
longstanding vascular disease. These extended up superiorly to
corona radiata just undercutting the frontal lobes. He was
unable to undergo MRI given pacemaker in place. Patient was
continued on ASA 325mg po daily. He was ordered for half dose
Metoprolol in order to allow his BP to autoregulate. He was
assessed for stroke risk factors with HgbA1C which was 5.7 and
Lipid panel which showed LDL 122. Patient had an episode after
CTA were he appeared confused and his speech was incoherent and
he was unable to answer questions correctly and appeared to be
staring. Patient subsequently underwent extended routine EEG to
evaluate encephalopathy, which showed generalized slowing but no
focal findings. He subsequently underwent more prolonged EEG,
which showed generalized slowing consistent with a mild
encephalopathy. Patient was started on Lamictal 25mg po BID on
___, with plan to increase to goal of 75mg po BID over 4
weeks. He had several episodes of confusion and agitation, worse
at nighttime, for which he received Olanzapine prn and required
posey restraint for a brief period of time, not for at least 24
hours prior to discharge. Patient was started on Donepezil 5mg
po daily on ___.
ID: Patient had UA to evaluate for infection which was negative
on multiple occasions. He also had LP which showed 1 WBC and 1
RBC and normal protein and glucose. HSV PCR was also sent and
was negative.
CV: Patient continued on home dose of digoxin for atrial
fibrillation. He was initially on half dose of his home
Metoprolol in order to allow his BP to autoregulate. His
Metoprolol was restarted at home dose prior to discharge.
FEN/GI: Laboratory indices identified a creatinine of 1.3 from a
baseline of 1.1, consistent with acute renal failure/possibly
hypovolemia related. Patient was started on IVF and creatinine
was trended daily. Urine electrolytes were checked and were
consistent with intrinsic renal etiology, which may have been
compunded by poor po intake, so patient was given IVF and
nephrotoxic medications were avoided. He underwent bedside
swallow evaluation and was started on regular diet once he
passed.
Endo: We maintained euglycemia and normothermia.
TOX: LFTs were sent and were normal. Urine and serum tox were
negative.
PPX: Patient was started on Subq Heparin and pneumoboots for DVT
prophylaxis. He was also started on bowel regim prn.
Dispo: ___ and OT evaluated patient and felt patient would
require discharge to rehab facilty. Given his insurance, patient
qualified for ___ nursing facility on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Donepezil 5 mg PO HS
5. LaMOTrigine 25 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary diagnosis: Vascular dementia, Metabolic encephalopathy
Secondary diagnosis: Atrial fibrillation, Acute on chronic
kidney injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to our hospital because of concerns of changes
in your behavior and difficulties with your language. You were
evaluate for a possible ACUTE ISCHEMIC STROKE, a condition where
a blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. However, you CT scan of your brain showed
evidence of chronic vascular changes, but no evidence of an
acute stroke. However, given we could not perform an MRI of your
brain because you have a pacemaker, we could not exclude a small
stroke.
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: Atrial fibrillation.
You were also found to have an elevated creatinine on admission,
which is a signs of kidney function. This may have contributed
to your confusion and decline in function. We felt this was most
intrinsic worsening of your kidney function, compounded by your
poo po intake, and we gave you fluids to try to correct this.
There was also a question of whether you were having seizures,
so we performed an EEG, which showed general slowing but no
seizure acitivity. You were started on Lamictal, an anti-seizure
medication, to prevent seizures.
Given your demenia and cognitive decline, you were started on
Donepezil to try to prevent worsening.
It is still unclear what caused your confusion and decline in
mental status. We believe it is most likely multifactorial,
onvolving longstanding vascular dementia, possible trigger of
dehydration or worsened kidney function, and possible
unidentificable small stroke. For this reason, we want you to
continue to be closely followed by Neurology.
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:
___
|
10611338-DS-2 | 10,611,338 | 25,688,656 | DS | 2 | 2153-07-16 00:00:00 | 2153-07-21 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with alcoholic fatty liver disease, hypertension, alcohol
use disorder who presents with severe chest pain, shortness of
breath. Pt reports that this began two days prior to admission,
when he started having loose, watery stools. At the same time,
he developed some mild lower abdominal pain, dry cough, and
nasal congestion. The day prior to admission, he continued to
have loose, watery stools ~every 2 hours with progressively
worse abdominal pain. He reports the pain began to spread
upwards into his epigastric and lower, central chest areas. The
pain was worsened by leaning forward. Not impacted by exertion.
No alleviating factors. He began to developed significant
dyspnea on exertion and postural lightheadedness. These symptoms
prompted him to seek medical attention.
He denies melena, blood in stool, N/V. No history of reflux. No
recent sick contacts. Endorses occasional sweating/chills over
last 2 days, but no temps taken. Recently had all of his teeth
extracted (___), has been eating broth since then. Generally
poor PO intake since that time.
Of note, the patient is followed by cardiology and hepatology at
___. There was stray documentation of the patient having
alcoholic cardiomyopathy; however, TTE in ___ showed mild
LVH, consistent with hypertension, and no evidence of
cardiomyopathy. Pt also reporting atypical chest pain in the
past - stress test (treadmill/EKG+echo on modified ___
protocol) in ___ showed no ischemic changes. Speculation that
patient had poor exercise tolerance and possible COPD, to
explain his SOB.
Past Medical History:
alcoholic fatty liver disease
hypertension
spinal stenosis
alcohol use disorder
diverticulosis
Social History:
___
Family History:
father - MI, CVA
mother - MI
paternal aunt - HTN
Physical ___:
ADMISSION EXAM
==============
Vital Signs: T 98.1, BP 169/99, HR 63, RR 18, SpO2 96/RA
General: Alert, oriented, no acute distress. Lying in bed.
HEENT: Sclerae mildly icteric, MMM, oropharynx clear,
edentulous. PERRL, neck supple, no LAD. Tender in submandibular
area.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Non-distended. Soft, exquisitely tender to light
palpation in lower quadrants. Voluntary guarding. Could not
assess for rebound. No epigastric, L/RUQ tenderness.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: moving all 4 extremities with purpose, grossly normal
sensation.
DISCHARGE EXAM
==============
Vitals: T 97.7, BP 133-148/84-87, HR 58-70, RR 16, SpO2 97/RA
General: Alert, oriented, no acute distress. Lying in bed.
HEENT: Sclerae mildly icteric, MMM, oropharynx clear,
edentulous.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Non-distended. Soft, no TTP, no rebound or guarding.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 02:10PM ___ PTT-26.2 ___
___ 02:10PM PLT COUNT-254
___ 02:10PM NEUTS-60.9 ___ MONOS-6.3 EOS-0.7*
BASOS-0.9 IM ___ AbsNeut-5.38# AbsLymp-2.71 AbsMono-0.56
AbsEos-0.06 AbsBaso-0.08
___ 02:10PM WBC-8.8 RBC-4.74 HGB-14.8 HCT-43.5 MCV-92
MCH-31.2 MCHC-34.0 RDW-12.5 RDWSD-42.4
___ 02:10PM ALBUMIN-4.3 CALCIUM-9.9 PHOSPHATE-4.1
MAGNESIUM-2.1
___ 02:10PM cTropnT-<0.01
___ 02:10PM LIPASE-21
___ 02:10PM ALT(SGPT)-37 AST(SGOT)-51* ALK PHOS-72 TOT
BILI-0.5
___ 02:10PM estGFR-Using this
___ 02:10PM GLUCOSE-67* UREA N-30* CREAT-1.3* SODIUM-135
POTASSIUM-5.8* CHLORIDE-94* TOTAL CO2-17* ANION GAP-30*
___ 02:22PM LACTATE-4.6* K+-4.4
___ 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:16PM CK-MB-3 cTropnT-<0.01
___ 09:19PM LACTATE-1.5
MICRO
=====
__________________________________________________________
___ 4:10 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 7:39 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 3:12 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
==============
___ 07:39AM BLOOD WBC-6.3 RBC-4.24* Hgb-13.7 Hct-39.8*
MCV-94 MCH-32.3* MCHC-34.4 RDW-13.0 RDWSD-44.5 Plt ___
___ 07:39AM BLOOD Plt ___
___ 07:39AM BLOOD ___ PTT-25.2 ___
___ 07:39AM BLOOD Glucose-88 UreaN-18 Creat-0.9 Na-136
K-4.4 Cl-99 HCO3-23 AnGap-18
___ 07:39AM BLOOD ALT-30 AST-34 AlkPhos-69 TotBili-0.9
___ 07:39AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
IMAGING/STUDIES
===============
___ Imaging CHEST (PORTABLE AP)
Streaky bibasilar opacities likely atelectasis. Otherwise
unremarkable exam noting that the costophrenic angles are
excluded from the field of view.
___ Imaging CTA TORSO
1. No evidence of aortic dissection, aneurysm, or intramural
hematoma. No
findings in the chest to explain patient's symptoms.
2. Long segment of mid small bowel wall edema with mesenteric
stranding and fluid worrisome for enteritis. Underlying
etiologies include inflammatory or infectious, ischemia not
excluded. Angioedema is additional diagnostic consideration in
the setting of ACE inhibitors.
3. Borderline right hilar adenopathy, nonspecific.
Brief Hospital Course:
___ with alcoholic fatty liver disease, hypertension, and
alcohol use disorder who presents with diarrhea, abdominal pain,
chest pain, and dyspnea.
# ABDOMINAL PAIN:
# DIARRHEA:
Possible etiologies included infectious, inflammatory, or
ischemia. The patient's CTA abdomen and pelvis was unremarkable
except for possible enteritis in the mid small bowel. Elevated
lactate was concerning for mesenteric ischemia, but patent
vessels on CT. One etiology that was raised by the appearance of
the CT was ACE-I related angioedema. Given report of preceding
emesis, stool norovirus PCR was tested and was negative. Stool
C. diff test was sent and pending at the time of discharge. His
symptoms improved significantly the day after discharge with
good appetite and ability to tolerate POs. Given the rapid
improvement, non-specific viral gastroenteritis is the most
favored diagnosis.
# DYSPNEA ON EXERTION:
# CHEST PAIN:
Patient reported chest pain on the day of admission with
associated shortness of breath and radiation down his left arm,
concerning for cardiac ischemia in the setting of a patient with
hypertension, current smoking status, and early age of MI in his
father. His EKG in the ED was concerning for hyperacute T waves.
He was ruled out for MI with 2 negative troponins. He had a CTA
in the ED that showed no acute PE or aortic dissection (has a
reported history of aortic dilation). He had a stress test in
___ that did not show any evidence of cardiac ischemia, but
he did not perform an adequate workload. Unclear exact etiology
of pain, which was resolved by the time he presented to the
floor with no recurrence.
# LACTIC ACIDOSIS:
# ACUTE RENAL FAILURE:
Lactate elevated to 4.6 on admission. Cr 1.3 on admission,
baseline 0.7-0.8. Likely in the setting of volume depletion from
diarrhea and poor PO intake. Cr improved to 0.9 and lactate to
1.5 with IVF.
# HYPERTENSION:
Continued chlorthalidone and held lisinopril with initial ___.
Resumed on discharge. See above for angioedema concern.
# SPINAL STENOSIS:
Continued home gabapentin.
# HEARTBURN:
Continued home omeprazole.
TRANSITIONAL ISSUES
[ ] Please monitor for recurrence of similar episode of abdomen
pain in the future as it may reflect ACE-I induced angioedema.
For now, lisinopril was continued.
[ ] Please consider performing a repeat stress test as
outpatient as the patient had chest pain concerning for cardiac
etiology, but negative troponins on testing.
[ ] Exertional dyspnea may be also related to lung disease from
smoking. Please consider PFTs as outpatient.
Greater than 30 minutes were spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 12.5 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Lisinopril 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Nicotine Polacrilex 4 mg PO Q1H:PRN nicetine craving
Discharge Medications:
1. Chlorthalidone 12.5 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Gabapentin 300 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Nicotine Polacrilex 4 mg PO Q1H:PRN nicetine craving
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Viral gastroenteritis
SECONDARY: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were having severe abdominal pain, nausea, and vomiting at
home. In additional, you also had chest pain, breathing
discomfort, and left arm numbness.
What did you receive in the hospital?
- We performed a CT scan of your chest, abdomen, and pelvis,
which showed inflammation of your small intestines.
- We did lab tests that showed no evidence of heart damage.
- We performed stool tests for common infections, which were
negative.
- The most likely cause of your symptoms is a viral infection of
the GI tract.
What should you do once you leave the hospital?
- Please drink plenty of fluids and stay hydrated as long as you
are still having some watery diarrhea.
- Please do your best to try to quit smoking, which will be the
best for your overall health.
- Please continue taking your current medications. There is a
very small possibility that your abdominal pain may be related
to the medication lisinopril, which can cause swelling in the
intestines. If you develop symptoms of mouth swelling and throat
swelling, you should report to the emergency room immediately as
this may also be an effect from the lisinopril. For now, we
believe you have a viral infection and that it is safe to
continue lisinopril.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10611508-DS-13 | 10,611,508 | 27,026,230 | DS | 13 | 2170-08-12 00:00:00 | 2170-08-12 10:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___ - CRPP of L fem neck
History of Present Illness:
Patient is a ___ with a history of depression and uterine
cancer ___ years ago who presents as a transfer from osh with
left
hip fracture. Ptn states she slipped while shoveling snow 1 day
prior, thought it was a muscle strain so waited until today to
see an doctor. Denies head strike, loc. Does report left hip
pain, denies numbness/tingling distally. Denies any L knee/L
ankle/L foot pain. Denies RLE pain, UE pain, neck pain, back
pain, headache. ROS otherwise negative.
Past Medical History:
-depression
-uterine cancer
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is in NAD AOx3
Vitals: 98.2 85 90/60 16 98%
Left lower extremity:
Skin intact
held in flexion, tender with any movement.
Full, painless AROM/PROM of knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Discharge PE:
AO3
NAD
LLE: wound c/d/i. nvid.
Pertinent Results:
see OMR
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 valus impacted L fem neck fracture and was admitted to
the orthopedic
surgery service. The patient was taken to the operating room on
___ for CRPP of the L hip, which the patient tolerated
well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LL extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
Effexor XR 150 mg capsule 2 tabs qday
Wellbutrin XL 300 mg 24 hr tablet qday
Effexor XR 75 mg qday
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Calcium Carbonate 500 mg PO TID
4. Diazepam 5 mg PO Q12H:PRN anxiety, spasm
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
6. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*14
Syringe Refills:*0
7. Multivitamins 1 CAP PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*50
Tablet Refills:*0
9. Senna 8.6 mg PO BID
10. Topiramate (Topamax) 200 mg PO QHS:PRN sleep
11. Venlafaxine XR 300 mg PO DAILY
12. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L valgus impacted femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
Followup Instructions:
___
|
10611631-DS-15 | 10,611,631 | 23,730,280 | DS | 15 | 2145-09-21 00:00:00 | 2145-09-21 17:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
EGD with biopsy (___)
Colonosocpy (___)
History of Present Illness:
___ F with a history of PE/DVT (on Lovenox), ___, and menorrhagia
s/p hysterectomy on ___, who presents with bleeding of
unknown origin (vaginal vs rectal) > 1 pad/hr and abdominal
pain.
Has a complex medical history that includes DVT/PE (___),
recurrent GI bleed requiring transfusions (___), pyelonephritis
c/b sepsis ___, ESBL+ E. Coli), ___, menorrhagia.
Two days after hysterectomy, was having increased pain, went to
ED, pain medication was increased. 3 days after procedure,
started to have small amount of rectal bleeding, went to Sturdy
ED, CT scan was unremarkable. Was fine until last night.
Yesterday, she started to have sharp abdominal pain and toilet
was filled with blood. She is unsure where the blood is coming
from. She woke up with the underwear drenched in blood, now
using
pads. 1 pad/hr. Abdominal pain is sharp, lower abdomen, twisting
feeling. ___ in severity. For the pain she has been taking 10
mg
oxy q4h and 2 mg dilaudid for breakthrough, with minimal relief.
She vomited x1 this AM, NBNB. Pt endorses dizziness that started
today. Has not fainted, no falls. Reports that she has problems
emptying her bladder, but no dysuria. No fever, chills, SOB, CP,
diarrhea or constipation, sick contacts.
In the ED, initial VS were: T98.2, HR 94, BP 113/72, RR 18, O2
99% RA
Exam notable for: Rectal Exam- Gross blood visible. Pad
drenched
in bright red blood. Guaiac test positive, could be due to
contamination.
Pelvic Exam- Sutures intact, no blood see at vault.
Labs showed: WBC 10.2, Hb 10.9, HCT 33.5, platelets 285. Chem
panel within normal limits. ___ 12.6, PTT 34.9, INR 1.2.
UA leukocyte negative, nitrite positive, moderate blood, 67
RBCs,
few bacteria
Imaging showed:
CT A/P: 1. Trace pelvic free fluid is within physiologic range
and/or could be related to recent surgery. Otherwise, no acute
process in the abdomen or pelvis.
2. Expected postoperative change status post interval
hysterectomy and
bilateral salpingectomy.
Consults: OB/GYN consulted in ED- no e/o vaginal bleeding on
exam
with guaiac positive stool. Low concern for intra-abdominal
infection given normal white count, benign exam and CT scan
results.
GI consulted- recommended IV PPI, 2 large bore PIVs, trending
H/H, NPO for now.
Patient received:
Dilaudid 1mg IV x2
Zofran 4mg
Pantoprazole 40mg IV
Diphenhydramine
1L NS
Transfer VS were: HR 90, BP 119/94, RR 18, O2 98% RA
On arrival to the floor, patient reports she had two episodes
of
emesis with dark red, large clots on arrival to the floor. She
continues to feel nauseated. She is continuing to have bright
red
blood per rectum. Last BM with stool was yesterday. She has been
taking Enoxaparin since her procedure, last dose was at 1000 on
___. Her abdominal pain is diffuse, but most severe in RUQ and
feels like a twisting sensation. She received relief with IV
Dilaudid in ED, but her PO dilaudid and Oxycodone at home was
not
helpful and made her nauseous. Denies fevers, chills, cough,
chest pain, shortness of breath, dysuria, or lower extremity
swelling.
Past Medical History:
PUD c/b GI bleed in ___
DVT/PE
s/p tubal ligation
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
Physical Exam:
ADMISSION EXAM
VS: 97.9PO 96 / 60 85 12 97 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
Prior to leaving AMA
VS: 98.6 ___ 97%RA
GENERAL: Teary-eyed, hyperventilating
HEENT: NC/AT, PERRL, EOMI, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Soft, non-distended, non-tender. No peritoneal signs.
No
guarding or re-bound tenderness. Stable infra-umbilical
ecchymosis from previous lovenox injections
EXTREMITIES: no c/c/e
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
Patient left AMA
ADMISSION LABS
___ 04:00PM BLOOD WBC-8.3 RBC-3.65* Hgb-11.2 Hct-33.6*
MCV-92 MCH-30.7 MCHC-33.3 RDW-12.9 RDWSD-43.5 Plt ___
___ 04:00PM BLOOD Neuts-68.6 ___ Monos-6.5 Eos-3.5
Baso-0.4 Im ___ AbsNeut-5.73 AbsLymp-1.64 AbsMono-0.54
AbsEos-0.29 AbsBaso-0.03
___ 04:00PM BLOOD ___ PTT-34.9 ___
___ 03:00PM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-140
K-4.7 Cl-102 HCO3-21* AnGap-17
___ 04:24PM BLOOD Lactate-1.1
INTERVAL LABS
___ 05:11AM BLOOD ALT-110* AST-111* AlkPhos-98 TotBili-0.4
___ 09:07AM BLOOD ALT-84* AST-43* AlkPhos-101 TotBili-<0.2
___ 05:11AM BLOOD Lipase-60
___ 05:48AM BLOOD Ferritn-139
___ 05:48AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
DISCHARGE LABS
___ 09:20AM BLOOD WBC-5.5 RBC-3.58* Hgb-10.9* Hct-32.6*
MCV-91 MCH-30.4 MCHC-33.4 RDW-12.7 RDWSD-41.4 Plt ___
___ 09:20AM BLOOD Glucose-113* UreaN-7 Creat-0.7 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-10
___ 09:20AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.8
MICROBIOLOGY
___ 12:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. PREDOMINATING ORGANISM. >100,000
CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES
CT A/P WO Contrast (___)
IMPRESSION:
1. Trace pelvic free fluid is within physiologic range and/or
could be related
to recent surgery. Otherwise, no acute process in the abdomen
or pelvis.
2. Expected postoperative change status post interval
hysterectomy and
bilateral salpingectomy.
Gastrointestinal Mucosal Biopsy Results (___)
PATHOLOGIC DIAGNOSIS:
Stomach, body, biopsy:
- Corpus-type gastric mucosa, no diagnostic abnormalities
recognized.
CXR ___
IMPRESSION:
Compared to chest radiographs ___ and ___.
Lungs are low in volume but clear. Cardiomediastinal and hilar
silhouettes
and pleural surfaces are normal.
Left subclavian central venous infusion catheter ends close to
the superior
cavoatrial junction.
Brief Hospital Course:
***PATIENT LEFT AGAINST MEDICAL ADVICE. SHE WAS ABLE TO STATE
THE RISKS OF LEAVING AND HAD CAPACITY TO LEAVE THE HOSPITAL.
PLEASE SEE BELOW REGARDING AMA DISCHARGE***
Ms. ___ is a ___ female with history of PE and DVT,
Fe deficiency anemia, menorrhagia status post hysterectomy on
___, recurrent UTI with previously ESBL E. Coli, ischemic
colitis with prior GI bleeds requiring PRBC transfusions, who
presented with a 2 day history of severe abdominal pain with
hematochezia, hospital course complicated by moderate volume
hematemesis, now status post EGD and colonoscopy showing small
patches of erythema in the stomach body, but without any
evidence of bleeding lesions with overall improvement of
hematochezia. Patient had ongoing episodes of hematemesis with
stable vital signs and hemoglobin. She refused to stay for
further monitoring or testing as she did not feel like her pain
was being adequately addressed. Of note, there is significant
concern for opiate use disorder as patient has filled 14
prescriptions for narcotics with 14 different providers over the
past year with several occurring in the past several months.
When confronted about our concern for her opiate use and pain
control, the patient became very tearful and angry and demanded
to leave against medical advice when we refused to offer IV
dilaudid. She declined oxycodone, Tylenol, or other PO
alternatives. She declined seeing an addiction specialist. The
patient ultimately signed out AMA.
ACUTE ISSUES
==============
#Hematemesis
#Hematocheiza - Patient initially presented with a 2 day history
of severe lower abdominal pain and hematochezia. Hospital course
was complicated by moderate volume hematemesis with clots.
Hemoglobin on admission was 10.9, down from recent baseline of
___, however patient also with severe iron deficiency anemia
with L sided port for IV Fe infusions, and is also status post
hysterectomy on ___. At times patient had brief episodes of
hypotension with SBPs in the ___, received intermittent IVF
boluses. She remained asymptomatic, otherwise hemodynamically
stable, with stable hemoglobin throughout hospital course.
Initial CT A/P demonstrated trace pelvic free fluid within
physiologic range or possibly related to recent hysterectomy.
There was no otherwise no acute intra-abdominal or pelvic
findings. Hematemesis and hematochezia was initially thought to
be secondary to possible PUD vs. ischemic colitis, and of note,
patient was restarted on Lovenox due to prior PE/DVT at time of
hysterectomy, with plan for 10 day duration of therapy, however
patient had continued to take lovenox beyond 10 days prior to
admission. Lovenox was subsequently held on admission.
GI was consulted and patient underwent EGD and colonoscopy,
revealing small patches of mild erythema in the stomach body
with biopsies taken, showing corpus type gastric mucosa without
abnormalities on pathology report. Otherwise normal mucosa and
no obvious source of bleeding on EGD or colonoscopy. Per GI,
hematochezia thought to be secondary to anal fissures. Patient
was initially placed on pantoprazole 40 mg IV BID, however later
switched to omeprazole 40 mg PO BID. Patient did not require any
blood products during hospitalization. Per GI, no indication for
any additional diagnostic workup at this time. Given pattern of
bleeding with hematemesis with blood clots, unlikely to be small
bowel bleed. Per GI, if patient continues to have hematemesis,
would pursue repeat EGD and possible colonoscopy at that time.
Diet was advanced to regular time of discharge. Patient left AMA
and refused to stay for further monitoring of her CBC.
#Abdominal Pain
#Possible Opioid Use Disorder
#AMA Discharge- Patient continued to have at times severe
subjective abdominal pain, which was inconsistent with physical
exam and diagnostic imaing findings. Patient also demonstrated
drug-seeking behavior. ___ PMP demonstrated
patient had filled 14 different prescriptions by 14 different
providers over the last year concerning for risky opioid use and
dependence. Pain management was consulted. Patient was
descalated from IV opioids to oxycodone 10 mg Q4H:PRN. Patient
became very upset when she was no longer able to get IV dilaudid
and refused alternative PO medications. When confronted about
her opiate use and our overall concerns about her usage over the
past year, the patient became angry, tearful and demanded to
leave AMA. She declined seeing an addiction specialist or
alternative pain medications or PO narcotics.
#UTI - Patient has a history of ESBL E. coli UTI, with initial
UA on admission consistent with UTI. Given history of ESBL E.
coli, she was initially started on meropenem. Urine cultures
eventually grew pansensitive E. coli, and antibiotics were
de-escalated to ciprofloxacin. Plan for 7 day course of
ciprofloxacin given history of urethral diverticulum status post
excision with suburethral sling. End date ___.
#Transaminitis - Patient presented with new transaminitis on
admission with AST/ALT 100/111, which down trended during
hospitalization. She is status post cholecystectomy. Was found
to be hepatitis B immune, HCV antibody negative, ferritin within
normal limits. CT abdomen/pelvis demonstrated no intra-hepatic
pathology. ___ consider outpatient workup of mild transaminitis
if LFTs persistently elevated.
CHRONIC ISSUES
===============
#DVT/PE - Patient has a history of ischemic colitis placing
patient at high risk for DVT, with DVT in ___ thought to be
secondary to ischemic colitis. Patient subsequently had PE which
occurred in the postoperative setting. Patient is followed by
Dr. ___ Hematology. She was initially treated with
warfarin and Eliquis, and was previously off anticoagulation
since ___. Hypercoagulability workup was subsequently
negative. Per above, patient was restarted on Lovenox prior to
hysterectomy which was stopped on admission. After improvement
of hematemesis, patient was restarted on subcutaneous heparin
for DVT prophylaxis given that she is at high risk for VTE.
#Menorrhagia s/p hysterectomy - Patient underwent hysterectomy
on ___ secondary to menorrhagia. CT A/P findings per above
were consistent with post-operative changes. OB/GYN was
consulted in the emergency department, and there was no blood in
the vaginal vault on physical exam.
#Anxiety/Depression - Patient was continued on home clonazepam,
citalopram, and hydroxyzine.
TRANSITIONAL ISSUES
===================
[ ] NEW/CHANGED Medications
-Cipro 500mg BID (end ___
-Omeprazole 40mg BID
Other:
-Please see details above regarding significant concern for
opiate use disorder/opiate seeking behavior and her decision to
leave against medical advice when we transitioned her off IV
opiates
-Will need repeat CBC within 1 week of discharge to monitor
anemia
-Continue cipro until ___ for complicated UTI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. HydrOXYzine 25 mg PO QPM:PRN insomnia
3. ClonazePAM 1 mg PO BID:PRN anxiety
4. Escitalopram Oxalate 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Ibuprofen 800 mg PO Q6H:PRN Pain - Mild
7. Enoxaparin Sodium 30 mg SC Q12H
8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe
9. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN BREAKTHROUGH PAIN
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*4 Tablet Refills:*0
2. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. ClonazePAM 1 mg PO BID:PRN anxiety
5. Escitalopram Oxalate 20 mg PO DAILY
6. HydrOXYzine 25 mg PO QPM:PRN insomnia
7. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe
8. HELD- HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN BREAKTHROUGH
PAIN This medication was held. Do not restart HYDROmorphone
(Dilaudid) until follow-up with your primary care physician
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
#Hematemesis
#Hematochezia with possible anal fissure
#Possible opioid use disorder
#UTI
#Transaminitis
SECONDARY DIAGNOSIS
#DVT/PE
#Menorrhagia s/p hysterectomy
#Anxiety/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 taking care of you at ___
___.
You initially came to the hospital because of abdominal pain and
because you were having blood in your stools.
What happened during her hospitalization?
-You continued to have bloody stools and you had several
episodes of vomiting blood
-You were evaluated by the gastroenterology team and underwent
an upper EGD or scope and colonoscopy
-The scope showed that you had some areas of inflammation in
your stomach and biopsies were taken
-Your bloody stools were thought to be from anal fissures
-You were treated with an antibiotic for a urinary tract
infection
-We were also evaluated by the pain management team due to your
severe abdominal pain
-You decided to leave against medical advice
What should you do when you leave the hospital?
-Continue to take all of your medications as prescribed
-Follow-up with your primary care physician ___ 1 week
-Please keep all of your other scheduled healthcare appointments
as listed below
Sincerely,
Your BIMDC Care Team
Followup Instructions:
___
|
10611631-DS-16 | 10,611,631 | 24,940,300 | DS | 16 | 2146-03-21 00:00:00 | 2146-04-10 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
Attending: ___.
Chief Complaint:
Upper GI bleed
Abdominal pain
Nausea
Anemia
Major Surgical or Invasive Procedure:
EGD and clip x1 in stomach
History of Present Illness:
Ms ___ is a ___ with PMH pertinent for recurrent GI bleeds
(likely ___ dieulafoy lesions), celiac stenosis, hx of DVT/PE
(not currently on AC ___ bleeds), iron deficiency anemia (had L
chest port for infusions until got infected 1mo ago) who
presents
as a transfer from ___ with abdominal pain,
nausea, and hematemesis.
Patient began having abdominal pain three days prior followed by
some nausea and vomiting, which has progressively worsened. Her
emesis initially was mostly bile with some flecks of blood but
has become mostly blood with a bit of bile. She was seen at
___ and received some IV PPI and pain med and
transferred over here for further care. Last hemetemsis was
around 4am this morning. She states this is similar to her prior
episodes. She admits to using NSAIDs about once a week. Has been
experiencing some associated weakness and fatigue but denies
lightheadednes, CP, SOB, dysphagia, odynophagia, melena or
BRBPR.
Pt Hgb down to 7.6 from 8.7 at ___ and baseline of
___.
Ms. ___ has had multiple hospitalization this year
for UGIB. She was hospitalized at ___ in ___. There she
underwent relatively unremarkable EGD and colonoscopy. She was
then hosptalized in ___ at ___ for hematemesis. She
had an EGD with clipping of dieulafoy lesion. She was again
hospitalized at ___ with hematemesis with EGD at that time
showing hematin and multiple clips in stomach but no active
bleeding.
ROS: 10 pt review of systems neg other than per above HPI.
Past Medical History:
History of cholecystectomy, appendectomy, hysterectomy
iron deficiency anemia
h/o dvt/pe
PUD c/b GIB ___
ischemic colitis in ___
Gynecologic History:
- Last pap ___ WNL, remote history of HPV positive
- Denies history of STIs
- DVT, PE on Eliquis -> transitioned to Lovenox after TLH BS
- menorrhagia
.
Past Surgical History:
- TLH BS (___)
- Bilateral tubal ligation (___)
- LSC x2 for ovarian cysts (___)
- LSC cholecystectomy (___)
- Removal of urethral diverticulum
- Suburethral sling for stress urinary incontinence
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
Physical Exam:
24 HR Data (last updated ___ @ 1846)
Temp: 98.4 (Tm 98.8), BP: 109/72 (94-111/54-72), HR: 85 (76-98),
RR: 18, O2 sat: 100% (97-100), O2 delivery: RA, Wt: 184 lb/83.46
kg
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
Pertinent Results:
LABS:
___ 06:32AM BLOOD WBC: 6.1 RBC: 3.12* Hgb: 7.9* Hct: 26.0*
MCV: 83 MCH: 25.3* MCHC: 30.4* RDW: 15.8* RDWSD: 47.6* Plt Ct:
279
___ 06:33AM BLOOD WBC: 7.2 RBC: 3.15* Hgb: 8.1* Hct: 26.6*
MCV: 84 MCH: 25.7* MCHC: 30.5* RDW: 15.6* RDWSD: 47.4* Plt Ct:
253
___ 06:32AM BLOOD Plt Ct: 279
___ 06:33AM BLOOD Plt Ct: 253
MICRO: None
IMAGING & STUDIES:
___ angiogram uploaded to PACS:
"Examination demonstrates a severe stenosis of the celiac trunk
by 1.5 cm from its origin
The SMA is widely patent
Unable to
safely were cannulated given critical stenosis
It is possible
that because of the severe stenosis of the celiac trunk origin
collateral vessels may be responsible for bleeding elected to
terminate the procedure to review the case with GI and vascular
surgery as to whether or not she should have a bypass
"
___ CT-A A/P
1. No evidence of contrast extravasation to suggest active
bleeding.
2. Patent celiac artery but severe narrowing proximally at the
expected level of the median arcuate ligament.
___ US Doppler LUE
IMPRESSION:
Nearly occlusive deep venous thrombosis of a left brachial vein.
___ EGD:
Personally reviewed the report. Unremarkable other than erythema
in the stomach, possible area of potential recent bleed that was
clipped. They recommend oral PPI BID and advance diet as
tolerated.
Brief Hospital Course:
Ms ___ is a ___ with ___ pertinent for recurrent GI bleeds
(likely ___ dieulafoy lesions from collaterals from celiac
stenosis), celiac stenosis (MALS unlikely per ___ surgery), hx
of DVT/PE (not currently on AC ___ bleeds), iron deficiency
anemia (had L chest port for infusions until got infected 1mo
ago) who presented ___ as a transfer from ___
___
with abdominal pain, nausea, and hematemesis.
#Hematemesis
#Upper GI bleed
Likely ___ dieulafoy lesions from collaterals from celiac
stenosis. GI recommends vascular surgery follow up since perhaps
if celiac stenosis can be improved, the flow through the
collaterals would go down and the bleeds from dieulafoy lesion
bleeds will go down. Pt has had several admits for UGIB and
severe abd pain, all admits are similar in presentation. EGD at
___ w/o lesions, though EGD at OSH in ___ reportedly with
5x
clips. Active UGIB in ED, now resolved. EGD ___ showed only one
area that could have been bleeding recently.
-plan to continue PPI BID x 1 month, then PPI daily after
-needs to set up vascular surgery clinic follow up
(___)
-needs PCP follow up
# Abdominal Pain
Unclear cause. On prior admission there was initial concern for
possible median arcuate ligament syndrome (MALS) but surgery
evaluated and felt strongly this was not the case but could see
the patient in clinic. They felt strongly enough to counsel that
if she goes to OSH, should be counseled that she should NOT have
celiac artery stenting per vascular.
We should note that we caution against long-term use of opioids
to treat the pain. They aren't good treatment long term because
the patient gets tolerant and there are so many side effects.
Treatment of anxiety/depression may help since it may exacerbate
her pain.
-continue management of pain with Tylenol
-provided a 2-week supply of oxycodone 10 mg (#42) to use prn
-needs to set up vascular surgery clinic follow up
(___)
-needs PCP follow up
# Subacute DVT
# Hx of DVT/PE
US ___ showed brachial DVT. Fortunately not likely to risk
pulmonary emboli. She does have a history of prior DVT in ___.
And PE occurred post-op. Hypercoagulability workup negative.
Initially treated with warfarin then Eliquis, off
anticoagulation since ___ due to bleeds. Prior to
hysterectomy was re-started on lovenox, but stopped in ___.
-patient, GI, and medicine all agree not start anticoagulation
at this time given frequency of bleeds
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO DAILY:PRN anxiety
2. Escitalopram Oxalate 20 mg PO DAILY depression
3. omeprazole 40 mg oral BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 10 mg 1 tablet(s) by mouth Every 6 hours as needed
Disp #*42 Tablet Refills:*0
3. Escitalopram Oxalate 20 mg PO DAILY depression
4. Omeprazole 40 mg oral BID
After a month, decrease frequency to daily
RX *omeprazole 40 mg 1 capsule(s) by mouth twice daily Disp #*60
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Abdominal pain
Nausea
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for belly pain and vomiting blood and found to
have anemia.
A scope didn't show active bleeding in your stomach although
they clipped one are that might have been a source recently.
We think your celiac artery stenosis may be leading to
collateral arteries getting more blood flow than typical to
compensate and get blood where it needs to go, but these
collaterals which include vessels that run along the stomach
maybe the source of the bleeding. So perhaps if the stenosis is
treated, the collaterals won't flow as much blood and the
bleeding risk you've had might be reduced. We don't know his for
sure, but our gastroenterologists have suggested this
hypothesis.
You were also found to have a DVT in your left brachial vein. We
considered and discussed with you the idea of anticoagulation,
but it's risky because of your GI bleeds. Fortunately upper arm
DVTs are unlikely to risk a pulmonary clot. You and we agreed to
hold off on anticoagulation and the clot should hopefully
dissolve on its own with time.
Please call to set up a follow up appointment with your primary
care doctor in the next week. Please ask your primary care
doctor to set up a blood draw so you can have your CBC checked
within a week of discharge.
Please call the vascular surgery clinic here (___) to
set up an appointment with them. You may need a referral from
your primary care doctor to set it up.
I am discharging you with medications for help with the pain to
bridge you until you can see your primary care doctor.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10611631-DS-18 | 10,611,631 | 25,107,060 | DS | 18 | 2146-06-05 00:00:00 | 2146-06-05 17:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ PMH unprovoked DVT not on anti-coagulants ___ bleeds),
celiac artery stenosis, iron deficiency anemia previous with
port for IV iron infusions but since removed ___ infection, and
previous admissions for upper GI bleeds (likely ___ dieulafoy
lesions), sent over from hematology for hematemesis and
abdominal pain.
The patient was in her usual state of health until yesterday
afternoon when she began having abdominal pain follow by emesis
with red-colored vomitus and clots. She reports about 6 episodes
in total, last around 8 am. She states this is similar to her
prior episodes. No new medications since her ___ visit. No
changes in bowel movements. Since yesterday the abdominal pain
has been constant and increasing in intensity. It does not
change with vomiting. At baseline, she experience abdominal
discomfort sometimes after eating.
Ms. ___ has had multiple hospitalizations for UGIB. In ___
at ___ for hematemesis. She had an EGD with clipping
of Dieulafoy lesion. She was again hospitalized at ___ with
hematemesis with EGD at that time showing hematin and multiple
clips in stomach but no active bleeding. Her last admission was
in ___ of this year.
In the ED, initial vitals: T 98.3, HR 81, BP 135/93, RR 16, 97%
RA
Labs were significant for
- hgb 9.9 -> 9.7 -> 8.6
- Lytes:
141 / 105 / 11
-------------- 84
4.4 \ 21 \ 0.8
Imaging was significant for: CXR with no acute process
In the ED, pt received IV protonix. Her right PIV is failing.
Past Medical History:
PUD c/b GI bleed in ___
DVT/PE
s/p tubal ligation
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
Physical Exam:
VITALS: Afebrile and hemodynamically 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.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation on left
side. Bowel sounds hypoactive
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, speech fluent
PSYCH: appropriate mood and affect
Pertinent Results:
___ 04:43PM BLOOD WBC-7.0 RBC-3.84* Hgb-9.9* Hct-30.9*
MCV-81* MCH-25.8* MCHC-32.0 RDW-17.9* RDWSD-53.0* Plt ___
___ 05:58AM BLOOD WBC-5.6 RBC-3.28* Hgb-8.6* Hct-27.4*
MCV-84 MCH-26.2 MCHC-31.4* RDW-18.3* RDWSD-55.9* Plt ___
___ 10:10PM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-21* AnGap-15
___ 03:14AM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-143 K-4.2
Cl-113* HCO3-21* AnGap-9*
___ 10:21PM BLOOD Lactate-0.9
___ 03:29AM BLOOD Lactate-1.2
___ 03:47PM BLOOD Lactate-0.6
Abd Duplex: Stenosis in the distal celiac axis. The remainder of
the vasculature is within normal limits.
CXR: The heart size is normal. The cardiomediastinal and hilar
contours are stable. The lung volumes are low. Otherwise, the
lungs are clear. No pleural effusion or pneumothorax. Multiple
vascular staples in the upper abdomen denote extensive prior
surgery.
Brief Hospital Course:
___ with PMH pertinent for recurrent GI bleeds (likely ___
dieulafoy lesions from collaterals from celiac stenosis), celiac
stenosis (MALS unlikely per vasc surgery), hx of DVT/PE (not
currently on AC ___ bleeds), iron deficiency anemia (had L chest
port for infusions until got infected 1mo ago) who presents with
abdominal pain and hematemesis.
#Hematemesis
#Upper GI bleed
Recurrent bleed are thought to be ___ dieulafoy lesions from
collaterals from celiac stenosis. Vascular surgery has not felt
it appropriate to intervene on the celiac stenosis though GI had
thought if this can be improved, the flow through the
collaterals would go down and the bleeds from dieulafoy lesion
bleeds will go down. She was started IV PPI BID. We obtained a
midline as we were unable to re-establish peripheral access. She
was hemodynamically stable without active bleeding and Hgb >7,
so no transfusions were performed. GI was discussing repeat
endoscopy; however, the patient expressed a desire to leave the
hospital after she returned from her abdominal duplex study. She
cited a family emergency and said she was the only person who
could deal with it. We discussed the risks her presenting
conditions pose, including death. She acknowledged those risks
and was able to recount the potential consequences in her own
words. We began working on her paperwork, but the patient could
not be found upon returning to her room.
#Iron deficiency anemia: Outpt hematologist Dr. ___ was
interested in replacing port ___ one removed to due infection)
to resume outpatient IV iron infusions. Discussed this with
___ and ___ NP ___. Patient required general
anesthesia in the past when done by ___ due to anxiety.
# Abdominal Pain
Unclear cause. On prior admissions there was initial concern for
possible median arcuate ligament syndrome (MALS) but surgery
evaluated and felt strongly this was not the case but could see
the patient in clinic. They felt strongly enough to counsel that
if she goes to OSH, should be counseled that she should NOT
have celiac artery stenting per vascular. Counseling has been
provided about avoiding long-term opioid use. Treatment of
anxiety/depression may help since it may exacerbate. She
received IV hydromorphone in the ED. No prescriptions were given
on discharge as the patient left before this could be done.
her pain.
# Subacute DVT
# Hx of DVT/PE
US ___ showed brachial DVT. She does have a history of prior
DVT in ___ and PE occurred post-op. Hypercoagulability workup
negative. Initially treated with warfarin then Eliquis, off
anticoagulation since ___ due to bleeds. Prior to
hysterectomy was re-started on lovenox, but stopped in ___.
# Anxiety/depression:
- Continue home PRN clonazepam and escitalopram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. ClonazePAM 1 mg PO DAILY:PRN Anxiety
3. Pantoprazole 40 mg PO Q12H
4. Escitalopram Oxalate 20 mg PO DAILY
5. HydrOXYzine 25 mg PO QHS:PRN Insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Celiac artery stenosis
Discharge Condition:
Left against medical advice
Discharge Instructions:
Ms. ___,
You were admitted to ___ for GI bleeding and abdominal pain.
We were concerned about this bleeding and wanted to perform a
repeat EGD to look for a source. We also wanted to evaluate the
narrow blood vessel in your abdomen. Both of these issues could
cause you further harm, including death. We would advise staying
to continue to manage these issues.
Followup Instructions:
___
|
10611631-DS-19 | 10,611,631 | 27,933,416 | DS | 19 | 2146-06-17 00:00:00 | 2146-06-17 20:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
Attending: ___.
Chief Complaint:
hematemesis, abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ PMH unprovoked DVT not on anti-coagulants ___ bleeds), h/o
lupus anticoagulant positivity c/b multiple DVTs, celiac artery
stenosis, iron deficiency anemia previously with port for IV
iron infusions but since removed ___ infection, and previous
admissions for upper GI bleeds (likely ___ dieulafoy lesions)
who presents for hematemesis, abdominal/chest pain radiating to
the back, and bilateral calf pain.
The patient was recently discharged ___ for abdominal pain
and hematemesis. She left against medical advice prior to having
an EGD. Last EGD in ___ showed normal duodenum, esophageal
hiatal hernia, and erythema in the stomach.
For the past few days, she has felt overall unwell. She endorses
pain in her epigastrum that is burning and she vomited blood.
She vomited cup fulls of bright red blood 6 times since
yesterday. Her abdominal pain became severe and radiates to the
back. She has pain with deep inspiration. She has taken NSAIDs
up to 800mg PO daily due to worsening pain, although she knows
she is not supposed to take this. She also endorses bilateral
calf pain.
She initially presented to ___ with HR in 100s intially.
They had difficulty with IV access so EJ was placed and transfer
to ___ initiated.
Per recent discharge summary from ___:
Ms. ___ has had multiple hospitalizations for UGIB. In ___
at ___ for hematemesis. She had an EGD with clipping
of Dieulafoy lesion. She was again hospitalized at ___ with
hematemesis with EGD at that time showing hematin and multiple
clips in stomach but no active bleeding. Her last admission was
in ___ of this year.
In the ED, initial VS were: T97.5 HR95 BP98/60 RR16 O2 Sat: 98
EXAM:
GEN: well appearing, in NAD
HEENT: pale conjunctiva
CV: tachycardic, regular rhythm, normal S1/S1
LUNGS: CTAB
ABD: tender to palpation in epigastrum and LUQ, no rebound or
guarding, no peritonitis
EXT: b/l calf pain tender to palpation
EKG:
SR ___, normal axis, normal intervals, no ST or T wave changes
Patient was given:
IV methylprednisolone 40mg, benadryl for contrast allergy
IV Zofran
IV Dilaudid
IV Pantoprazole
Imaging notable for:
CTA: no PE, dissection
LENIS: no DVT
On arrival to the FICU, she endorses ___ epigastric abdominal
pain radiating to the back. She has had 3 episodes of bright
red, bloody emesis since arrival to the ED. She denies fevers,
chills, lightheadedness, diarrhea.
REVIEW OF SYSTEMS: Complete 10-point ROS negative except as per
HPI.
Past Medical History:
PUD c/b GI bleed in ___
DVT/PE
s/p tubal ligation
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.6 BP 110/80 HR 107 R 17 O2 Sat 100% RA
GENERAL: Alert, oriented, appears uncomfortable but no acute
distress
HEENT: Sclera anicteric, pale conjunctiva, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, crackles, rhonchi.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, tender to palpation throughout most predominantly in
epigastric region, non-distended, bowel sounds present, no
rebound, + guarding, no organomegaly
EXT: WWP, no lower extremity edema
NEURO: A&Ox3, face symmetric, moving all extremities
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.6 BP 98/71 HR 85 R 10 O2 Sat 100% RA
GENERAL: Alert, oriented, appears comfortable but no acute
distress
HEENT: Sclera anicteric,, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, crackles, rhonchi.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, tender to palpation throughout most predominantly in
epigastric region, non-distended, bowel sounds present, no
rebound,
EXT: WWP, no lower extremity edema
NEURO: A&Ox3, face symmetric, moving all extremities
Pertinent Results:
ADMISSION RESULTS:
==================
___ 08:30AM WBC-7.3 RBC-3.36* HGB-8.7* HCT-28.2* MCV-84
MCH-25.9* MCHC-30.9* RDW-17.7* RDWSD-53.9*
___ 08:30AM PLT COUNT-240
___ 05:18AM GLUCOSE-103* UREA N-12 CREAT-0.6 SODIUM-143
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12
___ 05:18AM ALT(SGPT)-8 AST(SGOT)-23 ALK PHOS-57 TOT
BILI-<0.2
___ 05:18AM LIPASE-37
___ 05:18AM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-2.0
___ 05:18AM WBC-7.7 RBC-3.43* HGB-8.6* HCT-28.6* MCV-83
MCH-25.1* MCHC-30.1* RDW-17.7* RDWSD-54.4*
___ 05:18AM ___ PTT-26.2 ___
PERTINENT RESULTS:
==================
CBC Trend
___ 08:30AM BLOOD WBC-7.3 RBC-3.36* Hgb-8.7* Hct-28.2*
MCV-84 MCH-25.9* MCHC-30.9* RDW-17.7* RDWSD-53.9* Plt ___
___ 07:25PM BLOOD WBC-6.9 RBC-3.36* Hgb-8.3* Hct-28.0*
MCV-83 MCH-24.7* MCHC-29.6* RDW-17.4* RDWSD-53.7* Plt ___
___ 05:18AM BLOOD cTropnT-<0.01 proBNP-14
DISCHARGE RESULTS:
==================
___ 03:45AM BLOOD WBC-9.3 RBC-3.23* Hgb-8.1* Hct-26.7*
MCV-83 MCH-25.1* MCHC-30.3* RDW-17.5* RDWSD-53.0* Plt ___
___ 03:45AM BLOOD ___ PTT-20.9* ___
___ 03:45AM BLOOD Glucose-119* UreaN-8 Creat-0.6 Na-138
K-4.4 Cl-106 HCO3-23 AnGap-9*
___ 03:45AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.8
IMAGING/STUDIES:
================
___ Lower extremity US
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ CTA Chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. No acute pulmonary parenchymal findings.
___
EGD - Report pending
Clip placed for suspected bleeding lesion; Frank blood in
stomach, but no active bleeding visualized
Brief Hospital Course:
___ PMH unprovoked DVT not on anti-coagulants ___ bleeds), h/o
lupus anticoagulant positivity c/b multiple DVTs, celiac artery
stenosis, iron deficiency anemia previous with port for IV iron
infusions but since removed ___ infection, and previous
admissions for upper GI bleeds (likely ___ dieulafoy lesions)
who presents for hematemesis, b/l calf pain, and abdominal pain
and chest pain radiating to the back. s/p EGD on ___ which
frank blood but no obvious source of bleeding; possible lesion
was clipped. Pt left AMA after requesting IV Benadryl for nausea
with IV pain meds. Patient was offered appropriate nausea
medication including IV Zofran, Compazine, or Ativan and IV/PO
pain medication and pt elected to leave AMA. She understood and
was able to repeat back the risk of leaving, including death.
Discharged with PPI and follow up number for GI appointment.
ACUTE ISSUES:
=============
# Hematemesis:
# Upper GI Bleed:
Presented with abdominal pain and hematemesis c/f UGIB.
Differential includes ___ tear, gastric ulcer iso
NSAID use, dieulafoy lesion secondary to celiac artery stenosis.
She has a history of dieulafoy lesions, however has been
evaluated by vascular surgery in the past who felt intervention
on her known celiac stenosis was not indicated. CTA negative for
PE or aortic abnormality. Her recent discharge revealed Hgb 8.6,
and her presenting Hgb was 8.6, which was reassuring. She was
admitted to ICU for bedside EGD. She underwent EGD on ___
which demonstrated frank blood but no obvious source of
bleeding; possible lesion was clipped. She did not require any
blood transfusions. She received IV PPI and her blood hemoglobin
remained stable. It was recommended to stay in the hospital for
monitoring following the procedure with possible repeat EGD, but
patient elected to leave AMA after refusing proposed pain
management plan. She understood the risks, including
exsanguination and death and able to repeat the risks in her own
words. Discharge Hgb was 8.1.
# Acute on chronic abdominal pain:
# Chest pain:
She presented with abdominal pain radiating to the back; overall
her presentation is similar to prior admissions, most recently
on ___. Per most recent discharge summary: "On prior admissions
there was initial concern for possible median arcuate ligament
syndrome (MALS) but surgery evaluated and felt strongly this was
not the case but could see the patient in clinic. They felt
strongly enough to counsel that if she goes to OSH, should be
counseled that she should NOT have celiac artery stenting per
vascular. Counseling has been provided about avoiding long-term
opioid use. Treatment of anxiety/depression may help since it
may exacerbate." Duplex mesenteric arteries from last admission
with mild celiac stenosis. On this admission, patient noted
severe sharp pain and in the past she notes that it generally
lasts 24 hours. Her LFTs, lipase, and lactate were normal. She
noted that medications such as Tylenol and oxycodone were
unhelpful. During review of patient's chart, it was noted that
at several times she has requested IV opioids and has
particularly difficult-to-control pain. In many of those
instances, IV opioids were not offered, and she had left against
medical advice. While this emphasizes the importance of
administering opioids with caution, it was also determined that
the patient is in pain (and could have worsened pain and
discomfort in setting of EGD) and it is important to not
undertreat her pain. It was decided that patient would receive
limited IV dilaudid for 24 hours. She was aware that she would
not be prescribed any opioids on discharge and that the IV
opioid pain medications would not be continued past 24 hours.
She expressed understanding and agreement of this plan. She
subsequently requested IV Benadryl and IV pain medication for
nausea and pain and when explained there are other appropriate
medications, she decided to leave AMA.
# Sinus tachycardia:
Likely in setting of pain, versus intravascular volume
depletion. CTA without PE. She received IVF and pain control.
# Nausea:
Patient reported significant nausea in the setting of recent
EGD. Of note, this may also be related to her abdominal pain as
above. She requested IV Benadryl and noted that IV Zofran and
Prochlorperazine did not help. She reported that she would leave
the hospital if she was not given IV Benadryl 50mg "full dose".
She was educated on IV Benadryl not being the ideal choice for
nausea treatment. In the past, patient has been noted to have
bargaining behaviors and has left AMA when not administered IV
Benadryl, so this request was also taken with caution.
Ultimately it was decided that she would receive one dose of IV
Benadryl 50mg to see if it helped with her nausea but it was
made clear that she would not receive more than one dose and
that she needed to trial the other nausea medications as
prescribed. She subsequently requested more IV Benadryl and when
offered appropriate alternatives, she refused and left AMA.
CHRONIC ISSUES:
===============
# Subacute DVT
# Hx of DVT/PE
US ___ showed brachial DVT. She does have a history of prior
DVT in ___ and PE occurred post-op. Hypercoagulability workup
negative. Initially treated with warfarin then Eliquis, off
anticoagulation since ___ due to bleeds. Prior to
hysterectomy was re-started on lovenox, but stopped in ___.
CTA and LENIS negative in ED. Was not discharged on AC.
# Anxiety/depression: Continued home PRN clonazepam and
escitalopram
TRANSITIONAL ISSUES:
====================
Discharge Hgb: 8.1
[] Chronic pain treatment such as: Acupuncture, reiki, regional
nerve block
[] Consider amitriptyline for functional abdominal pain
[] Check CBC at follow up appointment
[] Caution to avoid using any NSAIDs.
[] Discharged with PPI BID script
[] Provided phone number for GI appointment: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO DAILY:PRN Anxiety
2. Escitalopram Oxalate 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. HydrOXYzine 25 mg PO QHS:PRN Insomnia
5. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. ClonazePAM 1 mg PO DAILY:PRN Anxiety
3. Escitalopram Oxalate 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Why were you admitted?
- You were admitted for blood in your vomit.
What happened while you were in the hospital?
- You had an EGD (upper esophageal scope procedure) to look for
bleeding. The GI doctors saw ___ of blood and placed a clip on
an area that had evidence of prior bleeding
- You did not require any transfusions.
- Your blood levels remained stable though slightly
downtrending. We recommended you stay in the hospital for
monitoring after the procedure, but you elected to go home
against medical advice.
- You went home with a prescription for pantoprazole which you
should take twice daily to prevent future GI bleeds and to
follow up with GI in the next ___ days. Please call ___
for an appointment.
What should you do when you leave the hospital?
- Please call the GI clinic at ___ to schedule your
follow up appointment in the next ___ days.
- Your discharge hemoglobin was 8.1.
- It is important that you continue to take your proton pump
inhibitor (pantoprazole) twice daily to prevent future GI
bleeds.
- You need to avoid taking NSAIDs like aspirin and ibuprofen due
to risk of ulcers.
- If you were to have repeat blood in your vomit, please come
back to the emergency department.
- You should follow up closely with your PCP for your abdominal
pain. You may find other medications are helpful for your
abdominal pain. Other therapies (such as nerve block, reiki, and
acupuncture) can also be very helpful for treating pain. We
believe that no one should have to live with the pain that you
experience and are committed to helping you get better
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
10611631-DS-20 | 10,611,631 | 29,734,324 | DS | 20 | 2146-07-02 00:00:00 | 2146-07-02 17:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan
Attending: ___.
Chief Complaint:
CC: ___ pain
Major Surgical or Invasive Procedure:
EGD- ___
History of Present Illness:
HPI: Ms. ___ is a ___ woman with history of DVT/PE
not
on anticoagulation due to bleeding, history of lupus
anticoagulant positivity, celiac artery stenosis, iron
deficiency
anemia, previous admissions for upper GIB now presenting with
hematemesis and abdominal pain.
The patient reports that she developed sudden onset left upper
quadrant abdominal pain around 0300. This pain was ___,
nonradiating and awoke her from sleep. This felt like her
typical
abdominal pain but was more severe. She felt nauseated, and had
an episode of emesis that was nonbloody. She then had three
episodes of hematemesis. She reports filling up one solo cup
full
of blood. She is having constant 10 out of 10 pain in left upper
quadrant. The pain is made worse by eating, but is not
associated
with any foods in particular. She denies any fevers, chills,
diarrhea, constipation, dysuria, chest pain, palpitations,
shortness of breath.
The patient records are reviewed and summarized as follows. The
patient was recently admitted from ___ to ___ for
hematemesis
and abdominal pain. The patient underwent EGD on ___ that
demonstrated frank blood but no obvious source of bleeding;
possible lesion was clipped. The patient ultimately left against
medical advice after requests for IV Benadryl for nausea with IV
pain medications were declined.
Per review of records, the patient has had at least three AMA
discharges or elopements in the last 5 months, and there has
been
concern that the patient exhibited opioid seeking behavior.
In the ED, initial vitals: 8 96.8 98 108/68 16 100% RA
Labs notable for: Hb 8.3, INR 1.2, lactate 0.7
Imaging:
- CXR:
Patient given:
___ 19:49 TD Scopolamine Patch
___ 20:06 IV HYDROmorphone (Dilaudid) 1 mg
___ 20:06 IV Ondansetron 4 mg
___ 21:12 IV HYDROmorphone (Dilaudid) 1 mg
___ 21:12 IV Prochlorperazine 10 mg
___ 00:27 IV HYDROmorphone (Dilaudid) 1 mg
Consults: GI
On arrival to the floor, the patient reports that she is
extremely itchy all over her body. She attributes this to the
Compazine she received in the ED. She also reports sever left
upper quadrant pain. She requests IV Benadryl and IV dilaudid.
She has no other complaints at this time.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Upper GIB
DVT/PE
?Lupus anticoagulant
Iron deficiency anemia
s/p tubal ligation
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
No known family history of gastrointestinal disease
Physical Exam:
VITALS: 98.4 99/61 71 18 99 Ra
GENERAL: Alert, vigorously scratching at skin on chest
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation to
palpation
in left upper quadrant with voluntary guarding
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Anxious affect
Exam on discharge:
98.2 BP:98/64 HR: 76 18 98 Ra
GENERAL: Alert in NAD
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant and cooperative
Pertinent Results:
___ 07:50PM BLOOD WBC: 7.7 RBC: 3.29* Hgb: 8.3* Hct: 26.8*
MCV: 82 MCH: 25.2* MCHC: 31.0* RDW: 17.0* RDWSD: 50.0* Plt Ct:
260
___ 07:50PM BLOOD Neuts: 63.1 Lymphs: ___ Monos: 7.7 Eos:
1.7 Baso: 0.1 Im ___: 0.3 AbsNeut: 4.85 AbsLymp: 2.08 AbsMono:
0.59 AbsEos: 0.13 AbsBaso: 0.01
___ 07:50PM BLOOD ___: 12.7* PTT: 23.7* ___: 1.2*
___ 07:50PM BLOOD Glucose: 93 UreaN: 13 Creat: 0.7 Na: 143
K: 3.8 Cl: 108 HCO3: 23 AnGap: 12
___ 07:50PM BLOOD ALT: 7 AST: 11 AlkPhos: 50 TotBili: <0.2
___ 07:50PM BLOOD Albumin: 3.9 Calcium: 8.8 Phos: 3.8 Mg:
1.8
___ 08:12PM BLOOD Lactate: 0.7
Imaging:
CXR (___): No evidence for acute cardiopulmonary process. No
free air. Recently placed port terminating in the right atrium.
Abdominal Duplex (___):
Mild stenosis in the distal celiac axis. The remainder of the
vasculature is within normal limits.
CTA A/P (___):
1. The site of GI bleed is not demonstrated.
2. Patent celiac artery but severe narrowing proximally at the
level of the median arcuate ligament. Given collaterals between
hepatic artery branches and SMA, this may represent median
arcuate syndrome.
EGD: ___
No clear sources of hematemesis seen, could represent a
Dieulefoy lesion related bleed that has resolved
- Continue PPI indefinitely and advance diet as tolerated
Brief Hospital Course:
Ms. ___ is a ___ woman with history of DVT/PE not on
anticoagulation due to bleeding, history of lupus anticoagulant
positivity, celiac artery stenosis, iron
deficiency anemia, previous admissions for upper GIB now
presenting with hematemesis and abdominal pain.
ACUTE/ACTIVE PROBLEMS:
# Anemia, iron deficiency:
# Hematemesis:
# History of upper GIB:
Patient with history of iron deficiency anemia and upper GIB
presenting with hematemesis. The patient was seen by
gastroenterology and underwent an upper GI endoscopy which did
not reveal a source of bleeding. Gastroenterology recommended
indefinite twice daily PPI. The patient's hemoglobin and
hematocrit were trended and remained low but stable. The
patient did not require a blood transfusion while hospitalized.
She will follow-up with her hematologist Dr. ___ to resume
iron infusions now that she has a port in place. She was
advised to return to the hospital with recurrence of
hematemesis.
# Acute on chronic abdominal pain:
Per review of OMR, there has
previously been discussion regarding whether the patient's
abdominal pain is secondary to median arcuate ligament syndrome
(MALS). However, the patient was seen by surgery and this was
not thought to be the case. The patient was counseled against
celiac artery stenting. The etiology of the patient's abdominal
pain remains unclear. The patient's pain was initially managed
with intravenous Dilaudid while she was vomiting and n.p.o. we
will did tolerate a diet intravenous narcotics were discontinued
oral oxycodone which she takes at home she was counseled against
the use of long-term narcotics for chronic pain. She should
follow-up with Dr. ___ surgery for further
evaluation as previously recommended . This referral was made on
discharge.
# History of DVT/PE: Patient was previously treated with
warfarin and then apixaban, however, has been off
anticoagulation since ___ due to bleeding.
# Pruritus: Patient reporting severe pruritus on admission. No
evidence of rash or respiratory compromise. Patient attributes
this to Compazine, but per review of records she has received
this medication on multiple previous occasions. She was given
one dose of IV Benadryl with improvement in symptoms.
CHRONIC/STABLE PROBLEMS:
# Anxiety/depression: Continued home clonazepam and escitalopram
Transitional issues:
- Patient to follow up with surgery regarding evaluation of
chronic abdominal pain
- Advised to continue BID PPI indefinitely
- Patient set up with new PCP to establish care
HCP: ___- ___
Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. ClonazePAM 1 mg PO DAILY:PRN Anxiety
3. Escitalopram Oxalate 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron [Zofran ODT] 8 mg 1 tablet(s) by mouth Q8hrs as
needed for nausea Disp #*9 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. ClonazePAM 1 mg PO DAILY:PRN Anxiety
4. Escitalopram Oxalate 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
6. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Iron deficiency anemia
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with vomiting blood. You
were seen by the gastroenterologists and had an upper GI
endoscopy which did not reveal a source of bleeding. It is
important that you continue to take your protein pump inhibitor
twice daily. Your blood counts were followed and remained stable
although you are anemic. It is important that you follow-up
with Dr. ___ to resume iron infusions.
In terms of your abdominal pain, please follow-up with surgery
as previously arranged.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
10611631-DS-21 | 10,611,631 | 28,448,363 | DS | 21 | 2146-07-09 00:00:00 | 2146-07-09 22:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
Mrs. ___ is ___ woman with history of DVT/PE not on
anticoagulation due to bleeding, history of lupus anticoagulant
positivity, celiac artery stenosis, iron deficiency anemia,
recent admissions for upper GIB now presenting as a transfer for
concerns of upper GI bleeding.
She was just admitted from ___ for upper GI bleed.
During admission gastroenterology was consulted and she
underwent
an EGD which did show source of bleeding. Her CBCs were trended
and on discharge her hemoglobin was 7.2. She then presented to
___ on ___ and was again admitted for upper GI bleed.
After hydration her hemoglobin was noted to be 5.4. She was to
have a repeat EGD there but left AMA on ___ due to childcare
issue.
Of note per review of records, the patient has had at least four
AMA discharges or elopements in the last 5 months, and there has
been concern that the patient exhibited opioid seeking behavior.
Today she presented to ___ reporting that she had
bright red blood per rectum over the last day as well as several
episodes of bright red emesis. At outside hospital, her
hemoglobin was 9.6, she was given 1 unit of pRBCs. Of note,
patient was always hemodynamically stable. After blood patient
noted new rash and was given Benadryl and Solu-Medrol. She was
then transferred to ___ for further care.
On arrival to the emergency on arrival to the emergency room her
vitals were T-max 97.5, heart rate 83, blood pressure 132/87,
respiratory rate 18, satting 93% on room air. Labs were drawn
and remarkable for hemoglobin of 10.0, white blood cell count
11.9, INR of 1.2. She was given normal saline IV Dilaudid x2,
Zofran, IV Ativan and admitted to medicine for further
monitoring.
On arrival to the floor she is actively vomiting bright red
blood
with some clots probably about 300cc. She is tearful and
describes worsening of her pain and nausea. She states the rash
that appeared after blood has now resolved.
14 point ROS reviewed and negative per HPI
Past Medical History:
Upper GIB
DVT/PE
?Lupus anticoagulant
Iron deficiency anemia
s/p tubal ligation
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
No known family history of gastrointestinal disease
Physical Exam:
Admission exam:
VSS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: in pain, crying, head over basin throwing up
blood
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: tender esp in the upper quadrants, no rebound
or guarding
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization.
GU: no catheter in place
Discharge exam:
None (pt left AMA before being seen by this provider)
Pertinent Results:
Admission labs:
___ 01:04AM ___ PTT-29.5 ___
___ 01:04AM PLT COUNT-272
___ 01:04AM NEUTS-87.6* LYMPHS-9.2* MONOS-1.5* EOS-0.7*
BASOS-0.3 IM ___ AbsNeut-10.44* AbsLymp-1.09*
AbsMono-0.18* AbsEos-0.08 AbsBaso-0.03
___ 01:04AM WBC-11.9* RBC-3.92 HGB-10.0* HCT-32.1* MCV-82
MCH-25.5* MCHC-31.2* RDW-16.6* RDWSD-49.3*
___ 01:04AM estGFR-Using this
___ 01:04AM GLUCOSE-121* UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
___ 01:17AM LACTATE-1.4
___ 01:17AM TYPE-MIX
___ 02:03AM PLT COUNT-261
___ 02:03AM WBC-15.0* RBC-3.76* HGB-9.7* HCT-30.9* MCV-82
MCH-25.8* MCHC-31.4* RDW-16.4* RDWSD-48.9*
___ 06:00AM D-DIMER-488
___ 06:00AM ___
___ 06:00AM PLT COUNT-271
___ 06:00AM WBC-10.0 RBC-3.74* HGB-9.2* HCT-30.5* MCV-82
MCH-24.6* MCHC-30.2* RDW-16.2* RDWSD-48.3*
___ 06:00AM CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-1.7
___ 06:00AM GLUCOSE-161* UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-11
___ 12:38PM PLT COUNT-255
___ 12:38PM WBC-10.0 RBC-3.62* HGB-9.0* HCT-29.1* MCV-80*
MCH-24.9* MCHC-30.9* RDW-16.2* RDWSD-47.8*
___ 06:16PM PLT COUNT-226
___ 06:16PM WBC-10.7* RBC-3.44* HGB-8.5* HCT-27.7*
MCV-81* MCH-24.7* MCHC-30.7* RDW-16.4* RDWSD-47.9*
___ 11:30PM PLT COUNT-258
___ 11:30PM WBC-9.0 RBC-3.38* HGB-8.5* HCT-27.4* MCV-81*
MCH-25.1* MCHC-31.0* RDW-16.5* RDWSD-48.7*
Brief lab Summary re: hgb trend:
Admission hgb 10.0--> 9.7-->9.2-->9.0-->8.5-->8.5
No discharge labs as pt eloped prior to AM labs being drawn.
Brief Hospital Course:
AMA DISCHARGE; I did not see patient on the morning of elopement
___
Mrs. ___ is ___ woman with history of DVT/PE not on
anticoagulation due to bleeding, history of lupus anticoagulant
positivity, celiac artery stenosis, iron deficiency anemia,
recent admissions for upper GIB now presenting as a transfer for
concerns of upper GI bleeding.
# Anemia, iron deficiency
# Hematemesis
# History of upper GIB
Patient with history of iron deficiency anemia and upper GIB
presenting with hematemesis. She has already undergone 3 EGDs
without clear etiology of her bleed in the recent past, >27 in
the last year and a half per GI chart review.
Continued IV PPI twice daily, IVFs.
She witnessed to vomit blood on ___ cc in the AM of
admission then add'l 50cc in the afternoon prior to AMA.
Hgb trend during her admission were as follows;
Brief lab Summary re: hgb trend:
Admission hgb 10.0--> 9.7-->9.2-->9.0-->8.5-->8.5. No
transfusions given during this admission.
Port used for IV access as unable to place other IVs despite IV
RN effort.
# Acute on chronic abdominal pain:
Per review of OMR, there has previously been discussion
regarding
whether the patient's abdominal pain is secondary to median
arcuate ligament syndrome(MALS). However, the patient was seen
by
surgery and this was not thought to be the case. The patient
was
counseled against celiac artery stenting. The etiology of the
patient's abdominal pain remains unclear. Rx'd with APAP sch, IV
dilaudid. Unable to wean opiods prior to pt leaving AMA on the
morning of ___.
Held on additional abdominal imaging, ___ surgery consult
(pt left before these could be entertained).
GI consulted, felt repeat EGD not indicated unless significant
bleeding; treat supportively.
They also raised c/f pt significant anxiety and history of
leaving AMA
multiple times which interferes with her long term care plan.
Rec'd considering consulting SW and possibly psychiatry for
assistance (pt left AMA before this could be entertained)
#Leukocytosis
Likely from steroids received at OSH. No localizing symptoms of
infection - RESOLVED s/p IVFs.
# History of DVT/PE:
?#Pleuritic CP:
Patient was previously treated with
warfarin and then apixaban, however, has been off
anticoagulation since ___ due to bleeding
Pt reporting a pleuritic component to pain, reminiscent of
prior PEs, however Ddimer negative so add'l workup held.
Transitional Issues:
[ ] Consider SW and possibly psychiatry for underlying anxiety,
propensity to leave AMA
[ ] Consider IP c/s for bronch as an outpatient or next
admission given pts ongoing blood loss but countless negative
EGDs; considerations include pulmonary AVM, though no such
suggestion seen on prior CT chest
[ ] Given some c/f drug seeking behavior and growing medical
literary (training to be an ___); ___ went to consider d/c port
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. ClonazePAM 1 mg PO DAILY:PRN Anxiety
3. Escitalopram Oxalate 20 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Pantoprazole 40 mg PO Q12H
6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
Pt left AMA, unable to confirm
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
upper GI bleed
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 because you were vomiting
blood. You continued to vomit blood while in the hospital. We
advised that you remain in the hospital for ongoing evaluation
and management however after discussing the risks you elected to
leave against medical advice. Please return to the hospital if
you have any recurrent bleeding, if you experience
lightheadedness or chest pain. Please call your primary care
doctor to schedule follow up within 1 week of discharge
Followup Instructions:
___
|
10611631-DS-26 | 10,611,631 | 26,493,066 | DS | 26 | 2146-11-13 00:00:00 | 2146-11-13 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan / daptomycin
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ woman with past medical history of DVT/PE on
___, median arcuate ligament syndrome, celiac artery
stenosis, and several recent admissions for upper GI bleeding
chronic abdominal pain who presents with abdominal pain and
hematemesis x3.
She was recently admitted to our hospital for 1 day, on ___.
At
that time she presented with hematemesis and abdominal pain. She
remained hemodynamically stable with hemoglobin at her baseline.
GI saw her at that time and recommended against repeat
endoscopy.
PPI twice daily was continued, her ___ was held, and she
was
discharged with plan for close follow-up with GI and hematology.
She had just presented to ___ last ___ for
ongoing pain, hematemesis, she underwent EGD and colonoscopy.
Two
lesions were clipped on upper endoscopy. She was discharged and
then presented to ___ on ___.
She has had 5 EGDs in ___. Most recent ___ showed
stomach fundus and body with old clips in place, otherwise
normal
mucosa in the whole esophagus stomach and duodenum. No clear
sources of hematemesis. Also of note, she is currently on Ancef
via a PICC line for episode of bacteremia on admission in
___ for infected port (in place for IV iron). She has
follow-up with ID for this.
Today, she developed hematemesis beginning around 1600. She
has
since had 5 episodes of hematemesis. She also had a single
episode of small volume maroon stool. She has had ongoing
nausea.
Additionally, this has exacerbated her chronic abdominal pain,
for which she follows with Dr. ___ also with vascular
surgery, and which is attributed to median arcuate ligament
syndrome as well as cervical artery stenosis. She complains of
ongoing nausea, epigastric and periumbilical abdominal pain, and
left lower quadrant abdominal pain. Due to persistence of the
symptoms, she presented to ___ for evaluation, and
was transferred here given the extent of her care here. She
denies EtOH use, no NSAID use, no recent steroids.
Overall ED course most notable for hemodynamic stability, GI
consult with recommendation for monitoring overnight and symptom
control prior to consideration of EGD after CTA.
In the ED, initial vitals: T: 97 HR: 82 BP: 112/75 RR: 16
SO2: 97% RA
Exam notable for:
scant blood in mouth, mod epigastric, periumbilical, and LLQ
ttp. Rectal exam with frankly guaiac positive brown stool.
Labs notable for: WBC: 6.7 Hgb: 8.7 (baseline 9.8) plt: 198
Imaging notable for: CXR: Right PICC tip in the mid SVC. No
acute cardiopulmonary abnormality.
Pt given:
___ 22:31 IV Morphine Sulfate 4 mg
___ 22:31 IV Ondansetron 4 mg
___ 22:50 IV MethylPREDNISolone Sodium Succ 40 mg
___ 22:50 IV Pantoprazole 40 mg
___ 23:13 IV HYDROmorphone (Dilaudid) .5 mg
___ 23:14 IV Ondansetron 4 mg ___
Consults: GI IV PPI, reglan 10 mg iv, Hgb goal > 7, decision
and
timing of repeat EGD pending clinical course.
Vitals prior to transfer: HR: 80 BP: 116/74 RR: 14 SO2: 96%
RA
Upon arrival to the floor, the patient reports ongoing abdominal
pain, no more episodes of hematemesis. No chest pain, SOB< no
dizziness nor lightheadedness.
Past Medical History:
DVT/PE (on ___
Lupus anticoagulant
Median arcuate ligament syndrome
Celiac artery stenosis
GERD
MRSA Bacteremia
Anxiety
Anemia
Cholecystectomy in ___
Urethral diverticulum surgery ___
Tubal Ligation ___
Appendectomy ___
Gastritis and PUD
G2P1 with miscarriage at 9 weeks, successful pregnancy at age ___
was complicated by hyperemesis and she was induced several weeks
early
s/p TAH and bilateral salpingectomy on ___ for menorrhagia
Cholecystectomy ___
B/l tubal ligation ___
Hysterectomy ___
Social History:
___
Family History:
Mother - HTN
Father - ___ Cancer
Brother - colon cancer
MGM - Factor V Leiden, Carotid stenosis, CVA
MGF - Colon Cancer
Physical Exam:
ADMISSION EXAM:
===============
VITALS: ___ 0020 Temp: 98.4 PO BP: 123/71 HR: 94 RR: 16 O2
sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ non-radiating
systolic murmur, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, picc c/d/i
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE EXAM:
==============
24 HR Data (last updated ___ @ 753)
Temp: 98.3 (Tm 98.6), BP: 101/68 (101-122/68-77), HR: 88
(86-102), RR: 18 (___), O2 sat: 99% (97-100), O2 delivery: ra,
Wt: 194.89 lb/88.4 kg
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ non-radiating
systolic murmur, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, picc c/d/i
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Pertinent Results:
ADMISSION LABS:
================
___ 09:50PM BLOOD WBC-6.7 RBC-3.19* Hgb-8.7* Hct-28.2*
MCV-88 MCH-27.3 MCHC-30.9* RDW-18.1* RDWSD-58.0* Plt ___
___ 09:50PM BLOOD Neuts-55.2 ___ Monos-7.9 Eos-2.5
Baso-0.1 Im ___ AbsNeut-3.67 AbsLymp-2.26 AbsMono-0.53
AbsEos-0.17 AbsBaso-0.01
___ 09:50PM BLOOD Ret Aut-2.6* Abs Ret-0.09
___ 09:50PM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-141 K-4.0
Cl-107 HCO3-22 AnGap-12
___ 09:50PM BLOOD Lipase-32
___ 09:50PM BLOOD Calcium-8.9 Phos-3.6 Mg-1.7 Iron-62
___ 09:50PM BLOOD calTIBC-276 Ferritn-236* TRF-212
___ 10:45PM BLOOD Lactate-0.6
RELEVANT LABS:
==============
___ 09:50PM BLOOD calTIBC-276 Ferritn-236* TRF-212
___ 09:50PM BLOOD Calcium-8.9 Phos-3.6 Mg-1.7 Iron-62
___ 09:50PM BLOOD Ret Aut-2.6* Abs Ret-0.09
IMAGING:
========
CTAP ___:
1. No evidence of active bleed or hematoma in the abdomen or
pelvis.
2. Unchanged severe narrowing and angulation of the proximal
celiac artery
with collateralization, in keeping with known median arcuate
ligament
syndrome.
EGD ___:
- normal mucosa in the whole esophagus
- old endoclips were visualized in the fundus. Small amount of
hematin suggestive of old blood was seen in the fundus. Despite
careful visualization, no sources of bleeding or stigmata of
bleeding was noted. A biopsy forceps was used to manipulate the
old endoclips but no bleeding or stigmata of bleeding was noted.
- normal mucosa in the whole examined duodenum
- erythema in the antrum compatible with gastritis
CXR PICC ___:
Right PICC tip in the mid SVC. No acute cardiopulmonary
abnormality.
MICROBIOLOGY:
=============
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHAGE LABS:
=============
___ 04:30AM BLOOD WBC-6.0 RBC-3.20* Hgb-8.9* Hct-28.8*
MCV-90 MCH-27.8 MCHC-30.9* RDW-18.9* RDWSD-60.5* Plt ___
___ 04:30AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-139
K-4.4 Cl-102 HCO3-28 AnGap-9*
___ 04:30AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.8
Brief Hospital Course:
******* THIS PATIENT LEFT THE HOSPITAL AGAINST MEDICAL ADVISE
***********
SAFETY ALERT: patient has had multiple AMAs and elopements,
there is concern for drug seeking behavior given these AMA
coincide with transition in pain regimen. Also with safety
alerts at ___
BRIEF HOSPITAL COURSE:
=====================
___ woman with past medical history of DVT/PE on
___, median arcuate ligament syndrome, celiac artery
stenosis, and several recent admissions for upper GI bleeding
chronic abdominal pain who presents with abdominal pain and
hematemesis x3. She had an EGD which did not show acute
bleeding. We transitioned the patient from IV pain medications
to her home oral pain medication and the patient left AMA when
she learned her father had a cardiac arrest.
ACUTE ISSUES:
=============
#Abdominal pain
# c/f median arcuate ligament syndrome
#Nausea:
Patient has acute on chronic abdominal pain first started in
___ consistent
with then 30lb weight. She was diagnosed with possible median
arcuate
ligament syndrome given celiac artery stenosis in this area. Per
discussions with vascular in the past, stenting would not be
beneficial, but may benefit from general surgery evaluation for
the possible ligament compression of the celiac artery. Of note,
she has no showed to multiple appointments. She was initially
started on IV dilaudid with plan to wean opioids, but on day of
weaning pain medications, she left AMA after hearing her father
had a cardiac arrest at ___.
**Addendum: Dr. ___ us back after she had already left
AMA. He reported that she had a mesenteric duplex study on
___ which excluded symptomatic celiac artery compression
syndrome. The duplex was repeated in ___ and showed the same
thing. He felt that the celiac artery is "effectively occluded"
which is why the studies have these results. This should not
cause ischemia of the GI tract as she has excellent collaterals
from the SMA.
# Hematemesis
# Recurrent Upper GI Bleeding:
The patient has had numerous prior admissions for UGIB and has
been found to have AVM v dieulafoy lesions in the past. She had
a CTA which was negative for acute bleed but showed
collateralization around area of celiac artery stenosis. EGD
showed only gastritis without area of acute bleeding. She was
started on a PPI BID and it was decided to hold anticoagulation
given she had not had a DVT/PE since ___ when her Hematologist
had discontinued her ___ and the "thrombus" at ___
___ was a superficial thrombophlebitis at the right
basilica vein at the site of a PICC. She had no additional
bleeding while inpatient. Hgb was stable during admission.
CHRONIC ISSUES:
===============
#History of MRSA and Enterococcus Bloodstream Infection
Had port-related bacteremia during ___ admission. Port
has since been removed. She then had recurrent MSSA bacteremia
at ___ in ___ with admission from
___. Of note, when requesting release of records from
___, the patient only consented to records from
___ - ___. Her records were faxed with a ED visit from
___ which showed the ED was planning for admission to
___, but patient refused after being denied IV pain
medicines. During ___ admission, She had a TTE which
did not show vegetation. The discharge summary is unclear and it
appears she was to continue IV antibiotics with follow up with
ID, but did not have a clear end date or discharge regimen. The
patient presented to ___ with a PICC and reportedly on IV
cefazolin for an unclear amount of time. It is unclear if the
patient made it to her ID follow up appointment. While admitted
at ___ she was continued on IV cefazolin. She left AMA prior
to reestablishing ___ to continue this regimen.
#Anxiety
-Continued home clonazepam 1mg BID and escitalopram oxalate 20mg
daily
# h/o DVT/PE:
First DVT provoked by ischemic colitis, then PE occurred
post-operatively, lupus anticoagulant testing has been positive
but then indeterminate on repeat, cardiolipin and
beta2-glycoprotein I antibodies were normal. She had been off
___ since ___, but patient then had thrombophlebitis of
the right basilica vein at the site of a PICC during ___
admission to ___ and ___ was restarted. After
discussion, the decision was made to hold ___ given concern
for recurrent hematemesis.
TRANSITIONAL ISSUES:
===================
[] Needs follow up with PCP to clarify PICC and antibiotic
course for MSSA bacteremia. Will need records from OSH ___ clinic
and full records from ___
[] Follow up with Dr. ___ to determine need for arcuate
ligament surgery for celiac artery compression.
[] plan to continue to hold anticoagulation until follow up with
Dr. ___ high risk of rebleeding
[] Reinforce need to avoid NSAIDs to limit gastritis and wean
opioids.
[] SAFETY ALERT: patient has had multiple AMAs and elopements,
there is concern for drug seeking behavior given these AMA
coincide with transition in pain regimen. Also with safety
alerts at ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. CeFAZolin 2 g IV Q8H bacteremia
2. ClonazePAM 1 mg PO BID
3. Escitalopram Oxalate 20 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Pantoprazole 40 mg PO Q12H
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
7. ___ 5 mg PO BID
8. Naloxone Nasal Spray 4 mg IH ONCE MR1
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
2. CeFAZolin 2 g IV Q8H bacteremia
3. ClonazePAM 1 mg PO BID
4. Escitalopram Oxalate 20 mg PO DAILY
5. Naloxone Nasal Spray 4 mg IH ONCE MR1
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
7. Pantoprazole 40 mg PO Q12H
8. HELD- ___ 5 mg PO BID This medication was held. Do not
restart ___ until you see your hematologist
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Hematemesis
Acute on chronic abdominal pain
SECONDARY DIAGNOSIS
=====================
Median arcuate ligament syndrome.
MSSA bacteremia
Recurrent deep vein thrombosis and pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******* THIS PATIENT LEFT THE HOSPITAL AGAINST MEDICAL ADVISE
***********
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___ ,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after developing abdominal pain and
vomiting blood.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had an endoscopic procedure which did not show any sources
of acute bleeding.
- You had a CT scan which did not show any acute change in your
abdomen.
- You received medicine to treat you abdominal pain.
- Unfortunately you left the hospital before discharge planning
could be completed understanding the risks of leaving before
this was completed.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You should continue to HOLD your ___ given concern for
repeat bleeding.
- please contact you ___ service to reestablish care.
- Please make sure you follow up with your primary care doctor.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10611631-DS-27 | 10,611,631 | 21,251,712 | DS | 27 | 2146-12-06 00:00:00 | 2146-12-06 17:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan / daptomycin
Attending: ___.
Chief Complaint:
Fevers, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with past medical history
of DVT/PE (until recently on apixaban), median arcuate ligament
syndrome (extrinsic celiac artery stenosis), recent MRSA and
MSSA
bacteremia related to a port infection, and several recent
admissions for upper GI bleeding chronic abdominal pain who
presents with fevers and abdominal pain.
A few days prior to admission the patient started feeling
generally unwell and more tired. Yesterday AM she recorded a
fever of 102. She had been experiencing some drenching sweats,
nausea, and a rapid HR. Otherwise she has not experienced
specific symptoms. She denies cough, rhinorrhea, headache,
toothache, mouth sores, rash, shortness of breath, changes in
bowel movements, dysuria, or hematuria.
She first presented to ___ where a temperature of
102 is recorded. Influenza was negative. Otherwise her labwork
and urine studies were largely within normal limits. She was
transferred to our ED where a CT abd w/ contrast showed no acute
pathology including and an unchanged celiac artery.
She has been on cefazolin since ___ for her most recent
MSSA
infection. It is due to finish, but she has not yet followed up
with ID to officially stop this. She has not experienced any
problems with her PICC.
She was here in ___ and left AMA, but at that time the team
discussed her celiac artery with Dr. ___ noted that with
two duplex studies not showing disease requiring intervention
and
good collaterals, no surgical intervention was planned. The
patient has missed several appointments, including with Dr.
___.
Past Medical History:
DVT/PE (on apixaban)
Lupus anticoagulant
Median arcuate ligament syndrome
Celiac artery stenosis
GERD
MRSA Bacteremia
Anxiety
Anemia
Cholecystectomy in ___
Urethral diverticulum surgery ___
Tubal Ligation ___
Appendectomy ___
Gastritis and PUD
G2P1 with miscarriage at 9 weeks, successful pregnancy at age ___
was complicated by hyperemesis and she was induced several weeks
early
s/p TAH and bilateral salpingectomy on ___ for menorrhagia
Cholecystectomy ___
B/l tubal ligation ___
Hysterectomy ___
Social History:
___
Family History:
Mother - HTN
Father - ___ Cancer
Brother - colon cancer
MGM - Factor V Leiden, Carotid stenosis, CVA
MGF - Colon Cancer
Physical Exam:
ADMISSION EXAM:
VITALS: ___ 1757 Temp: 98.8 PO BP: 118/77 HR: 87 RR: 18 O2
sat: 98% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, speech fluent
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: Afebrile, SBPs ___ while sleeping, HR 82-90, RR 16,
___ (see eFlowsheet)
GENERAL: Diaphoretic, but otherwise not in any distress
COR: S1, S2, no m/r/g, RRR
ABD: abdomen soft; she would not allow me to palpate her
epigastrum or abdomen otherwise.
CHEST: CTAB
SKIN: no rashes seen on her lower and upper extremities.
Pertinent Results:
ADMISSION LABS:
___ 02:00PM BLOOD WBC-5.8 RBC-3.02* Hgb-8.0* Hct-26.1*
MCV-86 MCH-26.5 MCHC-30.7* RDW-15.4 RDWSD-48.9* Plt ___
___ 05:05AM BLOOD WBC-4.9 RBC-2.90* Hgb-7.7* Hct-25.7*
MCV-89 MCH-26.6 MCHC-30.0* RDW-15.7* RDWSD-51.0* Plt ___
___ 05:05AM BLOOD Neuts-70.1 Lymphs-17.8* Monos-10.9
Eos-0.4* Baso-0.2 Im ___ AbsNeut-3.42 AbsLymp-0.87*
AbsMono-0.53 AbsEos-0.02* AbsBaso-0.01
___ 05:05AM BLOOD Ret Aut-2.4* Abs Ret-0.07
___ 05:05AM BLOOD Glucose-84 UreaN-5* Creat-0.6 Na-141
K-3.5 Cl-104 HCO3-22 AnGap-15
___ 05:05AM BLOOD Albumin-3.6 Iron-15*
___ 05:05AM BLOOD calTIBC-270 ___ Ferritn-41 TRF-208
___ 05:13AM BLOOD Lactate-0.8
CT SCAN:
1. No acute intra-abdominal process.
2. Redemonstration of proximal celiac artery stenosis with
multiple adjacent
metallic clips, unchanged from prior study dated ___.
Brief Hospital Course:
Ms. ___ was admitted out of concern for possible recurrent
sepsis given her fevers at home. Fortunately, her blood cultures
here and at ___ were negative, and infectious work
up was negative. I had originally intended to watch her for ___ultures given her history of blood stream
infection; however, she opted to discharge early from the
hospital. At this point, the ultimate cause of her fevers is
still uncertain, but with her stability safe for discharge. I
will call with any updates.
Otherwise, I am concerned that opiate use disorder may be
driving her admissions. She told me she would leave AMA when I
declined to prescribe her IV hydromorphone given her stability.
Furthermore, she has a history of multiple AMA discharges in the
same situation. I also reviewed her PMP in ___, which showed that
she does not have a home prescribed for her opiates, and has
been filling small amounts from multiple providers. I discussed
all of this with the patient -- she was tearful, but did not
deny her opiate use. She stated that her pain has been
incredible, and that she "wishes she could just start over." I
discussed my concerns, and the extensive and unrevealing work up
that she has had, and that I had concerns for hyperalgesia. She
denied any concerns about opiate use disorder.
Ultimately, I told her that I strongly felt that she should stay
inpatient given concerns for a blood stream infection; she
agreed with my concerns and said she was "80% certain" she had
one. However, because I would not give her IV hydromorphone she
insisted on going home.
This behavior is very suspicious for primary gain and opiate use
disorder. During future admissions, boundaries should be set
early on, and IV opiates should not be given unless she has a
compelling indication.
While I would ideally keep her for another 24 hours, given her
overall stability and her insistence on leaving, I will
discharge her and follow up her cultures with her.
> 30 minutes spent on this complex discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
2. CeFAZolin 2 g IV Q8H bacteremia
3. ClonazePAM 1 mg PO BID
4. Escitalopram Oxalate 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
6. Pantoprazole 40 mg PO Q12H
7. Apixaban 5 mg PO BID
8. Naloxone Nasal Spray 4 mg IH ONCE MR1
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
2. CeFAZolin 2 g IV Q8H bacteremia
3. ClonazePAM 1 mg PO BID
4. Escitalopram Oxalate 20 mg PO DAILY
5. Naloxone Nasal Spray 4 mg IH ONCE MR1
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
7. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
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 monitoring after having a
fever. Fortunately, you had no additional fevers, and an
infectious work up was otherwise negative. Your blood cultures
have been negative as well. You should follow up with your
infectious disease providers to finish the course of your
cefazolin.
Followup Instructions:
___
|
10611631-DS-29 | 10,611,631 | 25,064,973 | DS | 29 | 2147-03-24 00:00:00 | 2147-03-25 08:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
Penicillins / Iodinated Contrast- Oral and IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
hematemesis with abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
PCP: not listed
CC: hematemesis
HISTORY OF PRESENT ILLNESS:
===========================
___ year old woman with a history of SLE, APLS c/b recurrent VTE
(now on warfarin), prior UGIB, and iron deficiency anemia, who
presents today with hematemesis.
Of note, pt has a history of UGIBs. The first was attributed to
a
Dieulefoy lesion. About 1 month ago, she had another that was
secondary to ___ tear iso viral gastroenteritis. Due
to this acute bleed, her warfarin was held. Upon re-initiation,
her hematologist opted against bridging, and instead increased
her dose of warfarin from 7.5 mg to 5 mg in order to get her
therapeutic. She subsequently presented to ___ ___ for
similar symptoms though left AMA for unclear reasons; she
endorsed taking ibuprofen at that time.
Since leaving the hospital, she had been feeling OK up until
today at work, when she noticed mild right sided abdominal pain.
The pain continued to worsen, and she then had 3 episodes of
bloody emesis, prompting her to go return to ___ ED.
There, she reports having a few more episodes of hematemesis,
though per the referral this was not the case. Given need for
somewhat urgent intervention, she was transferred to ___.
Please note that there is no record of this ED visit in
___ portal.
In our ED, her vitals were unremarkable, as she was afebrile,
HRs
___, BPs 108-133/57-77, RR ___ and 96-98% on RA. Her Hb was
10.0 with a normal BUN, similar to labs on ___ when she first
presented to ___. She was given 4 mg IV Zofran, 1 mg IV
hydromorphone x2, 25 mg IV diphenhydramine and a liter of normal
saline. GI was consulted who recommended admission for EGD.
On arrival to the floor, pt is quite sleepy but arousable and
answering questions appropriately. She tells me that she had a
small black tarry stool just before I entered her room. She also
notes fairly significant waxing and waning right sided abdominal
pain that improved dramatically with IV dilaudid, and is
requesting an additional dose. She endorses taking ibuprofen
despite knowing that she's not supposed to. ROS notable for mild
post prandial pain over the last week.
About 10 minutes after leaving her room, she developed another
episode of large volume hematemesis with clot and felt that
another clot was stuck in her throat.
Past Medical History:
PAST MEDICAL HISTORY:
==============================
SLE
APLS
DVT/PE
UGIB secondary to Dieulefoy lesion and ___ tear
Iron deficiency anemia
Depression
Social History:
___
Family History:
FAMILY HISTORY: not pertinent to admission
===============
Physical Exam:
ADMISSION
BP 105 / 73
L Lying HR 99 20 98 Ra
98%, O2 delivery: Ra
GENERAL: Sleepy but arousable, mildly uncomfortable
HEENT: dry lips, sclera anicteric
CARDIAC: Regular rhythm, normal rate. No murmurs
LUNGS: Clear bilaterally
ABDOMEN: Nondistended, moderately tender to palpation along the
right upper quadrant and right epigastrum, - rebound and -
guarding, with mild tenderness along the left
quadrants as well,
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AOx3.
DISCHARGE
AVSS
GENERAL: in no distress
HEENT: dry lips, sclera anicteric
CARDIAC: Regular rhythm, normal rate. No murmurs
LUNGS: Clear bilaterally
ABDOMEN: Nondistended, non-tender
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS
=============
___ 11:00PM BLOOD WBC-7.4 RBC-3.62* Hgb-10.0* Hct-33.5*
MCV-93 MCH-27.6 MCHC-29.9* RDW-22.5* RDWSD-76.6* Plt ___
___ 11:00PM BLOOD ___ PTT-30.7 ___
___ 11:00PM BLOOD Glucose-92 UreaN-7 Creat-0.8 Na-142 K-4.5
Cl-106 HCO3-23 AnGap-13
___ 11:00PM BLOOD ALT-10 AST-12 AlkPhos-52 TotBili-0.2
___ 11:00PM BLOOD Albumin-4.3 Iron-46
___ 11:00PM BLOOD calTIBC-300 Ferritn-116 TRF-231
PERTINENT IMAGING
=============
EGD: Normal Mucosa in whole esophagus. Moderate amount of blood
in the stomach. After careful suctioning and irrigation good
visualization was obtained of the entire mucosal clip no active
bleeding was seen. No lesions with stigmata of bleeding were
seen. Normal mucosa in the whole examined duodenum.
PERTINENT MICRO
=============
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
DISHCARGE LABS
=============
___ 03:56AM BLOOD WBC-6.2 RBC-3.48* Hgb-9.7* Hct-31.1*
MCV-89 MCH-27.9 MCHC-31.2* RDW-22.3* RDWSD-72.9* Plt ___
___ 10:48AM BLOOD PTT-97.7*
___ 03:56AM BLOOD Glucose-132* UreaN-12 Creat-0.9 Na-141
K-4.2 Cl-105 HCO3-26 AnGap-10
___ 03:56AM BLOOD ALT-13 AST-19 AlkPhos-55 TotBili-<0.2
___ 11:00PM BLOOD WBC-7.4 RBC-3.62* Hgb-10.0* Hct-33.5*
MCV-93 MCH-27.6 MCHC-29.9* RDW-22.5* RDWSD-76.6* Plt ___
___ 01:50AM BLOOD WBC-6.8 RBC-3.22* Hgb-9.1* Hct-30.1*
MCV-94 MCH-28.3 MCHC-30.2* RDW-22.4* RDWSD-77.4* Plt ___
___ 05:21AM BLOOD WBC-5.6 RBC-3.24* Hgb-9.0* Hct-29.2*
MCV-90 MCH-27.8 MCHC-30.8* RDW-22.3* RDWSD-74.0* Plt ___
___ 08:40AM BLOOD WBC-5.2 RBC-3.19* Hgb-8.8* Hct-28.7*
MCV-90 MCH-27.6 MCHC-30.7* RDW-22.5* RDWSD-73.7* Plt ___
___ 06:21PM BLOOD WBC-5.9 RBC-3.39* Hgb-9.5* Hct-30.3*
MCV-89 MCH-28.0 MCHC-31.4* RDW-22.4* RDWSD-73.1* Plt ___
Brief Hospital Course:
SUMMARY:
===========
___ year old woman with an unclear history of possible SLE/APLS
c/b recurrent VTE(now on warfarin), multiple prior UGIB ___
___ tear, Duelofoys) and EGDs, and iron deficiency anemia, who
initially presented with hematemesis. In the ED the patient was
HD stable with a Hgb of 10. GI was consulted and an EGD revealed
blood in the stomach with no active bleed. Complicating the
patients history of upper GI bleeds is her use of warfarin for a
history of DVT's and a single case of provoked PE. Her work up
for coagulopathy is indeterminate and it is unclear whether she
actually has SLE or anti-phospholipid syndrome. Following her
EGD, she was cleared to restart warfarin. The patient was put on
a heparin bridge to warfarin but wanted to leave AMA. After a
long discussion with the patient about the risks of leaving
without completion of bridging therapy she still decided to
leave the hosptial. She initially agreed to receive Lovenox SC x
1 prior to leaving, after IV heparin drip was stopped, but then
declined the lovenox. She agreed to self-administer lovenox at
home while continuing bridge to therapeutic warfarin. The
patient promised that she would contact her hematologist on
___ and have her INR tested. of note, the patient has
two different MRN's in the ___ system, one under her married
name ___ and the other under the last name ___.
TRANSITIONAL ISSUES:
====================
[ ] Unclear if patient has APLS per prior ___ records testing
has been indeterminent and prior clots have been provoked.
Unclear if she truly needs chronic anticoagulation at this time
[ ] Should have INR checked at by ___ or ___
[ ] Patient not willing to remain inpatient for bridging
therapy. Wished to leave AMA despite conversation with medical
providers outlining risks of early discharge up to and including
life threatening clotting or bleeding events. We established her
capacity to leave prematurely.
[ ] Discharged on 80mg Lovenox BID for bridging therapy to
warfarin. Discharge INR 1.2. Patient stated she had plenty of
warfarin at home.
ACTIVE ISSUES:
=============
# Acute upper GIB
# Hematemesis:
# Melena:
Presented with 24 hours of frequent hematemesis as well as 1
episode of melena. Hb 10 on admission, down to 8.8 on repeat,
likely related in part to dilution though she was likely
actively bleeding. Patient has had a mutliple presentations for
hematesis and multiple EGD's performed. The last Endoscopy was
performed ___, which showed a Dieulafoy's lesion without
active bleed. An EGD was performed on this hospitalization which
demonstrated blood in the stomach without signs of an active
bleed or culprit lesion. She was informed of risks of
rebleeding. She agreed not to take any NSAIDs or ASA, and will
continue on PPI BID.
# Possible SLE, APLS:
The patient has a confusing medical history surrounding her
diagnosis of anti-phospholipid syndrome and whether she requires
long term anti-coagulation. From chart review of hematology
notes at ___, her first DVT was possibly provoked secondary to
ischemic colitis, and thereafter she suffered a PE
post-operatively which was also felt to be provoked. Per
hematology note on ___, evaluation for an underlying
inherited thrombotic disorder was negative. A test for a lupus
anticoagulant while off apixaban for several days was positive
by Silica Clotting Time. However, this was been repeated and was
as indeterminant, which hematology believes to represent a
negative test. Levels of cardiolipin and beta2-glycoprotein I
antibodies were normal. Thus hematology here felt that she does
not have an underlying hypercoagulable state. Patient told us
initially that she had a recent DVT in ___ followed by a
Dr. ___ at ___, ___ -- for whom she could not
provide any contact information, and for whom we could not
verify as an existent provider. We called her pharmacy to
ascertain the warfarin prescriber, and learned that it was
prescribed by Dr. ___. This clinician is at ___,
___. We confronted her with this information and she indicated
she remembered her most recently DVT was in ___, not ___,
and agreed Dr. ___ her INR. Her warfarin dose was
receently increased to 7.5mg daily. A full review of this
patients medical history pertaining to diagnostic tests and
clotting history is warranted to determine the appropriateness
of anti-coagulation however this could not be done during this
admission as she left prematurely after informed dissent (AMA).
#Drug seeking behavior
During this hospitalization the patient requested IV pain
medications plus IV Benadryl for abdominal pain. Per the
discharge summary on ___ the patient threatened to leave
AMA if she wasn't not given dilaudid. Per her ___, she is
filling small amounts of opioids from multiple providers in the
last year. There is concern the patients frequent presentations
to the hospital may be for secondary gain.
CHRONIC ISSUES
================
#Anterior cruciate ligament syndrome:
The patient has a celiac artery stenosis as described on US in
___ though a mesenteric duplex study on ___ excluded
symptomatic celiac artery compression syndrome as the source of
her abdominal pain. The duplex was repeated in ___ and
showed the same thing and also states that she has ample
collateral blood flow from the SMA. She didn't follow up with 2
appointments with Dr. ___ at ___ in past, but we were in
touch with him and he saw no evidence of chronic symptomatic
stenosis.
# Iron deficiency anemia:
Pt with history of iron deficiency likely in the setting of
menorrhagia for which
she receives IV iron infusions every 5 weeks through a
indwelling port-a-cath. Reports that her most recent ferritin
was 6.
# Depression / anxiety: continue chronic SSRI therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 7.5 mg PO DAILY16
2. Escitalopram Oxalate 20 mg PO DAILY
3. Pantoprazole 20 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Enoxaparin Sodium 40 mg SC BID
RX *enoxaparin 40 mg/0.4 mL 40 mg sc every twelve (12) hours
Disp #*14 Syringe Refills:*0
3. Escitalopram Oxalate 20 mg PO DAILY
4. Pantoprazole 20 mg PO Q12H
5. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
hematemesis
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___ ,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- you vomited blood and were found to have blood in your stomach
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You had a scope put into your stomach to look for the cause of
the bleeding which found old blood and clots but no places that
were currently bleeding
-You were given blood thinners (anti-coagulation) to prevent a
blood clot from forming
-We wanted to keep you in the hospital to make sure that your
blood thinners were at therapeutic levels before sending you
home however you decided to leave before this could occur
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
-Please call Dr. ___ tomorrow, to let her know that
you will need a blood test to determine if your blood in thin
enough but not too thin
-Please make sure to get the lovenox shots from you pharmacy and
take these twice a day, to protect you from blood clots until
your warfarin levels are therapeutic
-If you have questions, please reach out to Dr. ___
___ ___
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10611631-DS-32 | 10,611,631 | 25,896,880 | DS | 32 | 2147-07-17 00:00:00 | 2147-07-17 19:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan / daptomycin
Attending: ___
Major Surgical or Invasive Procedure:
___ upper endoscopy
attach
Pertinent Results:
ADMISSION LABS
___ 11:41PM ___ PTT-43.8* ___
___ 11:41PM PLT COUNT-177
___ 11:41PM NEUTS-80.0* LYMPHS-12.4* MONOS-3.8* EOS-3.0
BASOS-0.3 IM ___ AbsNeut-5.04 AbsLymp-0.78* AbsMono-0.24
AbsEos-0.19 AbsBaso-0.02
___ 11:41PM WBC-6.3 RBC-3.23* HGB-9.6* HCT-30.8* MCV-95
MCH-29.7 MCHC-31.2* RDW-16.1* RDWSD-56.5*
___ 11:41PM ALBUMIN-4.2
___ 11:41PM cTropnT-<0.01
___ 11:41PM ALT(SGPT)-13 AST(SGOT)-13 ALK PHOS-44 TOT
BILI-<0.2
___ 11:41PM estGFR-Using this
___ 11:41PM GLUCOSE-101* UREA N-9 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-12
___ 03:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:17AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:17AM URINE UHOLD-HOLD
___ 03:17AM URINE HOURS-RANDOM
___ 04:02AM PLT COUNT-186
___ 04:02AM WBC-7.8 RBC-3.32* HGB-9.9* HCT-31.7* MCV-96
MCH-29.8 MCHC-31.2* RDW-16.2* RDWSD-57.3*
___ 08:00AM PLT COUNT-196
___ 08:00AM WBC-5.1 RBC-3.34* HGB-10.0* HCT-31.8* MCV-95
MCH-29.9 MCHC-31.4* RDW-16.1* RDWSD-56.6*
___ 08:20PM PLT COUNT-192
___ 08:20PM WBC-7.8 RBC-3.21* HGB-9.6* HCT-30.5* MCV-95
MCH-29.9 MCHC-31.5* RDW-16.1* RDWSD-55.8*
MICROBIOLOGY
___ URINE CULTURE-FINAL
ECG
___: sinus rhythm, normal intervals, no other abnormalities
noted
IMAGING
___ CTA A/P: IMPRESSION: No acute abdominopelvic process.
___ CXR: IMPRESSION: No evidence of free subdiaphragmatic
air.
EGD
___: Normal mucosa in the whole esophagus. The stomach was
filled with old blood and large blood clots, without any
evidence of fresh blood. No bleeding source was identified.
Multiple prior clips were seen in the stomach antrum without
bleeding at those sites. A Rothnet was used to move the clot
more distally to better visualize the stomach body.
Recommendations: Follow-up recommendations per inpatient GI
team, repeat EGD tomorrow.
DISCHARGE LABS
___ 04:23AM BLOOD WBC-7.1 RBC-2.98* Hgb-8.9* Hct-28.3*
MCV-95 MCH-29.9 MCHC-31.4* RDW-16.4* RDWSD-57.1* Plt ___
___ 04:23AM BLOOD ___
___ 04:23AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-142
K-4.3 Cl-105 HCO3-27 AnGap-10
___ 04:23AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.9
___ 04:23AM BLOOD Vanco-9.6*
Brief Hospital Course:
___ woman w/PMHx recurrent VTE (with prior testing for APLS
negative) on warfarin, and recurrent upper GI bleeding possibly
due to to Dieulafoy lesions, who presented with recurrent
hematemesis of unclear etiology. Patient underwent upper
endoscopy, which found signs of significant recent bleeding but
no active bleeding. Unfortunately she decided to leave AGAINST
MEDICAL ADVICE, so no further evaluation could be performed.
On the day of discharge the patient was first seen at around 8
AM. We discussed her situation and the plan of care for repeat
endoscopy, as well as bridging anticoagulation with a heparin
drip without a bolus given her history of recurrent DVTs and
possible right atrial thrombus. She understood and agreed and
was amenable to this plan.
Not long thereafter, around 10 AM or so, she told the nurse that
she would like to leave because her husband had been in some
sort of accident involving a forklift. She said that he had
been admitted to a hospital in ___, and she wanted to
leave to be able to be there with him. She had no further
information, but had the sense that it was fairly serious.
Myself and the gastroenterology fellow at the bedside tried to
convince her to allow us to gather more information about the
situation with her husband to determine whether it was truly
serious and urgent or not. We emphasized the importance of her
taking care of herself, and the risks of not having further
evaluation for her GI bleeding, and other medical problems. She
said she understood but that it was her choice and she was
insistent on leaving. She declined to allow me to contact the
hospital in ___ to learn more about his condition, nor
did she agree to allow me to speak to her father, who was coming
to ___ to drive her to ___. She alluded to the need
to navigate some complex family dynamics ("my husband is not
very understanding" and "my dad does not really know what is
going on"). Her husband is her current healthcare proxy and I
pointed out that if he is incapacitated and cannot serve, she
will need to choose someone else, and she indicated her father
would be this person. I indicated it could be helpful to her
father to know what is going on should she have an acute medical
problem, but she still declined to allow me to contact him. She
and I reviewed all of her medications together, discussed how
she is going to stop her vancomycin, and start enoxaparin for
bridging, and confirmed that her she will follow-up for INR
checks where she has previously beginning her INR and warfarin
followed. I strongly encouraged her to seek urgent medical care
if she has any signs of bleeding or other complications. She
indicated that she would do so.
I communicated with her hematologist by phone and email, as well
as the infectious disease nurse practitioner that had been
following her at ___ in ___, the gastroenterology
fellow, the gastroenterology attending that has previously
followed her, and the cardiologist who saw her here during her
last admission. I also spoke with her primary care physician by
phone to coordinate care. Her PCP and hematologist both
conveyed that she has had a pattern of previously not appearing
for scheduled appointments, leaving AMA during hospital stays,
and multiple ED visits. If she re-presents for care, if
possible, further exploration of why she may be making these
choices could be helpful. Consider social work consultation in
the future, if she will allow it. She declined it today.
Discharge day exam: Vitals reviewed and notable for systolic
pressure in the ___ but a normal heart rate, with prior systolic
pressures in the low 100s, and on prior admissions in the ___ as
well. She was ambulating without difficulty. Inputs and
outputs reviewed, she had one loose stool overnight, but no
signs of further hematemesis or blood loss. Young woman seated
in bed, flat affect, alert, cooperative, NAD. Anicteric, MMM.
Equal chest rise, CTAB, no WOB or cough. Heart regular.
Abdomen soft, NTND. Extremities warm and well-perfused, no
pitting edema. Right upper extremity with a double lumen PICC
in place with no apparent complications.
SUMMARY BY PROBLEMS
# Acute recurrent upper GI bleed of unclear etiology
# Acute on chronic RUQ abdominal pain
She has a history of recurrent upper GI bleeding and was found
to have Dieulafoy's lesion in the past. She also has a history
of gastritis and PUD in the past. In ___ she had a
gastroepiploic artery embolization for recurrent hematemesis.
This most recent bleeding was in the setting of supratherapeutic
INR of 4.5 (per report). She had an EGD on ___ that was
unrevealing for source of
bleeding. The stomach was filled with old blood and clots. GI
recommended repeating the EGD on ___, but she decided to leave
AMA. She was hemodynamically stable, with a mild-moderate
anemia (Hemoglobin ~9), and no signs of ongoing bleeding on the
day of discharge. She was scheduled for an EGD the day after AMA
discharge (i.e. ___ at ___ with Dr. ___. It
was unclear whether she would be able to make that given her
husband's condition, but GI was to be in touch with her about
this.
# R atrial mass/possible thrombus
This was found during her ___ admission to ___ on a TEE
done given her MRSA bacteremia (which was found after she was
cultured for a fever). Dr. ___ of ___
at ___ was planning to follow-up with her once she was done
with her course of antibiotics for MRSA bacteremia. On
discharge, she was encouraged to follow-up with Dr. ___
was provided with the general Cardiology phone number to call
him. She was also placed on bridging anticoagulation while her
INR is subtherapeutic as noted below.
# MRSA bacteremia
She was recently admitted to ___ from ___ for
recurrent hematemesis s/p gastroepiploic artery embolization.
Durring that hospitalization, she developed a fever, and blood
cultures grew MRSA bacteremia. A TEE was done, finding the
right atrial mass concerning for thrombus vs. atrial myxoma. Her
port was removed in the setting of MRSA bacteremia and a PICC
was placed for vancomycin administration. From the OPAT note in
WebOMR it appears the patient's original course of antibiotics
was supposed to be from ___, but the patient tells me the
intent was actually for ___ wks starting ___ (the day after her
port was removed) because of the concern for endocarditis given
the mass seen on TEE. Then sometime prior to the end of the
course (i.e. prior to ___, the patient transitioned her care
from ___ to ___ in ___ (she
could not remember the name of the ___ physician
___. At some point after this transition, she says her
insurance coverage lapsed for a week, so she was off antibiotics
for a week. The ID specialist at ___ told her this mean
they needed to restart the course of vancomycin, which was done,
and on ___ the patient indicated that she was nearly
finished with this restarted course (she had been placed on
vancomycin IV 1000mg tid, and had only ___ doses left in her
fridge), and apart from a couple missed days while at the OSH
for the GIB that led to her transfer here, she'd been reliably
taking the vanco. After further discussion, she said she would
stop all antibiotics now, and I encouraged her to follow-up at
___ regarding the plan for any repeat BCx off antibiotics,
and to determine what happens with her PICC line.
# Recurrent VTE
# Supratherapeutic INR at OSH, treated with vitamin K, now
subtherapeutic
The patient has had a negative hypercoaguability evaluation at
___ with Dr. ___, and indicated that she was on
apixaban until sometime in ___, at which point she stopped
it because she was told she didn't need it. She did ok for a
while, then in ___ developed unprovoked R leg swelling and
was found to have a DVT there. She was then started on warfarin
with an INR goal of 2.5-3.0. She says her PCP manages this.
Her PCP denies this and says her Hematologist in ___
manages it. The patient was then admitted in ___ with
the GI bleed noted above, had a fever, found to have MRSA
bacteremia so TTE was done, which found the atrial mass, and her
port was removed. A PICC was placed, which clogged around
___ or so and was replaced. She continued on warfarin until
___, at which point she stopped taking it.
Then, the outside hospital where she initially presented
(___) found her INR was 4.5 and reversed her with vitamin K
(unsure how much or what route). On the day of discharge, her
INR was 1.2. Given her concerning history of multiple
unprovoked clots this year, and RA thrombus vs. mass we chose to
bridge her back to a therapeutic INR with enoxaparin. She will
be following up with her PCP about this, was also provided with
Dr. ___ phone number to schedule a follow-up
appointment, and strongly encouraged her to stop taking any
enoxaparin or warfarin if she has any signs of recurrent
bleeding.
# Acute on chronic RUQ abdominal pain
# Severe celiac artery stenosis
# Median arcuate ligament syndrome (MALS)
She was given some IV Dilaudid while inpatient, but was not
given any additional pain medication on discharge. A noted
transitional issue from a prior admission was to ensure she has
outpatient surgery evaluation for treatment of the median
arcuate ligament syndrome (MALS) once she is more clinically
stable / appropriate for potential surgery.
# Mood disorder, NOS
She was continued on her home escitalopram.
[x] The patient chose to leave AGAINST MEDICAL ADVICE today, and
I spent [ ] <30min; [x] >30min in discharge day management
services.
___, MD
___
Pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vancomycin 1000 mg IV Q 8H
2. DiphenhydrAMINE ___ mg IV Q8H pre-medication for vancomycin
3. Escitalopram Oxalate 20 mg PO DAILY
4. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea
6. Pantoprazole 40 mg PO Q12H
7. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Stop if you have any signs of bleeding.
RX *enoxaparin 80 mg/0.8 mL 80 mg SC every twelve (12) hours
Disp #*14 Syringe Refills:*0
2. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
3. Escitalopram Oxalate 20 mg PO DAILY
4. Ondansetron ODT 8 mg PO Q8H:PRN Nausea
5. Pantoprazole 40 mg PO Q12H
6. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
#Acute upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with an acute upper GI bleed. You underwent
an EGD which showed signs of recent bleeding, but no source of
bleeding was found. Our gastroenterologists recommended a
repeat EGD on ___ but you decided to leave against medical
advice to attend to a family emergency. The Gastroenterologist
and Hospitalist caring for you encouraged you to stay and
receiving ongoing care but you were adamant about leaving. You
declined to allow us to call the hospital where your family
member was taken today to try to learn more about the
urgency/severity of his medical condition, and also declined to
allow us to speak with your father, who you indicated should be
your surrogate decision maker if you lose capacity and your
current proxy is unable to serve in that position due to his
medical condition.
We recommend you follow-up with Gastroenterology as soon as
possible as an outpatient for repeat EGD. We expect they'll
contact you with the information about that appointment. Their
phone number is below.
We also found that your INR was sub-therapeutic (goal 2.5-3.0,
on the day you decided to leave it was 1.2, likely because it
had been reversed with vitamin K at the hospital from which you
were transferred to ___. We had started you on a heparin
drip to bridge you prior to you deciding to leave against
medical advice. We discussed using enoxaparin to bridge you.
You've previously taken this medication. *** We counseled you
to stop taking it immediately if you have any signs of recurrent
bleeding***. You will restart your warfarin at your home dose
and you will follow-up with your PCP about this and to figure
out when to stop taking the enoxaparin (we recommend doing so
after your INR is >=2.5 for 24hrs).
It is very important that if you develop any acute medical
problem such as recurrent bleeding, lightheadedness, dizziness,
increased pain, swelling, or any other concerning symptom that
you seek care for yourself at the nearest emergency department
as soon as possible. We wish you the best of luck with
everything.
Followup Instructions:
___
|
10611890-DS-9 | 10,611,890 | 26,473,531 | DS | 9 | 2144-06-15 00:00:00 | 2144-06-15 15:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right side weakness
Major Surgical or Invasive Procedure:
___ - MMA embolization
History of Present Illness:
___ presents from OSH ___ for evaluation of left sided acute on
chronic subdural hematoma with associated midline shift. She
states that on ___ she had a fall with a headstrike. She
had a head CT at that time, which she says was "negative".
Approximately 3 days later, she had a TIA and was admitted to
___ where she had a full comprehensive workup and
was started on Aspirin 81mg daily. About two weeks prior, she
noticed that her right upper extremity was tremulous and her PCP
attributed this to her high lithium
level. Her dosage was decreased from 300mg daily to 150mg daily.
About one week ago, she started to have memory difficulties and
word finding difficulties. On ___, her husband notes that she
could "barely walk" due to right sided weakness. At OSH she was
noted to have a large mixed density subdural hematoma with
associated midline shift. She was transferred to ___ for
further evaluation and Neurosurgery was consulted.
Past Medical History:
Bipolar
TIA
HTN
Hyperlipidemia
Osteoporosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
-------------
O: T: 98.6 BP: 141/80 HR: 81 R: 18 O2Sats: 96% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally EOMs intact - 2 beats of
horizontal nystagmus
Neck: Supple - full ROM noted
Extrem: Warm and well-perfused.
Left knee ecchymosis
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with two
beats of horizontal nystagmus.
V, VII: Facial strength and sensation intact - with very slight
right nasal labial fold flattening.
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.
Significant right upper extremity tremor
RUE pronation with downward drift
LUE ___ in strength
LLE ___ in strength
RLE 4+/5 in strength
Sensation: Intact to light touch bilaterally.
Coordination: dysmetria R>L with normal on finger-nose-finger,
slow and irregular rapid alternating movements bilaterally
Handedness: Right
-------------
ON DISCHARGE:
-------------
General:
___ 0811 Temp: 97.2 PO BP: 138/91 HR: 95 RR: 18 O2 sat: 97%
O2 delivery: RA
Exam:
Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: 2-1mm bilaterally
EOM: [x]Full [ ]Restricted
Face Symmetric: [x}Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: Right pronator drift
Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right 5 4 4 4 4
Left 5 5 5 5 5
IPQuadHamATEHLGast
Right4+ 4 4 4 4 4
Left4+ 5 5 5 5 5
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
#SDH
___ presented to the ___ ED on ___ as a transfer
from an OSH with an acute on chronic SDH. She was admitted to
the ___ under the neurosurgery service with plan for MMA
embolization on ___. Case was delayed until ___ over concern
for kidney function. On ___ she became acutely confused with
word finding difficulty. STAT head CT was stable. She underwent
MMA embolization of the SDH on ___. Please see separate report
in OMR for more information. Post-op, she returned to the neuro
ICU for close monitoring before being transferred to the floor
where she remained neurologically stable. Her home Aspirin 81mg
was resumed on POD#4. She received post-operative Keppra per
protocol. Head CT was obtained on ___.
___
On arrival, she was found to have elevated BUN and Cr. Patient
did not know her baseline Cr, but stated that she had baseline
chronic kidney disease. Renal was consulted. Amiloride,
Losartan, and Lithium were held. Lithium was restarted on ___
and levels were closely monitored.
#Nephrogenic DI/Hypernatremia
On arrival, she was found to be hypernatremic to 149. Renal was
consulted. She was started on D5W and transferred to the neuro
ICU for close Na monitoring. Post-op, her Na was 154 and was
restarted on D5W. Sodium was closely monitored, continued to
downtrend during her ICU stay and D5W was weaned off.
#Lithium toxocity
Pt has a history of bipolar disorder for which she takes
Lithium. Early in hospital course, ___ level elevated. Lithium
held until resolution of ___ home dose restarted on ___ per
Renal recommendations. ___ level sub-therapeutic to 0.3 on ___.
Psychiatry was consulted regarding medication management of her
bipolar disorder. Psychiatry determined that her Lithium dose
was previously being titrated by her outpatient psychiatrist,
whom was contacted. He recommended alternating 300mg and 150mg
of Lithium every other day with Lithium level recheck on
___ (goal ___ level 0.6-1.2). The rehabilitation facility
should call her outpatient psychiatrist, Dr. ___ at
___, with the results/to obtain further dose adjustment
recommendations.
#GI
Underwent SLP evaluation of oropharyngeal swallowing function
for recommendations regarding safest PO diet. Per their exam,
the patient was safe for regular diet and thin liquids without
need for further SLP follow up. Bowel regimen increased on ___
to encourage bowel movement.
#UTI
Obtained a UA on ___ which demonstrated elevated leuks. Patient
was started on ceftriaxone on ___ and urine culture sent.
Patient completed a 3-day course of ceftriaxone prior to
discharge.
Medications on Admission:
Amiloride 5mg daily
Aspirin 81mg daily
Atorvastatin 40mg daily
Bupropion XL 300mg daily
Lithium 150mg morning
Losartan 25mg daily
Raloxifene 60mg daily
Trazadone 50mg HS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. Labetalol 100 mg PO BID
5. Ramelteon 8 mg PO QHS:PRN insomnia
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Lithium Carbonate 300 mg PO EVERY OTHER DAY
8. Lithium Carbonate 150 mg PO EVERY OTHER DAY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. BuPROPion XL (Once Daily) 300 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subdural hematoma
Nephrogenic NI
Hypernatremia
Lithium Toxicity
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon. ___
continue aspirin as ordered.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication
Care of the Puncture Site
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
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 symptoms 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 puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
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
Followup Instructions:
___
|
10612095-DS-18 | 10,612,095 | 23,039,222 | DS | 18 | 2164-08-29 00:00:00 | 2164-08-29 21:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nizoral / adhesive tape / Mesalamine
Attending: ___
___ Complaint:
cough, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presenting with fever, cough, malaise for 8 days. Patient
was recently in the ___ for vacation
and returned 8 days ago, at which time his symptoms began. 24
hours after returning, he began to have a peculiar sensation in
his neck and next day had a T of 101 for three consecutive days
along with persistent productive cough, shortness of breath,
congestion around chest area, and rhinorrhea. Denies any sick
contacts, hiking or going to caves in ___, skin rashes, or
sore throat. He received his flu shot this ___. He went to
see his PCP 4 days ago for the above symptoms and his physical
exam was consisted with diffuse chest rhonchi at which point PCP
ordered ___ CXR. CXR was normal and patient was prescribed 5 day
course of azithromycin ending yesterday. Reports that during the
last 24 hours, he had a fever of 101 and began to feel worse.
His cough would occur every 5 minutes and he had decreased po
intake.
In the ED, initial vitals 99.6 66 136/67 22 98%RA, exam was
notable for decreased BS in LLL. Labs notable for normal CBC and
chem 7, lactate of 1.3. UA negative. Underwent a CXR that showed
LLL PNA. He received Levofloxacin 750mg, ketorolac x2, tylenol
___ x2, and albuterol neb. ED wanted to consider observation,
but pt stated that he was feeling too unwell to be in
observation. Viral swab sent.
Vitals prior to transfer: 101.0 76 158/84 18 96%RA.
On arrival to the floor, patient continues to complain of
productive cough, however, much improved since admission (not
having coughing fits). Also +headache and rhinorrhea.
ROS: per HPI, currently denies fever, chills, vision changes,
arthralgias, sore throat, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-CAD s/p cath and palcement of 4 stents in ___
-- (___) two overlapping DES to LAD and DES to Diagonal
-- (___) DES to LPDA
-- (___) Mild-moderate 2vCAD and diffuse slow flow consistent
with microvascular dysfunction, no intervention
-GERD
-HTN
-BPH
-Orthostatic hypotension: diagnosed after ___, improved
with fludrocortisone
-gastroparesis
-crohn's ileitis: diagnosed in ___, had reaction to mesalamine,
symptoms now controlled only with probiotics
-HLD
-Gout
-Degenerative spine disease
-- C4/5 subluxation, C4-C7 cord compression, and spinal stenosis
-- Nonsurgical cervical spondylotic myelopathy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
# Father -- ___ aortic valve, died from AS
# Mother -- ___ starting in ___, lived to ___ years old
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.8, 126/58, 73, 18, 95% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dried mucuous
membranes, OP clear without any tonsilar exudates, no sinus
tenderness
NECK - supple, no LD, no JVD appreciated
LUNGS - diffuse expiratory wheezes, no crackles or rhonchi, 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)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, steady gait
DISCHARGE PHYSICAL EXAM
VS - Tm99.6, Tc98.4, 141/76 (124-141/69-76), 59, 18, 95% RA, 2
loose BM yesterday, no BM since 5PM on ___
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dried
mucuous membranes, OP clear without any tonsilar exudates, no
sinus tenderness
NECK - supple, no LD, no JVD appreciated
LUNGS - occasional diffuse expiratory wheezes but improving
since admission, no crackles/rhonchi, 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)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, steady gait
Pertinent Results:
ADMISSION LABS
___ 12:09PM BLOOD WBC-9.8 RBC-5.01 Hgb-14.4 Hct-43.6 MCV-87
MCH-28.8 MCHC-33.1 RDW-13.7 Plt ___
___ 12:09PM BLOOD Neuts-79.1* Lymphs-13.1* Monos-6.7
Eos-0.8 Baso-0.2
___ 12:09PM BLOOD Glucose-113* UreaN-16 Creat-1.2 Na-139
K-4.2 Cl-98 HCO3-27 AnGap-18
___ 12:28PM BLOOD Lactate-1.3
OTHER LABS
___ 06:13AM BLOOD Glucose-106* UreaN-15 Creat-1.2 Na-141
K-3.7 Cl-102 HCO3-29 AnGap-14
___ 06:10PM BLOOD COCCIDIOIDES ANTIBODY,
IMMUNODIFFUSION-PND
URINE
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:00PM URINE Color-Yellow Appear-Clear Sp ___
MICRO
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture- {POSITIVE FOR RESPIRATORY SYNCYTIAL
VIRUS (RSV)} ___ URINE Legionella Urinary
Antigen - NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
___ URINE URINE CULTURE- <10,000 organisms/ml.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING
___ CXR (PA & LAT)
FINDINGS: As compared to the previous radiograph, there now is
an obvious parenchymal opacity in the left lower lobe that is
better seen on the lateral than on the frontal radiograph. The
opacity shows air bronchograms and has a slightly retractile
character, reflected by the partial elevation of the left
hemidiaphragm in its posterior portion. There also is a small
associated plate-like atelectasis. In light of the clinical
history, the presence of pneumonia is likely.
No other lung parenchymal changes. Known coronary stent. No
pleural
effusions. Normal size of the cardiac silhouette.
Brief Hospital Course:
___ M with hx of CAD s/p stent who presents with 8 days of
fevers, malaise, and URI symptoms despite 5 days treatment with
azithromycin.
# fevers/URI symptoms: viral swab ruled out flu and positive for
RSV. Symptoms likely a combination of RSV bronchiolitis (given
wheezes on exam) complicated by LLL community acquired pneumonia
as shown on CXR. Given recent history of travel to ___,
differential also includes coccidioidomycosis, however patient
is not immunosuppressed, has no chronic lung disease, and
appears clinically well, thus treatment would not be indicated
even if positive. In addition, treatment for RSV not indicated
due to clinical stability and no immunosuppresion or chronic
lung disease. During his hospitalization, has one Tmax of 100.3.
He appeared clinically well and satting >90% on RA. CAP was
treated with levofloxacin. Given his creatinine clearance, levo
was dosed at 750mg Q48h (day 1: ___. Supportive/symptomatic
care provided with albuterol nebs PRN, benzonatate TID for
cough, and guaifenesin q12h. Patient stated that he felt much
improved from the last 8 days, however, was concerned that he
was not improving appropriately given his one time low grade
fever and continued congestion. Requested ID consult and to
speak directly with Dr. ___. ID was consulted who
recommended continuing levofloxacin q48h until ___ given his
age and co-infection with RSV. Coccidioides antibody was also
sent and pending at discharge.
CHRONIC ISSUES
# CAD s/p stent: continued with metoprolol, ASA 81mg,
atorvastatin, fish oil
# HTN: continued with metoprolol, amlodipine
# gout: continued with probenecid
# BPH: continued with finasteride
# orthostatic hypotension: continued with fludrocortisone
4x/week
# TRANSITIONAL ISSUES
-please follow up with pending blood cultures
-please follow up with pending coccidioides antibody
-patient on levofloxacin 750mg q48h from ___ to ___ per ID
recommendations
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Metoprolol Tartrate 12.5 mg PO BID
3. Amlodipine 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Probenecid ___ mg PO DAILY
6. Calcium Carbonate 1200 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Fish Oil (Omega 3) 1200 mg PO TID
9. Finasteride 5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Fludrocortisone Acetate 0.05 mg PO 4X/WEEK (___)
12. Zolpidem Tartrate 10 mg PO HS
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcium Carbonate 1200 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Fish Oil (Omega 3) 1200 mg PO TID
7. Metoprolol Tartrate 12.5 mg PO BID
8. Omeprazole 20 mg PO BID
9. Probenecid ___ mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Zolpidem Tartrate 10 mg PO HS
12. Fludrocortisone Acetate 0.05 mg PO 4X/WEEK (___)
13. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
as needed for cough Disp #*30 Capsule Refills:*0
14. Guaifenesin ER 600 mg PO BID:PRN congestion
RX *guaifenesin 600 mg 1 tablet(s) by mouth twice a day as
needed for loosening phlegm/secretions Disp #*30 Tablet
Refills:*0
15. Levofloxacin 750 mg PO Q48H
last dose on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth every 48 hours Disp
#*4 Tablet Refills:*0
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortnes of breath,
wheezing
RX *albuterol sulfate 90 mcg 2 puff every 6 hours as needed for
wheezing or shortness of breath Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Community acquired pneumonia, RSV
SECONDARY: coronary artery disease, hypertension
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 during your stay at ___
___ ___ ___. You were admitted to the
hospital because of fevers and URI symptoms. A viral swab showed
that you have RSV. A chest x-ray also revealed a left lower lobe
pneumonia. You were treated with levofloxacin and the infectious
disease team saw you while you were hospitalized.
Please continue to take Levofloxacin to complete the course per
infectious disease recommendations (last day on ___.
Followup Instructions:
___
|
10612095-DS-19 | 10,612,095 | 29,295,710 | DS | 19 | 2166-09-02 00:00:00 | 2166-09-04 09:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nizoral / adhesive tape / Mesalamine / EKG pads
Attending: ___.
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male history of coronary artery disease presenting
with fever, cough, myalgia. Patient reports one day of
productive cough. He recently traveled to ___ for four
weeks, returned home on ___ when he began to have cough, and
fatigue. Patient seen yesterday in emergency Department and had
a chest x-ray that was unremarkable. He was sent home with
Tessalon Perles prescription. However since being home patient
had worsening symptoms including worsening cough, chills, muscle
aches, subjective fever as well as rigors. Also with decreased
p.o. intake. Denies lightheadedness, diaphoresis, chest pain,
lower extremity edema, calf pain, abdominal pain, GI or GU
symptoms.
In the ED initial vitals were: 102.2 97 177/88 18 98% RA.
- Labs showed WBC 6.9, UA was negative
- CXR was negative and flu swab was sent.
- Patient was given 1L NS, levofloxacin for "clinical pneumonia"
for question of RLL rhonchi on exam, tamiflu, and vicodin
___.
Vitals prior to transfer were: 99.8 88 160/71 16 100% RA.
On arrival to the floor, VS: 99.0 165/87 92 18 95%RA and flu
swab returned positive for flu A. Patient reported feeling
nauseated and had a nbnb emesis on arrival. He complained of
generalized weakness and "feeling washed out". He denies sick
contacts with anyone w/flu, and states he got his flu vaccine
this year.
Past Medical History:
-CAD s/p cath and placement of 4 stents in ___
-- (___) two overlapping DES to LAD and DES to Diagonal
-- (___) DES to LPDA
-- (___) Mild-moderate 2vCAD and diffuse slow flow consistent
with microvascular dysfunction, no intervention
-GERD
-HTN
-BPH
-Orthostatic hypotension
-gastroparesis
-crohn's ileitis: diagnosed in ___, had reaction to mesalamine,
symptoms now controlled only with probiotics
-HLD
-Gout
-Degenerative spine disease
-- C4/5 subluxation, C4-C7 cord compression, and spinal stenosis
-- Nonsurgical cervical spondylotic myelopathy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
# Father -- ___ aortic valve, died from AS
# Mother -- ___ starting in ___, lived to ___ years old
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 99.0 165/87 92 18 95%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM dry.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, split S2 and ___ systolic murmur heard best at
LUSB.
LUNG: Rhonchi heard anterior upper airway, clears with cough,
otherwise clear, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - Tm 101.3 99.0 142/72 78 18 95%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MM dry.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, split S2 and ___ systolic murmur heard best at
LUSB.
LUNG: clear to auscultation bilaterally, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 11:00AM BLOOD WBC-6.9 RBC-4.67 Hgb-13.2* Hct-39.8*
MCV-85 MCH-28.3 MCHC-33.2 RDW-14.7 Plt ___
___ 11:00AM BLOOD Neuts-79.3* Lymphs-11.9* Monos-5.5
Eos-2.7 Baso-0.5
___ 11:00AM BLOOD Glucose-120* UreaN-16 Creat-1.1 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
___ 10:34PM BLOOD Lactate-1.1
Discharge labs:
___ 06:30AM BLOOD WBC-5.2 RBC-4.34* Hgb-12.5* Hct-36.7*
MCV-85 MCH-28.7 MCHC-34.0 RDW-14.8 Plt ___
___ 06:30AM BLOOD Glucose-93 UreaN-18 Creat-1.2 Na-139
K-3.7 Cl-102 HCO3-26 AnGap-15
___ 06:01AM BLOOD ALT-18 AST-30 AlkPhos-32* TotBili-0.4
___ 06:01AM BLOOD Calcium-8.7 Phos-2.2* Mg-1.7
CXR: ___: IMPRESSION:
No acute cardiopulmonary process.
EKG: SR 96 bpm, QTc 393, no ST/T wave changes compared to prior.
Brief Hospital Course:
___ CAD, GERD, HTN, BPH, presenting with fever, cough, myalgia,
secondary to influenza. Treated with tamiflu for ___valuated by ___, and discharged home when clinically improved.
No clinical or radiographic evidence of pneumonia, so did not
treat with antibiotics.
# Influenza: Patient presented with fever, myalgias, cough and
found to have fluA PCR positive. Levofloxacin given in the ED,
although no CXR evidence of pneumonia; discontinued abx on the
floor. Treated with tamiflu. He improved clinically, denying
fever, myalgias, and cough resolved. Appetite good, pulmonary
exam clear.
# CAD: continued ___, metoprolol.
# Orthostatic hypotension: continued fludrocort.
# BPH: continued finasteride. Alfuzosin not formulary, was held.
TRANSITIONAL ISSUES:
[] Should continue tamiflu (oseltamivir 75 mg PO Q12H) for full
5 day course. Final day ___. Also discharged with albuterol
inhaler.
# Code: full (confirmed)
# Emergency Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Fludrocortisone Acetate 0.05 mg PO EVERY OTHER DAY
3. Atorvastatin 40 mg PO QPM
4. Cetirizine 10 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Probenecid ___ mg PO DAILY
7. Zolpidem Tartrate 5 mg PO BID:PRN insomnia
8. Aspirin 81 mg PO DAILY
9. Align (bifidobacterium infantis) 4 mg oral daily
10. Calcium Carbonate 1250 mg PO DAILY
11. Vitamin D 5000 UNIT PO 3X PER WEEK
12. alfuzosin 10 mg oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcium Carbonate 1250 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Fludrocortisone Acetate 0.05 mg PO EVERY OTHER DAY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Probenecid ___ mg PO DAILY
9. Vitamin D 5000 UNIT PO 3X PER WEEK
10. Zolpidem Tartrate ___ mg PO BID:PRN insomnia
11. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*6 Capsule Refills:*0
12. alfuzosin 10 mg oral daily
13. Align (bifidobacterium infantis) 4 mg oral daily
14. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath,
wheezing
RX *albuterol sulfate 90 mcg ___ puff inh every four (4) hours
Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
influenza
secondary diagnosis:
coronary artery disease
hypertension
benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr ___,
___ was a pleasure to care for you at ___. You were admitted to
the hospital because you were found to have influenza. We
prescribed you oseltamivir (tamiflu) for a 5 day course. Your
fevers and cough resolved and your appetite and breathing
improved. You were evaluated by physical therapy. Given your
clinical improvement, you were safe for discharge home.
You should continue to take your medications and follow up with
your primary care physician. You should continue taking tamiflu
through ___.
We wish you all the best.
-Your ___ care team
Followup Instructions:
___
|
10612095-DS-20 | 10,612,095 | 24,845,894 | DS | 20 | 2166-10-10 00:00:00 | 2166-10-10 14:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Nizoral / adhesive tape / Mesalamine / EKG pads
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Cervical laminectomy, medial facetectomy, and
foraminotomy of C5, C6, and C7.
2. Posterolateral arthrodesis, C4-T2.
3. Posterolateral instrumentation, C4-T2.
4. Application of autograft and allograft.
5. Application and removal ___ tongs.
6. Spinal cord monitoring.
7. Open treatment, fracture dislocation, C6-7.
History of Present Illness:
Mr. ___ is a ___ year-old man with a PMH of CAD s/p CABG,
Crohn's Disease, orthostatic hypotension (on fludrocort) who
presents s/p fall. Patient reports that he was walking up the
stairs from one floor to the next in his house about 15 when he
started feeling generalized weakness and then fell backwards. He
never lost consciousness and is able to re-account the entire
event. He denied any dizziness, lightheadedness, tunnel vision,
chest pain, SOB, DOE, bowel or bladder incontinence. After the
fall he was complaining of neck and back pain. He reported that
he has had similar episodes in the past called "drop attacks"
for which he was started on fludrocortisone 0.05 mg four times
per week. Reports pain in his mid upper back. He had not
ambulated since the event.
In Summary- The patient is a ___ year old male with significant
cardiac
history who presents with neck pain after sustaining fall from
the top of a staircase. The patient felt light-headed, weak, and
fell down his stairs at home, striking his head and neck. The
patient noted immediate sharp pain in the neck, and denies any
weakness, numbness, or tingling in the extremities.
He does note a history of lower extremity muscle spasms which
may have increased following his fall. The patient also notes
that the pain in his neck rarely radiates into his shoulders.MRI
results revealed
IMAGING:
CT of C-spine - fractures of the spinous processes of C6, C7,
T1,
and T2 with moderate displacement; fracture of anterior bone
spur
of C7; diffuse degenerative changes including C4/C5
anterolisthesis.
CT of T/L spine - no acute injuries; diffuse degenerative
changes
Given his C6,7, T1, T2 spinous process fractures s/p fall he is
now s/p FUSION CERVICAL POSTERIOR WITH DISCECTOMY, C4-T2 on
___ with Dr. ___
___ Medical History:
-CAD s/p cath and placement of 4 stents in ___
-- (___) two overlapping DES to LAD and DES to Diagonal
-- (___) DES to LPDA
-- (___) Mild-moderate 2vCAD and diffuse slow flow consistent
with microvascular dysfunction, no intervention
-GERD
-HTN
-BPH
-Orthostatic hypotension
-gastroparesis
-crohn's ileitis: diagnosed in ___, had reaction to mesalamine,
symptoms now controlled only with probiotics
-HLD
-Gout
-Degenerative spine disease
-- C4/5 subluxation, C4-C7 cord compression, and spinal stenosis
-- Nonsurgical cervical spondylotic myelopathy
ONCHOYMYCOSIS
PYURIA
SINUSITIS
CROHN'S DISEASE
BENIGN PROSTATIC HYPERTROPHY
AUTONOMIC NEUROPATHY
LPR
ACTINIC KERATOSIS
SCAR
ACTINIC KERATOSIS
RHINITIS
DYSPHONIA
KERATODEMA ACQUIRED
COUGH
ULCER, SKIN OTHER SITE
CONTACT DERMATITIS
GAIT DISORDER
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
# Father -- ___ aortic valve, died from AS
# Mother -- ___ starting in ___, lived to ___ years old
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - T:98.2 BP:171/95 HR:81 RR:18 02 sat: 93%RA
GENERAL: NAD, pleasant elderly male
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: ___ J collar in place
CARDIAC: RRR, split S2 and ___ systolic murmur heard best at
LUSB.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: NABS, soft, NT/ND
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ b/l upper and lower
extremities, sensatio of lower extremities intact
Babsinki downgoing
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
General:NAD,comfortable elderly male
___ J in place
Cardiac:RRR
Lungs:CTAB, no adventitious breath sounds
Abs:soft,ntnd,+bs's
Extremities:wwp,2+rad,2+dp pulses,no cyanosis or edema, MAE's
Skin:no lesions, or rashes. Cervical dressing C/D/I under ___
J collar
Strenth: Targeted UE exam: ___ RUE Del/EE/EF/WE/WF, 4+/5
Grip/IO, 4+/5 LUE.
BLE ___
Pertinent Results:
ADMISSION LABS
==============
___ 05:52PM BLOOD WBC-12.6*# RBC-4.80 Hgb-13.3* Hct-40.3
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.4 Plt ___
___ 05:52PM BLOOD Neuts-82.9* Lymphs-9.9* Monos-5.6 Eos-1.4
Baso-0.3
___ 05:52PM BLOOD ___ PTT-26.6 ___
___ 05:52PM BLOOD Glucose-105* UreaN-18 Creat-1.4* Na-137
K-4.1 Cl-98 HCO3-25 AnGap-18
___ 05:52PM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD CK-MB-7 cTropnT-<0.01
___ 07:40AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8
DISCHARGE LABS
==============
___ 09:10AM BLOOD WBC-8.6 RBC-3.43* Hgb-9.5* Hct-29.0*
MCV-85 MCH-27.7 MCHC-32.7 RDW-15.1 Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD ___ PTT-25.8 ___
___ 09:10AM BLOOD Glucose-198* UreaN-17 Creat-0.9 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
___ 09:10AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.7
___ 07:40AM BLOOD CK-MB-7 cTropnT-<0.01
Brief Hospital Course:
The patient is a ___ year old male with significant cardiac
history who presents with neck pain after sustaining fall from
the top of a staircase. The patient felt light-headed, weak, and
fell down his stairs at home, striking his head and neck. The
patient noted immediate sharp pain in the neck, and denies any
weakness, numbness, or tingling in the extremities.
The patient had a full work-up which revealed results as below:
IMAGING
=======
CT C-SPINE W/O CONTRAST Study Date of ___ 6:12 ___
IMPRESSION:
1. Anterior corner fracture of C7 with distracted fracture
through C7
posterior spinous process is worrisome for at least 2 column
injury, making this fracture unstable. Likely flexion type
mechanism of injury.
2. Nondisplaced fracture through left articular process of C6.
Single column injury.
3. Distracted posterior spinous process fracture at T1 and T2.
Single column injury.
4. Distracted posterior spinous process fracture at C6 is of
indeterminate age.
5. Mild anterolisthesis of C4 on C5 is most likely degenerative
in nature.
CT HEAD W/O CONTRAST Study Date of ___ 6:12 ___
IMPRESSION:
1. No acute intracranial abnormality. Specifically no
intracranial hemorrhage.
2. Chronic changes as described above.
CT CHEST W/O CONTRAST Study Date of ___ 6:15 ___
IMPRESSION:
1. Small intermediate density pericardial effusion is
incompletely evaluated and may be artifactual however dedicated
evaluation with echocardiogram is recommended.
2. No evidence of rib or thoracic spine fracture.
3. No retroperitoneal hematoma.
4. No thoracic spine fracture.
CT Chest ___:
No supraclavicular, axillary, mediastinal, or hilar lymph node
enlargement by CT size criteria. The thyroid gland is
unremarkable. No anterior mediastinal hematoma. A small hiatal
hernia is present.
The heart size is normal with a small intermediate density
pericardial effusion. Atherosclerotic calcifications are seen
within the thoracic aorta and coronary arteries. The great
vessels are normal caliber. No retroperitoneal hematoma. No
pleural effusion.No pneumothorax. The airways are patent to the
subsegmental level.
Bilateral lower lobe atelectasis is present.
OSSEOUS STRUCTURES: 0.5 x 0.5 cm densely sclerotic lesion along
posterior aspect of right 1st rib is most consistent with a bone
island. No lytic or blastic osseous lesions concerning for
malignancy. No thoracic spine or rib fracture.Degenerative
changes throughout the thoracic spine.Although this study is not
designed for the evaluation of subdiaphragmatic structures, the
imaged upper abdomen is unremarkable.
IMPRESSION:
1. Small intermediate density pericardial effusion is
incompletely evaluated and may be artifactual however dedicated
evaluation with echocardiogram is recommended.
2. No evidence of rib or thoracic spine fracture.
3. No retroperitoneal hematoma.
4. No thoracic spine fracture.
*****Given this finding, it is recommended to follow up with a
repeat Chest CT or echocardiogram if he were to become
symptomatic. This was discussed with the ___ team and
agrees with recommendation.
CT L-SPINE W/O CONTRAST Study Date of ___ 9:43 ___
IMPRESSION:
1. No acute fracture or acute malalignment in the lumbar spine.
2. Stable grade 1 anterolisthesis of L4 on L5.
3. Small disc bulge at L3-4 with mild canal narrowing at this
level.
4. Moderate spinal canal narrowing at L5-S1 due to thickening of
the
ligamentum flavum.
5. Enlarged prostate. Correlation with clinical history and PSA
is
recommended.
6. Multilevel degenerative changes throughout the lumbar spine
most notable at L1-2 and L5.
MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 1:13 ___
IMPRESSION:
Prevertebral fluid and possible anterior longitudinal ligament
injury.
Posterior ligamentous complex injury better demonstrated on the
CT.
Possible spinal cord contusion
C-SPINE NON-TRAUMA ___ VIEWS Study Date of ___ 6:50 ___
IMPRESSION:
Status post posterior fusion spanning C4-T2 without evidence of
hardware
complication. Please see the operative report for further
details.
Moderate to severe background degenerative disc disease at C2-C3
and C4-C5.
Previously demonstrated anterior corner and spinous process
fractures at C7, left articular process and spinous process
fractures at C6, and spinous process fractures at T1 and T2 are
poorly demonstrated on the current exam.
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for FUSION CERVICAL POSTERIOR WITH
DISCECTOMY, C4-T2 on ___ with Dr. ___. Refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. SC heparin was started on ___
when it was felt to be safe to start anticoagulation from a
spine standpoint. Intravenous antibiotics were continued for
24hrs postop per standard protocol. Initial postop pain was
controlled IV pain medication. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. The patient voided with a condom catheter as
he has urinary incontinence at baseline and is managed by his
urologist. Physical therapy and Occupational Therapy was
consulted for ADL's and mobilization OOB to ambulate.
The ___ team followed this patient per request of his PCP
for help with management of his orthostatic hypotension, mental
status changes and management of his medications. ___ team
felt that the patient had developed a hypoactive delirium during
his hospitalization given his age in combination with anesthesia
and pain medications from surgery. He has improved significantly
every day. The patient continues to have orthostatic hypotension
but has been medically managed. Initially his fludricortisone
dose was increased to 0.05 QD and his Alfuzosin was stopped on
admission. He developed hypertension to SBP 170's POD3. With
restarting the patient Alfuzosin, his SBP came back down to
110-130's. It is recommended by the ___ Service who also
discussed with his PCP to continue his Alfuzosin and now
continue his Fludricortisone back to QOD dosing, which was done
and should be continues as an outpatient. The patient continues
to be orthostatic but is asymptomatic. **If he becomes
symptomatic along with his orthostatic hypotension, then the
Alfuzosin should be stoped and his Fludricortisone should
continues at current QOD dosing. His PCP should be notified. The
patient agreed to this plan and will follow up with his PCP.
C-spine XR (AP/Lat) was completed on day of discharge for
follow-up spine purposes.
The patient continues to have a gait instability and will be
seen by neurology as an outpatient. He will benefit from
additional gait training.
On the day of discharge the patient voiced concern over
respiratory symptoms and requested a CXR for futher
investigation. The patients vitals signs were stable and
developed a slightly elevated HR due to anxiety over transfer
and the need for a cervical spine XR. His vital signs are
stable. The patient remained hemodynamically stable and
oxygenating 98-100% on RA without respiratory distress or
increased RR. A CXR was not ordered because it was felt that it
was not indicated given his stable vital signs and no further
reporting symptoms of respiratory distress. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcium Carbonate 1250 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Fludrocortisone Acetate 0.05 mg PO EVERY OTHER DAY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Vitamin D 5000 UNIT PO 3X PER WEEK
9. Zolpidem Tartrate ___ mg PO BID:PRN insomnia
10. alfuzosin 10 mg oral daily
11. Align (bifidobacterium infantis) 4 mg oral daily
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath,
wheezing
13. Omeprazole 20 mg PO BID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath,
wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcium Carbonate 1250 mg PO DAILY
5. Cetirizine 10 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fludrocortisone Acetate 0.05 mg PO EVERY OTHER DAY
8. Metoprolol Tartrate 12.5 mg PO BID
9. Omeprazole 20 mg PO BID
10. Vitamin D 5000 UNIT PO 3X PER WEEK
11. Zolpidem Tartrate ___ mg PO BID:PRN insomnia
12. Acetaminophen 1000 mg PO Q6H pain
13. Docusate Sodium 100 mg PO BID
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Multivitamins 1 TAB PO DAILY home dose
16. Polyethylene Glycol 17 g PO BID
17. Senna 17.2 mg PO BID
18. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nasal passages
19. alfuzosin 10 mg oral daily
20. Align (bifidobacterium infantis) 4 mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. C6-7 fracture dislocation with extension dish-type
fracture.
2. Cervical spondylitic myelopathy.
3. Cervical stenosis.
4. Spinal cord injury.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Posterior cervical fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for ___
minutes as part of your recovery. You can walk as much as you
can tolerate.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. . Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for
___ minutes as part of your recovery. You can walk as much as
you can tolerate.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
-Gait training
Treatments Frequency:
Remove the dressing in 2 days. If the incision is draining
cover it with a new sterile dressing. If it is dry then you can
leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Call the office at that time. If you have
an incision on your hip please follow the same instructions in
terms of wound care.
Followup Instructions:
___
|
10612379-DS-9 | 10,612,379 | 27,047,170 | DS | 9 | 2196-07-29 00:00:00 | 2196-07-30 20:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient reports that he has been becoming progressively more
short of breath for the last 2 months. He used to be able to
walk a few blocks or up a few flights of stairs without any
issue, however, now he cannot walk up a flight of stairs or even
to the bathroom without feeling short of breath. He has had a
great deal of difficulty at work (works as ___) and feels
more fatigued than usual. He reports that he has been unable to
lie down flat to sleep and needs to sit up. He used to be able
to lie down with 1 pillow and now needs ___ pillows. He also
reports lower extremity edema, abdominal swelling, and gaining
over 30 pounds. (reports baseline weihgt to be around 220 lbs).
Also he says that he had chest pain on and off for 2 months. He
reports occasional salty food intake. He does not take any
diuretic medications. He describes it more as a tightness that
is associated with his shortness of breath whenever he exerts
himself. The tightness is sometimes associated with nausea and
pain down his right arm. In the last day or 2 he reports
increasing pain in his right chest. The pain is worse with deep
inspiration.
He denies any fevers, chills, cough, abdominal pain, weakness or
dizziness.
In the ED intial vitals were: 97.6 61 132/99 24 97%
Exam significant for lower extremity edema.
Labs significant for trop negative x 1, BNP of 215, otherwise
unremarkable.
ECG showed NSR with PACs. no ischemic changes
CXR showed mild pulmonary edema and bibasilar opacities (likely
atelectasis)
Patient was given: ASA 325 and 20 mg IV lasix. Patient reports
he urinated about 1.5 urinals full.
Vitals on transfer: 97.9 74 130/91 18 96% RA
On the floor, he has no further complaints.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
DIABETES MELLITUS
HYPERTENSION
SLEEP APNEA - doesn't use CPAP
SEXUAL DYSFUNCTION
DEPRESSION
OBESITY
Social History:
___
Family History:
significant for DM and HTN in many family members
sister with cancer (unknown type) passed away
Physical Exam:
Admission Physical
VS: 97.7 129/74 74 20 96% RA
weight 114.3 kg
GENERAL: comfortable in NAD
HEENT: sclera anicteric, MMM.
NECK: Supple. difficult to interpret JVP given body habitus
CARDIAC: mostly regular with some ectopic beats. no murmur
appreciated.
LUNGS: diminished breath sounds at right base. otherwise clear
to auscultation
ABDOMEN: Obese. slightly distended but soft. nontender
EXTREMITIES: 2+ lower extremity edema bilaterally
SKIN: warm, dry
NEURO: A&Ox3. EOMI, tongue midline. moving all extremities.
Discharge Physical
S:T 97.6, BP 130/83-134/65 p 70, 100% on RA
I/O 1180/3050
WT: 111.9 down from 114 on admission
GENERAL: comfortable in NAD lying FLAT in bed
HEENT: sclera anicteric, MMM.
NECK: Supple. difficult to interpret JVP given body habitus
CARDIAC: mostly regular with some ectopic beats. no murmur
appreciated.
LUNGS: otherwise clear to auscultation
ABDOMEN: Obese. slightly distended but soft. nontender
EXTREMITIES: 2+ lower extremity edema bilaterally
SKIN: warm, dry
NEURO: A&Ox3. EOMI, tongue midline. moving all extremities.
Pertinent Results:
Admission Labs
====================================
___ 05:00PM ___ PTT-26.3 ___
___ 05:00PM PLT COUNT-182
___ 05:00PM NEUTS-47.3* LYMPHS-44.4* MONOS-4.6 EOS-2.6
BASOS-1.0
___ 05:00PM NEUTS-47.3* LYMPHS-44.4* MONOS-4.6 EOS-2.6
BASOS-1.0
___ 05:00PM WBC-5.7 RBC-4.73 HGB-14.5 HCT-45.2 MCV-96
MCH-30.8 MCHC-32.2 RDW-13.0
___ 05:00PM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 05:00PM proBNP-215*
___ 05:00PM cTropnT-<0.01
___ 05:00PM estGFR-Using this
___ 05:00PM GLUCOSE-143* UREA N-15 CREAT-0.9 SODIUM-137
POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
___ 06:34PM K+-3.8
EKG
normal sinus rhythm with frequent atrial premature complexes,
some of which
are blocked, others are conducted with aberrancy. Voltage
criteria for left
ventricular hypertrophy. Non-specific ST-T wave abnormalities.
Intra-atrial
conduction abnormality. Compared to the previous tracing of
___ atrial
premature complexes persist but there is no ventricular
premature complex.
There is no other change.
Imaging
=====================================
CXR
1. Bibasilar opacities most likely relate to atelectasis in
this patient with
low lung volumes and mildly elevated right hemidiaphragm,
however, underlying
infection or aspiration is not excluded in the appropriate
clinical setting.
2. Prominence of the central pulmonary vasculature may suggest
mild pulmonary
edema which may be in part accentuated by low lung volumes.
3. Possible trace right pleural effusion.
Echo
LVEF 50-55%
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal inferior
segment and of the basal to mid septum. Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality due to body habitus.
Moderately dilated left ventricle. Probable focal hypokinesis as
mentioned above. The right ventricle is not well seen but is
probably normal. Trace aortic regurgitaion. Normal pulmonary
artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
the septum appears hypokinetic on the current study.
Discharge Labs
==========================================
___ 06:05AM BLOOD WBC-5.6 RBC-5.13 Hgb-15.7 Hct-49.3 MCV-96
MCH-30.7 MCHC-31.9 RDW-13.1 Plt ___
___ 06:05AM BLOOD Glucose-118* UreaN-23* Creat-1.1 Na-141
K-4.0 Cl-102 HCO3-31 AnGap-12
___ 06:05AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ yo M with hx of HTN, DM2 who presents with 2
months of worsening shortness of breath and chest pain and exam
and imaging consistent with volume overload.
# congestive heart failure exacerbation - This admission the
patient demonstrated orthpnea, DOE, lower extremity edema, and
pulmonary edema on CXR and exam consistent clinically with CHF
exacerbation. His troponins were negative and his EKG was
remarkable for NSR with occasionally blocked PACs and
nonspecific ST segment abnormalities. Review of his records
revealed perfusion imaging from 13 months prior with Mild
reversible inferior wall perfusion defect, and a subsequent
cardiac catheterization with no angiographically apparent CAD.
The progressive nature of his symptoms and normal cardiac
enzymes with a recent normal cardiac cath was reassuring against
scute coronary syndrome. The patient has not previously been on
diuretics, and he responded well to 20mg IV lasix. Echo revealed
global LV dilatation with possible septal hypokinesis and normal
EF of 50-55%. Review of his previous echo suggested a more
global hypokinesis and a new focal coronary lesion was
considered extremely unlikely. The patient was transitioned to
PO diuretics and given his risk factors of He has risk factors
for coronary disease of HTN, DM2, obesity, he was started on
atorvastatin 80, and lisinopril 10. He was continued on his
home aspirin 81 and metoprolol 50 mg daily. He was advised to
adhere to a low sodium diet and instructed to call his doctor if
his weight increases by more than 3 lbs.
# hypertension Patient remained with stable blood pressures in
house. He was started on lisinopril 10 mg to reduce cardiac
redmodeling, and for renal protection.
# diabetes: Patient was continued on lantus in house and
instucted to adhere to a low carb diabetic diet on discharge and
to follow up with his primary care doctor regarding better
glycemic control.
# depression
He was continued on citalopram.
TRANSITIONAL ISSUES:
- Will need chem 7 in a week after starting lisinopril this
admission.
- ___ benefit from treatment of obstructive sleep apnea
- Patient requested glucometer, may need further follow up to
ensure he is using it appropriately
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Glargine 60 Units Breakfast
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Viagra (sildenafil) 50-100 mg oral daily:prn sexual activity
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
DAILY Disp #*30 Tablet Refills:*0
2. Citalopram 20 mg PO DAILY
3. Glargine 60 Units Breakfast
4. Furosemide 40 mg PO DAILY Duration: 1 Dose
RX *furosemide 20 mg 2 tablet(s) by mouth every morning Disp
#*60 Tablet Refills:*0
5. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth DAILY Disp #*30 Tablet Refills:*0
7. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
8. Viagra (sildenafil) 50-100 mg oral daily:prn sexual activity
9. diabetes supplies
FREESTYLE GLUCOMETER (#1)
No refills
ICD 9: 250.00 Diabetes
10. diabetes supplies
FREESTYLE TEST STRIPS (#50)
No refills
ICD 9: 250.00 Diabetes
11. diabetes supplies
FREESTYLE LANCETS (#50)
No refills
ICD 9: 250.00 Diabetes
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Acute on Chronic Heart Failure with preserved
ejection fraction
Secondary Diagnosis: Diabetes Mellitus Type II, Hypertension,
obstructive sleep apnea.
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 recent admission to
the ___. You were admitted
with shortness of breath and found to have an exacerbation of
heart failure. We performed tests to examine your heart and
reviewed previous tests of your heart and we were reassured that
you had not had a heart attack. We treated you with medications
to help remove fluid from your body and adjusted your home
medications to treat your heart failure. The cause of your
worsening heart failure is likely related to your diabetes and
it is very important that you check your blood sugars frequently
and eat a low sugar diet. It is very important that you control
your diabetes by taking your insulin every day and following up
frequently with your diabetes doctor.
Additionally, for your heart failure it is very important that
you weigh yourself every day and call your doctor if your weight
increases by more than 3 lbs. We discharged you on a medication
that helps to remove fluid from your body and will help prevent
you from becoming short of breath.
If you develop any worsening chest pain shortness of breath or
other concerning symptoms please return to the hospital for
further evaluation.
Please talk to your doctor about treating your obstructive sleep
apnea.
Followup Instructions:
___
|
10612451-DS-25 | 10,612,451 | 20,282,470 | DS | 25 | 2173-06-13 00:00:00 | 2173-06-20 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Dilaudid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
s/p cholecystectomy ___
History of Present Illness:
___ female status post cholecystectomy discharged
from the hospital today presents with progressively
increasing right upper quadrant pain, drainage from her
surgical sites, no nausea, no fevers.
Timing: Constant
Severity: Moderate
Location: Right upper quadrant
Past Medical History:
1. Diabetus mellitus
2. Hypertension
3. Hypercholesterolemia
4. Concern for coronary artery disease - last catheterization
___ with R dominant system, no significant CAD
5. Asthma
6. S/p two C-sections
7. Abdominal cellulitis (over ___ years ago) s/p pannilectomy
8. Pulmonary infection (?PCP) at ___ (___)
9. Hematuria of unclear etiology
Social History:
___
Family History:
Mother - CAD, ESRD on HD. Maternal aunt - breast ca. Maternal
uncle - prostate ca. Breast and ovarian cancer, mother had
diabetes
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 99.0 HR: 113 BP: 201/84 Resp: 16 O(2)Sat: 97 Normal
Constitutional: In pain, nontoxic
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds,
Regular Rate and Rhythm
Abdominal: Soft, mildly tender right upper quadrant
Skin: Surgical sites clean, dry, intact
Physical examination upon discharge: ___
vital signs: 99.6, hr=96, bp=156/56, rr=20, 94% room air
CV: ns1, s2, -s3, s-4
LUNGS: clear
ABDOMEN: soft, non-tender, port sites clean and dry
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 09:00AM BLOOD WBC-5.7 RBC-4.30 Hgb-12.2 Hct-39.7 MCV-92
MCH-28.5 MCHC-30.8* RDW-12.7 Plt ___
___ 07:05PM BLOOD WBC-7.3 RBC-4.39 Hgb-12.6 Hct-40.4 MCV-92
MCH-28.8 MCHC-31.2 RDW-12.6 Plt ___
___ 10:00PM BLOOD WBC-9.7 RBC-4.50 Hgb-13.1 Hct-41.6 MCV-93
MCH-29.1 MCHC-31.5 RDW-12.6 Plt ___
___ 10:00PM BLOOD Neuts-74.8* Lymphs-16.4* Monos-4.2
Eos-4.2* Baso-0.4
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD ALT-43* AST-23 AlkPhos-61 TotBili-0.3
___ 09:00AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0
___: liver/gallbladder US:
Cholecystectomy surgical bed not well seen due to fatty liver
infiltration and rib shadows. No biliary dilatation
___: gallbladder scan:
Normal hepatobiliary scan. No abnormal accumulation of tracer
concerning for a bile leak, status post cholecystectomy.
___ 9:33 am URINE Source: ___.
URINE CULTURE (Pending):
Brief Hospital Course:
___ year old female s/p cholecystectomy who was discharged on
___. She returned to the hospital on ___ with increasing
abdominal pain and wound drainage. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging.
An abdominal US was done which showed which did not show any
fluid collection. The patient's vital signs were monitored and
she remained afebrile. She continued to have abominal pain and
there was concern for a bile leak. The patient underwent a HIDA
scan on HD # 3 which was negative for a leak. On HD #4, the
patient reported decreased level of pain and resumed a regular
diet.
The patient was discharged home with ___ services on HD #4 in
stable condition. She was afebrile and her appetite was slowly
improving. Her abdominal pain had decreased in intensity.
Follow-up appointments which were made at the initial discharge
were maintained.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. QUEtiapine Fumarate 25 mg PO DAILY
7. Zolpidem Tartrate 10 mg PO HS
8. Acetaminophen 1000 mg PO Q8H
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN PAIN
10. Senna 8.6 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
13. Lantus (insulin glargine) 100 unit/mL subcutaneous Bedtime
14. HumaLOG (insulin lispro) 100 unit/mL subcutaneous QAC
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Zolpidem Tartrate 10 mg PO HS
8. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
9. Senna 8.6 mg PO BID
10. QUEtiapine Fumarate 25 mg PO DAILY
11. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Stop taking if you begin to have loose stools
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth twice a day Refills:*1
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*10
Capsule Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
15. Acetaminophen 650 mg PO Q6H:PRN pain
16. Glargine 50 Units Bedtime
Humalog 30 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause drowsiness, avoid driving while on this medication
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
abdominal pain
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were previously admitted to the hospital with acute
cholecystitis. You were taken to the operating room and had your
gallbladder removed laparoscopically. You were readmitted for
pain and constipation following your laparascopic
cholecystectomy which is better controlled now and you have had
multiple bowel movements. You are now preparing for discharge
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:
___
|
10612451-DS-27 | 10,612,451 | 25,163,350 | DS | 27 | 2175-03-04 00:00:00 | 2175-03-04 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilaudid
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/h/o asthma, ___ (EF 55% in ___, HTN, DM2 p/w
cough, chest tightness & SOB x 2d w/significant weight gain 9lbs
over past ___ days. Cough started ___ d ago, chest tightness &
SOB yesterday - taking asthma controllers, using albuterol ~6 x
day since yesterday w/out relief. Has gained 9lb over past few
days w/feeling of abdominal fullness & leg swelling. Denies
fever, nauasea/vomiting or diarrhea. On review of patient's
history she has had similar admissions for shortness of breath,
mostly at ___ x 6 in ___. It is unclear exactly what
workup she has had there. In ___ at ___ she had left heart
catheterization which showed no disease.
In the ED, initial vital signs were:
98.0 ,105 ,204/83 ,22
- Exam was notable for:
significant wheezing, poor air movement
- Labs were notable for:
___
21:41
Urinalysis w/o infection
___
17:56
Trop-T: <0.01
137 101 21
============< 374
4.1 27 1.1
ALT: 39 AP: 81 Tbili: 0.2 Alb: 3.8
AST: 24 LDH: Dbili: TProt:
___: Lip:
Other Blood Chemistry:
proBNP: 449
___: 10.8 PTT: 34.4 INR: 1.0
8.9 <13.3/41.6> 273
- Imaging:
CXR ___:
The lungs are clear without consolidation, effusion, or
pneumothorax. Increased interstitial markings are likely in part
due to overlying soft tissues. There is no overt pulmonary
edema. Cardiac silhouette is mildly enlarged. Hypertrophic
changes are noted in the spine.
IMPRESSION:
No definite acute cardiopulmonary process.
- The patient was given:
___ 19:41 PO Azithromycin 500 mg
___ 19:41 PO Acetaminophen 1000 mg
___ 19:41 IH Albuterol 0.083% Neb Soln 1 NEB
___ 19:41 IH Ipratropium Bromide Neb 1 NEB
___ 19:41 PO PredniSONE 60 mg
___ 20:23 IH Albuterol 0.083% Neb Soln 1 NEB
___ 20:23 IH Ipratropium Bromide Neb 1 NEB
___ 21:26 IH Albuterol 0.083% Neb Soln 1 NEB
___ 21:26 IH Ipratropium Bromide Neb 1 NEB
___ 21:26 IV Magnesium Sulfate 2 gm
___ 21:26 IV Ketorolac 30 mg
- Consults: none
Vitals prior to transfer were:
96.6 ,85 ,159/73 ,24 ,98% RA
Upon arrival to the floor, patient tearful, still remains short
of breath. Notes that she measures 2L of water daily in liter
bottles and has been completely adherent to low salt diet and
low liquid 2L input limit. She has gained 19 pounds since
___. She is having trouble w/ADLs at home and
failure to thrive and is worried she needs rehab. Her son had to
help her bathe the other day. She cried throughout the
interview. She unfortunately is unable to confirm her home
medications, and her pharmacy is closed. We confirmed the vital
ones, however.
REVIEW OF SYSTEMS:
[+] per HPI
Otherwise 10 point ROS is negative.
Past Medical History:
1. Diabetus mellitus
2. Hypertension
3. Hypercholesterolemia
4. Concern for coronary artery disease - last catheterization
___ with R dominant system, no significant CAD
5. Asthma
6. S/p two C-sections
7. Abdominal cellulitis (over ___ years ago) s/p pannilectomy
8. Pulmonary infection (?PCP) at ___ (___)
9. Hematuria of unclear etiology
Social History:
___
Family History:
Mother - CAD, ESRD on HD. Maternal aunt - breast ca. Maternal
uncle - prostate ca.
Physical Exam:
ADMISSION PHYSICAL:
VITALS - ___, 155/75, pulse 75, rr20, 96% on RA
GENERAL - obese F, tearful, uncomfortable and coughing every few
sentences
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, unable to assess JVD ___ habitus
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - poor air movement w/bilateral wheeze, bibasilar
crackles
ABDOMEN - obese, distended, nontender, no rebound/guarding
EXTREMITIES - warm, well-perfused, trace edema bilateral lower
extremities
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - tearful, upset throughout interview
DISCHARGE PHYSICAL:
VITALS: 97.7, 123/52, 63, 22, 96% RA
GENERAL: lying in bed on her side with duoneb running at the
bedside; later ambulating without difficulty and breathing
comfortably
HEENT: normocephalic, atraumatic, no conjunctival injection or
scleral icterus, OP clear
NECK: supple, no JVD appreciated
CARDIAC: distant heart sounds; regular rate & rhythm, normal
S1/S2, no murmurs rubs or gallops
PULMONARY: Patient intermittently coughing with deep
inspiration; mildly decreased air movement throughout; loud
upper airway sounds, but no wheezes or crackles
ABDOMEN: obese, distended, tender to palpation today diffusely,
no rebound/guarding; BS hypoactive but present
EXTREMITIES: warm, well-perfused, no edema
NEUROLOGIC: alert, appropriately interactive, no focal deficits
on exam
Pertinent Results:
ADMISSION:
___ 05:56PM BLOOD WBC-8.9 RBC-4.61 Hgb-13.3 Hct-41.6 MCV-90
MCH-28.9 MCHC-32.0 RDW-13.2 RDWSD-43.0 Plt ___
___ 05:56PM BLOOD Neuts-67.8 ___ Monos-6.4 Eos-4.3
Baso-0.6 Im ___ AbsNeut-6.06 AbsLymp-1.85 AbsMono-0.57
AbsEos-0.38 AbsBaso-0.05
___ 05:56PM BLOOD Glucose-374* UreaN-21* Creat-1.1 Na-137
K-4.1 Cl-101 HCO3-27 AnGap-13
___ 05:56PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.6# Mg-2.0
___ 09:41PM URINE Color-Straw Appear-Clear Sp ___
___ 09:41PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:41PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
OTHER IMPORTANT LABS:
IMAGING AND OTHER STUDIES:
___ CHEST X RAY:
The lungs are clear without consolidation, effusion, or
pneumothorax.
Increased interstitial markings are likely in part due to
overlying soft
tissues. There is no overt pulmonary edema. Cardiac silhouette
is mildly
enlarged. Hypertrophic changes are noted in the spine.
MICROBIOLOGY:
DISCHARGE LABS:
___ 06:24AM BLOOD WBC-8.1 RBC-4.59 Hgb-13.0 Hct-41.5 MCV-90
MCH-28.3 MCHC-31.3* RDW-13.1 RDWSD-43.0 Plt ___
___ 06:24AM BLOOD Glucose-302* UreaN-25* Creat-0.9 Na-135
K-4.5 Cl-102 HCO3-23 AnGap-15
___ 06:24AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.2
___ 06:15AM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:56PM BLOOD cTropnT-<0.01
___ 05:56PM BLOOD proBNP-449*
Brief Hospital Course:
Mrs. ___ is a ___ y/o woman with h/o asthma, dCHF (EF 55% in
___, HTN, DM2, depression, presenting with 4 days of
worsening dyspnea and wheezing suggestive of asthma
exacerbation, with less likely component of acute on chronic
dCHF exacerbation.
# Dyspnea/Asthma Exacerbation: The patient was admitted for
acutely worsening shortness of breath. She did endorse
significant weight gain but her measurements were unlikely to be
precise as she reported a large range of error ___ lbs). She
also did not appear volume overloaded on exam and her CXR was
without evidence of pulmonary edema. In this setting, she was
felt to most likely have acute asthma exacerbation given her
poor air movement and wheezing on exam, likely triggered by URI
as she developed coughing and chills around the same time. She
was managed supportively with 5 day course of prednisone burst
___ - ___ with one dose to be completed at home, in
addition to duonebs and home regimen of montekulast for asthma
and Lasix 40mg PO BID for CHF. On discharge, she was saturating
well on RA and breathing comfortably without any signs of
respiratory distress.
# Compensated Chronic Diastolic CHF: The patient, as above, has
history of diastolic CHF, which was felt to be compensated. She
was continued on home Lasix as above in addition to ASA,
carvedilol, lisinopril, and pravastatin.
# Hypertension: The patient was continued on her home regimen of
lisinopril, carvedilol, and hydralazine with blood pressures
well controlled at time of discharge.
# Chronic Pain: The patient has chronic hip and back pain and
was managed on home gabapentin and PRN Tylenol during this
admission.
# Type 2 Diabetes Mellitus, Insulin Dependent: The patient was
initially managed on lantus 80u qHS with sliding scale in place.
She was also on a diabetic diet. On discharge, she was
instructed to transition back to her home insulin regimen of
lantus and prandial insulin without sliding scale.
# Insomnia: The patient was managed on Trazodone and Seroquel
for sleep during this admission.
Transitional Issues:
- Patient discharged on 60 mg prednisone for 5 day course (last
dose ___
- Would recommend outpatient sleep study to assess for
Obstructive Sleep Apnea
- CODE STATUS: FULL CODE confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Lisinopril 40 mg PO DAILY
4. QUEtiapine Fumarate 25 mg PO QHS
5. Pravastatin 40 mg PO QPM
6. HydrALAzine 25 mg PO Q8H
7. Furosemide 40 mg PO BID
8. Carvedilol 25 mg PO BID
9. Montelukast 10 mg PO DAILY
10. Docusate Sodium 100 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
13. Lantus (insulin glargine) 100 unit/mL subcutaneous unknown
14. Tiotropium Bromide 1 CAP IH DAILY
15. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Furosemide 40 mg PO BID
4. Docusate Sodium 100 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Gabapentin 600 mg PO TID
7. HydrALAzine 25 mg PO Q8H
8. Lisinopril 40 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Pravastatin 40 mg PO QPM
11. QUEtiapine Fumarate 25 mg PO QHS
12. TraZODone 50 mg PO QHS:PRN insomnia
13. Tiotropium Bromide 1 CAP IH DAILY
14. PredniSONE 60 mg PO DAILY Duration: 1 Day
Last dose on ___
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
15. Glargine 40 Units Breakfast
Glargine 90 Units Bedtime
Novolog 45 Units Breakfast
Novolog 45 Units Lunch
Novolog 45 Units DinnerMax Dose Override Reason: Home dose
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnosis/es:
-Acute Asthma Exacerbation
-Viral Upper Respiratory Tract Infection
Secondary Diagnosis/es:
-Chronic Diastolic Congestive Heart Failure, Compensated
-Diabetes Mellitus, Type 2
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___
because you were having difficulty breathing. Your trouble
breathing was likely due worsening of asthma triggered by a
viral infection. We treated you with steroids and nebulizers and
your breathing improved. You will complete your course of
steroids at home (last dose on ___ to help control your
asthma.
Please take note of the changes in your home medications and
follow up with your outpatient doctors as detailed in the rest
of your discharge paperwork.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10612563-DS-17 | 10,612,563 | 26,891,950 | DS | 17 | 2161-11-12 00:00:00 | 2161-11-12 15:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP w/biliary stent placement
Percutaneous chole drain placement
History of Present Illness:
___ year old male with h/o ___, diabetes, and chronic
pancreatitis (possibly from alcohol but unclear) since ___
presents as transfer from ___ with acute on chronic
pancreatitis and biliary involvement with acute cholecystitis.
The patient states that for the last four days he has had
increasing epigastric pain and has been unable to take PO food
or medications. He has been dry heaving and nauseated. The pain
currently is ___ and is across the epigastrium/RUQ. He has been
having chills at home, has not checked his temperature for
fevers. There is no diarrhea, last BM this morning small amount
but normal. He denies urinary symptoms, headache, chest pain,
dyspnea except when in severe pain. He has not had a drink for
at least 6 months. Labs at ___ showed WBC 21K, sodium
126, creatinine 0.9.
He was recently seen by Dr. ___ who scheduled MRCP for
___ and follow-up in late ___ but the patient could
not wait until then since the pain is worsening.
In the ED, initial vitals were 98.3 102 135/85 16 95% RA. Exam
showed mild RUQ tenderness to palpation, epigastric and LUQ
tenderness to palpation, no distention, abdomen soft. Labs
showed WBC 15.9K, hemoglobin 10.6, INR 1.4, ALT 128, AST 122, AP
1652, Tbili 3.3, albumin 2.5. Sodium was 129, potassium 3.6.
Urine tox testing was positive for opiates. Lactate was 1.1.
He received 2 liters NS, 0.5 mg IV hydromorphone, 4.5 grams IV
piperacillin-tazobactam. Blood and urine cultures were sent.
UA was unremarkable. Surgery was consulted and did not see any
need for emergent surgical intervention.
Currently, the patient reports ___ abdominal pain, no nausea
or vomiting, no fevers or chills.
Review of systems:
10 pt ROS negative other than noted
Past Medical History:
Diabetes mellitus type 2
Alcohol abuse
___ disease
Chronic pancreatitis
Diverticulitis
Gastrointestinal bleeding
Social History:
___
Family History:
Does not know family
Physical Exam:
ADMISSION EXAM:
Vitals: 98.0PO 119/87 102 18 955 on 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 anicteric, OP
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, moderately tender in epigastrium, non-distended, +
bowel sounds. Negative ___ sign.
EXTR: No lower leg edema
DERM: No active rash
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 06:45PM BLOOD WBC-15.9* RBC-3.48* Hgb-10.6* Hct-30.7*
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.5 RDWSD-43.1 Plt ___
___ 06:45PM BLOOD Neuts-77.9* Lymphs-8.4* Monos-12.7
Eos-0.3* Baso-0.1 Im ___ AbsNeut-12.35* AbsLymp-1.34
AbsMono-2.01* AbsEos-0.04 AbsBaso-0.02
___ 06:45PM BLOOD ___ PTT-30.5 ___
___ 06:45PM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-129*
K-6.3* Cl-91* HCO3-24 AnGap-20
___ 06:45PM BLOOD ALT-128* AST-122* AlkPhos-1652*
TotBili-3.3*
___ 06:45PM BLOOD Lipase-24
___ 06:45PM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD Albumin-2.5*
___ 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:56PM BLOOD Lactate-1.1 K-3.6
___ 06:41PM URINE Color-DkAmb Appear-Clear Sp ___
___ 06:41PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-MOD Urobiln-8* pH-6.5 Leuks-NEG
___ 06:41PM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 06:41PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
IMAGING
-------
RUQ US ___ucts are abnormally dilated. There is intrahepatic
biliary
ductal dilatation. There is distention of the gallbladder with
edematous wall thickening. These findings are concerning for
acute
cholecystitis and obstruction of the common bile duct. Further
evaluation with MRCP is recommended.
CT abd/pelvis ___
1. The gallbladder is distended and there is new thickening of
the
gallbladder wall and pericholecystic fluid consistent with
cholecystitis or involvement with pancreatitis. Associated
intrahepatic biliary dilatation has increased slightly compared
to
___.
2. The complex multiloculated fluid collection in the posterior
left
flank has increased in size consistent with pseudocyst or
abscess.
3. Persistent peripancreatic inflammatory stranding consistent
with
chronic and acute pancreatitis with possible involvement of
adjacent
stomach and splenic flexure of the colon.
ERCP ___
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
A single tight stricture that was seen at the lower third of
the common bile duct. There was dilation of the CBD.
The left and right hepatic ducts and all intrahepatic branches
were normal.
A biliary sphincterotomy was made with a sphincterotome. There
was no post-sphincterotomy bleeding.
Due to an unstable postion, no brushings were obtained.
A ___ X 7 cm ___ biliary stent was placed
successfully using a OASIS stent introducer kit.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
MRCP ___
1. Acute cholecystitis, manifested as marked mural thickening
and edema of the gallbladder, with perforation of the fundus.
2. Necrosis of the pancreatic head and neck with multiple
rim-enhancing fluid collections in the region of the pancreatic
head and porta hepatis, the largest measuring 4.7 x 2.3 cm in
greatest axial dimension, compatible with walled-off necrosis.
Occlusion of the right hepatic artery by the dominant
fluid collection with distal reconstitution and associated
perfusional change of the right hepatic lobe.
3. Additional small areas of walled-off necrosis in the region
of the
esophageal hiatus.
4. Multiloculated, rim-enhancing fluid collection in the left
flank deep to the posterolateral abdominal wall, with extension
toward the pancreatic tail, difficult to accurately measure
secondary to the irregular shape but
approximately 7.7 x 2.5 x 9.3 cm, also compatible with
walled-off necrosis.
5. Moderate central intrahepatic and extrahepatic biliary ductal
dilatation. Stent within the common bile duct.
Brief Hospital Course:
___ year old male with h/o ___, diabetes, and chronic
pancreatitis (possibly from alcohol but unclear) since ___
presented to ___ with epigastric pain and poor PO
intake; he was found on imaging to have cholecystitis with
biliary leak, bile duct obstruction, and acute-on-chronic
pancreatitis. Transferred to ___.
# Cholecystitis c/b biliary leak
# CBD obstruction
# Acute on chronic pancreatitis: ___ underwent ERCP with removal
of CBD stones and biliary stent placement. MRCP showed biliary
leak, ___ surgery recommended percutaneous
cholecystostomy tube and defer cholecystectomy for now.
Percutaneous cholecystostomy tube was placed without
complication. He was continued on cipro/flagyl x7 days. Pt will
follow up with GI to consider surgery referral and CCY when
appropriate.
MRCP also showed significant pseudocysts and necrosis of the
pancreas, but not more than 50% necrosis per discussion with
radiology. He was treated with IVF and pain meds and diet was
advanced as tolerated. He will be discharged with ___ following.
Billing: Greater than 30 minutes spent on discharge counseling
and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO QID
2. FLUoxetine 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. rotigotine 4 mg/24 hour transdermal DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
12 hours Disp #*8 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every ___
hours Disp #*15 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*12 Tablet Refills:*0
4. Carbidopa-Levodopa (___) 1 TAB PO QID
5. FLUoxetine 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. rotigotine 4 mg/24 hour transdermal DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis w/ biliary leak
Bile duct obstruction
Pancreatitis, acute on chronic
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with an obstruction of your bile ducts and
inflammation of your gallbladder and pancreas. The gallbladder
was so inflamed that it developed a perforation. You had a
drain placed to drain your gallbladder as it was felt that
surgery would not be safe at this time.
You will have a repeat MRI in a few weeks and follow-up with Dr.
___ to discuss when surgery may be appropriate for your
gallbladder.
___ 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).
-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 bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you while
in
the hospital and at home on an every-other day basis as they
can.
-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.
-Change the dressing daily. Cleanse skin with ___ strength
hydrogen peroxide. Rinse with saline moistened q-tip. Apply a
DSD.
-Catheter Flushing: Do not flush catheter. Can flush 5 cc saline
into bag as needed to clear line.
-Catheter Security: Every shift check the patency of tube and
that the tube and drainage bag are secured to the patient.
For questions regarding care of catheter call: in-patient
___ out-patient call ___.
Troubleshooting: If catheter stops draining suddenly:
1) Check that the stopcock is open.
2) Remove dressing carefully and inspect to make sure that there
is no kink in the catheter.
3) inspect to be sure that there is no debris blocking the
catheter. If there is, then firmly flush 5 cc of sterile saline
into the catheter.
- If you develop worsening abdominal pain, fevers or chills
please call your surgeon or Interventional Radiology at ___ at
___ and page ___.
Followup Instructions:
___
|
10613271-DS-21 | 10,613,271 | 22,255,734 | DS | 21 | 2125-07-29 00:00:00 | 2125-07-31 15:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, diarrhea, hematochezia
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
___ year old male w/no significant PMH who presents for 3 weeks
of diarrhea and bloody stools. He endorses a baseline stool of
___ and now is stooling large, loose stools with mucus and
blood approximately ___ daily for the last 3 weeks. He has had
red clot and blood streaked stool but no melena. He has not
traveled recently, only has eaten sushi in terms of
raw/undercooked foods. He is not aware of a family history of
IBD or autoimmune disease. He has cut lactose out of his diet
w/out effect. He thinks he may have hemorrhoids. He has been
having gradually worsening crampy abdominal pain that is
exacerbated by eating and has not been able to tolerate PO for
the last 24h. He describes it as sharp pain that occurs all over
the abdomen 5 minutes after eating, which is not immediately
resolved with defecation, as he has had tenesmus, but is unable
to pass stool at times. He had a scheduled GI appointment as an
outpatient but couldn't wait. He presented today for worsening
pain to ___. He endorses chills, denies fevers. + NS. He
endorses nausea, denies vomiting. He does note some pain when
hitting a pothole while driving.
In the ED, initial vitals were: 97.9 64 122/74 16 99%
- Labs were significant for Lipase 120, Lactate 1.2. AP140.
- Imaging revealed panproctocolitis.
- The patient was given IVF and zofran.
Vitals prior to transfer were: 98.0 62 127/78 16 100% RA
Upon arrival to the floor, patient notes pain is much better
(___) since not eating. Notes the zofran given to him in the ED
helped with nausea, as well as some of the gas discomfort.
REVIEW OF SYSTEMS:
(+) Per HPI. otherwise negative.
Past Medical History:
History of exercise-induced asthma
Social History:
___
Family History:
Negative for inflammatory bowel disease. Diabetes mellitus in
maternal grandmother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tmax 98.8 Tc 98.8 HR ___ BP 106/56-116/65 RR ___
SpO2 100% RA
General: Well-appearing in NAD
SKIN: Warm and well perfused, no lesions or rashes
HEENT: Sclera clear, moist mucus membranes, no oropharynx
lesions or ulcers
NECK: No jugular venous distension, supple
Heart: Regular rate and rhythm, no murmurs or rubs
Lungs: Clear to auscultation bilaterally, no ronchi, rales, or
wheezes
Abdomen: Soft, tenderness to palpation diffusely. Slight rebound
tenderness.
Genitourinary: No foley
Extremities: No cyanosis, clubbing, or edema
Neurological: Moving all extermities, grossly within normal
limits
DISCHARGE PHYSICAL EXAM:
VS: 97.7, afebrile overnight BP 116/61 HR 58 RR 20, O2 98% on RA
GENERAL: No acute distress
SKIN: Warm and well perfused, no lesions or rashes
HEENT: Anicteric sclerae, pink conjunctivae. MMM
NECK: Nontender supple neck
CARDIAC: Regular rate and rhythm, normal S1/S2; no murmurs,
gallops, or rubs
LUNG: Breathing comfortably without use of accessory muscles,
clear to auscultation bilaterally, no wheezes, rales, or rhonchi
ABDOMEN: + Bowel sounds. Soft, nontender, nondistended, no
organomegaly. No rebound or guarding.
EXTREMITIES: No cyanosis, clubbing or edema, 2+ dorsalis pedis
pulses bilaterally
NEURO: Alert and appropriate, normal gait
Pertinent Results:
ADMISSION LABS:
___ 03:22PM BLOOD WBC-9.9 RBC-5.89 Hgb-15.5 Hct-47.1
MCV-80* MCH-26.3* MCHC-32.8 RDW-14.8 Plt ___
___ 03:22PM BLOOD Neuts-69.4 ___ Monos-7.0 Eos-4.5*
Baso-0.2
___ 03:22PM BLOOD Glucose-79 UreaN-13 Creat-1.0 Na-140
K-4.2 Cl-102 HCO3-29 AnGap-13
___ 03:22PM BLOOD ALT-33 AST-26 AlkPhos-140* TotBili-1.2
___ 03:22PM BLOOD Lipase-120*
___ 03:22PM BLOOD Albumin-4.2 Iron-45
___ 03:22PM BLOOD calTIBC-303 Ferritn-123 TRF-233
___ 03:27PM BLOOD Lactate-1.2
___ 03:22PM BLOOD CRP-3.0
___ 07:25AM BLOOD CRP-5.1*
___ 03:44PM BLOOD SED RATE-17
___ 07:25AM BLOOD SED RATE-6
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 09:00AM BLOOD HCV Ab-NEGATIVE
___ 09:00AM QUANTIFERON(R)-TB GOLD-NEGATIVE
___ 02:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:45PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:45PM URINE MUCOUS-MANY
DISCHARGE LABS:
___ 07:00AM BLOOD CRP-7.1*
___ 07:25AM BLOOD WBC-8.4 RBC-5.29 Hgb-14.3 Hct-41.2
MCV-78* MCH-27.0 MCHC-34.7 RDW-14.0 Plt ___
___ 09:00AM BLOOD Na-139 K-4.1 Cl-103
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
MICROBIOLOGY:
___ OVA + PARASITES (Final ___: NO OVA AND PARASITES
SEEN. MANY POLYMORPHONUCLEAR LEUKOCYTES. FEW RBC'S.
___
- 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.
- OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN.
- FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND.
- FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
- FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI
0157:H7 FOUND.
IMAGING/STUDIES:
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
Proctocolitis, with wall thickening involving the entire ___,
most pronounced in the cecum and ascending ___, findings which
are likely infectious or inflammatory in etiology. No small
bowel involvement.
___ Sigmoidoscopy
Impression:
Ulceration, granularity, friability, erythema, congestion and
abnormal vascularity in the rectum, sigmoid, and descending
___ compatible with moderate-severe colitis. Otherwise normal
sigmoidoscopy to distal descending ___.
___ Sigmoidoscopy
PATHOLOGIC DIAGNOSIS:
___, mucosal biopsy (sigmoidoscopy): Chronic moderately active
colitis. No granulomata or dysplasia identified.
Brief Hospital Course:
___ year-old male with no significant past medical history who
presents with abdominal pain, hematochezia, and diarrhea, found
to have moderate to severe ulcerative colitis.
# New-onset, moderate to severe ulcerative colitis:
Patient presented with abdominal pain, hematochezia, and
diarrhea. He was also unable to eat during the day prior to
admission, but began eating on his first day in-hospital.
During this admission, he remained afebrile and without
peritoneal signs on abdominal exam. CT abdomen and pelvis
showed proctocolitis without small bowel involvement.
Sigmoidoscopy showed diffuse colitis involving the rectum with
continuous involvement proximally, consistent with ulcerative
colitis. Sigmoidoscopy biopsy showed moderately active colitis
without granulomas or dysplasia. Infectious work-up was
negative for C. difficile, salmonella, shigella, campylobacter,
vibrio, yersinia, E. Coli O157:H7, and ova and parasites. Given
these findings, he was diagnosed with moderate to severe
ulcerative colitis. He received five days of IV
methylprednisolone, and then was transitioned to oral prednisone
his day of discharge. On discharge, the patient's bloody
diarrhea slowed down, had minimal abdominal pain, and was
tolerating PO intake without difficulty.
TRANSITIONAL ISSUES:
[]CODE STATUS: Full
[]Patient will be discharged with Prednisone 40 mg orally once
daily, will take until ___ when patient has GI
followup. At this follow-up appointment, his At___ doctor
___ determine prednisone taper and transition to Asacol.
[]Patient discharged on Calcium/Vitamin D supplementation
[]Patient will have PCP and GI followup
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Calcium Carbonate 500 mg PO TID W/MEALS
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth TID W/MEALS Disp #*90 Tablet Refills:*0
2. PredniSONE 40 mg PO ONCE Duration: 1 Dose
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
3. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half)
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Ulcerative colitis
Secondary diagnosis:
History of exercise-induced asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. You were admitted for
abdominal pain, diarrhea, and blood in your stool. We did a CT
scan of your abdomen, a sigmoidoscopy, and tests for infection.
Based on these tests, and the recommendations of our
gastroenterology doctors, we found that you have moderate to
severe ulcerative colitis. We also did tests that showed that
you do not have a gastrointestinal infection. We gave you
steroids IV then switched you to take steroids as a pill. We
also monitored your symptoms, and had a nutritionist talk with
you about nutritional tips for people with ulcerative colitis.
Please take your medications as instructed, including prednisone
40 mg orally once daily- this will be the dose until you see
your GI doctors on ___. Please also take a calcium and
vitamin D supplement while you are taking prednisone, because
prednisone can lower your calcium levels. Please follow up with
your scheduled primary care and gastroenterology appointments
(see below). Please seek medical attention urgently if you
develop any concerning symptoms, including bloody stool, severe
abdominal pain, or fever.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10613328-DS-10 | 10,613,328 | 20,288,527 | DS | 10 | 2131-08-18 00:00:00 | 2131-08-20 20:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Morphine / Vicodin / Mercaptopurine / Minocycline /
Minocycline / peanut / egg / coconut / milk / Corn
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o eosinophilic gastroenteritis, hidradenitis
suppurativa, psoriasis presents to ED with sharp pleuritic
right-sided chest and back pain x few days. Pain worsened by
deep breathing and lying down. No history of similar pain. Also
endorses diarrhea for a few days but has chronic loose stools as
well. Denies shortness of breath, vomiting, fevers, cough,
abdominal pain, leg pain, recent travel, personal or family
history of blood clots (mother diagnosed with PE but diagnosis
was later refuted), or recent surgery. No recent dental work or
IV drug use.
In the ED, initial vital signs were 98.7 87 120/62 16 99%. CBC
notable for WBC 15.8 (65% polys), H/H 12.5/38.0, Plt 797. BMP
unremarkable. Bedside ultrasound showed good cardiac squeeze
with no pericardial fluid. CXR notable for atelectasis of the
right lower lobe accompanied by a small right pleural effusion.
CTA with contrast showed no PE or acute aortic pathology, but
did show multiple peripheral right-sided wedge-shaped opacities
mostly in RLL with with denser linear areas of consolidation,
right hilar lymphadenopathy, non-loculated, non-hemorrhagic
small
right pleural effusion, and a small number of sharply demarcated
nodules 4-5 mm in diameter in RLL possibly representing enlarged
pulmonary lymph nodes. He was given IV levofloxacin 750mg, PO
azithromycin 500mg, and PO ibuprofen 600mg. Transfer vital
signs were 98.2 75 116/65 16 99%. 3 sets BCx pending.
On the floor, patient reports improvement in pain after
ibuprofen. He denies shortness of breath, cough, fever, chills.
Other that the chest pain, he feels quite well.
Past Medical History:
eosinophilic gastroenteritis, hidradenitis suppurativa,
psoriasis, depression, bulimia, childhood asthma
Social History:
___
Family History:
Parents are both healthy. Maternal grandparents have heart
disease. No family history of clotting disorders or recurrent
miscarriages. Otherwise non-contributory.
Physical Exam:
Admission:
Vitals- 98, 130/73, 79, 20, 98% RA
General: Well appearing young man in NAD
HEENT: Sclera anicteric, MMM, no oropharyngeal lesions, fair
dentition without visible dental abscesses
Cardiac: RRR, normal S1 and S2, no murmurs or rubs
Lungs: Decreased breath sounds with crackles over right lung
base, otherwise clear
Abdomen: Soft, nontender, nondistended, normoactive bowel
sounds, no hepatosplenomegaly
Extremities: No edema, 2+ DP pulses
Skin: Macular rash covering face, chest, arms and legs.
Erythematous/silvery plaques in groin area
Psych: Poor eye contact, quiet speech, full affect
Discharge:
Pertinent Results:
Admission:
___ 05:05AM BLOOD WBC-15.8* RBC-3.98* Hgb-12.5* Hct-38.0*
MCV-96 MCH-31.4 MCHC-32.9 RDW-12.7 Plt ___
___ 05:05AM BLOOD Neuts-64.8 Lymphs-14.4* Monos-9.1
Eos-10.4* Baso-1.3
___ 05:05AM BLOOD Glucose-81 UreaN-12 Creat-0.7 Na-141
K-4.2 Cl-103 HCO3-28 AnGap-14
___ 05:05AM BLOOD ALT-16 AST-20 CK(CPK)-44* AlkPhos-47
TotBili-0.2
___ 05:05AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:40AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.5*
Microbiology:
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Imaging:
___ Chest Xray:
Atelectasis of the right lower lobe accompanied by a small right
pleural
effusion. Given the unusual nature of the presentation, if
there is further
clinical concern, more definitive evaluation could be considered
with CT.
___ CTA Chest:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Peripheral right pulmonary opacities as described above.
This appearance can be seen in both atypical, multifocal
pneumonia, and pulmonary vasculitis. Septic emboli, which can
also present similarly, is less likely given the unilateral lung
involvement and the lack of rapid cavitation.
3. Given the patient's history of eosinophilic enterocolitis, a
unifying
diagnosis of eosinophilic granulomatosis with polyangiitis
___
syndrome) should be considered.
4. Minimally dilated loops of bowel seen only on the scout film.
If there is clinical concern for acute abdominal process,
consider further evaluation with abdominal radiograph.
___
CXR
There is moderate right-sided pleural effusion has increased
compared to the
study from 2 days prior. There is associated volume loss and
infiltrate in
the right lower lobe. There is mild pulmonary vascular
redistribution. The
left lung is relatively clear.
IMPRESSION:
Compared to prior study the effusion, infiltrate, and volume
loss in the right
are increased.
ECHO ___
The left atrial volume is mildly increased. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
Bronchoscopy ___
Biopsies pending
BAL pending
Ruled out for TB with three negative sputum for AFB ___.
___ 06:58AM BLOOD WBC-14.5* RBC-4.36* Hgb-13.7* Hct-41.0
MCV-94 MCH-31.4 MCHC-33.4 RDW-12.2 Plt ___
___ 07:29AM BLOOD HIV Ab-NEGATIVE
___ 07:40AM BLOOD ANCA-NEGATIVE B
___ 07:40AM BLOOD B-GLUCAN- Negative
___ 07:40AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-Negative
___ 08:34AM BLOOD QUANTIFERON-TB GOLD- Intermediate
___ Lung biopsy
Lung, right lower lobe, transbronchial biopsies (A):
Multiple fragments of alveolated lung parenchyma and airway
tissue with atelectasis and blood in the alveolar spaces (likely
procedural).
There is no evidence of malignancy, granulomas, or significant
acute or chronic inflammation.
Gram, GMS, and AFB stains are negative for microorganisms.
Brief Hospital Course:
___ with h/o eosinophilic gastroenteritis, hidradenitis
suppurativa, psoriasis presents to ED with sharp pleuritic
right-sided chest and back pain x few days.
Active Issues:
# Chest pain: CTA negative for PE but showed multiple right lung
nodules and small right pleural effision. Differential diagnosis
includes multifocal atypical pneumonia vs. vascultitis. Septic
emboli are less likely because there is no cavitation and the
unilateral involvement would be unusual, also no risk factors.
Vasculitis such as ___ or Wegener's should be
considered in setting of patients history of eosinophilia and
atopic history. No clinical symptoms of pneumonia other than
leukocytosis which is mildly elevated compared to patient's
baseline. Urine legionella neg. Cardiac enzymes neg. Patient was
empirically treated for pneumonia with 7 days of levofloxacin.
Rheumatology was consulted who recommended checking ANCA but
felt that Churg ___ and ___ vasculitides were less likely
given no vasculitic skin rash, no palpable purpura, hemoptysis,
frequent sinusitis, asthma, and has unremarkable kidney
function. Pulmonology was consulted who recommended TTE, fungal
serologies, tox screen, HIV, and TB rule out. TTE, HIV, and
fungal studies negative, ruled out for TB with sputum for AFBx3,
but quant gold result intermediate. Patient had 60cc diagnostic
tap that was culture negative exudative. Bronchoscopty ___ of
RLL advanced to the pleural revealed vascular airways with
multiple biopsies and BAL. Biopsies showed normal tissue with no
organisms. The patient was clinically stable, with a persistent
leukocytosis and thrombocytosis, satting well on room air,
afebrile, and was discharged home
Inactive Issues
# Eosinophilic Gastroeneteritis: Patient reports baseline stool
frequency and consistency. No abdominal pain or nausea
currently. Continue budesonide 9mg daily
# Psoriasis: Primary groin involvement. Continue triamcinolone
ointment and hydroxyzine for itch
# Depression: Continue duloxetine
Transitional Issues:
-Patient will need follow up CT scan in the future to assess for
resolution/improvement of pulmonary nodules and pleural
effusion. There is significant pending culture data and biopsies
from his bronchoscopy on discharge, and close follow-up was
arranged in HCA and with the interventional pulmonary team. We
suspect an etiology is forthcoming, and the patient and his
mother are aware of the need for close follow-up.
# Code: Full (discussed with patient)
# Emergency Contact: Mom ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine *NF* 10 mg Oral daily
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. benzoyl peroxide *NF* 5 % Topical QAM
4. Budesonide 9 mg PO DAILY
5. Calcipotriene 0.005% Cream 1 Appl TP BID
mix with iodoquinol cream
6. HydrOXYzine 10 mg PO QHS:PRN itch
take ___ tabs at bedtime as needed for itch
7. lactobacillus acidophilus *NF* 1 mg Oral BID
take 2 capsules twice daily
8. Ondansetron 8 mg PO BID:PRN nausea
9. selenium sulfide *NF* 2.5 % Topical 3 times per week
wash affected area 3 times per week and rinse after 5 minutes
for rash
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
___ tablets
11. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY
OTHER DAY
apply to groin area
12. Duloxetine 60 mg PO DAILY
13. Humira *NF* (adalimumab) 40 mg/0.8 mL Subcutaneous monthly
40mg SC monthly
Discharge Medications:
1. Budesonide 9 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. HydrOXYzine 10 mg PO QHS:PRN itch
4. Ondansetron 8 mg PO BID:PRN nausea
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY OTHER
DAY
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
8. benzoyl peroxide *NF* 5 % Topical QAM
9. Calcipotriene 0.005% Cream 1 Appl TP BID
10. Cetirizine *NF* 10 mg Oral daily
11. Humira *NF* (adalimumab) 40 mg/0.8 mL Subcutaneous monthly
12. lactobacillus acidophilus *NF* 1 mg Oral BID
13. selenium sulfide *NF* 2.5 % Topical 3 times per week
14. Levofloxacin 750 mg PO DAILY Duration: 1 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chest pain
Pulmonary nodules
Secondary:
Eosinophilic gastroenteritis
Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___, you were admitted
with chest pain and found to have nodules on your CT scan that
was concerning for an atypical infection versus a vasculitits.
Rheumatology and Pulmonology were consulted and your lungs were
inspected with a scope. There was no obvious cause identified
for your fluid collection, and some tissue samples were obtained
for testing.
If you are having difficulty breathing, fever, or pain, it is
important to come to the emergency room immediately. It is
important to complete your course of levofloxacin, last dose is
tomorrow. Finally, it is important to make your followup visits
as scheduled below.
Followup Instructions:
___
|
10613328-DS-11 | 10,613,328 | 29,354,992 | DS | 11 | 2131-08-31 00:00:00 | 2131-09-02 08:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Morphine / Vicodin / Mercaptopurine / Minocycline /
Minocycline / peanut / egg / coconut / milk / Corn
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Video assisted thoracic surgery
History of Present Illness:
Mr. ___ is a ___ gentleman with eosinophilic
gastroenteritis on budesonide and psoriasis recently on Humira
(last injection one month ago), who was admitted to ___
___ with right-sided pleuritic chest and back pain and was
found to have a small right-sided pleural effusion and multiple
peripheral right lung opacities on imaging, read as concerining
for atypical pneumonia vs. vasculitis vs. less likely septic
emboli. At presentation he had leukocytosis to 15.8 (64.8% PMNs,
10.4% eos), but was afebrile and without shortness of breath or
chills. He was treated for possible community-aquired pneumonia
with levofloxacin x7 days.
He underwent diagnostic thoracentesis on ___ which yielded
14,750 WBCs (60% PMNs), and 1,400 RBCs, total protein 4.8,
glucose 105, LDH 187, pH 7.42. Negative extensive infectious
work-up.
On ___, he underwent bronchoscopy with BAL and multiple
biopsies, which showed 1+ PMNs, no AFB, negative infectious
work-up. Pathology yielded negative Gram, GMS, and AFB stains.
Cytology showed numerous neutrophils and macrophages but no
eosinophils. He was discharged on ___ with persistent
leukocytosis but no fevers or oxygen requirement.
In clinic on ___, he was again found to have a right pleural
effusion and desaturated with ambulation to the low ___ so was
sent to the ED. In the ED, he was again afebrile and without
respiratory complaints. WBC was 19.1 with 79% PMNs and 3.6% eos.
Thoracentesis for 800cc by IP revealed serous fluid with thin
loculations, 300 WBCs (14% PMNs, 59% lymphs), 220 RBCs, with
total protein 5, glucose 80, LDH 242, pH 7.36. The effusion
reaccumulated while he was in the ED, and he was admitted for
surgical consultation. He was started on linezolid and cefepime
for possible empyema. On ___, he underwent VATS for trapped
lung. Per the operative report, 50 mL of thin, serous fluid were
drained, and the entire right lung was adherent to the chest
wall, diaphragm, and mediastinum. Gram stain and cultures were
again negative.
Today, the patient reports that his pain is well-controlled and
denies subjective fever, sweats, chills, shortness of breath, or
cough. Denies any new skin rash (few psoriatic lesion on medial
aspect of thighs), changes in vision, Sicca like symptoms
(minimal dryness in his mouth), denies oral ulceration. Denies
any GI symptoms, no Joint pain, muscle pain or neurological
weakness or sensory deficits.
ROS:
Denies fevers, chills, night sweats, unintended weight loss,
anorexia, fatigue, malaise, headache, paresthesias, focal
weakness, rash, recent URI, dry eyes, abdominal pain, nausea,
vomiting, GERD, diarrhea, constipation, dysuria, urogenital
complaints. Denies alopecia, photosensitivity, mucosal
ulcerations, and Raynauds symptoms, history of seizures or
blood clots in lungs or legs. Denies ocular inflammation,
sausage digits, nail changes, urethritis, low back pain,
personal or family history of soriasis or inflammatory bowel
disease.
Denies scalp tenderness, visual changes, jaw claudication, dry
cough, and upper extremity claudication.
Past Medical History:
eosinophilic gastroenteritis, hidradenitis suppurativa,
psoriasis, depression, bulimia, childhood asthma
Social History:
___
Family History:
Parents are both healthy. Maternal grandparents have heart
disease. No family history of clotting disorders or recurrent
miscarriages. Otherwise non-contributory.
Physical Exam:
Vitals: 98.1 68 121/68 14 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: BS decreased at right base
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Small, erythemetous macules covering face and body. Do not
appear infected.
DISCHARGE EXAM:
Resp Rate 16, O2 saturation 98-100%RA, ambulatory saturation
96-100%RA
CHEST: Chest tube incision sites clean, dry, intact x2, breath
sounds audible with crackles in right lower lobe, no crepitus,
otherwise clear breath sounds throughout upper lobe and entire
right lung.
Heart: RRR, no murmurs
Abd: Soft, nontender
Pertinent Results:
___ 01:06PM BLOOD WBC-19.1* RBC-3.85* Hgb-11.8* Hct-36.8*
MCV-96 MCH-30.7 MCHC-32.1 RDW-12.6 Plt ___
___ 05:30PM BLOOD WBC-16.7* RBC-3.69* Hgb-11.4* Hct-34.6*
MCV-94 MCH-30.8 MCHC-32.9 RDW-12.2 Plt ___
___ 05:10AM BLOOD WBC-14.1* RBC-3.73* Hgb-11.7* Hct-35.0*
MCV-94 MCH-31.4 MCHC-33.6 RDW-12.2 Plt ___
___ 06:35AM BLOOD ___-16.2* RBC-3.83* Hgb-12.1* Hct-36.0*
MCV-94 MCH-31.5 MCHC-33.5 RDW-12.3 Plt ___
___ 07:00PM BLOOD WBC-18.1* RBC-4.06* Hgb-12.9* Hct-37.7*
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.3 Plt ___
___ 06:50AM BLOOD WBC-23.3*# RBC-4.05* Hgb-12.6* Hct-37.9*
MCV-94 MCH-31.0 MCHC-33.1 RDW-12.1 Plt ___
___ 05:35AM BLOOD WBC-12.9* RBC-3.63* Hgb-11.4* Hct-34.0*
MCV-94 MCH-31.5 MCHC-33.6 RDW-12.6 Plt ___
___ 09:20AM BLOOD WBC-15.3* RBC-3.63* Hgb-11.4* Hct-33.5*
MCV-92 MCH-31.3 MCHC-33.9 RDW-12.8 Plt ___
___ 07:20AM BLOOD WBC-11.5* RBC-3.56* Hgb-11.1* Hct-32.7*
MCV-92 MCH-31.3 MCHC-34.1 RDW-13.0 Plt ___
___ 06:40AM BLOOD ESR-83*
___ 05:30PM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
___ 07:20AM BLOOD Glucose-73 UreaN-10 Na-138 K-4.3 Cl-100
HCO3-27 AnGap-15
___ 09:20AM BLOOD Glucose-68* UreaN-10 Creat-0.6 Na-141
K-3.8 Cl-104 HCO3-30 AnGap-11
___ 06:30AM BLOOD ALT-13 AST-17 AlkPhos-49 TotBili-0.2
___ 05:30PM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8
___ 06:40AM BLOOD CRP-88.4*
___ 06:40AM BLOOD CRP-88.4*
___ 05:43PM BLOOD Lactate-1.1
MICRO:
Serum Histo Antibody IgG/IgM: Pending
Urine Histo Antigen: Pending
Serum Mycoplasma Antibody IgG/IgM: Pending
Pleural Fluid Studies:
___ WBC-300* RBC-220* Polys-14* Lymphs-59* Monos-18*
Macro-9*
___ TotProt-5.0 Glucose-80 Creat-0.6 LD(LDH)-242
TotBili-0.4 Albumin-2.6 Cholest-80 Triglyc-27
___ CD45-DONE Kappa-DONE CD19-DONE Lamba-DONE
___ IPT-DONE
___ UNIVERSAL PCR (BACTERIA, FUNGI, AND AFB)-PND
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 4:15 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 6:40 am SEROLOGY/BLOOD
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
**FINAL REPORT ___
TOXOPLASMA IgG ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.
Many lymphocytes and scattered mesothelial cells.
FLOW CYTOMETRY IMMUNOPHENOTYPING:
The following tests (antibodies) were performed: Kappa, Lambda
and CD antigens: 4,8,19 and 45.
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Due to specimen age, a limited panel is performed.
Gated lymphocytes (CD45-bright, low side-scatter) are ~43% of
total analyzed events, and approximately 26% of analyzed events
are in the cell debris (low CD45, low side-scatter) region.
Of the gated lymphocytes, 8% are CD19-positive B cells which
appear polytypic by surface immunoglobulin light chain staining.
CD4 positive lymphocytes are ~ 63% of lymphoid gated events,
while CD8 positive cells are 18% (CD4 to CD8 ratio 3.6).
Non-specific T cell dominant, CD4-dominant lymphoid profile;
diagnostic immunophenotypic features of involvement by lymphoma
are not seen in specimen, on a limited panel.
Of note, the sample was collected on ___, and received in
the flow cytometry laboratory on ___ hence loss of an
abnormal population due to specimen age cannot be entirely
excluded. Flow cytometry immunophenotyping may not detect all
lymphomas due to topography, sampling or artifacts of sample
preparation. Nonetheless, review of cytospin preparations
prepared on the date of sample collection (submitted for cell
counts) was reviewed; the cellularity consists of macrophages,
and mainly small mature lymphocytes and plasmacytoid forms
lacking significant atypia.
Correlation with clinical findings is recommended.
IMAGING:
CXR ___
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph, three views.
FINDINGS: Compared to prior examination, there has been
moderate improvement of a large right-sided pleural effusion
with adjacent compressive atelectasis. There is no pneumothorax.
The left lung is clear.
IMPRESSION: Moderate improvement of large right pleural
effusion.
CXR ___ status post thoracentesis
There is been slight interval decrease in size of the small to
moderate right pleural effusion. Right basilar opacification
likely reflects atelectasis though infection is not excluded.
No pneumothorax is identified. Subsegmental atelectasis in the
left lung base is present. The cardiac and mediastinal
contours are unchanged.
IMPRESSION:
No pneumothorax. Small to moderate size right pleural effusion
with
persistent right basilar opacification possibly reflecting
atelectasis but infection is not excluded. Left basilar linear
atelectasis.
MRI Abd/Pelvis
COMPARISON: CT chest dated ___.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired
on a 1.5 Tesla magnet including dynamic 3D imaging obtained
prior to, during and after the uneventful intravenous
administration of 7 mL of Gadavist.
Unfortunately, many of the sequences are severely limited by
motion artifact.
ABDOMEN:
The liver is within normal limits. No focal liver lesions. The
portal and hepatic veins are patent. No intra or extrahepatic
duct dilatation. The gallbladder is unremarkable.
The kidneys are within normal limits. No hydronephrosis. The
adrenals and spleen are unremarkable. The pancreas is within
normal limits. Normal caliber pancreatic duct.
There is a large amount of food debris within the stomach.
Bowel gas is
limiting the evaluation of the small and large bowel. However,
the visualized small large bowel is unremarkable. No
retroperitoneal or mesenteric adenopathy.
Note is made of a small loculated right pleural effusion
containing pockets of gas within it (4:9). There is mild
enhancement of the right sided pleura, consistent with the
recent surgery. There is atelectasis within the right lower
lobe. There is subcutaneous edema within the soft tissues of
the right flank, again consistent with the recent surgery (9:8).
There is also a trace left pleural effusion with minor
atelectasis in the left lung base. Bone marrow signal is
normal. No destructive osseous lesions.
PELVIS:
The bladder is within normal limits. There is trace free fluid
within the pelvis. The prostate gland and seminal vesicles have
not been imaged. No pelvic adenopathy. Bone marrow signal is
normal. No destructive osseous lesions.
IMPRESSION:
1. Small loculated right pleural effusion with associated right
lower lobe atelectasis. Trace left pleural effusion.
2. No significant pathology within the abdomen or pelvis.
Brief Hospital Course:
Mr. ___ is a ___ y/o M who was recently hospitalized due to a
large right pleural effusion and is now re-admitted with
ambulatory dyspnea and persistent effusion.
# Pleural Effusion - Etiology unclear. The patient was recently
discharged with stable right pleural effusion after hospital
course without fever or significant respiratory distress.
Therapeutic tap failed due to pain during initial
hospitalization, completed 7 day course of levofloxacin. He was
seen 2 days after discharge and had ambulatory O2 sat 92% so was
readmitted. He underwent therapeutic tap in ER and had trapped
lung physiology. He was started on Linezolid and cefepime and
underwent VATS decortication of right lung with two chest tubes
placed. Pleural fluid cultures were negative. Abx were continued
for 10 days, rheum and ID were reconsulted. ID felt no
infectious agent was responsible given absent fever and negative
studies. They recommended sophisticated workup including CMV
IgG/IgM (neg), crypto antigen (neg), toxo IgG/IgM (neg),
legionella urine Ag (neg), serum/urine histo antibody/antigen
(pending), serum mycoplasma IgG/IgM (pending), universal PCR for
fungi, bacteria, mycobacteria (pending), as well as abd/pelvis
MRI which was negative. Cytology was negative for malignancy or
abnormal clonal population. If any results come back positive ID
will see in followup. Rheumatology felt this was not suggestive
for connective tissue disease or vasculitis. No sicca symptoms,
oral ulcers, vasculitic rash, joint or muscle involvement, lack
of active destructive sinusitis or hemopthysis, no GI bleed or
neurological abnormalities. The only condition that might come
to mind is Eosinophilic Granulomatosis with Polyangiitis
___ Vasculitis), given history of peripheral
eosinophilia (up to 40% in the past and childhood asthma. and
lung involvement. As for the asthma has not been active in many
years and in CSS tend to be severe, active and refractory. As
for eosinophilia, not currently present (however, on oral
steroids). As for the lung involvement: current lung involvement
is very atypical for CSS: large, unilateral effusion leading to
need for decortication, pleural fluid did not have eosinophils
and pathology of lung bx did not reveal vasculitis or eos. They
felt there was no active autoimmune process and will see in
clinic.
# Depression: Psych was consulted for increased withdrawal and
kicking his mother out of the room. It was determined that he
was not a threat to himself and that his prior history of
bulimia was not bulimia nervosa- he was purging food that he
thought was bad for him, not in an effort to lose weight.
Chronic Issues:
# Eosinophilic Gastroeneteritis: Patient reports baseline stool
frequency and consistency. No abdominal pain or nausea
currently. Continued home regimen.
# Hidradinitis: Continue augmentin.
# Psoriasis: Primary groin involvement. Continue triamcinolone
ointment and hydroxyzine for itch.
TRANSITIONAL ISSUES:
# If patient is felt to decompensate, he should be directely
admitted to the ___ medical service, bypassing the ER.
# Follow up Universal PCR, Mycoplasma, Histoplasma studies.
# Patient's PCP aware, will monitor studies and refer to ID if
infectious studies positive.
# Thoracic will followup for chest tube site.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. HydrOXYzine 10 mg PO QHS:PRN itch
4. Ondansetron 8 mg PO BID:PRN nausea
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY OTHER
DAY
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
8. benzoyl peroxide *NF* 5 % Topical QAM
9. Calcipotriene 0.005% Cream 1 Appl TP BID
10. Cetirizine *NF* 10 mg Oral daily
11. Humira *NF* (adalimumab) 40 mg/0.8 mL Subcutaneous monthly
12. lactobacillus acidophilus *NF* 1 mg Oral BID
13. selenium sulfide *NF* 2.5 % Topical 3 times per week
Discharge Medications:
1. benzoyl peroxide *NF* 5 % Topical QAM
2. Budesonide 9 mg PO DAILY
3. Calcipotriene 0.005% Cream 1 Appl TP BID
4. Cetirizine *NF* 10 mg Oral daily
5. Duloxetine 60 mg PO DAILY
6. HydrOXYzine 10 mg PO QHS:PRN itch
7. lactobacillus acidophilus *NF* 1 mg Oral BID
8. Ondansetron 8 mg PO BID:PRN nausea
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth Q6H:PRN Disp #*20 Tablet
Refills:*0
10. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY
OTHER DAY
11. Humira *NF* (adalimumab) 40 mg/0.8 mL Subcutaneous monthly
12. selenium sulfide *NF* 2.5 % Topical 3 times per week
13. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Exudative 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 at ___
___.
You were admitted with a fluid collection in your lung, and you
required surgery to free up the lung so that it could expand. It
is still unclear what caused this, and the workup is still
underway. You will see the rheumatologists to determine if there
is an autoimmune cause. You will also see the thoracic surgeons
to monitor your surgery. You have been protected from infection
with antibiotics.
Followup Instructions:
___
|
10613328-DS-13 | 10,613,328 | 20,443,181 | DS | 13 | 2134-02-16 00:00:00 | 2134-03-11 05:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Morphine / Vicodin / Mercaptopurine / Minocycline /
peanut / egg / coconut / milk / Corn
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
This is a ___ year old M with PMHx of eosinophilic
gastroenteritis, psoriasis, and acne who is presenting with
altered mental status s/p seizure 4 days ago. The patient was in
his usual state of health until approximately 6 pm on ___
___ when he fell to the ground from his bed and had a
witnessed generalized tonic clonic seizure that lasted for
approximately one minute. He was noted to have some mental
slowing post-seizure. He was brought to ___
where he reportedly informed them that he ingested some type of
medication, possible Tylenol Cold and Flu. At ___, he
had a normal head CT and was found to be hypertensive,
tachycardia, and hypoglycemic with FSBG 29. He was admitted to
the ICU where he had q1hour neuro checks and received D5NS with
subsequent normal POC glucose testing (154, 128, 124, 125, 76,
72) and the infusion was discontinued. Tox screen was
non-revealing. Psychiatry saw him and recommended inpatient
psychiatry placement. His parents were upset that he was never
evaluated by neurology so they left AMA and brought him to our
Emergency Department.
He has not had any further seizures. Since he had the seizure,
his mental status has not been at baseline. Per the patient and
his family, his speech has been very slow and at times slurred.
He has some abdominal pain, pruritis, and feels generally weak.
Here, the patient denies ingesting any medications prior to this
episode other than his scheduled Tramadol. The only recent
change in medication was an increase in his Nortryptiline dosing
from 10 mg daily to 20 mg daily one week ago.
In the ED, initial vitals were: 96.8 86 135/88 20 100% RA
- Labs were significant for:
- WBC 14.5 Hgb 13.4 Hct 39.5 Plt 408 (N:81.0 L:8.3 M:6.7 E:3.3
Bas:0.3 ___: 0.4)
- Na 138 K 4.5 Cl 100 CO2 29 BUN 5 Cr 0.8
- Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
- CXR: Minimal patchy right basilar opacity which may reflect
atelectasis though infection is not completely excluded.
- The patient was given: Famotidine 20 mg, DiphenhydrAMINE 50
mg, 1000 mL NS 1000 mL, PO Acetaminophen 1000 mg
Vitals prior to transfer were: 98.0 79 124/73 16 99% RA
Upon arrival to the floor, the patient reports that he feels
very weak and has some abdominal pain. He is in no distress but
his speech is very slow and at times dysarthric.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting,
constipation. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
eosinophilic gastroenteritis, hidradenitis suppurativa,
psoriasis, depression, bulimia, childhood asthma
Social History:
___
Family History:
Mother had 1x seizure in adulthood after receiving an injection.
Parents are both otherwise healthy. Maternal grandparents have
heart disease. No family history of clotting disorders or
recurrent miscarriages. Otherwise non-contributory.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
Vitals: 97.8 127/74 69 16 97% RA
General: Alert but slow to respond, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses
Neuro: CNII-XII intact, ___ strength upper/lower extremities -
generalized weakness, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred.
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: T: 99.1 BP: 110s-150s/70s-80s P: 70s-80s R: 18 O2: 98 RA
General: Alert, oriented, fair eye contact, slow to get words
out
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, attentive, able to do days of week backwards
without any difficulty.
Pertinent Results:
===============
ADMISSION LABS
===============
___ 07:50PM NEUTS-81.0* LYMPHS-8.3* MONOS-6.7 EOS-3.3
BASOS-0.3 IM ___ AbsNeut-11.71* AbsLymp-1.20 AbsMono-0.97*
AbsEos-0.48 AbsBaso-0.04
___ 07:50PM PLT COUNT-408*
___ 07:50PM WBC-14.5* RBC-4.06* HGB-13.4* HCT-39.5*
MCV-97 MCH-33.0* MCHC-33.9 RDW-12.6 RDWSD-45.0
___ 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:50PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-1.8
___ 07:50PM cTropnT-<0.01
___ 07:50PM LIPASE-28
___ 07:50PM ALT(SGPT)-17 AST(SGOT)-28 CK(CPK)-139 ALK
PHOS-57 TOT BILI-0.3
___ 07:50PM GLUCOSE-99 UREA N-5* CREAT-0.8 SODIUM-138
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14
===============
DISCHARGE LABS
===============
___ 12:31AM BLOOD WBC-12.0* RBC-3.62* Hgb-11.8* Hct-34.8*
MCV-96 MCH-32.6* MCHC-33.9 RDW-12.6 RDWSD-44.2 Plt ___
___ 12:31AM BLOOD Glucose-106* UreaN-5* Creat-0.7 Na-141
K-4.0 Cl-105 HCO3-28 AnGap-12
===============
STUDIES
===============
CXR: Minimal patchy right basilar opacity which may reflect
atelectasis though infection is not completely excluded.
EEG
BACKGROUND: Waking background is characterized by a ___ Hz
alpha rhythm, which attenuates symmetrically with eye opening.
Symmetric ___ mcV beta activity is present, maximal over
bilateral frontal regions.
HYPERVENTILATION: Hyperventilation was contraindicated due to
the patient s stated history of recent head injury.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as the
test was
requested as a portable study.
SLEEP: Sleep is not recorded.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm with an average rate of 70 bpm.
IMPRESSION: This is a normal waking EEG. No focal abnormalities
or
epileptiform discharges are present. If clinically indicated,
repeat EEG with sleep recording may provide additional
information.
===============
MICRO
===============
Brief Hospital Course:
___ year old M with PMHx of eosinophilic gastroenteritis,
psoriasis, and acne who is presenting with persistent altered
mental status s/p seizure 4 days ago.
=============
Active Issues
=============
# Toxic metabolic encephalopathy. He presented with some
cognitive slowing and mild dysarthria, which is not his baseline
per his parents. He had a normal NCHCT at OSH. He did not any
focal neurologic deficits on exam. He did not have signs
concerning for meningitis. EEG was done which was normal.
Gabapentin dose was decreased and nortriptyline was discontinued
given concern for lowered seizure threshold (especially with
SSRI) and medication induced cognitive impairment/altered mental
status. Over the course of his hospitalization his speech
cadence increased. His mild cognitive slowing remained but
returned to his baseline per his parents assessment. He was
discharged to home with close neurology follow up as an
outpatient.
# Seizure. s/p first documented seizure 4 days ago, generalized
tonic colonic per clinical description. This was likely due to
hypoglycemia as his glucose was 27 on admission to the OSH.
Infectious work up was negative. Non-con head CT was negative.
He did not display further seizure activity during
hospitalization at ___. EEG was done which was normal.
Nortriptyline was discontinued and gabapentin dose decreased as
above.
# Hypoglycemic episode (blood glucose 27 on presentation to OSH
in setting of seizure). His blood sugars were 80-90s during
hospitalization at ___. Hypoglycemia labs were added to OSH
labs from ___. Insulin, proinsulin, c-peptide,
beta-hydroxybutyrate, and sulfonylurea were pending at the time
of discharge. Exogenous insulin use was largely ruled out as a
cause for initial hypoglycemia given no access to insulin at
home. He will follow up with endocrinology for a complete
hypoglycemia work up after discharge.
# ?Mild Cognitive Impairment. His cognition appeared mildly
depressed (mistake with clock drawing and intense concentration
required to accurately complete serial 7's.) Per review of
outpatient notes and discussion with his PCP, this level of
cognitive delay appears consistent with his baseline.
===============
Chronic Issues
===============
# Eosinophilic gastroenteritis: Followed by ___ GI, Dr. ___.
Last visit on ___, with stable symptoms. He was continued on
9mg of budesonide. Home gabapentin was decreased to (300 mg BID
and 500 mg QHS), noritriptyline was discontinued and tramadol
was continued. Lidocaine patch was added for pain control.
# Psoriasis: Continued on Clobetasol Propionate, Triamcinolone
Acetonide.
# Depression: Continued Fluoxetine 20 mg daily
# Osteoporosis: Continued vitamin D and chlorhexidine mouth
rinse
====================
Transitional Issues
====================
- Please recheck fingerstick glucose at follow up
- Please follow up hypoglycemic labs performed at ___.
___ from ___
-- Insulin, Proinsulin, Cortisol, sulfonylurea (I have asked
that these results be faxed to pt's PCP and endocrinologist).
C-peptide 1.1 ___, Beta-hydroxybutyrate 0.8.
- Neurology follow up as outpatient (appointment scheduled)
- Decreased Gabapentin to 300mg BID, with 500mg qHS
- Stopped noritriptyline and tramadol
- Started lidocaine patch
# CODE STATUS: Full
# CONTACT: ___ (mother) ___ Arty (Father)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Budesonide 9 mg PO DAILY
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
4. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY OTHER
DAY
5. Clindamycin 1% Solution 1 Appl TP BID
6. Mupirocin Ointment 2% 1 Appl TP BID
7. Gabapentin 600 mg PO QHS
8. Gabapentin 500 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. HydrOXYzine 25 mg PO QHS:PRN itching
11. TraMADOL (Ultram) 50 mg PO BID:PRN pain
12. Cetirizine 10 mg PO DAILY
13. Fluoxetine 20 mg PO DAILY
14. Nortriptyline 20 mg PO QHS
15. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Budesonide 9 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
3. Clindamycin 1% Solution 1 Appl TP BID
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
5. Fluoxetine 20 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Gabapentin 500 mg PO QHS
8. HydrOXYzine 25 mg PO QHS:PRN itching
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Mupirocin Ointment 2% 1 Appl TP BID
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY
OTHER DAY
13. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
-------------------
Toxic Metabolic Encephalopathy
Seizure
Hypoglycemia Episode
Eosinophilic gastroenteritis
Psoriasis
Depression
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were hospitalized after suffering
a seizure. Your blood sugar was found to be very low. After the
seizure your speech and thinking were slowed but gradually
improved. You were discharged home with follow up with a
Neurologist as an outpatient.
We wish you the best!
Your ___ Treatment Team
Followup Instructions:
___
|
10613328-DS-16 | 10,613,328 | 26,295,771 | DS | 16 | 2135-02-19 00:00:00 | 2135-02-19 20:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Mercaptopurine / Minocycline / peanut / egg /
coconut / milk / Corn / Tegaderm
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male with a past medical history of
autism,
eosinophilic gastroenteritis, recent hospital stay ___ for
abdominal pain attributed to functional pain vs gastroenteritis,
then hospital stay ___ for new tonic-clonic seizures
prompting initiation of keppra, course also notable for
initiation of workup for eosinophilia, discharged ___, with
recent ED visits for recurrence of seizures ___, then
abdominal
pain ___, who re-presents with worsening abdominal pain, now
admitted to medicine service.
Patient reports that 1 week prior to presentation, he was in his
normal state of health since his recent hospital stays, he
subsequently had 2 generalized tonic-clonic seizures prompting
ED
visit, where he was seen by neurology service, who recommended
increasing his keppra. He was discharged home with neurology
follow-up. 3 days after this, he developed L upper quadrant
abdominal pain, described as cramping, associated with nausea.
He was seen in the ED, felt to have post-seizure myalgias vs gas
cramping, and discharged home. Following discharge from
emergency department, patient's symptoms change--pain moved to R
lower quadrant. Still with associated nausea. Reported pain
ranged from ___. Reports 1 loose stool without blood. No
vomiting. No constipation. No cough or chest pain. No rashes,
no confusion. He presented to ED for further workup.
In the ED, initial VS were 98.7 57 133/92 18 98%RA. ___ 68. Exam
was reported as "Moderate right lower quadrant tenderness. No
guarding, rigidity, or rebound". Labs were notable for WBC 15.1
(N 63.5%, Eos 16.5%), Hgb 11.0, Plt 383; Cr 0.7, K 4.0; ALT 26,
AST 34, AP 68, Tbili 0.2, Lipase 35. UA with negative blood,
nitrite, leuks. Patient underwent CT scan without clear acute
process, but unable to rule out appendicitis. Patient was given
oxycodone 5mg x 1, dextrose 50%, dilaudid 1mg IV x 3, and IV
fluids and was admitted to medicine for further management.
On arrival to the floor, patient confirmed above. I also called
mother who confirmed above as well. Added that pain is worsened
by eating and walking, alleviated by pain medications given in
ED. Full 10 point review of systems positive where noted,
otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY
Autism
Epilepsy
Eosinophilic gastroenteritis
Glucocorticoid-induced osteoporosis with spinal fractures
Adrenal Insufficiency
Depression
Gastric ulcers / GERD
Psoriasis
Anxiety
Hyponatremia ___ psychogenic polydipsia
Unknown Bleeding disorder
h/o bulimia
h/o suicide attempt
Past Surgical History
Tonsillectomy and adenoidectomy
Meniscus repair
VATS decortication of right lung and drainage of right pleural
effusion ___
Social History:
___
Family History:
- Mother - reported thyroid removal for unknown reason; Seizure
in adulthood
- Father - eosinophilic esophagitis
- Sister - PCOS, unspecified allergies
- Brother - reported tympanostomy tubes, unspecified allergies
MGM - heart disease
MGF - heart disease
Maternal great grandmother - reported hx of lupus
Physical Exam:
ADMISSION
VS: 98.1 115/67 61 18 97%RA ___ 98
Gen: supine in bed, comfortable appearing
Eyes - EOMI, anicteric
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft; tenderness to moderate palpation in RLQ; no
rebound/guarding; negative obturator's sign; no LUQ or RUQ
tenderness, negative ___ no CVA tenderness; normoactive
bowel sounds;
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - odd affect
DISCHARGE
VS - 98.3 102/57 61 16 97%RA
Gen - supine in bed, comfortable appearing
Eyes - EOMI, anicteric
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, nontender no rebound/guarding; no CVA tenderness;
normoactive bowel sounds;
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - odd affect
Pertinent Results:
ADMISSION
___ 06:45AM BLOOD WBC-6.2# RBC-1.82*# Hgb-5.9*# Hct-18.4*#
MCV-101* MCH-32.4* MCHC-32.1 RDW-12.9 RDWSD-46.6* Plt ___
___ 06:45AM BLOOD Neuts-60.2 Lymphs-10.3* Monos-7.2
Eos-21.8* Baso-0.3 Im ___ AbsNeut-3.76 AbsLymp-0.64*
AbsMono-0.45 AbsEos-1.36* AbsBaso-0.02
___ 06:45AM BLOOD Glucose-60* UreaN-5* Creat-0.7 Na-142
K-4.5 Cl-103 HCO3-30 AnGap-14
___ 06:45AM BLOOD ALT-22 AST-35 AlkPhos-62 TotBili-<0.2
WORKUP
___ 06:00AM BLOOD Cortsol-9.1
DISCHARGE
___ 07:25AM BLOOD WBC-11.2* RBC-3.73* Hgb-12.0* Hct-35.5*
MCV-95 MCH-32.2* MCHC-33.8 RDW-12.9 RDWSD-44.4 Plt ___
___ 06:16AM BLOOD Neuts-50.4 Lymphs-11.0* Monos-6.5
Eos-30.8* Baso-1.0 Im ___ AbsNeut-6.77* AbsLymp-1.48
AbsMono-0.87* AbsEos-4.14* AbsBaso-0.14*
___ 07:25AM BLOOD Glucose-79 UreaN-4* Creat-0.7 Na-143
K-4.3 Cl-104 HCO3-31 AnGap-12
CT Abd/Pelvis with Contrast - ___
1. Appendix not directly visualized. No secondary signs of
appendicitis,
however, given paucity of intra-abdominal fat, it would be
difficult to
exclude early acute appendicitis.
2. Multifocal pulmonary nodular opacities are improved in
appearance since
prior study of ___, partially visualized, likely
resolving
infectious or inflammatory.
Abdomen XR - ___
No free air. No evidence of obstruction.
Brief Hospital Course:
This is a ___ year old male with a past medical history of
autism, eosinophilic gastroenteritis, recent hospital stays for
abdominal pain of unclear etiology, new tonic-clonic seizures
prompting initiation of keppra, who was admitted ___ for
abdominal pain and hypoglycemia, cleared by GI and endocrine
services without recommendation for steroids, thought to have
some component of functional abdominal pain, spontaneously
resolving without intervention, able to be discharged home
# Acute RLQ Abdominal Pain - Patient presented with worsening
RLQ in setting of episode of diarrhea and nausea.
Cross-sectional imaging was unremarkable. Labs were notable for
neutrophilia and hypereosinophilia. Patient concerned that
symptoms were similar to prior eosinophilic gastroenteritis
symptoms. GI service was consulted, but patient's symptoms
rapidly removed. Discussion was had that, given his prior
complications secondary to long-term steroid use (osteoporosis
and secondary adrenal insufficiency), potential benefit of
steroids would have to be high to justify initiation. Given
rapid clinical improvement and toleration of regular diet, it
was suspected he had likely had viral gastroenteritis vs
functional abdominal pain vs mild resolving eosinophilic
gastroenteritis flare. Patient recommended for close follow-up
with outpatient GI physician. Continued home Tylenol, Zofran.
# Hypoglycemia - In ED, patient initially had ___ in the ___
given that this was the presenting symptom of his prior
secondary adrenal insufficiency, endocrine service was
consulted. AM cortisol was appropriate and his hypoglycemia
resolved, so it was felt that this was not reflective of adrenal
insufficiency. Maintained fingersticks without issue for
remainder of hospital stay
# Eosinophilia - In the past has been attributed to eosinophilic
gastroenteritis, however additional hematologic causes have not
been completely ruled out. Completed initial workup for other
potential causes during recent admission and as outpatient with
outpatient hematologist Dr. ___ without notable
positive. Per discussion with Dr. ___ has plans for
referral of patient to eosinophilia expert for further workup.
# Seasonal Allergies - continued Cimetidine, azelastine
# Osteoporosis - continued Calcitrate-Vitamin D, Reclast
# Seizure disorder - continued keppra; at request of outpatient
neurologist, sent Very Long Chain Fatty Acids, pending at
discharge.
# Depression - continued fluoxetine
# Chronic pain - continued gabapentin
# Osteoporosis - continued calcium and vitamin D
# Psoriasis - continued topical steroid
Transitional Issues
- Discharged home with mother
- At request of primary neurologist, sent very long chain fatty
acids, pending at discharge
- At request of endocrinologist, sent ACTH, pending at discharge
- Spoke with outpatient hematologist Dr. ___ plans
to refer patient to eosinophilia expert for discussion of
further workup
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
2. Benzoyl Peroxide Gel 10% 1 Appl TP DAILY
3. Cimetidine 200 mg PO DAILY:PRN heartburn
4. FLUoxetine 40 mg PO DAILY
5. Gabapentin 600 mg PO TID
6. Ketoconazole Shampoo 1 Appl TP ASDIR
7. Loratadine 10 mg PO DAILY
8. Mupirocin Ointment 2% 1 Appl TP DAILY
9. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY OTHER
DAY
10. Vitamin D 3000 UNIT PO DAILY
11. LevETIRAcetam 1500 mg PO BID
12. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
13. lidocaine HCl 2 % mucous membrane DAILY:PRN
14. Reclast (zoledronic acid-mannitol-water) 5 mg injection
QYEAR
15. tazarotene 0.1 % topical DAILY
16. azelastine 137 mcg (0.1 %) nasal BID
17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
18. Clindagel (clindamycin phosphate) 1 % topical BID
19. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
20. Ondansetron 4 mg PO DAILY:PRN nausea
21. Selenium Sulfide 5 mL TP TIW
22. Lactobacillus acidophilus 1 pill oral DAILY
23. ginkgo biloba 1 tablet oral DAILY
24. B Complete (vitamin B complex) 1 pill oral DAILY
25. Zinc Sulfate 50 mg PO DAILY
26. Multivitamins 1 TAB PO DAILY
27. milk thistle 1 pill oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
2. azelastine 137 mcg (0.1 %) nasal BID
3. B Complete (vitamin B complex) 1 pill oral DAILY
4. Benzoyl Peroxide Gel 10% 1 Appl TP DAILY
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Cimetidine 200 mg PO DAILY:PRN heartburn
8. Clindagel (clindamycin phosphate) 1 % topical BID
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
10. FLUoxetine 40 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. ginkgo biloba 1 tablet oral DAILY
13. Ketoconazole Shampoo 1 Appl TP ASDIR
14. Lactobacillus acidophilus 1 pill oral DAILY
15. LevETIRAcetam 1500 mg PO BID
16. lidocaine HCl 2 % mucous membrane DAILY:PRN
17. Loratadine 10 mg PO DAILY
18. milk thistle 1 pill oral DAILY
19. Multivitamins 1 TAB PO DAILY
20. Mupirocin Ointment 2% 1 Appl TP DAILY
21. Ondansetron 4 mg PO DAILY:PRN nausea
22. Reclast (zoledronic acid-mannitol-water) 5 mg injection
QYEAR
23. Selenium Sulfide 5 mL TP TIW
24. tazarotene 0.1 % topical DAILY
25. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP EVERY
OTHER DAY
26. Vitamin D 3000 UNIT PO DAILY
27. Zinc Sulfate 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute RLQ Abdominal Pain
# Hypoglycemia
# Eosinophilia / Eosinophilic Gastroenteritis
# Seizure disorder
# Depression
# Chronic pain
# Seasonal Allergies
# Osteoporosis
# Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain and nausea. You were seen by GI doctors and
___. They recommended against treatment with
steroids and you improved on your own. You are now ready for
discharge.
It will be important for you to see your primary care doctor and
GI doctor.
Followup Instructions:
___
|
10613328-DS-20 | 10,613,328 | 22,075,981 | DS | 20 | 2136-01-29 00:00:00 | 2136-01-29 11:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Mercaptopurine / Minocycline / peanut / egg /
coconut / milk / Corn / Tegaderm
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
EGD/Colonoscopy
History of Present Illness:
CC: ___ Pain
.
HPI: ___ year old M with a PMH of eosinophilic gastroenteritis,
epilepsy, secondary adrenal insufficiency ___ budesonide use),
osteoporosis, multiple admissions for hypoglycemia and abdominal
pain who presents with worsening abdominal pain and was
found to be hypoglycemic in the ED.
The patient and his mother discuss things getting worse over the
last three weeks with increasing sharp diffuse abdominal pain.
He
was seen in the ED ___ where he had a CT abdomen which was
consistent with gastroenteritis. He was discharged with a few
days of oxycodone. He states this did not help his pain. They
called his GI team who recommended increasing budesonide to 9mg
daily for two weeks. He took this for three days and did not
feel
any better.
Per OMR last EGD ___ showed duodenitis and gastritis. He has
since had multiple CT scans.
Of note, the patient has has had multiple admissions since ___
for hypoglycemia and possible adrenal insufficiency with largely
negative workups, including multiple unrevealing (although
partial) fasts and normal ___ stim tests. No clear evidence of
insulinoma by imaging or lab tests. Endocrine had been involved.
On arrival to the ED vitals were T 98, HR 122, Bp 132/88, RR16,
O2Sat 100% RA. He was given IV Tylenol and Zofran. He was noted
to be hypoglycemia to 47 and was given an AMP of D50 subsequent
fingerstick blood sugars were 69 --> 67 --> 57 --> 91. He was
admitted to medicine for ongoing management of hypoglycemia and
pain control.
.
ROS: 14 point ROS negative except HPI
Past Medical History:
Autism
Epilepsy
Eosinophilic gastroenteritis
Glucocorticoid-induced osteoporosis with thoracic compression
fractures s/p Reclast x 2 in ___ and ___
Adrenal Insufficiency
Hypoglycemia
Depression
Gastric ulcers / GERD
Psoriasis
Anxiety
Hx of silent thyroiditis
Hyponatremia ___ psychogenic polydipsia
h/o bulimia
h/o suicide attempt
Osteoporosis
- He has multiple thoracic fractures and osteoporosis noted on
BMD, thought to be in the setting of malabsorption(from
eosinophilic GE, chronic previous steroid use, and bulimia in
the past). He is s/p Reclast ___. He is on
vitamin D3 4000 units daily as well as Ca supplementation
* Thyrotoxicosis:
- He has history of silent thyroiditis in ___ with low uptake
on
thyroid scan. TSH in ___ was 0.51, however repeat TFTs showed
normal FT4, TT3, TT4. Most recent TFTs have been normal.
PSH:
Tonsillectomy and adenoidectomy
Meniscus repair
VATS decortication of right lung and drainage of right pleural
effusion ___
Social History:
___
Family History:
- Mother: ___, Cholelithiasis
- Father: ___
- Sister: ___
- Brother: ___
Physical ___:
VS: T 99.1, BP 112/75, HR 62, Rr16, O2Sat 96% RA
General Appearance: pleasant, comfortable, anxious appearing
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, non-tender to palpation
diffusely,
no rebound or guarding
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization.
GU: no catheter in place
Pertinent Results:
___ 06:55AM BLOOD WBC-3.8* RBC-2.79* Hgb-11.3* Hct-32.8*
MCV-118* MCH-40.5* MCHC-34.5 RDW-12.9 RDWSD-56.1* Plt ___
___ 05:42AM BLOOD ALT-23 AST-20 AlkPhos-51 TotBili-<0.2
___ 05:42AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.2
___ 05:25AM BLOOD CRP-4.0
___ 05:25AM BLOOD ZINC-Test
___ 05:25AM BLOOD SED RATE-Test
___ 05:37AM BLOOD C-PEPTIDE-Test
CT Abdomen Pelvis- CT enterography
IMPRESSION:
1. No acute process within the abdomen or pelvis.
2. No evidence of bowel wall thickening to suggest the presence
of
inflammatory bowel disease. If ongoing concern for this entity
remains, MR enterography could be performed for additional
evaluation.
EGD
Mucosa: Normal mucosa was noted. Cold forceps biopsies were
performed for histology at the duodenum.
Impression: Normal mucosa in the esophagus (biopsy)
Retained fluids in stomach
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Colonoscopy
Normal mucosa was noted. Cold forceps biopsies were performed
for histology at the random colon.
Other Oozing blood at one biopsy site in the cecum. One
endoclip was successfully applied to the colon for the purpose
of hemostasis.
Impression: Normal mucosa in the colon (biopsy)
Oozing blood at one biopsy site in the cecum. (endoclip)
Otherwise normal colonoscopy to cecum
Recommendations: -Follow-up final pathology
-Further recommendations from inpatient GI consult team
Brief Hospital Course:
Assessment and Plan:
___ year old M with a PMH of eosinophilic
gastroenteritis, epilepsy, secondary adrenal insufficiency ___
budesonide use), osteoporosis, multiple admissions for
hypoglycemia and abdominal pain who presents with worsening R
sided abdominal pain and was found to be hypoglycemic to 40's in
the ED.
ACUTE/ACTIVE PROBLEMS:
# Abdominal Pain
# Eosinophilic Gastroenteritis
# Hypereosinophilic Syndrome
Presented with imaging findings for gastroenteritis and
increased abdominal pain. This was likely a flair of his known
eosinophilic gastroenteritis. GI was consulted and he was
started on 9mg of budesonide and q4hrs dilaudid. GI also felt
that some of his symptoms could be consistent with gastroparesis
and started him on standing reglan. He felt the reglan was
worsening his mood and due to this it was stopped. CRP and ESR
were checked and not elevated. GI wanted a MRE but due to his
autism this would need heavy sedation and given in MRE you need
to swallow contrast 60 minutes before anesthesia felt this was
not safe. Instead had a CT-enterography which was negative. He
underwent an EGD and ___ which were unremarkable. Several
biopsies were taken and are pending. One biopsy site bleed and
required a clip. His pain was improved. Gi recommended SIBO
testing as outpatient and possible gastric emptying study for
gastroparesis.
#Hypoglycemia
#Secondary Adrenal Insufficiency?
Patient has had multiple admissions since ___ for hypoglycemia
and ___ insufficiency with largely negative workups
for insulinomas, adrenal insufficiency. Rapid improvement in
FSBG
and hypoglycemia not associated with oral intake/fasting. CT A/P
with no adrenal masses, no hyperpigmentation. Endocrine saw him
while he was inpatient and felt nothing further needed to be
done now. He did not have any more episodes of hypoglycemia.
# Thoracic Myofascial Pain
Known h/o chronic rib fractures. Pain very similar to that for
which he has presented in the past. receives trigger point
injections for this.
-lidocaine patch
-Gabapentin 800 mg PO TID
-continue dicyclomine 10 mg q8h PRN
#Macrocytic anemia
-will start Vit B12, MVI, Folate
CHRONIC/STABLE PROBLEMS:
# Anxiety, Depression w h/o Suicide Attempt
-continue buspirone 10 mg PO daily
-continue fluoxetine 60 mg PO daily
# Seizure d/o, h/o epilepsy?
Appears that seizures in the past have been ___ hypoglycemia.
First noted in ___.
-continue Keppra 1500 mg PO q12h
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 10 mg PO DAILY
2. DICYCLOMine 10 mg PO Q8H:PRN cramping
3. FLUoxetine 60 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. Hydroxyurea 1000 mg PO DAILY
6. LevETIRAcetam 1500 mg PO BID
7. Loratadine 10 mg PO BID:PRN itching, allergies
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. PredniSONE 2.5 mg PO DAILY
10. TraZODone 50 mg PO QHS
11. clindamycin phosphate 1 % topical BID:PRN
12. Tretinoin 0.05% Cream 1 Appl TP QHS
13. Clindamycin 1% Solution 1 Appl TP BID
14. Polyethylene Glycol 34 g PO BID
15. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP QOD
16. TraMADol 50 mg PO Q8H PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
17. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral TID
18. Vitamin D 3000 UNIT PO DAILY
19. Glucose Tab ___ TAB PO PRN hypoglycemia
20. Budesonide 9 mg PO DAILY
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*10 Tablet Refills:*0
2. PredniSONE 20 mg PO DAILY
RX *prednisone 5 mg 2 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
3. Budesonide 9 mg PO DAILY
RX *budesonide [Uceris] 9 mg 1 tablet(s) by mouth once a day
Disp #*20 Tablet Refills:*0
4. BusPIRone 10 mg PO DAILY
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral TID
6. Clindamycin 1% Solution 1 Appl TP BID
7. clindamycin phosphate 1 appl topical BID:PRN acne
8. DICYCLOMine 10 mg PO Q8H:PRN cramping
9. FLUoxetine 60 mg PO DAILY
10. Gabapentin 800 mg PO TID
11. Glucose Tab ___ TAB PO PRN hypoglycemia
12. Hydroxyurea 1000 mg PO DAILY
13. LevETIRAcetam 1500 mg PO BID
14. Loratadine 10 mg PO BID:PRN itching, allergies
15. Ondansetron 8 mg PO Q8H:PRN nausea
16. Polyethylene Glycol 34 g PO BID
17. TraMADol 50 mg PO Q8H PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
18. TraZODone 50 mg PO QHS
19. Tretinoin 0.05% Cream 1 Appl TP QHS
20. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP QOD
21. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Abdominal Pain
# Eosinophilic Gastroenteritis
# Hypereosinophilic Syndrome
#Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted after you began to have increasing abdominal
pain at home. You had a CT scan of your abdomen which showed
some inflammation consistent with gastroenteritis.
Gastroenterology was consulted and felt this might be consistent
with your eosinophilic gastroenteritis. You were started on
budesonide 9mg daily and will need to continue this until your
follow up with Dr. ___ on ___. You also underwent an EGD and
colonoscopy which looked normal, they did take several biopsy
with the pathology pending. This should also be discussed with
Dr. ___.
Your blood sugars were monitored and remained normal. You need
to follow closely with your endocrinologist. You were given
stress dosed prednisone for colonoscopy. You are being tapered
back to your 2.5mg of prednisone. The taper is as follows
Tomorrow take 10 mg (2 pills) prednisone
___ take 5mg (1 pill) prednisone
___ go back to taking your regular 2.5 mg daily
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
10613392-DS-7 | 10,613,392 | 29,267,250 | DS | 7 | 2162-09-17 00:00:00 | 2162-09-19 11:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old female with a history of COPD presents
with RLQ pain. The pain first started AM of admission and was
associated with mild nausea. She denies emesis, diarrhea, fever,
chills.
Of note, the patient was recently admitted from ___ to ___
with a COPD exacerbation where she was treated with azithromycin
and 5 day course of prednisone and started on tiotropium. She
reports that she was doing quite well until AM of admission when
she awoke with the pain. Denies any fever, chills, nausea,
vomiting, diarrhea, chest pain or SOB. Endorsed cough but no
hemoptysis.
In the ED, initial vitals: 97.3 58 97/33 16 94% RA. Patient was
given morphine 4 mg IV X 1 and KCL 10 mEQ X 1. Labs were
significant for HCT 42.1 and K 3.1. CT A/P showed right rectus
sheath hematoma measuring approximately 6.8 x 3.9 x 10.0 cm with
small blush of contrast within the hematoma with a possible tiny
feeding vessel, concerning for active extravasation. The patient
was seen by surgery in the ED, who felt that the bleeding was
secondary to a heparin injection. Vitals prior to transfer: 98.0
48 93/50 14 98% RA.
Currently, complains of ___ pain.
This AM, patient having mild pain at hematoma site. No other
complaints.
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:
"borderline" COPD
depression
bipolar disease
migraines
HSV
insomnia
cerebral aneurysm, s/p bleed and clipping ___
cervical DJD with ruptured disc, s/p hardware and rod ___
Social History:
___
Family History:
father and maternal grandfather had strokes. No other illnesses
including DM, CAD/MI, malignancy or sudden death.
Physical Exam:
ON ADMISSION
98.1, 93/41, P-55, RR-16, 94RA
GENERAL: NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD
HEART: PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS: CTAB, no rales, faint end expiratory wheezes, good air
movement, resp unlabored, no accessory muscle use
ABDOMEN: NABS, soft/ND, TTP on right side, negative murphys, no
masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
ON DISCHARGE
UNCHANGED
Pertinent Results:
ON ADMISSION
___ 10:45AM WBC-9.9 RBC-4.48 HGB-14.0 HCT-42.1 MCV-94
MCH-31.3 MCHC-33.2 RDW-12.8
___ 10:45AM NEUTS-60.5 ___ MONOS-8.6 EOS-0.3
BASOS-0.8
___ 10:45AM ___
___ 10:45AM GLUCOSE-81 UREA N-11 CREAT-0.8 SODIUM-143
POTASSIUM-3.1* CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
___ 10:45AM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-46 TOT
BILI-0.3
___ 10:45AM LIPASE-19
CT A/P:
1. Right rectus sheath hematoma measuring approximately 6.8 x
3.9 x 10.0 cm. Small blush of contrast within the hematoma(2,53)
with a possible tiny feeding vessel, concerning for active
extravasation. The appendix is normal.
2. The gonadal veins are dilated bilaterally, are pelvic
varices, and reflux of contrast into the gonadal veins. This can
be seen in pelvic congestion syndrome, correlate clinically.
2. Subcentimeter hypodensity in the lower pole of the left
kidney that is too small to characterize.
LABS ON DISCHARGE
___ 06:35AM BLOOD WBC-12.3* RBC-4.30 Hgb-13.6 Hct-41.5
MCV-97 MCH-31.6 MCHC-32.7 RDW-12.9 Plt ___
___ 10:45AM BLOOD ___
___ 12:45PM BLOOD PTT-26.9
___ 06:35AM BLOOD Glucose-73 UreaN-10 Creat-0.7 Na-144
K-4.0 Cl-108 HCO3-28 AnGap-12
___ 06:35AM BLOOD Calcium-8.1* Phos-4.3 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ year-old female with a history of COPD,
depression, and bipolar who presents with RLQ pain and found to
have a right rectus sheath hematoma.
# Right Rectus Sheath Hematoma:
Revealed on CT and likely etiology of patient RLQ pain. Concern
for active extravasation given small blush on CT. Pt evaluated
by surgery in ED and was felt to be secondary to heparin SQ and
recommended admission to medicine for further management.
Patient had recent Prednisone use which could likely have
predisposed to hematoma. This was discotninued (PCP wanted ___
___ taper after recent admission). Hct stable at ___ischarged with PCP ___.
# Cough: likely related to recent inflammatory process.
Completed course of steroids. Was given Guaifenisen PRN.
# Depression/Bipolar disease:
- continued home meds including abilify, paroxetine, and
ritalin.
# Insomnia: continued home trazodone
# Chronic Constipation: Continued bisacodyl
Transitional Issues
-Should have PCP follow up ___ or ___ with repeat Hg/Hct
checked at that time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Aripiprazole 5 mg PO QPM
3. Bisacodyl 40 mg PO HS
4. Paroxetine 60 mg PO QPM
5. traZODONE 150 mg PO HS
6. MethylPHENIDATE (Ritalin) 60 mg PO QAM
7. Nicotine Patch 21 mg TD DAILY
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
9. Propranolol LA 180 mg PO DAILY
hold for sbp < 90 and hr < 60
10. PredniSONE 30 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
3. Aripiprazole 5 mg PO QPM
4. Bisacodyl 40 mg PO HS
5. MethylPHENIDATE (Ritalin) 60 mg PO QAM
6. Nicotine Patch 21 mg TD DAILY
7. Paroxetine 60 mg PO QPM
8. Propranolol LA 180 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. traZODONE 150 mg PO HS
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Rectus Sheath Hematoma
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with abdominal pain. A scan showed you
have a hematoma likely from heparin shots from your last stay in
the hospital. Fortunately, your blood counts are stable.
You have been discharged with ___ with your primary care
physician.
You should NOT continue steroid treatment. Steroids can make
blood vessels weaker and potentially cause more bleeding.
It was a pleasure taking care of you, Ms ___.
Followup Instructions:
___
|
10613905-DS-10 | 10,613,905 | 21,514,237 | DS | 10 | 2203-11-10 00:00:00 | 2203-11-17 16:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
E-Mycin / levofloxacin / potassium chloride
Attending: ___.
Chief Complaint:
Weakness, malaise, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of pancreatic
CA on C2D13 of nab-paclitaxel/gemcitabine, HLD, psoriatic
arthritis, presenting with 1 day acute onset weakness, malaise
and fevers.
Of note, patient was seen by Dr. ___ at ___ on ___, at
that time the patient felt weak and dizzy and was found to be
orthostatic. After receiving IVF, his symptoms and orthostasis
resolved and he was cleared to received C2D8 of his regimen.
Patient's symptoms started suddenly when he woke up and started
ambulating this AM. Per wife, patient was "off, not making sense
when talking." This has happened before with chemotherapy.
Weakness. No falls. No LOC. ROS positive for fevers (temp to 103
this AM), negative for pain, dysuria, cough, SOB, chest pain,
abdominal pain, nausea, vomiting, diarrhea.
In the ED, initial vitals: 101.3 | 102 | 124/60 | 22 | 98% RA
-ED Exam: non focal, AOx3, neuro intact, attentive
-ED Labs were notable for: no leukocytosis, ANC 4000, anemia
7.9/25.3, thrombocytopenia plts 88, bicarb 21 Cr 1.2 (1.1-1.3
baseline), lactate 1.1, UA negative. Flu swab negative.
-CXR showed low lung volumes and bibasilar opacities suggestive
of atelectasis.
- Patient was given: oxycodone 5mg, APAP 1g, 500cc LR
-Decision was made to admit for further workup of fever of
unclear etiology and weakness
-Vitals prior to transfer were 102.8 | 100 | 134/72 | 19 | 100%
RA
On arrival to the floor, patient reports feeling much better
although still feels too weak to safely get out of bed. He
describes his previous malaise this afternoon in more detail as
throbbing in his head, discomfort in his abdomen, nausea without
vomiting and lack of appetite.
Patient denies night sweats, headache, vision changes,
numbnesss, shortness of breath, cough, hemoptysis, chest pain,
palpitations, abdominal pain, vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: Presented to PCP with choluria. LFTs showed a TB 2.5,
ALT 205, AST 84, ALP283. CA ___ was 76.8. He had a mild
increase
in fatigue for a few weeks prior. Denies weight loss but has
lost
a few pounds since his diagnosis. CT abdomen revealed dilated
intra- and extra-hepatic bile ducts to the head of the pancreas
and pancreatic duct dilatation. No discrete pancreatic mass
demonstrated.
-___: EUS 1.4 x 1.6 cm ill-defined mass in the head of
pancreas with abutment of portal confluence. ERCP revealed 1.5
cm
irregular stricture in distal CBD with upstream dilatation.
Pancreatic duct stent was placed but removed at end of
procedure;
biliary duct stent was placed. FNA from the EUS did reveal
adenocarcinoma.
-___ Pancreatic ___ by Dr. ___
___
Dr. ___. Stage II resectable disease. CTA torso: ill-defined
hypodense pancreatic head mass abutting approximately 15 degrees
of adjacent SMV w/o SMV contour abnormality. CT chest: GGOs RUL
and a punctate nodule in LUL not thought to be metastatic
disease.
-___: ___ with Dr. ___ T3N0 disease, grade 2. +margin
at superior mesenteric vein
-___: C1W1 Gemcitabine
-___: Cyberknife, Dr. ___
-___: XRT with Dr. ___. Concurrent capecitabine
-___: C2W1 Gemcitabine
-___ C6 Gemcitabine
-___: Restarted Gemcitabine for recurrent disease. 3
cycles
given.
- ___: Given rising CA ___ on gemcitabine (disease
progression) C1W1 Gem/nab-paclitaxel
-___- C2D8 Gem/nab-paclitaxel
PAST MEDICAL HISTORY:
-Psoriatic arthritis
-Hypercholesterolemia
-GERD
-Chronic pain
-Anemia
-BPH (benign prostatic hyperplasia)
-Anxiety
-OA R THUMB
-Calcific shoulder tendinitis left
-Epidermal inclusion cyst; L hand
-Trigger finger Left long finger
Social History:
___
Family History:
No Hx CAD, stroke, arrhythmias.
Physical Exam:
VS: T 99 Tmax 101.7 BP 119/63 HR 57 RR 18 O2 sat 95% RA
GENERAL: NAD
HEENT: Anicteric, EOMI, OP clear, moist mucous membranes.
CARDIAC: RRR, normal s1/s2.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally.
ABD: Flat abdomen, soft, non-tender.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, No focal deficits.
SKIN: No significant rashes.
Pertinent Results:
___ 08:25AM BLOOD WBC-4.6# RBC-2.80* Hgb-7.9* Hct-25.3*
MCV-90 MCH-28.2 MCHC-31.2* RDW-18.3* RDWSD-60.0* Plt Ct-88*#
___ 07:40AM BLOOD WBC-2.9* RBC-2.66* Hgb-7.5* Hct-24.0*
MCV-90 MCH-28.2 MCHC-31.3* RDW-18.5* RDWSD-59.9* Plt Ct-58*
___ 08:25AM BLOOD Glucose-131* UreaN-19 Creat-1.2 Na-137
K-3.5 Cl-103 HCO3-21* AnGap-17
___ 07:40AM BLOOD Glucose-102* UreaN-19 Creat-1.1 Na-136
K-3.4 Cl-100 HCO3-27 AnGap-12
___ 08:25AM BLOOD ALT-117* AST-191* AlkPhos-312*
TotBili-0.7
___ 07:40AM BLOOD ALT-74* AST-69* AlkPhos-209* TotBili-0.8
___ 07:40AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.5*
___ 08:35AM BLOOD Lactate-1.1
Chest X-ray:
Mild bibasilar opacities are likely atelectasis in setting of
low lung
volumes.
RUQ U/S:
No evidence of biliary ductal dilatation.
2.4 cm hyperechoic, avascular lesion within the right hepatic
lobe was not
visualized on the prior CT scan of the abdomen and pelvis.
While its
appearance is suggestive of a hemangioma, a metastatic lesion
cannot be
excluded.
Brief Hospital Course:
___ year old gentleman with history of pancreatic CA on C2D13 of
nab-paclitaxel/gemcitabine, HLD, psoriatic
arthritis, who presented with 1 day acute onset weakness and
fevers.
Fever and Weakness
- Fever and weakness are thought to be due to the patient's
chemotherapy. He had this in the previous cycles. Discussed with
his primary oncologist. Chest x-ray and RUQ ultrasound are
negative and cultures were negative at the time of discharge he
will follow up with his primary oncologist as an outpatient.
Physical therapy was consulted and recommended home ___ and a
walker.
Pancreatic Adenocarcinoma
- Thought to be the cause of his pancytopenia and transaminitis
he will follow up with his oncologist as an outpatient.
Transaminitis
- Likely due to gemcitabine chemotherapy. Simvastatin was held.
Lab work to be monitored as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
3. Creon 12 3 CAP PO TID W/MEALS
4. Simvastatin 40 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach upset
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach upset
2. Citalopram 20 mg PO DAILY
3. Creon 12 3 CAP PO TID W/MEALS
4. Omeprazole 20 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. HELD- Simvastatin 40 mg PO QPM This medication was held. Do
not restart Simvastatin until taking to your outpatient doctor
about your liver function tests.
8.Rolling Walker
Diagnosis: Weakness
Prognosis: Good
Length of Need: 12 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatic Cancer
Fever
Weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with fevers and weakness. There was a concern
for infection but so far one has not been found. Your symptoms
are most likely from your chemotherapy. You will be set up with
home nursing and physical therapy and a walker.
Followup Instructions:
___
|
10613905-DS-8 | 10,613,905 | 25,755,574 | DS | 8 | 2202-05-26 00:00:00 | 2202-05-26 11:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
E-Mycin
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is been followed post-operatively since his ___
whipple after which his course complicated by delirium in the
immediate post-operative period. Since that time, he has
communicated with staff on several occasions about his concerns
regarding his constipation/runny output. He reported ongoing
loose stools resembling "cornmeal ush," requiring six diapers
daily, and accompanied by lower abdominal and rectal "crampy"
pain. He denies
fevers, nausea, vomiting, or hematochezia/melena. In the
outpatient setting, he appeared grossly distended with mild
tenderness and fecal incontinence. A KUB showed severe
constipation, for which the patient elected to be admitted and
treated.
Past Medical History:
Hyperlipidemia
Osteoarthritis
Benign prostatic hyperplasia
Social History:
___
Family History:
Patient does not recall
Physical Exam:
Temp: 99.0 ; BP: 145/67 ; P: 62 ; RR: 20 ; O2:96%RA
General: alert and oriented X3, ambulating well
HEENT: oral mucosa moist, absent lymphadenopathy.
Resp: clear breath sounds bilaterally
CV: RRR, absent murmurs, rubs or gallops
Abd: soft, non-distended, dressing and steri-strips clean, dry
and intact
extremities: skin intact, atraumatic
Pertinent Results:
___ 03:24PM BLOOD WBC-6.9# RBC-3.80* Hgb-10.4* Hct-32.7*
MCV-86 MCH-27.4 MCHC-31.8* RDW-13.4 RDWSD-41.5 Plt ___
___ 03:24PM BLOOD Neuts-71.4* Lymphs-15.5* Monos-12.2
Eos-0.4* Baso-0.1 Im ___ AbsNeut-4.91 AbsLymp-1.07*
AbsMono-0.84* AbsEos-0.03* AbsBaso-0.01
___ 03:24PM BLOOD Plt ___
___ 03:24PM BLOOD Glucose-124* UreaN-13 Creat-1.0 Na-143
K-3.7 Cl-102 HCO3-29 AnGap-16
Adbominal Xray
The bowel gas pattern is unremarkable with gas seen in
nondistended loops of
large and small bowel. There is no evidence of ileus or
obstruction. There is
no evidence of intraperitoneal free air although exam is limited
by supine
technique. The bony structures are unremarkable. Surgical clips
are seen in
the upper abdomen.
Brief Hospital Course:
Mr. ___ was admitted on ___ via the emergency department,
where he received a Fleets enema and PO mineral oil, which
initiated his disimpaction. Overnight, he continued to put out
copious amounts of feces. In the morning of ___, he received
a soap suds enema, followed my magnesium citrate. In afternoon,
he received a dose of lactulose
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN Pain
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Simvastatin 40 mg PO QPM
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
5. Omeprazole 20 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID:PRN Pain
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
3. Simvastatin 40 mg PO QPM
4. Tamsulosin 0.4 mg PO QHS
5. Acetaminophen ___ mg PO TID pain
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Omeprazole 20 mg PO BID
8. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp
#*60 Capsule Refills:*0
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to aid in the alleviation of your
constipation. You received multiple enemas and oral medication
to aid in the evacuation of stool.
Please call your doctor or nurse practitioner if you experience
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 is 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.
.
General Discharge Instructions:
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.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
___
|
10613905-DS-9 | 10,613,905 | 23,617,495 | DS | 9 | 2202-07-08 00:00:00 | 2202-07-10 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
E-Mycin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
ID: Mr. ___ is a ___ gentleman with T3N0 pancreatic
adenocarcinoma s/p robotic-assisted pylorus-preserving
pancreaticoduodenectomy on ___ now on adjuvant gemcitabine
chemotherapy presents with fever and AFib with RVR.
HISTORY OF PRESENTING ILLNESS:
___ with a past medical history notable for pancreatic cancer
with recent initiation of gemcitabine (~2 weeks ago, last dose 2
days ago) presents with with fever and myalgias. The patient
reports that he underwent chemotherapy on 2 days ago and this
morning he awoke with general malaise and took his temperature
which was measured at 103.9°F. Since that time, his temperature
is gradually trended down without any antipyretics however he
called his doctor who said to come in. He also endorses some
nasal congestion and an intermittent cough. He denies sick
contacts, rashes, or pharyngitis. He has had some fevers prior
to this episode, including to 101.5 the day prior to getting
chemo (although he was afebrile in clinic). He has been
tolerating POs well.
He also reported some episodes of chest pain accompanying these
general myalgias. He has no known history of cardiac problems or
arrhythmias. He denies any shortness of breath, abdominal pain,
nausea, vomiting, dysuria, bowel changes.
In the ED, the patient was afebrile. He was found to have AFib
with RVR that converted to sinus rhythm with HR in the ___
diltiazem. Troponins were negative x 2.
EKG: Atrial fibrillation with RVR at 166, normal intervals, ST
depressions in the lateral leads. QTc 395.
Interval: On arrival to the floor, patient became febrile to 103
again. After initial interview, the patient undressed and begain
urinating on the floor of his room. Pt continued to be in sinus
rhythm.
REVIEW OF SYSTEMS: 10 pt review of systems negative except as
noted in HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___- Primary care visit w/ five days of dark urine
___- EUS showed 1.4 x 1.6 cm ill-defined mass in the head
of the pancreas
___- CTA showed ill-defined hypodense pancreatic mass.
Chest CT showed no mets.
___- robot-assisted minimally invasive
pancreaticoduodenectomy. Path showed grade II, pT3 N0 pancreatic
ductal adenocarcinoma, surgery had positive margin.
___- Plan for gemcitabine adjuvant tx and recommendation of
external beam radiation therapy as well as a stereotactic
radiotherapy boost dose to the positive margin at the SMV
PAST MEDICAL HISTORY:
1. Pancreatic adenocarcinoma as detailed in the history of
present illness.
2. Hyperlipidemia.
3. Gastroesophageal reflux disease.
4. Osteoarthritis.
5. Benign prostatic hypertrophy.
6. Headache.
7. Chronic low back pain.
8. Psoriasis.
9. Acute nephritis in ___.
10. Viral pneumonia in ___.
11. Bilateral knee arthroscopies.
12. Back pain for which he is taking oxycodone for the last ___
years.
Social History:
___
Family History:
No Hx CAD, stroke, arrhythmias.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 103 122/68 104 20 96%RA
ADMIT WT: 159.9
GENERAL: Appears acutely ill. Flushed, diaphoretic. Odd affect.
Appears younger than stated age.
HEENT: NC/AT, oropharynx clear no erythema, lesions, or
exudates.
CARDIAC: Rapid regular rate, no MRG.
LUNG: Bibasilar crackles.
ABD: soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema or tenderness. Very warm.
NEURO: A&O x 3, odd affect.
SKIN: Warm, diaphortic. Redness over chest.
DISCHARGE PHYSICAL EXAM:
VS: 98.2 110-116/62-64 61-68 16 97% RA
GENERAL: ___. NAD. Appears younger than stated age.
HEENT: NC/AT.
CARDIAC: RRR no MRG.
LUNG: CTAB.
ABD: soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema or tenderness.
NEURO: A&O x 3.
SKIN: Warm, dry.
Pertinent Results:
ADMIT:
___ 06:10AM BLOOD WBC-4.0 RBC-4.21* Hgb-11.3* Hct-35.9*
MCV-85 MCH-26.8 MCHC-31.5* RDW-15.3 RDWSD-45.6 Plt ___
___ 06:10AM BLOOD Neuts-84.5* Lymphs-11.4* Monos-3.8*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-3.35 AbsLymp-0.45*
AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00*
___ 06:10AM BLOOD Glucose-146* UreaN-15 Creat-0.9 Na-132*
K-4.3 Cl-97 HCO3-23 AnGap-16
___ 06:10AM BLOOD ALT-209* AST-302* AlkPhos-215*
TotBili-0.7
___ 06:10AM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8
___ 06:10AM BLOOD TSH-2.4
___ 06:10AM BLOOD Free T4-1.3
___ 06:22AM BLOOD Lactate-1.7
DISCHARGE:
___ 06:15AM BLOOD WBC-2.4* RBC-3.87* Hgb-10.6* Hct-33.1*
MCV-86 MCH-27.4 MCHC-32.0 RDW-15.3 RDWSD-45.6 Plt ___
___:15AM BLOOD Neuts-33.6* ___ Monos-16.6*
Eos-0.9* Baso-0.4 Im ___ AbsNeut-0.79* AbsLymp-1.11*
AbsMono-0.39 AbsEos-0.02* AbsBaso-0.01
___ 06:15AM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
___ 06:35AM BLOOD ALT-60* AST-27 LD(LDH)-158 AlkPhos-147*
TotBili-0.2
___ 06:35AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
IMAGING:
TTE ___
IMPRESSION: Preserved left ventricular cavity size, wall
thickness and global systolic function. Mild diastolic
dysfunction. No significant valvular disease.
CXR ___
IMPRESSION:
Bibasilar opacities may represent atelectasis or infection in
the appropriate clinical setting.
EKG: Atrial fibrillation with RVR at 166, normal intervals, ST
depressions in the lateral leads. QTc 395.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with T3N0 pancreatic
adenocarcinoma s/p robotic-assisted pylorus-preserving
pancreaticoduodenectomy on ___ with positive margins now on
adjuvant gemcitabine chemotherapy who presented with fever and
afib with RVR.
# Fever: The patient endorsed mild cough and some runny nose
without pharyngitis or dyspnea. The fever was assoc. with
general malaise. Up to 41% of pts on Gemcitabine develop fever
but 103 is higher than would be expected and pt had reported
fever prior to starting. He also had not had fevers with prior
doses. Cough + indeterminate CXR + high fever could be
suggestive of a viral or bacterial PNA. Pt had received IV chemo
and had been in the hospital within the last 90 days, so there
was concern for HCAP. Flu swab negative as were viral cultures.
The patient did have a temp spike on levofloxacin so he was
broadened to vancomycin and cefepime but after no addition
fevers he was de-escalated back to levofloxacin. He will be sent
home to continue a 7-day course of Levofloxacin.
# Atrial Fibrillation: Likely ___ high fever >103. CHADS2 score
= 0; he does not need anticoagulation at this time. AFib w/ RVR
to 166 resolved with diltiazem in ED ___. Echo showed grade I
dyastolic dysfx but otherwise WNL. He was treated with
Metoprolol Tartrate 12.5 mg PO Q6H and was transitioned to
50qDay Metoprolol XL at discharge
# Delerium: Pt was found naked urinating all over his room while
febrile to 103, so the delerium was determined to be likely
fever-induced. It was managed with redirection and did not
recurr.
# Transaminitis: Had normal LFTs after his resection but was
noticed to have transaminitis on admission which downtrended
without intervention. He did not complain of abd pain, N/V. A CT
of his abdomen divulged no e/o infection.
# Pancreatic CA s/p resection: Now on adjuvant gemcitabine
chemotherapy with plan for radiation. Gemcitabine commonly
causes fevers. He was continued on his home Creon and Oxycodone
5mg q4h PRN for post-op pain
# Psoriasis: Continued his home topical clobetasol
# BPH: Pt had some increased urination at night requiring condom
cath, likely because his tamsulosin was given late on admission.
This urinary frequency resolved over the course of his admission
and he no longer required the condom cath.
TRANSITIONAL ISSUES:
-Neutropenia: Pt's ANC downtrending as expected s/p chemo. ANC
on discharge 790. Afebrile x 48 hours.
-Fevers: Discharged to complete 7 day course of Levofloxacin
ending ___.
-Pancreatic cancer: Pt has follow-up with Dr. ___ on ___ at
10am
-Atrial fibrillation: Pt was started on metoprolol XL 50qDay.
Will need outpatient monitoring/titration. Consider outpatient
cardiology follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN Pain
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
3. Simvastatin 40 mg PO QPM
4. Tamsulosin 0.4 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
7. Ketoconazole 2% 1 Appl TP BID
8. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY:PRN scalp
psoriasis
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
10. fluticasone 50 mcg/actuation nasal BID:PRN nasal congestion
Discharge Medications:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
2. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY:PRN scalp
psoriasis
3. Omeprazole 20 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
5. Tamsulosin 0.4 mg PO DAILY
6. Creon 12 2 CAP PO TID W/MEALS
7. Levofloxacin 750 mg PO DAILY
Please complete the last 3 days of your week-long treatment.
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
8. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
10. Cyclobenzaprine 10 mg PO TID:PRN Pain
11. fluticasone 50 mcg/actuation NASAL BID:PRN nasal congestion
12. Ketoconazole 2% 1 Appl TP BID
13. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Health Care Associated Pneumonia
2. Sepsis
3. Fever
4. Atrial fibrillation
Secondary Diagnosis:
1. Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaluation of a high fever. Your fever may have been due to
your chemotherapy or possibly a pneumonia. You were started on
antibiotics for an infection. Please complete your antibiotic
course.
Additionally, your heart rhythm was noted to be abnormal in the
emergency department. This arrythmia is called atrial
fibrillation. The arrhythmia resolved, however you will need to
take a medication (metoprolol) to keep your heart rate in a
normal range. Additionally, you had an echocardiogram which
showed no structural cause of your arrhythmia. You may require
a referral to a cardiologist for continued management /
evaluation of atrial fibrillation, however, you can discuss this
with your primary care physician.
You should follow up with your oncologist for continued
management of your pancreatic cancer. Should you develop
fevers, shortness of breath, chest pain or palpitations, please
seek evaluation at your nearest emergency department.
We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
10614292-DS-18 | 10,614,292 | 25,183,664 | DS | 18 | 2132-02-25 00:00:00 | 2132-02-25 16:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending: ___.
Chief Complaint:
Abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for asthma, obesity, and fibromyalgia
who presents with abdominal pain. Patient seen today in urgent
care with 3 days of abdominal cramping. The pain is located in
the ___ region, and is described as constant, sharp
and severe. It radiates around her back. She also has diarrhea,
on average of 6 episodes per day. Her stool consistency ranges
from soft to watery. This morning, she noticed bright red blood
x 2. The blood was located on the toilet paper, in the bowel,
and mixed with stool. No vaginal bleeding or discharge. She also
describes discomfort, but no pain with BMs, and no tenesmus. She
reports feeling warm, but no documented fevers. No nausea and
vomiting. She denies any unusual oral intake, no family travel,
and no history of inflammatory bowel disease. Urgent care
recommended urgent GI appointment for workup of inflammatory
bowel disease. However, given the severity and inability to
tolerate POs, the patient opted to go to the ED for further
evaluation and management.
In the ED, initial vitals were: T98.0 P81 BP095/83 RR18 SpO2 99%
RA. Labs were unremarkable. Patient did not have any imaging.
Patient was given morphine.
Upon arrival to the floor, patient reports significantly
improved abdominal pain secondary to morphine. She notices her
stools have been softer in the last 6 weeks, however she has not
had hematochezia prior to today.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Obesity
Rhinitis, Allergic
Sleep apnea
Menorrhagia
Vitamin D deficiency
Vitamin B12 deficiency
Chronic intractable pain
BPPV (benign paroxysmal positional vertigo)
Asthma with bronchitis
Migraine
Arthralgia of knee, right
Fibromyalgia
S/p cholecystectomy
Social History:
___
Family History:
Father: ___ type 2, hypertension
Mother: ___ cancer, bacterial meningitis, ___
Uncle: ___- unclear what type.
Maternal Aunt: ___ cancer s/p colostomy.
Physical Exam:
ON ADMISSION:
===============================
Vitals: T98.3 BP112/68 P71 RR20 98RA
General: Obese, well-appearing, no acute distress.
HEENT: Pupils equal and reactive to light. Sclera anicteric. No
oral lesions. Oropharynx clear.
Neck: Supple, no lymphadenopathy.
CV: RRR, normal S1, S2. No murmurs.
Lungs: Clear to auscultation bilaterally.
Abdomen: Hypoactive bowel sounds. Soft, obese. Tender to
palpation diffusely, but most prominently in the epigastric
region and left quadrants.
GU: DRE with pain but not blood on glove. Possible internal
hemorrhoids, hemoccult positive.
Ext: Warm and well perfused. Pulses 2+. No peripheral edema.
Neuro: Grossly intact.
Skin: No rash.
ON DISCHARGE:
================================
VS: T97.8 ___ HR72 RR18 99RA
GENERAL: Obese, well-appearing, no acute distress. Ambulatory.
CV: RRR, normal S1, S2. No murmurs.
LUNGS: Clear to auscultation, no wheezes or rales.
ABD: Hypoactive bowel sounds. Soft, obese. Tender to palpation
in epigastric region but also diffusely in lower abdomen. No
rebound or guarding.
BACK: No spinal or paraspinal tenderness. No CVA tenderness.
Tender in right lower back muscles.
EXT: Warm. DP pulses 2+. No peripheral edema.
NEURO: Grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 05:15PM BLOOD WBC-10.1 RBC-3.89* Hgb-12.0 Hct-36.8
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.3 Plt ___
___ 05:15PM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-141
K-4.9 Cl-104 HCO3-28 AnGap-14
___ 05:15PM BLOOD ALT-20 AST-41* AlkPhos-83 TotBili-0.3
___ 05:15PM BLOOD Albumin-4.3
MICROBIOLOGY:
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
URINE:
___ 12:21PM URINE Color-Yellow Appear-Cloudy Sp
___
___ 06:45PM URINE Color-Straw Appear-Clear Sp ___
___ 12:21PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-2* pH-6.0 Leuks-NEG
___ 06:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:21PM URINE RBC-6* WBC-0 Bacteri-NONE Yeast-NONE
Epi-15
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-8.2 RBC-3.86* Hgb-12.0 Hct-36.9
MCV-96 MCH-31.1 MCHC-32.5 RDW-13.2 Plt ___
___ 05:40AM BLOOD Glucose-81 UreaN-8 Creat-0.8 Na-136 K-3.8
Cl-100 HCO3-31 AnGap-9
___ 05:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
URINE AND BLOOD CULTURES - NGTD
___ CT ABD PELVIS W CONTRAST
No acute process seen in the abdomen or pelvis. Normal
examination.
Brief Hospital Course:
___ with obesity, asthma, chronic back pain, and fibromyalgia,
who presents with 3 days of abdominal pain and bloody diarrhea.
# VIRAL GASTROENTERITIS / ABDOMINAL PAIN: Most likely given
associated diarrhea and acute time course without other risk
factors. IBD unlikely given acute time course. Her exam was not
consistent with level of stated pain. No fissures visualized on
rectal exam, but she is guiaic positive. She had regular bowel
movements. Some abdominal pain after meals, but not
consistently. Exam with mildly tender epigastric area.
Presentation most likely viral gastroenteritis and she was
treated with IV fluids and symptomatic medications. She had no
fevers, normal CBC, chemistries, lipase, UA. CT abdomen and
pelvis with contrast was normal. Stool studies were normal. No
further diarrhea or bloody stools in the hospital. She was
treated with omeprazole and Maalox. She was initially given
morphine IV but this was quickly transitioned to PRN Zofran,
Tylenol, and tramadol. She tolerated a regular diet. She
continued to have abdominal pain of unclear etiology, but exam
was reassuring and labs and imaging were normal. We set her up
with outpatient GI. She was given prescriptions for omeprazole
and symptom control with ondansetron and tramadol.
# Asthma: Asymptomatic. Cont flovent BID. Albuterol PRN.
# Fibromyalgia: Stable. Cont cymbalta.
### TRANSITIONAL ISSUES ###
-Started on omeprazole for 2 weeks for empiric gastritis
-PRN ondansetron and tramadol for symptom control
-Outpatient GI consultation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 20 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Duloxetine 20 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Ondansetron 8 mg PO Q8H:PRN nausea, vomiting
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
5. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
6. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Abdominal pain of unclear etiology
-Viral gastroenteritis
SECONDARY:
-Obesity
-Asthma
-Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
abdominal pain and bloody diarrhea. Your exam and bloodwork were
reassuring. You had a normal CT scan of your abdomen. You most
likely have a viral gastroenteritis, and this will improve.
Please keep up your fluids and nutrition.
You have been started on omeprazole for two weeks, which will
help to heal your stomach in case you have any gastritis or
inflammation in your GI tract. You have follow up scheduled with
your primary care and Gastroenterology.
Followup Instructions:
___
|
10614384-DS-22 | 10,614,384 | 29,975,933 | DS | 22 | 2139-04-11 00:00:00 | 2139-04-11 15:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
near syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with a history of renal artery
stenosis s/p stenting of the L renal artery (___), a history of
a single episode of afib ___ (not treated), and HTN on
metoprolol succinate who presents with near syncope and
bradycardia after getting a prostate MRI for elevated PSA. At
the MRI he received dye and glucagon (he believes it was IM),
his BP afterwards was 126/72 with a HR of 48-52. He was driving
home from the MRI today and he felt nauseous, diaphoretic, and
like he was going to pass out. He has never had an episode like
this in the past. It was not associated with CP/SOB or
palpitations. He had afib in the past but his was a different
sensation. He has had no recent peripheral edema. Denies
f/c/s, parasthesias, weakness, HA, visual changes.
He presented to ___ where he was found to have a HR in
the 40's (per patient baseline is in 50's) and low blood
pressure. Labs significant for negative troponin, CBC and
Chem10 WNL. He received IVF, and then had another episode where
he was brady to ___ and was treated with .5mg atropine and
responded appriopriately. In our ___ initial vitals were 97.6 58
148/68 18 99% 2L Nasal Cannula, and he was admitted to ___ for
symptomatic bradycardia.
Of note, patient had Holter monitoring performed in ___ and was
in sinus rhythm with rates from ___ with an average rate of
50bpm. Per patient, he measures BP and pulse at home and his HR
is generally in the 40's-50's and BP in 120's to 130's.
On arrival to the floor patient has no complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
History of paroxysmal afib, not on coumadin (CHADS score of 1)
Holter monitor ___ -
Predominant sinus rhythm/sinus bradycardia (34-93 BPM; average
50 BPM), normal intervals; no significant pauses. 2. Small
amount of atrial ectopy (APBs, couplets/short atrial
tachycardia/ectopic atrial rhythm runs). 3. Negligible
ventricular ectopy. 4. No symptoms.
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
left renal artery stenosis, status post stenting in ___.
BPH, multiple benign prostate biopsies, followed by urology
Social History:
___
Family History:
His mother has sick sinus syndrom (tachy brady) and afib, she is
alive in her ___. Dad died in ___ of renal failure. 4
siblings, all healthy. No family history of early MI,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
74.2kg
98.1, 141/61, 51, 18, 100%RA
GENERAL: WDWN man 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 of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
exam essentially unchanged on discharge
Pertinent Results:
___ 06:37AM BLOOD Glucose-94 UreaN-17 Creat-0.9 Na-139
K-4.5 Cl-107 HCO3-25 AnGap-12
___ 09:03PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:37AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:37AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1
___ 06:37AM BLOOD TSH-0.28
___ 14:44 - Sinus bradycardia, left axis deviation.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of renal artery
stenosis s/p stenting of the L renal artery (___), afib ___,
and HTN on metoprolol succinate who presents with near syncope
and bradycardia after getting a prostate MRI for elevated PSA.
#Presyncope with bradycardia. Patient reports prodrome, nausea,
diaphoresis, pallor, and sensation of seeing bright light, all
compatible with a vasovagal episode. Possible trigger is the
glucagon which was administered IM and could have made him
nauseous and hypotensive even ___ hours after he got his
prostate MRI. Patient likely has increased vagal tone at
baseline given his resting heart rate in the ___ and known
heart rate to 30's on his holter monitor test in ___. Ischemia
unlikely given benign EKG and negative CE's. Sick sinus syndrom
also in differential given his family history, however this is
his only episode of presyncope and he is able to mount an
appropriate response to exercise (he jogs 4 miles at a time ___
/ week). During his stay he had no events on tele; his HR
ranged from 30___s-___'s and he had no symptoms. TSH was WNL.
#HTN. BP's were 101/69-141/61. He was continued on his home
lisinopril 5mg daily but we discontinued his home metoprolol
given his bradycardia.
Chronic Issues:
#HLD
-continued home simvastatin 5mg
#History of paroxysmal a-fib. CHADS score of 1 for HTN.
Anticoagulation not indicated.
# CORONARIES:
-continued ASA 325 mg daily for primary prevention
Transitional Issues:
Bradycardia - will follow up with PCP and cardiologist. He is
advised to call if he has any symptoms. He was discharged off
metoprolol. He will also call if he has any symptoms of afib.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
hold for SBP<110
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Simvastatin 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
hold for SBP<110
3. Simvastatin 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
bradycardia
pre-syncope
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 first went to ___
___ after feeling faint while driving home from an MRI.
You were found to have a very slow heart rate. They transferred
you to our facility to evaluate this slow heart rate
(bradycardia) and decide if you needed a pacemaker or other
procedure.
You have not had further episodes of feeling lightheaded. Our
overnight monitoring of your heart showed a slow but regular
rhythm. We believe that your symptoms are due to a slowing of
the heart partially due to your metoprolol medication and
partially due to your body's response to the MRI. We stopped
the metoprolol to keep your heart rate slightly higher and avoid
this symptomatic effect.
You should discuss the use of metoprolol with your cardiologist.
You were started on this medication to reduce the chance of
having a rapid, irregular heart rate. However, it may overshoot
and give you a heart rate that is as times too low.
Please review your medication list carefully. Please also book
appointments to see your primary care physician and cardiologist
as noted below.
Followup Instructions:
___
|
10614625-DS-24 | 10,614,625 | 25,554,833 | DS | 24 | 2143-02-27 00:00:00 | 2143-03-04 10:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Zantac / Penicillins
Attending: ___.
Chief Complaint:
Asthma/Flu
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a a ___ woman with PMHx significant for DM,
HTN, asthma, and multiple chronic pain issues including low back
pain and migraines, who presents with a 1 day history of
generalized body aches, headache, fever, chills, nausea, and
vomiting. The patient states that ___ days ago she developed
fever, cough productive of light sputum, and sore throat. Since
then it has progressed to severe body aches. States it hurts
when she coughs. She reports that yesterday she vomited ___
times non-bloody, has not vomited today. Normal bowel movements
with the last one being yesterday. Today she complains of
subjective feeling of abdominal distention. Additionally she has
had a headache for the last few days.
In the ED, initial vital signs were: T 104 P 95 BP 117/53 R 18
O2 sat 97%. Exam was notable for diffuse mild expiratory wheeze,
generalized body tenderness, intact neurologic exam. Labs were
notable for lactate 1.0, WBC 2.7, H/H 9.2/28.8, BUN/Cr ___.
Patient was held overnight for further evaluation. Patient was
given 1L of fluids, tamiflu and her usual medications as well as
metoclopramide.
Past Medical History:
PMH: Chronic Back Pain, Asthma, DM, Hyperlipidemia, HTN,
migraine, OA, OSA, diverticulosis
PSH: History of 11 prior abdominal procedures including ovarian
procedure, bowel perforation, Hysterectomy, Ovaryiectomy
w/single remaining ovary
Social History:
___
Family History:
Family history is notable for cardiac disease of her sisters.
Physical Exam:
ADMISSION EXAM:
Vitals- T98.2 P72 BP104/66 RR 18 O2 Sat 100% Room Air
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Oropharynx is clear.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Diffuse expiratory wheezes bilaterally.
ABDOMEN: Obese, Normal bowels sounds, non distended, mildly
tender to deep palpation, worse on left. No organomegaly
aprreciated.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. Grossly normal strength througout.
Normal sensation.
DISCHARGE EXAM:
Vitals- 98.1| 124-144/60-90| 60-90s| 18| 100% on RA
GENERAL: AOx3, NAD, sitting up in bed
HEENT: EOMI
NECK: No cervical lymphadenopathy.
CARDIAC: RRR, no m/r/g
LUNGS: Few expiratory wheezes bilaterally
ABDOMEN: Obese, non distended, no TTP
EXTREMITIES: No edema
NEUROLOGIC: Alert and oriented.
Pertinent Results:
ADMISSION LABS:
___ 03:40PM BLOOD WBC-4.7# RBC-3.59* Hgb-10.2* Hct-32.0*
MCV-89 MCH-28.4 MCHC-31.9* RDW-14.9 RDWSD-47.9* Plt Ct-78*
___ 03:40PM BLOOD Neuts-53.7 ___ Monos-10.4
Eos-0.4* Baso-0.6 Im ___ AbsNeut-2.52# AbsLymp-1.60
AbsMono-0.49 AbsEos-0.02* AbsBaso-0.03
___ 03:40PM BLOOD Glucose-119* UreaN-22* Creat-1.3* Na-134
K-4.3 Cl-99 HCO3-21* AnGap-18
___ 03:45PM BLOOD Lactate-2.2*
___ 06:37AM BLOOD Lactate-1.0
___ 05:21AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.5
___ 05:21AM BLOOD Glucose-213* UreaN-21* Creat-1.0 Na-140
K-4.2 Cl-107 HCO3-24 AnGap-13
___ 05:21AM BLOOD WBC-2.3* RBC-3.29* Hgb-9.1* Hct-29.7*
MCV-90 MCH-27.7 MCHC-30.6* RDW-14.7 RDWSD-48.9* Plt Ct-65*
DISCHARGE LABS:
___ 05:21AM BLOOD WBC-2.3* RBC-3.29* Hgb-9.1* Hct-29.7*
MCV-90 MCH-27.7 MCHC-30.6* RDW-14.7 RDWSD-48.9* Plt Ct-65*
___ 05:21AM BLOOD Glucose-213* UreaN-21* Creat-1.0 Na-140
K-4.2 Cl-107 HCO3-24 AnGap-13
___ 06:37AM BLOOD Lactate-1.0
IMAGING/REPORTS:
CXR ___
No focal consolidation is seen. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are stable.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
HEAD CT ___
There is no hemorrhage, acute infarction, edema, large mass, or
mass effect. Mild prominence of the ventricles and sulci is
consistent with age-appropriate global involutional change.
There is preservation of gray-white matter differentiation. The
basal cisterns are patent, and there is no shift of normally
midline structures. There is mild left maxillary sinus,
sphenoid sinus, and ethmoid air cell mucosal thickening. The
frontal and right maxillary sinuses are clear. The mastoid air
cells are clear. The globes and bony orbits are intact and
unremarkable.
IMPRESSION:
No acute intracranial process.
ABDOMINAL XRAY ___
There are no abnormally dilated loops of large or small bowel.
Air and stool is seen in the large bowel to the rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Surgical clips are seen in
the right
pelvis. Note is made of 6 lumbar type vertebral bodies.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
IMPRESSION:
Nonobstructive bowel gas pattern.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
___ woman with PMHx significant for DM, HTN, asthma, and
multiple chronic pain issues including low back pain and
migraines, who presented with Flu A and asthma flare.
#Asthma Flare: Patient has known asthma but baseline peak flow
is unknown, she has never been admitted or intubated in the past
for asthma. She uses her albuterol ___ per wk. Peak flow on
admission was 150, on discharge 225 with ambulatory saturation
at 97%. She was started on prednisone 40mg per day, Day 1
___. She was given duonebs PRN Q4HPRN. Her oxygenation
saturation remained good on room air. The patient was adamant
about leaving on day of discharge, understood that should her
symptoms worsen or not continue to improve she should return to
the emergency department.
#Patient reported approximately a week of symptoms including
fevers and body aches as well as sore throat, nausea and
vomiting. She was found to be flu A positive in the ED. She was
started on Tamiflu BID x 5 days. D1 ___. Last ___.
#Abdominal Pain: Patient has had EGD and colonoscopy several
years ago which showed diverticulosis. Patient has had history
of multiple abdominal surgeries. Current pain possibly secondary
to repeated retching and vomiting. However she has been passing
gas and having normal bowel movements. KUB without obstruction.
LFTs stable to chronic mild elevation. Lipase WNL.
CHRONIC
# Thrombocytopenia: 50 on admission. Has continued to drop over
the last year. Recent baseline appears to be ___. Followed by
Heme Dr. ___, MD. ___ etiology is likely ITP. Held SC
Heparin for low platelets.
# DIABETES MELLITUS: Last hgA1C 7.7%. On Metformin, Glipizide,
and insulin. Held oral medications. Continued insulin, added
sliding scale.
# HYPERLIPIDEMIA: Continued on home simivstatin 40 mg.
# HYPERTENSION: Home lisinopril and furosemide held in setting
of mild hypotension, restarted on discharge.
TRANSITIONAL ISSUES:
-Re-check Peak flow (peak flow 225 on discharge)
-Prednisone 40 mg PO for 7 days D1 ___ last day ___
-Patients WBC decreased, please re-check CBC with diff to ensure
patient isn't neutropenic. On D/C WBC was 2.4.
-Thrombocytopenia has continued to decrease platelets on D/C 56
(known ITP).
-Tamiflu D1 ___ last day ___
# Code Status: Full Code confirmed
# Emergency Contact/HCP: Son ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 20 mg PO BID
2. Acetaminophen w/Codeine 1 TAB PO DAILY:PRN head ache
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
5. ClonazePAM 1 mg PO QID:PRN anxiety
6. FeroSul (ferrous sulfate) 325 mg (65 mg iron) oral DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
9. Furosemide 20 mg PO DAILY
10. Gabapentin 600 mg PO TID
11. GlipiZIDE XL 10 mg PO BID
12. Glargine 20 Units Bedtime
Humalog 10 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
14. Lisinopril 5 mg PO DAILY
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Montelukast 10 mg PO DAILY
17. Nortriptyline 10 mg PO QHS
18. Omeprazole 20 mg PO BID
19. QUEtiapine Fumarate 200 mg PO QHS
20. Simvastatin 40 mg PO DAILY
21. Cetirizine 10 mg PO DAILY
22. Docusate Sodium 100 mg PO BID:PRN constipation
23. DiCYCLOmine 10 mg PO BID
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. ClonazePAM 1 mg PO QID:PRN anxiety
3. DiCYCLOmine 10 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fluoxetine 20 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 600 mg PO TID
8. Glargine 20 Units Bedtime
Humalog 10 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
9. Montelukast 10 mg PO DAILY
10. Nortriptyline 10 mg PO QHS
11. Omeprazole 20 mg PO BID
12. QUEtiapine Fumarate 200 mg PO QHS
13. Simvastatin 40 mg PO DAILY
14. OSELTAMivir 30 mg PO Q12H
Last day ___
RX *oseltamivir [Tamiflu] 30 mg 1 capsule(s) by mouth every 12
hours Disp #*3 Capsule Refills:*0
15. PredniSONE 40 mg PO DAILY
Last day ___
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
16. Acetaminophen w/Codeine 1 TAB PO DAILY:PRN head ache
17. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath
18. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
19. FeroSul (ferrous sulfate) 325 mg (65 mg iron) oral DAILY
20. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
21. Furosemide 20 mg PO DAILY
22. GlipiZIDE XL 10 mg PO BID
23. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
24. Lisinopril 5 mg PO DAILY
25. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Flu A
Asthma Flare
Secondary:
Thrombocytopenia
DM2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ for fevers, headache, and
body aches. We found that you had the flu which caused you to
have an asthma flare. We treated you with medications and your
symptoms improved. You told us you had abdominal pain which was
likely because of all your vomiting. Your x-ray did not show
anything concerning and your labs were stable. Your symptoms
should continue to improve after you leave. Please take all of
your medications as prescribed and attend all of your follow up
appointments, particularly the scheduled follow-up you mentioned
with your primary care provider this coming ___. Take care
and be well.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10614625-DS-25 | 10,614,625 | 29,597,160 | DS | 25 | 2143-04-09 00:00:00 | 2143-04-09 19:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Motrin / Zantac / Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ ___ with multiple previous abdominal
surgeries presenting with one day of abdominal pain and
vomiting. She woke up yesterday morning with diffuse, throbbing
abdominal pain, then had 5+ episodes of non-bloody, yellow
emesis. Her last bowel movement was yesterday at around 5pm, and
was normal in quality and caliber. She has not passed gas for
more than 24 hours. She feels that her stomach is more distended
than usual. Denies fever within the last week or diarrhea. No
recent sick contacts or travel. She explains that a few weeks
ago she had a fever associated with a respiratory infection,
which is improving but she is still experiencing cough,
congestion.
Past Medical History:
Past Medical History:
- IDDM
- HTN
- HLD
- asthma
- migraines
- chronic back pain
- depression & anxiety, recent ED evaluation on ___ for SI
Past Surgical History:
___: L salpingo-oophorectomy complicated by sigmoid
perforation
___: Sigmoid resection, creation ___ pouch,
takedown of splenic flexure and sigmoid colostomy.
___: I&D, debridement of abdominal abscess
___: Left colectomy/colostomy closure, takedown splenic
flexure, diverting ileostomy
___: Ileostomy take-down
___: Laparotomy, excision of scar and extensive
adhesiolysis.
___: Ventral hernia repair w/ vicryl mesh
___: Incisional hernia repair w/ mesh
___: Medial L knee meniscectomy
___: R knee meniscectomy
___: R total knee replacement
Social History:
___
Family History:
Family history is notable for cardiac disease of her sisters.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.4 BP:130/74 HR:110 RR:18 O2:96% on 2.5L NS
GEN: A&Ox3
HEENT: No scleral icterus, dry membranes moist
CV: Tachycardic, regular rhythm, no M/G/R
PULM: Rhonchi throughout
ABD: Obese, multiple prior surgical scars, no umbilicus,
moderately distended, tender in RLQ and LLQ without rebound or
guarding, no palpable masses/hernia
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 98.4, BP: 112/62, HR: 82, RR: 20, O2: 98% RA
General: A+Ox3, NAD
CV: RRR
PULM: rhonchi with cough, CTA b/l at bases
ABD: soft, non-distended, non-tender
Extremities: no edema, warm, well-perfused b/l
Pertinent Results:
___ 09:50PM GLUCOSE-128* UREA N-15 CREAT-0.9 SODIUM-135
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-12
___ 09:50PM CALCIUM-8.8 PHOSPHATE-1.7* MAGNESIUM-2.8*
___ 05:19AM GLUCOSE-255* UREA N-25* CREAT-1.2* SODIUM-138
POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 05:19AM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-1.4*
___ 05:19AM WBC-7.1 RBC-4.09 HGB-11.4 HCT-36.7 MCV-90
MCH-27.9 MCHC-31.1* RDW-15.0 RDWSD-49.5*
___ 05:19AM PLT SMR-LOW PLT COUNT-88*
___ 02:45AM cTropnT-<0.01
___ 02:45AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 02:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-TR
___ 02:45AM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-9 TRANS EPI-<1
___ 02:45AM URINE HYALINE-4*
___ 02:45AM URINE MUCOUS-RARE
___ 09:04PM LACTATE-1.7
___ 08:11PM GLUCOSE-189* UREA N-24* CREAT-1.2* SODIUM-136
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
___ 08:11PM ALT(SGPT)-52* AST(SGOT)-46* ALK PHOS-133* TOT
BILI-0.5
___ 08:11PM LIPASE-32
___ 08:11PM cTropnT-<0.01
___ 08:11PM ALBUMIN-4.5
___ 08:11PM WBC-6.0 RBC-4.34 HGB-12.0 HCT-38.8 MCV-89
MCH-27.6 MCHC-30.9* RDW-14.7 RDWSD-47.8*
___ 08:11PM NEUTS-78.9* LYMPHS-12.9* MONOS-5.8 EOS-1.3
BASOS-0.3 IM ___ AbsNeut-4.76# AbsLymp-0.78* AbsMono-0.35
AbsEos-0.08 AbsBaso-0.02
___ 08:11PM PLT COUNT-101*#
Imaging:
___: EKG:
Sinus tachycardia. Left axis deviation. ST segment depression
and T wave
inversion in leads V1-V2 with early precordial R wave transition
raising the question of active posterior ischemic process, new
as previously compared with ___. Followup and clinical
correlation are suggested.
___: KUB:
Unremarkable exam.
___: CT ABD/PEL:
1. Likely complete small bowel obstruction with a transition
point in the
right lower quadrant adjacent to ventral hernia repair mesh. No
bowel wall thickening, pneumatosis, or pneumoperitoneum.
Evaluation for bowel wall ischemia is limited without the use of
IV contrast.
2. Mild splenomegaly.
___: CXR:
New enteric tube terminates within the stomach.
___: KUB:
No evidence of obstruction or perforation.
___: CXR:
Compared to prior chest radiographs since one ___,
most recently ___.
No free subdiaphragmatic gas. Mild cardiomegaly. Lungs clear.
No pleural abnormality.
Brief Hospital Course:
Ms. ___ is a ___ year-old female with a history of multiple
previous abdominal surgeries who presented this admission with
abdominal pain and emesis. CT abd/pelvis revealed a small bowel
obstruction with a transition point in the right lower quadrant
adjacent to ventral hernia repair mesh. She was made NPO, had a
NGT placed to low continuous wall suction and started on IVF.
On HD1, the patient passed flatus and had minimal NGT output, so
her NGT was removed. Her admission EKG showed new ST depressions
in the anterior, left axis and troponins were sent which were
negative. CXR was unremarkable.
On HD2, the patient was advanced to a regular diet which was
well-tolerated. The patient was ordered oxycodone for a
migraine. The patient was later febrile to 103, urinalysis,
urine culture and blood culture were ordered. There was no
leukocytosis. CXR was unremarkable.
On HD3, the patient reported facial and ear pain and she was
diagnosed with acute sinusitis. Given her allergy to
penicillin, she was started on Azithromycin. The patient has a
history of migraines and PO fioricet prn was started. A social
work consult was placed to address her current housing and
coping issues.
On HD4, the patient was again febrile to 103 at night time and
she received acetaminophen with good effect. On HD5, the
patient reported her facial pain had greatly improved, was
afebrile and reported no abdominal pain. She had a bowel
movement and was passing flatus.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with po oxycodone and acetaminophen.
Oxycodone was discontinued as she reported her pain had
improved. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. 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.
The patient's intake and output were closely monitored. 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, voiding without assistance, and pain was well
controlled. The patient received discharge with the aid of
___ interpreter services. Teaching and follow-up
instructions were discussed with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
scheduled with the patient's Primary Care Provider.
Medications on Admission:
Medications: (per psych ED eval note on ___
1.Cetirizine 10 mg PO DAILY
2.ClonazePAM 1 mg PO QID:PRN anxiety
3.DiCYCLOmine 10 mg PO BID
4.Docusate Sodium 100 mg PO BID:PRN constipation
___ 20 mg PO BID
___ Propionate NASAL 1 SPRY NU DAILY
7.Gabapentin 600 mg PO TID
8.Glargine 20 Units Bedtime
Humalog 10 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
___ 10 mg PO DAILY
10.Nortriptyline 10 mg PO QHS
11.Omeprazole 20 mg PO BID
12.QUEtiapine Fumarate 200 mg PO QHS
13.Simvastatin 40 mg PO DAILY
14.Acetaminophen w/Codeine 1 TAB PO DAILY:PRN head ache
15.Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath
16.Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
___ (ferrous sulfate) 325 mg (65 mg iron) oral DAILY
___ HFA (fluticasone) 220 mcg/actuation inhalation BID
___ 20 mg PO DAILY
20.GlipiZIDE XL 10 mg PO BID
21.Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
22.Lisinopril 5 mg PO DAILY
___ (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Montelukast 10 mg PO DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
4. Nortriptyline 10 mg PO QHS
5. QUEtiapine Fumarate 200 mg PO QHS
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
7. Omeprazole 20 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. FLUoxetine 40 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. ClonazePAM 1 mg PO QID:PRN anxiety
13. Cetirizine 10 mg PO DAILY
14. Acetaminophen 500 mg PO Q4H:PRN Fever
15. Azithromycin 500 mg PO Q24H Duration: 3 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth Q24H Disp #*1
Tablet Refills:*0
16. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every eight (8) hours Disp #*10 Tablet
Refills:*0
17. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
18. Single Point Cane
Dx: Small bowel obstruction
Px: Good
Duration: 13 (thirteen) months
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Small bowel obstruction
Secondary:
Acute sinusitis
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 with a small bowel
obstruction. You were managed non-operatively and had a tube
placed in your nose into your stomach to help decompress your
abdomen. Your obstruction resolved on its own and the tube was
removed. You are now having bowel function, tolerating a
regular diet, and your pain is better controlled.
You were also diagnosed with acute sinusitis, an infection of
your sinuses which can cause facial pain and fevers. You were
started on an antibiotic called Azithromycin and will be
discharged with a prescription.
You are now medically cleared 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.
Followup Instructions:
___
|
10614625-DS-26 | 10,614,625 | 26,074,363 | DS | 26 | 2143-05-28 00:00:00 | 2143-05-30 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Zantac / Penicillins / levofloxacin
Attending: ___
Chief Complaint:
cough, fatigue, back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ F with PMHx DM, HTN, HLD, asthma, depression
& anxiety with ED evaluation on ___ for SI (discharged to
follow-up with Arbour), recent admission ___ for SBO
managed conservatively (also treated for acute sinusitis; noted
to have new anterior ST depressions with L axis compared to EKG
1mth prior but troponins were negative), now admitted for PNA.
She returns to the ED today with several days of malaise, cough
and dyspnea. She also had myalgias of her back. She had some CP
with coughing, none with exertion.
In the ED, initial VS were: 98.6 101 113/61 18 96% Nasal
Cannula.
Exam notable for: scattered wheeze, rhonchi most pronounced
right base, there is suprapubic tenderness
Labs showed: No leukocytosis or bandemia. Hct 33. BUN/Cr ___.
Mg 1.4. P 1.6. AP 116 (TBili 1.0). proBNP 1014. Lactate 1.7. UA
negative for infection.
Imaging showed: CXR: Right lower lobe focal opacity which could
be pneumonia in the proper clinical setting. Repeat after
treatment suggested to document resolution.
EKG with NSR, nl axis, QTc 481msec, TWI V1-V3.
Received:
___ 16:38 PO Acetaminophen 1000 mg
___ 16:38 IV Levofloxacin 750 mg
*Suffered localized skin rash at IV site, was given Benadryl and
switched to CTX.
___ 16:58 IH Albuterol 0.083% Neb Soln 1 NEB
___ 16:58 IH Ipratropium Bromide Neb 1 NEB
___ 16:59 IVF 1000 mL NS 1000 mL
___ 17:45 IV Azithromycin 500 mg
___ 17:45 IV DiphenhydrAMINE 50 mg
Transfer VS were: 98.6 86 103/61 18 96% RA.
On arrival to the floor, patient reports that she is feeling
so-so. Last night she developed pain in her back and waist. She
had to go to bed with this. Also reports chronic cough that has
worsened over the last several days. Says that she was coughing
so much that she was unable to get out of bed. Regarding her
back pain, she has chronic back pain but says this pain was
worse. Notes intermittent radiation to her legs. Denies
urinary/fecal incontinence, new focal weakness,
numbness/tingling or fevers/chills. Denies fevers, chills, n/v,
diarrhea, constipation, chest pain, SOB, dysuria. Also reports
some chest pain at home that she has a hard time describing. Is
non radiating. Not associated with SOB, diaphoresis, vomiting,
but she did have some nausea. Denies recent sick contacts. Has
not had recent falls or trauma but says she has fallen at home
before, but has never lost consciousness. Has felt dizzy before
and felt dizzy earlier today.
Past Medical History:
Past Medical History:
- IDDM
- HTN
- HLD
- asthma
- migraines
- chronic back pain
- depression & anxiety, recent ED evaluation on ___ for SI
Past Surgical History:
___: L salpingo-oophorectomy complicated by sigmoid
perforation
___: Sigmoid resection, creation ___ pouch,
takedown of splenic flexure and sigmoid colostomy.
___: I&D, debridement of abdominal abscess
___: Left colectomy/colostomy closure, takedown splenic
flexure, diverting ileostomy
___: Ileostomy take-down
___: Laparotomy, excision of scar and extensive
adhesiolysis.
___: Ventral hernia repair w/ vicryl mesh
___: Incisional hernia repair w/ mesh
___: Medial L knee meniscectomy
___: R knee meniscectomy
___: R total knee replacement
Social History:
___
Family History:
Family history is notable for cardiac disease of her sisters.
Physical Exam:
ADMISSION EXAM:
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: distant, RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Diffuse rhonci heard along the R middle base
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
DISCHARGE EXAM:
VS - 97.9 72 113/61 17 94 r/a
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: distant, RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Diffuse rhonci heard b/l, with audible wheezing
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
LABS UPON ADMISSION:
___ 04:30PM BLOOD WBC-9.8 RBC-3.64* Hgb-10.2* Hct-33.0*
MCV-91 MCH-28.0 MCHC-30.9* RDW-16.0* RDWSD-52.9* Plt Ct-74*
___ 04:30PM BLOOD Glucose-137* UreaN-28* Creat-1.4* Na-137
K-4.0 Cl-103 HCO3-23 AnGap-15
___ 04:30PM BLOOD ALT-40 AST-33 AlkPhos-116* TotBili-1.0
___ 04:30PM BLOOD Albumin-3.9 Calcium-8.7 Phos-1.6* Mg-1.4*
___ 04:30PM BLOOD proBNP-1014*
LABS UPON DISCHARGE:
___ 12:24AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD cTropnT-<0.01
OTHER LABS:
___ 05:40AM BLOOD WBC-5.3 RBC-3.58* Hgb-10.1* Hct-32.0*
MCV-89 MCH-28.2 MCHC-31.6* RDW-15.0 RDWSD-48.9* Plt Ct-97*
___ 05:40AM BLOOD Glucose-211* UreaN-22* Creat-1.1 Na-134
K-5.1 Cl-100 HCO3-22 AnGap-17
___ 05:40AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.4
___ 04:33PM BLOOD Lactate-1.7
___ 04:30PM BLOOD ALT-40 AST-33 AlkPhos-116* TotBili-1.0
___ 04:30PM BLOOD Lipase-20
IMAGING:
IMPRESSION:
CXR ___
Right lower lobe focal opacity which could be pneumonia in the
proper clinical setting. Repeat after treatment suggested to
document resolution.
TTE ___
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 diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional/global systolic
function.
Brief Hospital Course:
___ yo ___ F with PMHx DM, HTN, HLD, asthma,
depression & anxiety with ED evaluation on ___ for SI
(discharged to follow-up with Arbour), recent admission
___ for SBO managed conservatively (also treated for acute
sinusitis; noted to have new anterior ST depressions with L axis
compared to EKG 1mth prior but troponins were negative),
admitted with fatigue, back pain and cough found to have CAP.
# RLL PNA:
CURB 65 score 1. S/p treatment with levofloxacin and
azithromycin in ED. Developed rash with levo. CXR with RLL
opacity. Given asthma and persistent cough with wheezing, likely
experiencing exacberation of asthma as well. Pt was transitioned
to cefpodoxime 400 mg BID to complete five day course (end date
___ and prednisone 60 mg daily for five days (end date ___.
# Chest Pain:
# Anterior TWI:
Pt reported CP prior to hospitalization. Pt also endorsed DOE
and relief with rest. Pt also with new EKG changes with anterior
ST depression and TWI. Troponins negative x2 during
hospitalization. Echo w/o focal wall motion abnormality and
preserved EF. A dobutamine pharmacologic stress test was
ordered and it was attempted two times, but the nuclear lab
would not perform the test given the patient's concurrent lung
disease. We requested cardiology follow up appointment, which
was pending upon discharge.
# Asthma exacerbation:
Currently wheezing on exam and report of worsening DOE at home
c/w asthma exacerbation. Pt was continued on at home meds-
Montelukast 10 mg PO DAILY, Fluticasone Propionate 110mcg 2 PUFF
IH BID, Ipratropium-Albuterol Neb 1 NEB NEB Q6H, cetirizine.
Prednisone 60 mg daily was initiated.
#Chronic pain and back pain
No warning signs of back pain given chronicity, lack of fevers,
change in weight, and new neurologic symptoms. Continued
gabapentin at reduced renal dose
# Anemia:
Baseline Hb ___. Fe level 13. TF sat 4%. C/w both ___ and ACD.
Recommend IV iron therapy as an outpatient given concurrent
infection
# Psych:
Patient continued on at home medications.
# Diabetes Mellitus:
Initiated long acting insulin at reduced dose and ISS while in
the hospital.
**Transitional issues**
-Patient's medication list in OMR was slightly different than
the medications that the pt reported taking. We did not change
any of her current medications, just added the antibiotic and
steroid.
-Patient was instructed to continue taking all of her
medications and to complete cefpoxodime and prednisone
-New medications added:
--Cefpodoxime 400 mg PO BID, to complete 7 day course ___ to
___
--Prednisone 60 mg daily, to complete 5 day course ___ to ___
-Please ensure cardiology follow up and pharm stress test upon
discharge given changes in EKG and reported chest pain and DOE.
-Patient has evidence of iron deficiency anemia and IV iron
should be considered for treatment
>30 minutes spent in coordination of care and counseling on day
of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. Montelukast 10 mg PO DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
4. Senna 8.6 mg PO BID:PRN constipation
5. Omeprazole 20 mg PO BID
6. Furosemide 20 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. FLUoxetine 40 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. ClonazePAM 1 mg PO QID:PRN anxiety
11. Cetirizine 10 mg PO DAILY
12. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Amitriptyline 100 mg PO QHS
15. Simvastatin 40 mg PO QPM
16. QUEtiapine Fumarate 200 mg PO QHS
17. Lisinopril 5 mg PO DAILY
18. Nortriptyline 10 mg PO QHS
19. Glargine 22 Units Breakfast
Humalog 10 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
20. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Amitriptyline 100 mg PO QHS
2. Cetirizine 10 mg PO DAILY
3. ClonazePAM 1 mg PO QID:PRN anxiety
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. FLUoxetine 40 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Furosemide 20 mg PO DAILY
9. Gabapentin 600 mg PO TID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
11. Lisinopril 5 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. QUEtiapine Fumarate 200 mg PO QHS
15. Senna 8.6 mg PO BID:PRN constipation
16. Simvastatin 40 mg PO QPM
17. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice daily Disp
#*16 Tablet Refills:*0
18. PredniSONE 60 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*9 Tablet
Refills:*0
19. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
Do not exceed 6 tablets/day
20. Nortriptyline 10 mg PO QHS
21. DME
Rolling walker
Dx: Asthma J45.909., Unsteady gait R26.81
Prognosis: good
Length of need: 13 months
22. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough Duration:
5 Days
RX *dextromethorphan-guaifenesin [Adult Cough Formula DM Max]
200 mg-10 mg/5 mL 5 ml by mouth q 6 hours Refills:*0
23. MetFORMIN (Glucophage) 1000 mg PO BID
24. Glargine 22 Units Breakfast
Humalog 10 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Community acquired pneumonia
Chest pain
Asthma exacerbation
Secondary diagnoses:
Chronic back pain
Anemia
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
Why did I come to the hospital?
-You came to the hospital because of cough and back pain
What happened while I was in the hospital?
-We treated you with antibiotics for pneumonia and steroids to
help with your lung inflammation
What should I do when I leave the hospital?
-Continue taking your antibiotics
-We have not made other changes to your medications so you can
continue taking your medications as prescribed
-You should follow up with your primary care physician and your
cardiologist.
Best,
Your ___ Team
Followup Instructions:
___
|
10614625-DS-29 | 10,614,625 | 29,561,176 | DS | 29 | 2146-05-05 00:00:00 | 2146-05-05 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Zantac / Penicillins / levofloxacin / amoxicillin
Attending: ___.
Chief Complaint:
CC: ___
Major ___ or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of IDDMII,
HTN, HLD, depression/anxiety presenting with dizziness and back
pain.
The patient is interviewed with the assistance of a ___
telephone translator. She reports that she has been feeling
unwell for several days prior to admission. She reports that she
has had about 1 week of right lower back pain and dysuria. She
tried cranberry juice and drinking more water, but this did not
help. She also reports that her blood sugars have become very
high, so high that they are reading over her glucometer; she has
been taking her insulin as prescribed. She reports polyuria and
polydipsia. She reports that in the days preceding her
presentation she began to feel dizzy, particularly when get up
from sitting to walk.
She denies any fevers or chills. No nausea, vomiting, abdominal
pain, or diarrhea. Denies chest pain, palpitations, shortness of
breath. She reports a cough, which has been ongoing for many
months and is worse at night.
In the ED, vitals: 97.6 116 110/63 16 95% RA
Exam notable for: right CVA tenderness, dry mucous membranes,
poorly localized mild abdominal pain without peritoneal signs
Labs notable for: Hb 10.5, plt 72, BUN/Cr ___, AG 20; lactate
5.4->2.1
Imaging: CXR
Patient given: 2L LR, magnesium sulfate 2 gm, insulin gtt,
insulin SC 4 units, ceftriaxone 1 gm
On arrival to the floor, the patient reports ongoing right lower
back pain. She reports that she feels somewhat better than when
she came to the ED.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Past Medical History:
- IDDM
- HTN
- HLD
- asthma
- migraines
- chronic back pain
- depression & anxiety, recent ED evaluation on ___ for SI
Past Surgical History:
___: L salpingo-oophorectomy complicated by sigmoid
perforation
___: Sigmoid resection, creation ___ pouch,
takedown of splenic flexure and sigmoid colostomy.
___: I&D, debridement of abdominal abscess
___: Left colectomy/colostomy closure, takedown splenic
flexure, diverting ileostomy
___: Ileostomy take-down
___: Laparotomy, excision of scar and extensive
adhesiolysis.
___: Ventral hernia repair w/ vicryl mesh
___: Incisional hernia repair w/ mesh
___: Medial L knee meniscectomy
___: R knee meniscectomy
___: R total knee replacement
Social History:
___
Family History:
Family history is notable for cardiac disease of her sisters.
Physical Exam:
VITALS: 97.5 168/88 78 18 100 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate; dry
mucous membranes
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation; right CVA
tenderness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
Pertinent Results:
Labs:
___ 10:15AM BLOOD WBC: 4.0 RBC: 3.92 Hgb: 10.5* Hct: 34.9
MCV: 89 MCH: 26.8 MCHC: 30.1* RDW: 14.1 RDWSD: 45.___*
___ 10:15AM BLOOD Glucose: 409* UreaN: 27* Creat: 1.9* Na:
138 K: 4.3 Cl: 100 HCO3: 18* AnGap: 20*
___ 10:15AM BLOOD Calcium: 9.3 Phos: 3.5 Mg: 1.2*
___ 11:17AM BLOOD Lactate: 5.4*
___ 03:26PM BLOOD Lactate: 2.1*
U/A: Nit+, ___ large, >182 WBC
Urine cx:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
OTHER DATA:
# CXR (___): No acute cardiopulm process
Brief Hospital Course:
ASSESSMENT & PLAN: ___ h/o DM2, HTN, HLD, depression/anxiety
presenting with dizziness and back pain, found to have suspected
pyelonphritis, ___, and hyperglycemia.
ACUTE/ACTIVE PROBLEMS:
# Suspected pyelonephritis:
Ms. ___ was admitted with dysuria, R flank pain,
positive urinalysis c/f pyelonephritis. She was initially
treated with IV CTX - with good symptomatic improvement. Urine
cx grew Ecoli - which was sensitive to cephalosporin. She was
placed on PO cefpodoxime (allergic to quinolones) and observed
overnight. She continued to do well - and was discharged for 8
additional days to complete a 10 day course. Pain control with
Tylenol as needed
# Acute kidney injury: Baseline Cr 1.1, admit Cr 1.9. Likely
pre-renal azotemia in setting of hyperglycemia with osmotic
diuresis. After hydration, Cr stabilized to 1.3. She may
benefit from ___ in setting of diabetes - to be explored as
an outpt.
# DM2 with hyperglycemia: She presented with dizziness,
polyuria, polydipsia, and hyperglycemia in setting of infection
as above. Elevated lactate. Although there was an elevated
anion gap, U/A ket neg, betahydroxybutyrate 0.3 making DKA
unlikely. Metformin, glipizide were held and restarted on
discharge. She was continued on Lantus, Humalog with meals,
hISS.
# Asthma: Patient with reported history of asthma and has
chronic
cough. No wheezing on exam. Per pharmacy records, pulmonary
medications have not been filled recently. Stable during this
admission.
CHRONIC/STABLE PROBLEMS:
# Thrombocytopenia
# Anemia: Chronic, stable, thought to be related to NASH
# HTN:
- Continue clonidine
# HLD:
- Continue simvastatin
# Depression/Anxiety:
- Continue venflafaxine, quetiapine, chlorpromazine, dozepin,
clonazepam, clonidine
# GERD:
- Continue pantoprazole
GENERAL/SUPPORTIVE CARE:
# Nutrition/Hydration: Diabetic
# Functional status: Activity as tolerated
# Bowel Function: As needed
# Lines/Tubes/Drains: PIV
# Precautions: None
# VTE prophylaxis: ___ if plt>50
# Consulting Services: None
# Contacts/HCP/Surrogate and Communication: See OMR
# Code Status/Advance Care Planning: Full presumed
# Disposition: Home, no services.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Doxepin HCl 100 mg PO HS
3. Pantoprazole 40 mg PO Q24H
4. QUEtiapine Fumarate 400 mg PO QHS
5. Simvastatin 80 mg PO QPM
6. Venlafaxine XR 300 mg PO QAM
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. GlipiZIDE 10 mg PO DAILY
9. ClonazePAM 1 mg PO Q8H:PRN anxiety
10. CloNIDine 0.1 mg PO TID
11. Glargine 10 Units Bedtime
Novolog 10 Units Breakfast
Novolog 13 Units Lunch
Novolog 13 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
12. ChlorproMAZINE 200 mg PO QHS
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 8 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*16 Tablet Refills:*0
3. Glargine 10 Units Bedtime
Novolog 10 Units Breakfast
Novolog 13 Units Lunch
Novolog 13 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. ChlorproMAZINE 200 mg PO QHS
5. ClonazePAM 1 mg PO Q8H:PRN anxiety
6. CloNIDine 0.1 mg PO TID
7. Doxepin HCl 100 mg PO HS
8. Ferrous Sulfate 325 mg PO DAILY
9. GlipiZIDE 10 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. QUEtiapine Fumarate 400 mg PO QHS
13. Simvastatin 80 mg PO QPM
14. Venlafaxine XR 300 mg PO QAM
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis, UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure looking after you. As you know, you were
admitted with dizziness and back pain. You were found to have a
urinary tract infection which likely involved your kidney as
well. This may partly account for your back pain. You were
treated with intravenous antibiotics and switched to oral
antibiotics once the urine cultures identified the bacteria
(E.coli) and confirmed its sensitivity to the antibiotic you are
being prescribed.
Please complete the antibiotics (Cefpodoxime) for an
additional 8 days to complete a 10 day course. Otherwise, to
avoid future urinary tract infection, please ensure that you are
well hydrated and that your diabetes is in good control. This
will prevent future urinary tract infections from happening.
You were also found to be dehydrated and with mild acute kidney
injury. After hydration, your kidney function improved. Please
insure good oral intake of fluids and good control of sugars
(higher sugars can lead to loss of water).
You may have a component of musculoskeletal back pain too. For
this, we recommend following with your medical doctor and taking
acetaminophen (Tylenol) as needed.
There are otherwise, no changes to your medication. We wish you
a quick recovery!
Your ___ team.
Followup Instructions:
___
|
10614673-DS-19 | 10,614,673 | 21,771,978 | DS | 19 | 2129-04-30 00:00:00 | 2129-05-01 18:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toradol / Imitrex / Phenothiazines / Nsaids / Morphine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ year old woman with an unclear hx of partial
complex seizures, fibromyalgia, chronic back pain s/p L3-L5
fusion, chronic prescription medication abuse (opiods, benzos,
barbs), mild intermittent asthma, depression, prolonged QTc,
domestic violence, homelessness, who presents to the ED with
AMS. Per report she usually receives her care at ___ but was
___ in to ___ by EMS after someone found her in the
___ hotel unresponsive with pill bottles next to her. On
initial evaluation she was obtunded and uncooperative with
examiners. She would answer "no" when asked if she took too much
of her medication.
On review of her partners records she recently self presented to
her psychiatrist office requesting psych admission for SI but
was not found to have active plan and therefore was not
admitted. She has also had multiple recent hospital admissions
for syncope and falls, and most recently being "hit by a cab"
during which she appeared lethargic.
She was also recently admitted here on ___ for chest pain
(neg trops, no EKG changes and negative stress test), before
eloping prior to formal discharge.
In ED initial VS: afebrile, 70, 84/56, 12, 99% RA
Exam: She has no clonus on exam. Her pupils are 1-2 mm but
responsive to light. She is minimally cooperative with her
neurologic exam.
Patient was given:
___ 20:40 IVF NS 1000 mL
___ 21:36 IV Naloxone 2 mg
Imaging notable for: normal head CT
VS prior to transfer: afebrile, 59, 108/55, 9, 99% RA
On arrival to the MICU, the patient is answering questions from
nursing, but is minimally cooperative. In the morning she
complains of chest pain and feeling ill.
REVIEW OF SYSTEMS: unable to obtain
Past Medical History:
(Per partner's records):
Unclear history of partial seizures with impairment of
consciousness
Smoker
Gastroesophageal reflux disease
Migraine
Depressive disorder
Hypercholesterolemia
Cardiac arrest
Seasonal affective disorder
Adrenal hypofunction
fibromyalgia
chronic back pain s/p L3-L5 fusion
chronic prescription medication abuse (opiods, benzos, barbs)
mild intermittent asthma
prolonged QTc
domestic violence
homelessness
Social History:
___
Family History:
Depression - Mother
___ disorder - Sister
Physical ___:
ADMISSION EXAM:
================
VITALS: afebrile, 69, 112/83, 18, 95% RA
GENERAL: obtunded
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, early ___ systolic
murmur, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash
DISCHARGE EXAM:
================
VS: 98.9 72 100/72 14 96% on RA
GENERAL: Adult female in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP no edema
Pertinent Results:
ADMISSION LABS:
================
___ 10:56PM BLOOD WBC-11.4*# RBC-3.92 Hgb-11.7 Hct-36.7
MCV-94 MCH-29.8 MCHC-31.9* RDW-13.9 RDWSD-47.9* Plt ___
___ 10:56PM BLOOD Neuts-68.9 ___ Monos-5.8 Eos-1.1
Baso-0.5 Im ___ AbsNeut-7.86*# AbsLymp-2.65 AbsMono-0.66
AbsEos-0.12 AbsBaso-0.06
___ 03:00AM BLOOD ___ PTT-29.3 ___
___ 09:34PM BLOOD Glucose-74 UreaN-9 Creat-0.5 Na-134 K-4.5
Cl-98 HCO3-27 AnGap-14
___ 09:34PM BLOOD ALT-13 AST-26 CK(CPK)-129 AlkPhos-99
TotBili-0.2
___ 09:34PM BLOOD CK-MB-3
___ 09:34PM BLOOD cTropnT-<0.01
___ 03:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:34PM BLOOD Albumin-3.8 Calcium-8.6 Phos-4.4 Mg-1.8
___ 09:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-POS* Tricycl-NEG
___ 09:44PM BLOOD ___ pO2-81* pCO2-42 pH-7.42
calTCO2-28 Base XS-2
___ 09:44PM BLOOD Lactate-1.0
DISCHARGE LABS:
================
___ 03:00AM BLOOD WBC-10.4* RBC-3.70* Hgb-11.3 Hct-34.1
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.6 RDWSD-46.5* Plt ___
___ 03:00AM BLOOD Plt ___
___ 03:00AM BLOOD Glucose-95 UreaN-8 Creat-0.5 Na-137 K-3.9
Cl-102 HCO3-27 AnGap-12
___ 03:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.6
STUDIES:
===============
CXR (___):
FINDINGS:
AP supine chest radiograph demonstrates cardiomegaly without
evidence of
pulmonary edema. Retrocardiac opacities are new relative to
prior
examination. There is no pneumothorax or pleural effusion.
There is no air under the right hemidiaphragm. Lumbar spinal
hardware is partially imaged.
IMPRESSION:
Retrocardiac opacities are new relative to prior examination for
which
infectious process is difficult to exclude. Cardiomegaly
without pulmonary edema.
Head CT (___):
FINDINGS:
There is no hemorrhage, edema, or mass effect. Ventricles and
sulci are age appropriate in size and configuration. There is
no shift of normally midline structures. Gray-white matter
differentiation is preserved. Basal cisterns are patent.
The orbits are unremarkable bilaterally. Imaged paranasal
sinuses are clear. Left mastoid air cells are clear. Minimal
opacification involves the inferior most right mastoid air
cells. Middle ear cavities are clear. There are no significant
carotid artery siphon calcifications. Bony calvarium appears
intact.
IMPRESSION:
No acute intracranial abnormality.
MICROBIOLOGY:
==============
___: Urine culture pending
Brief Hospital Course:
___ with an unclear history of partial complex seizures,
fibromyalgia, chronic back pain s/p L3-L5 fusion, chronic
prescription medication abuse (opioids, benzos, barbs), mild
intermittent asthma, depression, prolonged QTc, domestic
violence, homelessness, who presented with AMS. She was treated
with naloxone and improved. She was called out from the ICU to
the floor, and remained medically stable. On recent admission,
patient's home narcotics were tapered down with plan for patient
to follow-up with her PCP to address her other chronic medical
concerns. On this admission, psychiatry was consulted given
concern for a possible suicide attempt. Their team deemed the
overdose to be unintentional, and recommended a cross-taper from
citalopram to duloxetine. Wellbutrin was continued, though had
planned for it to be weaned by patient's PCP given history of
epilepsy and concern for lowering the seizure threshold. Patient
was discharged with a prescription for naloxone.
On this admission, patient demonstrated behaviors similar to
prior raising concern for secondary gain including attempts to
delay discharge by claiming inability to walk despite witnesses
ambulation under own power. Patient was also found to be
snorting an unknown white substance in bathroom prior to
leaving the hospital raising additional concern for medication
abuse.
===============================
TRANSITIONAL ISSUES:
===============================
[ ] Provided prescription for naloxone
[ ] STARTED DULoxetine 40 mg PO DAILY
[ ] STOPPED citalopram
[ ] Consider discontinuing buproprion, as it is contraindicated
in individuals with epilepsy.
[ ] Continued home prednisone 5mg daily given patient carries
diagnosis of adrenal insufficiency and episodic hypotension;
recommend further evaluation as outpatient
[ ] Discharged on reduced dose of hydromorphone (2mg q.4hr),
though recommend further taper of opioids given ongoing issues
regarding prescription medication abuse. Patient was not
provided a prescription at the time of discharge.
[] If readmitted, please refer to Safety Alert and prior
attending notes for details of interactions with patient
related to discharge. SW and CM should be involved in ED prior
to admission
[ ] ***See below for attending attestation from note dated
___, which outlines additional behaviors exhibited during
recent admissions***
# CODE: Full
# CONTACT: ___, ___
~~~
Patient well known to ___ A team after recent discharge from
our service. Readmitted after being found with AMS and admitted
to ICU, recovered rapidly after naloxone administration making
overdose highly likely, now transferred to floor. Seen by psych
who felt that patient did not overdose intentionally and has no
indication for involuntary inpatient psych admission but
recommended switching citalopram to duloxetine for better pain
control. Evaluation during this admission without concern for
acute medical issue given labs largely wnl, no evidence of
infection, stable VS.
On prior admission, patient was evaluated extensively for "drop
attacks" and has been evaluated as outpatient without clear
evidence of medical etiology. After completion of medical
evaluation, discharged was delayed repeatedly as patient noted
social issues including family conflict and homelessness for
which social work was intricately involved and offered multiple
options. Each day she would say that she had a plan in place
with
a family member or new financial options that would not come
together by the end of the day, leading to inability to
discharge. On her day of discharge previously, she was offered
cab vouchers and a bus ticket to get where she needed to go. She
eloped prior to receiving discharge paperwork, purportedly to
get
rx from ___, then returned after discharge where she obtained
paperwork.
She noted repeatedly today that she has been told she has a
hypothalamic issue and needs to see a specialist in this area,
which she requested today. She has had prior evaluation without
clear evidence of adrenal insufficiency as a source of putative
orthostasis and drop attacks but has been on chronic low dose
prednisone, which has been continued in house. No evidence on
labs or vitals for acute adrenal insufficiency. She was adamant
that she did not "take a mouthful of pills" and that there is
something else going on her body that has led to these multiple
drop attacks. We explained there is really not another
explanation for rapid recovery with naloxone other than opioid
overdose, so even if she did not purposefully overdose it is
clear that this is the explanation for her current admission. We
explained that similar to her last admission her inpatient
evaluation and treatment have been completed and that following
up as an outpatient would be the most appropriate plan at this
point.
She noted that she often has trouble making appointments with
her
PCP but that she loves him and does not want to switch, so I
noted that if she really cannot establish continuity with her
PCP
and wants to work on her various health issues, she may need to
consider finding another doctor. We explained that given our
past
experience where after her medical evaluation was completed her
discharge was delayed, that today would be her discharge day.
She
became upset and requested patient relations phone number, which
was provided. She also became tearful, expressing that she can't
go back to the shelter she went to before because people stole
her clothing and that she doesn't want to go to the area near
___
because she was previously raped there and it is too painful to
be near there. She expressed frustration that her brother, whom
she notes is a ___, would not be helping her find
a
place to stay. She additionally stated that she is severe pain
which limits her ability to walk.
Later in the day, she stated that her daughter would be coming
at
6pm to pick her up and that she wanted to leave. This was
similar
to her prior admission when she would claim that she made
arrangements with various family members but that plans would
always fall through later in the day. She asked that we call her
brother to discuss her case, but given that she had purportedly
made plans with her daughter, we called her daughter and were
unable to contact her. We decided that we would be discharged
patient in the afternoon, and would call security to assist with
discharge if necessary. On entering the room, the patient was
speaking with her daughter. She expressed that her daughter
would
not be coming to get her, which is consistent with events on
prior admission. She also noted that she had to get to ___ by 5
pm in order to get her prescriptions. She denied eloping in the
past, stating that a nurse told her it was ok. She also noted
several times that she couldn't walk and needed to get to
___ in order to arrange housing. We pointed out that
this behavior is nearly identical to prior, and for this reason
we would be discharging her immediately. She then became upset
and, standing up, stated she needed her IVs removed and needed
to
get dressed. At this point the MD team left the room while RNs
helped the patient get ready to go and provided discharge
paperwork. She was provided with rx for naloxone and duloxetine.
After formal discharge, the RN team reported that patient went
into bathroom to change. ___ RN was monitoring her outside the
bathroom, and as she was inside for some time the RN knocked and
opened the door where she witnessed the patient snorting an
unknown white powder. Security was called to escort her off
hospital premises, at which point she was witnessed walking
under
her own power towards ___.
~~~
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. Senna 8.6 mg PO BID:PRN constipation
3. HydrOXYzine 50 mg PO TID:PRN nausea
4. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
5. Citalopram 40 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. PredniSONE 5 mg PO DAILY
8. PHENObarbital 32.4 mg PO QID
9. Mupirocin Ointment 2% 1 Appl TP BID
10. Diazepam 5 mg PO Q8H:PRN anxiety
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Gabapentin 600 mg PO TID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every eight (8) hours Disp #*60 Tablet
Refills:*0
2. DULoxetine 40 mg PO DAILY
RX *duloxetine 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
RX *lidocaine 5 % 1 PTCH DAILY Disp #*30 Patch Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin [One-Tablet-Daily] 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
6. naloxone 4 mg/actuation nasal ONCE:PRN
RX *naloxone [Narcan] 4 mg/actuation 2 mL IN ONCE Disp #*2
Syringe Refills:*0
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
8. BuPROPion XL (Once Daily) 150 mg PO DAILY
9. Diazepam 5 mg PO Q8H:PRN anxiety
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Gabapentin 600 mg PO TID
12. HydrOXYzine 50 mg PO TID:PRN nausea
13. Mupirocin Ointment 2% 1 Appl TP BID
14. Omeprazole 20 mg PO BID
15. PHENObarbital 32.4 mg PO QID
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. PredniSONE 5 mg PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Narcotic Overdose
Secondary Diagnoses:
Depression
Chronic back pain
Chest pain
Asthma
Possible adrenal insufficiency
Epilepsy
Skin excoriations
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 found passed
out outside of the hospital. While you were here, we gave you a
medication that counteracts your pain medications and other
opioid medications, and you woke up. We believe that your
medications may have played a role in you symptoms.
We recommend that you see your primary care doctor to continue
discussing your ongoing medical care.
We are sorry that you have felt frustrated with some aspects of
your care. We encourage you to call ___ Patient relations at
___ if you would like to discuss any concerns or
questions in regards to your hospitalization.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
10614891-DS-13 | 10,614,891 | 24,624,448 | DS | 13 | 2148-09-01 00:00:00 | 2148-09-02 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Percodan
Attending: ___.
Chief Complaint:
headache and right leg weakness
Major Surgical or Invasive Procedure:
Angiogram
History of Present Illness:
This is a ___ year old woman with a history of breast cancer
(unclear type, thought to be in remission for ___ years) s/p
right mastectomy and chemotherapy, heart failure (presumed
etiology as side effect of chemotherapy), hypertension,
diverticulitis, GERD who presents as transfer from BI-P for
further management of left IPH. History obtained by patient and
as per chart review.
Patient notes that she was in her usual state of health up until
this morning when she gradually noticed a posterior throbbing
headache that began after she was moving heavy furniture (a
rug).
The pain was not thunder clap in onset but was rather sub-acute
over the span of ___ minutes. She sat down to catch her breath
and to check her blood pressure (140s/60s) and pulse (90s). Her
headache persisted but was tolerable. She then got up to walk to
the kitchen to drink some water and noticed at that time that
her
right leg felt funny, as if it was not cooperating with her to
walk. She notes feeling this sensation a few times over the past
week before but not making much of it, however this morning her
right leg was "far less cooperative" and while she initially
could bare weight after she sat down again she soon noticed that
she could not bend her leg. She then called her husband (who is
an ___ and former EN___) who came and noticed a right facial droop
and called EMS. On EMS arrival, she had stable vital signs. She
was taken to BI-P and while traveling in backwards motion in the
ambulance felt nauseous but did not throw up, noting that
backwards driving motion for her always causes nausea. At BI-P
NCHCT was performed and demonstrated left IPH prompting transfer
to ___.
On further prompting of intermittent right lower extremity funny
sensations, the patient continues to have vague descriptions of
right leg intermittently not always wanting to "cooperate" with
her movements over the past few weeks. No recent weight loss or
night sweats. Regarding her cancer history, she notes that she
continues to follow regularly with her oncologist at ___ and
has
thought to have been in remission for ___ years off
chemotherapy.
She doesn't know what type of cancer she had and does not recall
the chemotherapy but does note that she thinks her heart failure
and long-standing peripheral neuropathy was a side effect of the
chemo.
Review of systems otherwise notable for recent stressors from
her
grandchildren (high functioning autistic), son (suffers from
paranoid delusions but is refusing medical care) and a new
family
friend who is recovering from drug addiction and is living at
home with her. She notes that she did have a verbal argument
with
her family friend yesterday and this morning prior to moving
furniture throughout the house and prior to the onset of her
headache. No recent fever, chills.
Of note, her right leg strength began to improve without
intervention while she was at ___, although she still feels
some
funny sensations.
Past Medical History:
diverticulitis
? mitral vs aortic regurgitation
hypertension
right breast cancer s/p mastectomy and chemotherapy ___ years
ago)
systolic heart failure
Surgical History:
- s/p right mastectomy ___
Social History:
___
Family History:
Mother with ___ Cancer
Father with cancer
no history of brain aneurysm, bleed
no history of stroke
Physical Exam:
ADMISSION EXAM:
Vitals: afebrile, HR70-80s, BP 120s/80s, RR16, SaO2 98
General: alert, comfortable, appears stated age
HEENT: no lesions
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Chest: s/p right mastectomy
Abdomen: Soft, non-distended. Normal BS. No pain to palpation in
LLQ.
Extremities: trace bilateral ___ edema
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x3. Able to relate history
without difficulty. Attentive, able to name serial digits
backwards (span of 5) without difficulty. Language is fluent
with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Initially called pinky finger "baby
finger"
then corrected to pinky finger. Referred to hammock as swing. No
other naming difficulties. No difficulty following complex
commands. Able to read without difficulty. No dysarthria. Able
to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves: PERRL 3>2. EOMI without nystagmus. Visual
fields
full to finger counting and to confrontation. Slight right NLFF
with slight delay in activation. Facial sensation intact. No
dysarthria. Tongue midline.
-Motor: Normal bulk and tone throughout. Right pronator drift..
No adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 4 4+ 4- 4 4 4 4 4+ 4- 4 4 4-
-Sensory: Diminished vibration to 8 seconds in both toes
bilaterally. Proprioception intact to large but not medium
movements bilaterally. No extinction.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on right and flexor on left.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred secondary to right sided weakness on exam.
DISCHARGE EXAM:
BP 111/73 HR 92 RR16 O2sat93 Ra
General Exam: left groin puncture site clean, dry, intact. No
hematoma or oozing.
Neurologic exam: Only neurologic deficit is 4 in EDL on right
Pertinent Results:
___ 05:35AM BLOOD WBC-9.3 RBC-4.47 Hgb-12.9 Hct-40.7 MCV-91
MCH-28.9 MCHC-31.7* RDW-13.3 RDWSD-44.3 Plt ___
___ 05:35AM BLOOD Neuts-62.9 ___ Monos-7.6 Eos-2.5
Baso-0.6 Im ___ AbsNeut-5.87 AbsLymp-2.42 AbsMono-0.71
AbsEos-0.23 AbsBaso-0.06
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD ___ PTT-28.5 ___
___ 05:35AM BLOOD Glucose-87 UreaN-19 Creat-0.8 Na-143
K-4.3 Cl-106 HCO3-26 AnGap-11
___ 05:35AM BLOOD ALT-15 AST-16 CK(CPK)-90 AlkPhos-126*
TotBili-0.6
___ 05:35AM BLOOD TotProt-6.5 Calcium-8.5 Phos-3.8 Mg-2.2
Cholest-186
___ 05:35AM BLOOD Triglyc-105 HDL-51 CHOL/HD-3.6
LDLcalc-114
___ 05:35AM BLOOD TSH-4.3*
MR HEAD W & W/O CONTRAST
-Re-demonstrated is a left frontal lobe intraparenchymal
hematoma measuring 12
mm x 9 mm not significantly changed compared to the prior exam.
No definite
underlying enhancing lesion is identified however recommend
evaluation in ___
weeks once the acute blood products have resolved.
CTA HEAD AND CTA NECK
1. There is 1 cm acute parenchymal hematoma left frontal vertex,
no evidence
of underlying mass or vascular formation.
2. Possible 3 mm focus of calcification or hemorrhage in the
left frontal
lobe.
3. There is 2 mm infundibulum, less likely aneurysm, right
supraclinoid ICA.
4. Otherwise normal neck CTA, head CTA.
5. Asymmetric enlargement right palatine tonsil, ENT consult
recommended to
exclude neoplasm.
Brief Hospital Course:
___ PMH of breast cancer s/p mastectomy and chemotherapy thought
to be in remission for ___ years, HF, HTN, who presented for
evaluation of headache and right leg weakness, found to have
left IPH.
#Left pre-central gyrus hemorrhage
History notable for intermittent right leg weakness over past
few weeks prior to presentation although with recent trigger of
heavy-lifting of furniture prompting acute onset of headache.
MRI does not show evidence for CVT, tumor. Angiogram negative
for AVF. Risk factor labs show LDL 114, HbA1c 5.7. Repeat MRI in
8 weeks with follow-up with neurosurgery and neurology (Atrius).
#Systolic heart failure
Secondary to chemotherapy. Continued on entresto 97-103mg PO
BID, continue furosemide 40mg PO BID. proBNP pending at
discharge. ProBNP 488 (not significantly elevated). Potassium
and magnesium have been normal throughout admission so
supplementation was not given; will half the dose on discharge.
#Pauses on telemetry
Has had a history of these in the past. Seen by inpatient
cardiology who thinks they are PACs with compensatory pauses.
Patient is asymptomatic and is hemodynamically stable. Ziopatch
placed prior to discharge. Will follow-up with outpatient
cardiology (Atrius).
# Pulmonary:
CXR at OSH with ?right chest consolidation vs artifact, consider
CT chest as outpatient or inpatient pending MRI and need for
further cancer work-up.
Transitional Issues:
-F/u with neurosurgery at ___
-F/u with ___ neurology and cardiology
-CT chest per discretion of PCP
===============
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
3. Omeprazole Dose is Unknown PO BID
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Potassium Chloride 20 mEq PO DAILY
3. Furosemide 40 mg PO BID
4. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
5. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until ___
6.Rolling walker
Dx: Stroke
Length of need: 13 months
Prognosis: good
ICD: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right face, arm and leg
weakness and found to have a small bleed in the brain, called an
intracerebral hemorrhage. After extensive testing, we do not
know the reason that you had the bleed, but we do know it's not
from a tumor or other mass, or abnormal blood vessels in that
area. Because of the bleed, do not take aspirin until ___.
Please follow-up with your primary care doctor, who can refer
you to a neurologist for follow-up. You should see your
cardiologist as well. You will follow-up with neurosurgery here
at ___.
Thank you for allowing us to participate in your care.
Sincerely,
___ Neurology
Followup Instructions:
___
|
10615036-DS-8 | 10,615,036 | 29,924,972 | DS | 8 | 2111-02-03 00:00:00 | 2111-02-03 14:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
perfume / wool / Sulfa (Sulfonamide Antibiotics) / aspirin /
gabapentin / Cymbalta / levofloxacin / milk / morphine /
Macrobid / Thiazides / Topamax / gluten
Attending: ___
Chief Complaint:
Dyspnea, lower extremity redness and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of anemia,
CKD, HLD, HTN,
osteomyelitis, pulmonary nodules, and thrombocytopenia as well
as
CABG this past ___ with ppor wound healing of graft
harvest site who presents with dyspnea and concern for RLE
cellulitis.
Recently she had noted worsening chest/epigastric pain on
exertion. Given her multiple cardiac risk factors, she was
referred for coronary angiogram which demonstrated two-vessel
coronary artery disease and is now status CABG ___: CABG x3
(LIMA-LAD, SVG-PDA, SVG-Diag) (veins from RLE).
Patient was started on po Keflex on ___. According to
NP at rehab, patient is very concerned that she does not respond
well to po abx. She was changed to IV Vancomycin 1gm IV QD on
___ but wound has not significantly improved. Her last
dose of vanc was ___ at 5pm and her next trough was high at
27. Her peak temp remains ___ since then. She was seen in clinic
on ___ and her wound was debrided and re-packed. The wound
appeared to have good granulation tissue and there was no
obvious sign of infection. There her weight was noted to have
increased 3lbs in 6 days, increased ___ edema, and DOE. Since
clinic, the patient reports redness has spread to her ankle and
up to her inner thigh. It is painful to the touch. She denies
fever or chills. Notes progressive dyspnea on exertion and
orthopnea.
In the ED
- Initial vitals: 98.7 76 102/68 24 100% 3L NC
- EKG: sinus 74, TWI precordial leads, Qs anteriorly
- Labs/studies notable for:
132 89 22 138 AGap=16
============
3.7 27 1.6
___: 19.1 PTT: 30.9 INR: 1.8
RLE US:
No evidence of deep venous thrombosis in the visualized right
lower extremity veins with limited visualization of the
posterior
tibial and peroneal veins secondary to overlying bandage.
Per report, bedside echo with no effusion or tamponade
- Patient was given: 40 IV Lasix, Zosyn
- Vitals on transfer: 99.2 82 101/52 20 95% Nasal Cannula
On the floor she confirms the above. Notes dyspnea has been
going
on for weeks, was referred here by staff at ___. Said she has
gained ~20 lbs in water weight since surgery. +cough. no fever,
chest pain, abdominal symptoms, dizziness. Had felt like RLE
wound was healing. However, notes redness was up to her knee
earlier today, now up to groin.
Upon arrival to the floor she was in afib, HR 120s-150. Said she
had 2 episodes of afib after her surgery.
She is unable to confirm her meds. Says they are "in our
system."
EKG with AFib HR 130s per my interpretation.
Past Medical History:
Aberrant Right Subclavian Artery
Anemia
Anxiety
Atrial Septal Defect/Patent Foramen Ovale
Chronic Kidney Disease
Depression
Gastroesophageal Reflux Disease
GI Bleed
Hyperlipidemia
Hypertension
Ischemic Colitis
Liver Disease
Osteomyelitis
PTSD
Pulmonary Nodules
Raynaud's Syndrome
Spinal Stenosis
Thrombocytopenia
Urinary Tract Infection, recurrent
Past Surgical History:
Breast implants
Spinal w/rods placed, L3-L4 laminectomy and L4-L5 fusion with
rod ___ and ___
T10-pelvis fusion and fixation ___
Social History:
___
Family History:
Family history of premature CAD son died of massive heart attack
at age ___
Father - died from high blood pressure and heart complications
at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VS: 98.8 PO 91 / 60 Lying HR 100s - 150s 22 97 RA
GENERAL: NAD
HEENT: anicteric sclera
NECK: JVP just below earlobe at 45 degrees
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: diffuse expiratory wheezing, bibasilar crackles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: bilateral pitting edema. RLE with SVG harvestation
wound. erythema on posterior aspect of RLE extending from calf
to
inguinal region, warm and blanching
PULSES: palpable DP pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM
======================
General: WDWN elderly female in NAD
HEENT: MMM, no cyanosis
Neck: JVP at ~9 cm at 45 degrees
Lungs: No wheezing auscultated. Faint basilar crackles.
CV: RRR. Normal S1, S2, systolic murmur at RUSB.
Abdomen: Soft, nontender, nondistended.
Ext: Warm, well perfused. RLE with redness on medial side of
leg
from top of ankle to just below groin with patch on anterior
thigh. No fluctuance. Erythema mostly within previously marked
borders except for splotches of erythema on lateral aspect of R
anterior thigh. 1+ edema to below knees bilaterally. R saphenous
vein graft site with packing. No pus or drainage or increased
induration around area. Trace pitting edema bilaterally.
Pertinent Results:
==================
ADMISSION LABS
==================
___ 10:23PM BLOOD WBC-11.7* RBC-2.92* Hgb-8.8* Hct-28.0*
MCV-96 MCH-30.1 MCHC-31.4* RDW-15.3 RDWSD-53.5* Plt ___
___ 10:23PM BLOOD Neuts-69.9 Lymphs-15.9* Monos-9.4 Eos-3.3
Baso-0.5 Im ___ AbsNeut-8.16* AbsLymp-1.86 AbsMono-1.10*
AbsEos-0.39 AbsBaso-0.06
___ 10:23PM BLOOD Plt ___
___ 10:23PM BLOOD Glucose-138* UreaN-22* Creat-1.6* Na-132*
K-3.7 Cl-89* HCO3-27 AnGap-16
___ 10:23PM BLOOD cTropnT-0.23* ___
___ 07:32AM BLOOD CRP-118.1*
===========
IMAGING
===========
TTE ___
The left atrium is normal in size. There is no evidence for an
atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal
cavity size. There is suboptimal image quality to assess
regional left ventricular function. The visually
estimated left ventricular ejection fraction is 55-60%. There is
no resting left ventricular outflow tract
gradient. No ventricular septal defect is seen. Tissue Doppler
suggests an increased left ventricular filling
pressure (PCWP greater than 18mmHg). Normal right ventricular
cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic arch is
mildly dilated. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is mild
[1+] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Bilateral Lower Extremity U/S:
No evidence of deep venous thrombosis in the visualized right
lower extremity veins with limited visualization of the
posterior tibial and peroneal veins secondary to overlying
bandage.
=============
MICROBIOLOGY
=============
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 Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
==============
DISCHARGE LABS
==============
___ 06:01AM BLOOD WBC-11.1* RBC-2.64* Hgb-7.9* Hct-24.7*
MCV-94 MCH-29.9 MCHC-32.0 RDW-15.7* RDWSD-54.1* Plt ___
___ 06:01AM BLOOD Plt ___
___ 06:01AM BLOOD Glucose-117* UreaN-18 Creat-1.7* Na-137
K-3.8 Cl-96 HCO3-25 AnGap-16
___ 06:01AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.7 Iron-22*
___ 06:01AM BLOOD calTIBC-286 Ferritn-77 TRF-220
___ 04:24AM BLOOD CRP-71.8*
___ 06:01AM BLOOD Vanco-21.8*
Brief Hospital Course:
=========
SUMMARY
========
Ms. ___ is a ___ year old woman with a history of anemia,
CKD, HLD, HTN, osteomyelitis, pulmonary nodules, and
thrombocytopenia as well as
CABG this past ___ with poor wound healing of graft
harvest site who presents with dyspnea and concern for RLE
cellulitis.
Ms. ___ is a ___ yo F with PMH of anemia, CKD, HLD, HTN,
osteomyelitis, pulmonary nodules and recent CABG x ___,
presenting with dyspnea, HFpEF exacerbation, AFib and RLE
cellulitis complicated skin and soft tissue infection related to
SVG donor site extending through thigh, groin on IV antibiotics.
===========
ACUTE ISSUES
============
#Complicated skin and soft tissue infection:
Presented with extensive erythema of RLE with rapid progression.
There was no fluctuance, drainage, or evidence of subcutaneous
gas on exam. She had been on outpatient vancomycin per cardiac
surgery for delayed wound healing of graft harvest site. Clinic
visit 2 days prior to admission without any signs of infection.
ID was consulted and recommended ceftriaxone for suspected strep
infection and continuing vancomycin, and clindamycin for
antitoxin effect. Patient showed improvement with this
antibiotic course. Patient was given vancomycin on discharge
which will essentially give her a 7 day course (___)
(have been dosing vanc based on daily level but unable to check
daily levels at rehab so will complete 7 day course prior to
discharge to prevent vanc toxicity). Low suspicion for MRSA and
suspect most improvement in cellulitis is due to CTX. Please
continue IV Ceftriaxone for total 14 day course ___ -
___. Low threshold to add back on vanc if worsening.
#Atrial fibrillation with rates 120s-140s
Onset of atrial fibrillation since CABG in ___, for which
she was on eliquis and metoprolol. On admission, she had
asymptomatic rapid rate to 140. Likely triggered by infection
and co-occurring with heart failure exacerbation. She converted
to NSR on HD1 and remained in NSR with rates in ___ with
metoprolol 50 q8h (increased from home does 37.5 TID). Her
anticoaguation was switched to a heparin gtt as her renal
function was decreased on admission. With slight improvement of
her renal function, apixaban was re-started at low dose of 2.5mg
BID. Please, increase dose to 5mg BID once renal function
improves.
#Acute HFpEF Exacerbation:
Symptoms included lower extremity edema, orthopnea, and dyspnea
on exertion. Elevated BNP to 18k, found to be hypervolemic on
exam. Home medications were bumex and metolazone. Likely
triggered by infection and coincident with atrial fibrillation
with rapid rates. Diuresed with IV lasix 40 mg BID and UOP
closely monitored with foley. Home lisinopril held due to ___
and soft BPs. TTE (___) showed preserved global biventricular
systolic function with mild mitral and tricuspid regurgitation
and mild pulmonary hypertension.
___ on CKD: Cr 1.6 from baseline around 0.8
Suspect that this is likely ATN from RLE infection. Baseline Cr
in early ___ was 0.8-1.1 Cr during hospitalization was
initially stable at 1.8 and improved to 1.5-1.7. Cr on day of
discharge was 1.7. All medications, including Vancomycin, were
renally dosed. Apixaban was switched to a heparin drip while
CrCl decreased. With some improvement, apixaban was re-started
at a low dose (2.5mg daily).
#Troponinemia: No signs of active ischemia on EKG, and in the
setting of ___. Trops downtrended and this was likely demand
ischemia
in setting of tachycardia/afib.
#Hyponatremia: Noted at last admission. Likely hypervolemic
hyponatremia given volume overload. After diuresis, sodium was
improved to 135-137.
# Elevated INR: On apixaban at home. 1.8 on admission and
improved to 1.3. Recently INR prior to hospitalization ranged
from 1.2-1.3. Likely nutritional, may be ___ antibiotics. No
signs of active bleeding and H/H stable.
#Leukocytosis: Chronic, may be acutely worsened in setting of
cellulitis. but improving with treatment in ___.
#Anemia: Near baseline, but expected to be decreased with active
infection. Hgb has been stable in 7.5-9s.
============
CHRONIC ISSUES
=============
#CAD s/p CABG: continued ASA, atorvastatin.
================
TRANSITIONAL ISSUES
================
[ ] Please continue Ceftriaxone for total 14 day course
___ - ___.
[ ] Patient was given vancomycin on discharge which will
essentially give her a 7 day course (___) (have been
dosing vanc based on daily level but unable to check daily
levels at rehab so will complete 7 day course prior to discharge
to prevent vanc toxicity). Low threshold to add back vancomycin
if worsening.
[ ] Discharged on apixaban 2.5mg BID, reduced from 5mg BID due
to renal function. Resume 5mg BID once Cr improves closer to
baseline.
[ ] Discharge creatinine is 1.6 from baseline of 0.8-1.1
(___), despite adequate diuresis. Suspect may have component
of ATN from infection. Avoid nephrotoxic agents. Please recheck
BMP early next week (___) to assess renal function and fax
results to patient's PCP and cardiologist.
[ ] Holding ACE inhibitor (enalapril) at discharge given ___,
please consider restarting once renal function
improved/stabilized
[ ] Appears euvolemic at discharge and discharged on Lasix 40mg
BID (home diuretic regimen includes bumetanide 1mg BID and
metolazone 5mg daily). Able to maintain euvolemia on current
diuretic dosing. Please reassess diuretic needs as outpatient
once renal function stabilized.
[ ] Anemia: chronic per chart review. Stable here from prior
level. Checked iron studies which show iron deficiency anemia
with transferrin sat of 7.6%. Held off on iron repletion given
active infection. Please consider PO vs IV iron repletion as
outpatient and make sure patient up to date with age appropriate
cancer screening
[ ] Increased metoprolol and changed to long acting formulation
of 150mg metop succinate daily from metop tartrate 37.5mg TID
[ ] Holding home gabapentin due to changing renal function. Has
not needed in hospital.
[ ] Please reassess patient's need for oxycodone for pain and
try alternative medications if possible.
DISCHARGE WEIGHT: 63.5kg
DISCHARGE CREATININE: 1.6
CODE STATUS: Full code
CONTACT: Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
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. Aspirin 81 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Sertraline 50 mg PO DAILY
4. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
5. Meladox (melatonin) 3 mg oral DAILY:PRN
6. Vitamin D 800 UNIT PO DAILY
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
8. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 5 billion cell
oral DAILY
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nares
10. Senna 17.2 mg PO DAILY:PRN Constipation - First Line
11. Polyethylene Glycol 17 g PO DAILY
12. Alavert (loratadine) 20 mg oral BID:PRN
13. Ampicillin 500 mg PO Q6H
14. Apixaban 5 mg PO BID
15. Atorvastatin 20 mg PO QPM
16. Bisacodyl ___AILY:PRN constipation
17. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
18. Gabapentin 200 mg PO BID
19. Lidocaine 5% Patch 1 PTCH TD QPM
20. Metoprolol Tartrate 37.5 mg PO TID
21. OxycoDONE Liquid ___ mg PO Q3H:PRN Pain - Moderate
22. Bumetanide 1 mg PO BID
23. Docusate Sodium 100 mg PO BID
24. Potassium Chloride 20 mEq PO BID
25. Enalapril Maleate 20 mg PO BID
26. Estrogens Conjugated 0.625 mg PO DAILY
27. Metolazone 5 mg PO DAILY
28. Vancomycin 1000 mg IV Q 24H
29. LORazepam 0.5 mg PO Q8H:PRN anxiety
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
2. Furosemide 40 mg PO BID
3. Metoprolol Succinate XL 150 mg PO DAILY
4. Alavert (loratadine) 20 mg oral BID:PRN
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Bisacodyl ___AILY:PRN constipation
8. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
9. Docusate Sodium 100 mg PO BID
10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose
11. Estrogens Conjugated 0.625 mg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. LORazepam 0.5 mg PO Q8H:PRN anxiety
14. Meladox (melatonin) 3 mg oral DAILY:PRN
15. Omeprazole 40 mg PO DAILY
16. OxycoDONE Liquid ___ mg PO Q3H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 5 mL by mouth every four hours
Refills:*0
17. Polyethylene Glycol 17 g PO DAILY
18. Potassium Chloride 20 mEq PO BID
Hold for K >
19. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 5 billion cell
oral DAILY
20. Senna 17.2 mg PO DAILY:PRN Constipation - First Line
21. Sertraline 50 mg PO DAILY
22. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nares
23. Vitamin D 800 UNIT PO DAILY
24. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
25. HELD- Bumetanide 1 mg PO BID Duration: 7 Days This
medication was held. Do not restart Bumetanide until you
follow-up with your cardiologist
26. HELD- Enalapril Maleate 20 mg PO BID This medication was
held. Do not restart Enalapril Maleate until you see your
primary care doctor and your renal function has improved
27. HELD- Gabapentin 200 mg PO BID This medication was held. Do
not restart Gabapentin until you follow up with your primary
care physician
28. HELD- Metolazone 5 mg PO DAILY This medication was held. Do
not restart Metolazone until you follow-up with your
cardiologist
29.Outpatient Lab Work
ICD-10: N17.9
LAB TEST: Basic Metabolic Profile
DATE: ___
PLEASE FAX RESULTS TO: ___ ___ MD
AND ___: Dr. ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Right lower extremity cellulitis in setting of recent saphenous
vein harvest.
===================
SECONDARY DIAGNOSIS
===================
Heart failure exacerbation
___ on CKD
Afib with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had an infection of your leg
that developed after your recent cardiac surgery. This infection
led to fluid overload and you were admitted to the Cardiology
service for antibiotics and fluid removal.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given antibiotics in through your IV to treat your
leg infection
- You were given a medication called furosemide (Lasix) which
helped to remove extra fluid from your lungs and legs.
- You were seen by the wound nurse who evaluated your vein graft
site and recommended daily dressing changed.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You will go to rehab with a long-term IV called a PICC line so
that you can continue to receive antibiotics. You will complete
a 14 day course with your last day of antibiotics on ___.
- You will be started on a pill form of the furosemide that you
should take twice a day to prevent fluid from accumulating
again.
- Please continue to take all your other medications as
prescribed
- We will be sure to let the rehab know the clear instructions
for dressing changes of your left leg.
- IF you develop fevers/chills, worsening redness and swelling,
increasing pain in the left lower extremity, or increasing
drainage from the wound, please call your doctor or go to the
nearest emergency room.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10616316-DS-3 | 10,616,316 | 22,962,066 | DS | 3 | 2115-10-04 00:00:00 | 2115-10-05 10:27:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
triethanolamine
Attending: ___
Chief Complaint:
Fevers, cough, dyspnea, hpoxia
Major Surgical or Invasive Procedure:
Dual chamber permanent pacemaker placement (___)
History of Present Illness:
___ female with Down syndrome, prolonged QT, complete AV
canal defect s/p surgical repair ___ infancy with residual mild
MR, ALL s/p treatment (at age ___ c/b CVA with resulting R sided
hemiparesis, childhood leukemia, and hypothyroidism, who
presented with acute respiratory failure and shock.
Patient was seen by her PCP on the day of presentation for
fevers, cough, and increasing shortness of breath since ___.
She was found to be hypoxic (O2 84-89%), with wheezes and
crackles bilaterally ___ the office and referred to the ED.
On admission to ED, patient was found to be tachypnic and
bradycardic. HR on admission 51bpm, which worsened significantly
___ the ED to 30bpm, requiring dopamine gtt and levophed for
pressor support. EF on bedside ___ estimated to be 50%, without
evidence of pericardial effusion. EKG was significant for new
LBBB morphology with decompensation to complete heart block.
Patient was admitted to the CCU for intubation and emergent
transvenous pacing.
Past Medical History:
Down syndrome
Prolonged QTc syndrome
Common atrioventricular canal, repaired at age ___
Asthma
CVA, R sided, with residual hemiparesis
Developmental delay
Alopecia
Nasolacrimal duct stenosis, acquired
Hypothyroidism ___ autoimmune thyroiditis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T: 100.6, HR: 80, BP: 126/52, RR: 21, 100% on vent
GENERAL: Well developed, well nourished female ___ NAD. Intubated
and sedated.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. ___ JVD.
CARDIAC: Normal rate, regular rhythm. ___ murmurs, rubs, or
gallops.
LUNGS: On mechanical ventilation. ___ chest wall deformities or
tenderness. Respiration is unlabored with ___ accessory muscle
use. ___ adventitious breath sounds.
ABDOMEN: Soft, non-tender, non-distended. ___ hepatomegaly. ___
splenomegaly.
EXTREMITIES: Warm, well perfused. ___ clubbing, cyanosis, or
peripheral edema.
SKIN: ___ significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCAHRGE PHYSICAL EXAM:
========================
Vitals: 0738 Temp: 98.4 PO BP: 90/58 L Lying HR: 82 RR:
16 O2 sat: 90% O2 delivery: Ra
Weight: 49.2 kg
General: awake/alert, laying comfortably ___ bed
HEENT: Thrush still present, but improving
Lungs: poor air movement, ctab (but difficult to hear)
CV: rrr, ___ sem ___ LUSB
Abdomen: soft, ntnd
Ext: ___ peripheral edema
Neuro: Alert and oriented x1. CN II-XII intact b/l. Mild R
hemiparesis (chronic per mother)
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 09:14PM BLOOD WBC-8.6 RBC-4.04 Hgb-12.5 Hct-37.4 MCV-93
MCH-30.9 MCHC-33.4 RDW-15.1 RDWSD-51.3* Plt ___
___ 09:14PM BLOOD Neuts-88.6* Lymphs-6.8* Monos-3.4*
Eos-0.1* Baso-0.8 Im ___ AbsNeut-7.64* AbsLymp-0.59*
AbsMono-0.29 AbsEos-0.01* AbsBaso-0.07
___ 09:14PM BLOOD ___ PTT-26.6 ___
___ 09:14PM BLOOD Glucose-101* UreaN-19 Creat-1.4* Na-137
K-5.7* Cl-100 HCO3-21* AnGap-16
___ 09:14PM BLOOD ALT-23 AST-77* AlkPhos-63 TotBili-0.3
___ 09:14PM BLOOD cTropnT-0.06*
___ 10:30PM BLOOD proBNP-5317*
___ 01:53AM BLOOD CK-MB-5 cTropnT-0.59*
___ 02:02PM BLOOD CK-MB-14* MB Indx-7.4* cTropnT-0.41*
___ 09:14PM BLOOD Albumin-3.6 Calcium-7.7* Phos-3.2 Mg-2.1
___ 10:30PM BLOOD TSH-7.8*
___ 04:47AM BLOOD Cortsol-20.2*
___ 02:02PM BLOOD ___ Titer-1:80*
___ 09:14PM BLOOD ___ pO2-29* pCO2-49* pH-7.34*
calTCO2-28 Base XS--1
___ 03:11AM BLOOD ___ Temp-37.8 pO2-53* pCO2-52*
pH-7.26* calTCO2-24 Base XS--4 As/Ctrl-ASSIST/CON
Intubat-INTUBATED
___ 06:43AM BLOOD ___ pO2-42* pCO2-56* pH-7.24*
calTCO2-25 Base XS--4
___ 09:14PM BLOOD Lactate-2.2* K-6.3*
___ 06:43AM BLOOD O2 Sat-65
===============
DISCHARGE LABS:
===============
___ 08:45AM BLOOD WBC-6.1 RBC-4.00 Hgb-12.1 Hct-37.7 MCV-94
MCH-30.3 MCHC-32.1 RDW-17.3* RDWSD-59.3* Plt ___
___ 08:45AM BLOOD Glucose-73 UreaN-17 Creat-0.8 Na-139
K-4.5 Cl-101 HCO3-22 AnGap-16
___ 05:43AM BLOOD ALT-22 AST-19 LD(LDH)-304* AlkPhos-60
TotBili-0.3
___ 08:45AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.4
================
IMAGING STUDIES:
================
___ (___):
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45-50%). There is ___ ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and ___ aortic stenosis. ___ aortic
regurgitation is seen. The mitral valve leaflets are thickened.
There is anterior leaflet cleft, with an associated jet of
severe (4+) mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is ___ pericardial effusion.
IMPRESSION: Cleft mitral valve (?failure of prior repair) with
severe mitral regurgitation. Mild left ventricular systolic
dysfunction.
TEE (___):
MITRAL VALVE (MV)
Reguritant Oriface Area: 0.5cm²
Regurgitant Volume: 80mL
FINDINGS:
LEFT ATRIUM ___ VEINS: ___ spontaneous echo contrast
___ the ___ thrombus/mass ___ ___. Normal ___
ejection velocity (>0.2m/s).
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
___ RA/RA
appendage spontaneous echo contrast. ___ RA/RA appendage mass.
Normal right atial appendage ejection
velocity (>0.2m/s). Catheter/wire ___ RA/RV ___ atrial septal
defect by 2D/color Doppler.
LEFT VENTRICLE (LV): ___ ventricular septal defect. Mildly
depressed ejection fraction (40-55%).
RIGHT VENTRICLE (RV): Depressed free wall motion.
AORTIC VALVE (AV): Nl (3) leaflets. ___ mass/vegetation. ___
abscess. ___ regurgitation.
MITRAL VALVE (MV): Moderately thickened leaflets. Leaflets fail
to coapt. ___ mass/vegetation. ___
abscess. Severe [4+] regurgitation. Central regurgitant jet.
TRICUSPID VALVE (TV): Normal leaflets. ___ mass/vegetation. ___
abscess. Physiologic regurgitation.
PERICARDIUM: ___ effusion.
RIGHT HEART CATH (___):
IMPRESSION:
Borderline bi-ventricular filling pressures.
Borderline high SVR ___ the setting of elevated MAP and 2
pressors compatible with septic physiology.
Normal-high cardiac output and index.
Tracing did not show large V-waves arguing against severe MR.
___ indication for mechanical support.
Succeful RRA a-line placement.
Succesful LIJ venous sheath placement with temp wire.
Succesful VIP Swan placement through RIJ.
4 endomyocardial biopsies were obtained.
CT HEAD (___):
1. Study is mildly degraded by motion.
2. Within limits of study, ___ definite evidence of acute
intracranial
abnormality. Please note MRI of the brain is more sensitive for
the detection
of acute infarct.
3. Left frontal encephalomalacia may reflect sequela of old
infarct.
4. Pansinus disease with findings concerning for acute
sinusitis, as
described.
CT CHEST (___):
1. Small bilateral pleural effusions bibasilar atelectasis and
small pericardial effusion.
2. Status post prior cardiac surgery.
3. Perihilar opacification bilaterally most likely represents
pulmonary edema.
4. ET tube, NG tube, left-sided Swan-Ganz catheter are ___
acceptable position.
5. ___ evidence of septic emboli
CT ABD/PELVIS (___):
1. ___ acute abnormalities visualized within the imaged abdomen
and pelvis.
2. Irregular appearance of the gallbladder wall without luminal
distention
suggests chronic cholecystitis.
3. Please see same-day chest CT for detailed intrathoracic
findings.
=============
MICROBIOLOGY:
=============
__________________________________________________________
___ 8:15 pm BLOOD CULTURE Source: Venipuncture 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:27 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 5:04 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
___ respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 11:43 am BLOOD CULTURE Source: Line-L IJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: ___ GROWTH.
__________________________________________________________
___ 11:43 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: ___ GROWTH.
__________________________________________________________
___ 2:02 pm Blood (LYME) Source: Line-a line.
**FINAL REPORT ___
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. bu___ infection.
Patients
___ early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
__________________________________________________________
___ 4:15 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 10:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: ___ GROWTH.
__________________________________________________________
___ 9:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: ___ GROWTH.
__________________________________________________________
___ 9:14 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: ___ GROWTH.
Brief Hospital Course:
SUMMARY STATEMENT:
==================
___ female with Down syndrome, prolonged QT, complete AV
canal defect s/p surgical repair ___ infancy with residual mild
MR, ALL s/p treatment (at age ___ c/b CVA with resulting R sided
hemiparesis, childhood leukemia, and hypothyroidism, who
presented with acute respiratory failure and septic shock
secondary to pneumonia, as well as new complete heart block and
severe mitral regurgitation.
ACUTE ISSUES:
==================
#Acute Hypoxic Respiratory Failure
#Multifocal PNA
#Septic Shock
Patient presented with fevers, cough, and hypoxic respiratory
failure. Patient was intubated ___ for hypoxic respiratory
failure, requiring levophed and vasopressin for blood pressure
support. CXR on admission concerning for multifocal pneumonia
and pulmonary edema. EKG also with new complete heart block.
Concern initially for distributive shock ___ PNA) vs.
cardiogenic shock ___ the setting of new heart block). She
subsequently underwent right heart catheterization which showed
normal to high cardiac index, and normal to borderline filling
pressures/SVR ___ the setting of being on 2 vasopressors, most
consistent hemodynamically with septic shock likely
___. Sputum cultures were positive for growing GPC ___
pairs/clusters. CT head, CT chest, and CTAP negative for
alternate infectious source. Completed 8 day course of
Vancomycin/Cefepime (D1: ___ for pneumonia, and was
successfully extubated on ___. After extubation, patient
continued to have wheezing and O2 requirement on nasal cannula.
Pulmonary was consulted. She was treated supportively with
inhalers, chest ___, and steroid burst x 3 days given concern for
asthma exacerbation. On transfer, she is saturating well on RA.
Patient was noted to have multiple de-sat events ___ evening.
This finding was discussed with ENT over the phone who advised
that patients with Down's syndrome often have OSA and that she
should have this worked up as an outpatient if it continues to
be an issue.
#Complete heart block
#Congenital cardiac disease, AV canal defect s/p repair
Etiology of complete heart block likely ___ AV canal defect and
repair. TSH, lyme serologies, and endomyocardial biopsies
otherwise negative for alternate etiology. Temporary transvenous
pacing wires were placed on admission and patient underwent
successful permanent pacemaker placement on ___ without
complications.
#Severe Mitral Regurgitation
Severe MR was noted on ___, likely ___ AV canal defect and
repair. Would likely benefit from mitral valve repair as an
outpatient. Spoke with patient and mother about surgical
options. Will follow up with outpatient pediatric cardiologist,
___, with plan for surgery ___ the next few weeks.
Otherwise, continue afterload reduction with low-dose captopril
3.125 po tid.
#Femoral artery dissection
Right heart catheterization complicated by posterior right
femoral artery dissection. Concern for limb ischemia initially,
but pulses still dopplerable and duplex with only partial
obstruction. Vascular surgery consulted, with ___ indication for
acute intervention.
#THRUSH: on fluconazole for 21-day course, started ___ and plan
to end ___.
CHRONIC ISSUES:
===============
# Hypothyroidism: Continue home levothyroxine.
# Prolonged QTc: QTc 508 on admission. Avoid QTc prolonging
medications.
TRANSITIONAL ISSUES:
====================
[ ]Follow up with cardiology on ___
[ ]Please continue fluconazole po through ___ for thrush
[ ]New med: captopril 3.125 tid for afterload reduction due to
severe MR
[ ]Discharge weight 49.2kg
[ ]Please follow-up symptoms of OSA and order sleep study if
necessary
#CODE: Full code, confirmed with mother
#CONTACT/HCP: Sister: ___ ___ Mother: ___
___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
RX *acetaminophen 160 mg/5 mL 20 mL by mouth Every 6 hours
Refills:*0
2. Captopril 3.125 mg PO TID
3. Fluconazole 200 mg PO Q24H
last day ___
RX *fluconazole 200 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
Nebulizer Every 6 hours Disp #*30 Ampule Refills:*0
5. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
6. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN sore
throat
7. Simethicone 40-80 mg PO QID:PRN gas pain
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
9. Aspirin 81 mg PO DAILY
10. Cetirizine 10 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Septic Shock
Acute Respiratory Failure
Pneumonia
Complete Heart Block
Severe Mitral Regurgitation
Oral and esophageal candidiasis
Secondary Diagnosis:
Down syndrome
***Anticipated SNF stay < 30 days***
Discharge Condition:
Mental Status: Baseline per family.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had trouble breathing and low
oxygen levels and were found to have pneumonia.
- You were also found to have an abnormal heart rhythm.
What happened while I was ___ the hospital?
- You were treated with antibiotics for your pneumonia.
- You also underwent a procedure with our electrophysiology
(heart) doctors to ___ a pacemaker. This should prevent your
heart from going into an abnormal rhythm.
- On our heart imaging, we also found that you have a heart
valve which is leaky. This valve will need to be repaired. You
should see your cardiologist, Dr. ___ you go home to
schedule this surgery.
- You developed an infection ___ your mouth that made it
difficult for you to eat
- This was treated with anti fungal medications and pain
medications and you started to improve, but you will need to
continue to take the antifungal medications when you leave
What should I do after leaving the hospital?
- Please take your medications as listed ___ discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved ___ your care, we wish
you all the best!
***Anticipated SNF stay < 30 days***
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10616357-DS-11 | 10,616,357 | 20,759,481 | DS | 11 | 2175-06-28 00:00:00 | 2175-06-28 10:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of laparoscopic left colectomy for sigmoid
diverticulitis done approximately 8 weeks previously who now is
returning to care for concern of abdominal pain. Ms. ___
enjoyed an uncomplicated recovery after her surgery. She is
currently residing in ___, and two days ago had insidious
onset of predominantly left sided abdominal pain.
The patient first noticed the pain on ___ morning. There was
no prodrome. The pain was in her left lower quadrant, and felt
similar to the pain she has experienced with diverticulitis.
Over
the course of the day, the pain migrated to her left upper
quadrant. The pain is worse with movement and the area is very
tender to palpation. She has not had an appetite since the onset
of pain; eating food does not make the pain worse. She last ate
at 5:30pm today.
The patient had diarrhea and loss of appetite for several months
following the colectomy, but her appetite and bowel movements
have been regular for the past few weeks. No sick contacts and
no
unusual foods recently. She denies headache, fevers, nausea,
vomiting, BRBPR, diarrhea, and pain with urination.
Past Medical History:
Previous surgeries/procedures: exostectomy L ___ and ___
metatarsal (___), R foot bunionectomy (___), L foot
bunionectomy (___), arthroscopy L knee w/major synovectomy
and partial meniscectomy (___)
PAST MEDICAL HISTORY: ascending thoracic aortic aneurysm
measuring (4.6cm in max diameter, CTA ___ 4.9cm on MRA
___, chronic AFib on direct Factor Xa inhibitor (Eliquis),
HTN, anxiety, OA, lichenoid mucositis
Social History:
___
Family History:
FAMILY MEDICAL HISTORY:
Inflammatory Disease: No
Colon Cancer: No
Cancer (other): No
Brief Hospital Course:
Ms. ___ is a ___ year old female with past medical history
significant for sigmoid diverticulitis s/p laparscopic left
colectomy who was admitted for complaints of left sided pain.
She was admitted to the emergency department. Patient complained
of pain similar to the pain she has experienced with
diverticulitis. She has not had an appetite since the onset
of pain; eating food does not make the pain worse. She last ate
at 5:30pm today.
Patient had a CT abdomen pelvis which was significant for
dilated loops of jejunum, focus of inflamed fat with stranding
along with anterolateral left abdomen significant for omental
infarct. Labs were within normal limits. Patient also had a
positive UA on admission. Ms. ___ was started on Cipro.
On HD2, patient denies nausea/vomiting/fever/chills. Pain well
controlled. Patient was started on a regular diet. She tolerated
this well. Patient was stable for discharged. She will be
discharged home on Tylenol. She will resume all her home
medications.
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Calcium Carbonate 500 mg PO BID
4. Ciprofloxacin HCl 750 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
5. losartan-hydrochlorothiazide 100-12.5 mg oral daily
6. Metoprolol Succinate XL 200 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
Omental infarct.
Discharge Condition:
Patient ambulatory
Stable condition
Alert, oriented, mental status complete.
Discharge Instructions:
Ms. ___ you were admitted under the colorectal surgery
service from ___. Your main complaints was abdominal
pain in your left lower quadrant. After monitoring you
overnight, you are now ready to be discharged.
Here are the following discharge instructions:
You underwent a CT scan of the abdomen and pelvis. The
significant finding was a focus of inflamed fat with stranding
along the anterolateral left abdomen significant for an omental
infarct. Omental infarct is a benign inflammatory process that
will usually resolve with time. You should take Tylenol whenever
you experience pain. No narcotics are necessary for this
process.
Diet:
Please continue regular diet. You have no restrictions on your
daily dietary intake. You tolerated breakfast well on ___.
Activity level:
Resume all normal daily activities
Medication:
Resume all medications including Apixaban. You will also be sent
home on a 5 day course of Ciprofloxacin. This is because on your
admission, your urinary analysis was positive for a urinary
tract infection. Like stated above please take Tylenol for your
left sided pain.
Followup Instructions:
___
|
10616466-DS-5 | 10,616,466 | 26,420,177 | DS | 5 | 2120-02-12 00:00:00 | 2120-02-17 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Valium
Attending: ___
Chief Complaint:
hypotension, LLQ abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ YO M with ___ CABG, CHF, COPD, GERD, stage 4
CKD, seizure, stroke, and dementia who presents as a transfer
from ___ for sepsis.
At ___, the patient was noted to have abdominal pain
and there was concern for a surgical abdomen. His initial blood
pressure was 60 systolic. Immediate right femoral line placed
for access. He was given 3L IVF and surgery was consulted. A CT
A/P showed left sided colitis, ischemic versus infectious.
Patient's blood
pressure responded to intravenous fluids, Zosyn/vanco, surgery
recommends trial of fluids and antibiotics. He was transferred
to ___ as there were no ICU beds there.
Labs @ OSH:
WBC 22.4, H&H 13.6/40.7, plt 221
Sodium 135, potassium 3.3, chloride 95, bicarbonate 24, BUN 53,
creatinine 2.4, glucose 139, calcium 9.3 AST 38, ALT 25,
alkaline phosphatase 214, troponin negative INR 1.2, lactate 4.6
In the ___ ED, initial vitals were: 96.9 77 120/66 16 100% RA
Exam notable for Rectal: brown stool, heme negative
Labs showed
Leukocytosis WBC 17.2
Cr 1.6, K 2.9, HCO 17 anion gap 16
lactate 1.6
Trop <0.01
___ ___ NCCT C/A/P
IMPRESSION:
-No acute abnormality identified.
-Incidental lung nodules measuring 5 mm or less in size.
-There is wall thickening and pericolonic soft tissue stranding
along the left colon consistent with nonspecific colitis which
could
be infectious, inflammatory, or ischemic.
-There is a 16 mm nonspecific cyst or nodule along the medial
midpole of the right kidney and a 1 cm hyperdense cyst or
nodule along
the inferior aspect of the left kidney.
Received D5NS + 40 mEq Potassium Chloride at 250cc/hr in the
___ ED, previously received Zosyn (___), Vanc (1630) & Got 3L
IVF @ OSH.
Transfer VS were
97 72 111/45 22 95% RA
Surgery were consulted and felt there was no acute surgical
issue. They recommended IVF resuscitation, antibiotics and
workup including c.diff, stool cultures.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports abdominal pain, but
otherwise has not complaints. History is limited due to
dementia.
Review of systems:
Unable to illicit due to mental status
Past Medical History:
Hx Cardiac Disorders: CAD, MI, CABG, CATH, CHF
COPD
Gastro Reflux
Hx Renal Disorder: ST 4 CKD
Seizure
Stroke
hyperkalemia
dementia
BPH
ANEMIA
Social History:
___
Family History:
Unable to illicit due to mental status
Physical Exam:
Admission physical exam:
Vital Signs: 97.5 82 147/79 16 98RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no rebound, some guarding and tenderness to deep
palpation to LLQ
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge physical exam:
Vital Signs: 97.9 76 147/74 18 96%
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
Admission labs/ pertinent results:
___ 07:00PM BLOOD WBC-17.2* RBC-3.72* Hgb-11.0* Hct-33.4*
MCV-90 MCH-29.6 MCHC-32.9 RDW-14.9 RDWSD-48.8* Plt ___
___ 07:00PM BLOOD Neuts-88.0* Lymphs-6.1* Monos-5.0
Eos-0.2* Baso-0.2 Im ___ AbsNeut-15.14* AbsLymp-1.05*
AbsMono-0.86* AbsEos-0.03* AbsBaso-0.04
___ 01:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+
___ 07:00PM BLOOD ___ PTT-27.7 ___
___ 07:00PM BLOOD Plt ___
___ 06:50AM BLOOD ___
___ 07:00PM BLOOD Glucose-136* UreaN-46* Creat-1.6* Na-138
K-2.9* Cl-105 HCO3-17* AnGap-19
___ 07:00PM BLOOD ALT-14 AST-21 CK(CPK)-22* AlkPhos-160*
TotBili-1.0
___ 07:00PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 03:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 10:58AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:00PM BLOOD Albumin-2.6*
___ 03:35AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.8
___ 05:27PM BLOOD Hapto-98
___ 12:20PM BLOOD Vanco-11.8
Discharge labs:
___ 06:35AM BLOOD WBC-7.4 RBC-2.81* Hgb-8.4* Hct-25.9*
MCV-92 MCH-29.9 MCHC-32.4 RDW-16.1* RDWSD-55.2* Plt ___
___ 06:35AM BLOOD Neuts-56.0 ___ Monos-8.5
Eos-11.1* Baso-0.4 Im ___ AbsNeut-4.12 AbsLymp-1.68
AbsMono-0.63 AbsEos-0.82* AbsBaso-0.03
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-138 K-3.6
Cl-107 HCO3-22 AnGap-13
___ 06:50AM BLOOD ALT-8 AST-13 LD(LDH)-151 AlkPhos-90
TotBili-1.0
___ 06:35AM BLOOD Calcium-7.5* Phos-3.2 Mg-1.7
Microbiology:
Blood culture: no growth
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ENTEROCOCCUS FAECIUM. 10,000-100,000 CFU/mL.
Sensitivity testing performed by Sensititre.
AMPICILLIN >16 MCG/ML.
TETRACYCLINE >16 MCG/ML.
VANCOMYCIN >128 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ENTEROCOCCUS FAECIUM
| |
AMIKACIN-------------- 32 I
AMPICILLIN------------ R
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
LINEZOLID------------- 2 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- R
TOBRAMYCIN------------ =>16 R
VANCOMYCIN------------ R
Stool culture: No growth
___ 5:45 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___
14:10.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
Radiology:
___ CT abdomen from OSH: Left sided fat stranding suggestive
of inflammation, infection or ischemia. Please refer to outside
records for more information
___ CT Chest: No acute process. Please refer to outside
records for more information
___ CXR
IMPRESSION:
Compared to chest CT one ___.
Lungs are hyperinflated but clear. Cardiomediastinal and hilar
silhouettes
and pleural surfaces are normal. There is no pulmonary edema or
evidence of
active infection.
___ KUB:
There are no abnormally dilated loops of large or small bowel.
There is an overall of the haustral appearance of the descending
colon likely
compatible with the the colitis seen on the recent CT scan.
There is no free
intraperitoneal air.
Osseous structures are notable for degenerative changes of the
lumbar spine.
A right femoral catheter is present, the tip projecting over the
right sacral
ala. Vascular calcification is noted.
IMPRESSION:
Featureless appearance of the descending colon, consistent with
the colitis
visualized on the CT scan of the abdomen and pelvis from ___.
Otherwise, nonobstructive bowel gas pattern.
Brief Hospital Course:
Mr. ___ is an ___ YO M with past medical history significant
for CAD s/p CABG, heart failure (LVEF unknown), chronic
obstructive pulmonary disease, gastrointestinal reflux, stage IV
chronic kidney injury, seizure, stroke, dementia, BPH status
post TURB with persistent BPH, now with spanner last changed
___ (over due for his usual 6 week change), recurrent MDR
pseudomonas UTI who presented as a transfer from ___
for hypotension in the setting of sepsis secondary to c.
difficile colitis. Initially, history notable for LLQ pain and
dizziness; physical exam notable for hypotension, LLQ guarding;
labs notable for lactate >4, Cr >2; CT abdomen notable for
left-sided colitis. UA positive, stools returning with + c.
difficile. Initially treated as severe complicated c. difficile
infection with PO vancomcyin, PR vancomycin, IV metronidazole,
and for MDR pseudomonas/Enterococcus UTI. Initially patient was
constipated, colorectal surgery involved, KUB without signs of
megacolon. He was kept NPO, gradually improved, with lactate,
Cr, and WBC back to baseline. Diet was advanced slowly as
tolerated. Infectious disease recommended discontinuing
treatment for UTI since he is likely a chronic colonizer and
unlikely with active UTI. Plan to continue treatment for c.
difficile infection with PO vancomycin 2 weeks after last dose
of IV antibiotics for possible UTI (___). On discharge,
patient insisting on going home rather than rehabilitation, with
daughter/HCP and son aware and agreeable to palliative ___ for
patient at his daughter's request, given multiple chronic
medical conditions. He will be living with his son. ___
___ set up with home ___ services.
# Sepsis/C. difficile colitis: History of recurrent UTI with
MDR pseudomonas, currently with foley and spanner last changed
___. Patient became symptomatic with dizziness, diffuse
upper abdominal pain that has been chronic, new left sided
abdominal pain at home. His son ___ called the ambulance,
SBP at this time was in the ___. He was taken to BI Plymoth,
where he was found to have leukocytosis to 22, Cr 2.4, lactate
4.9, hypotension, and worsening left-sided abdominal pain and
weakness. He received 3L via new femoral line, 1 dose of
vancomycin and piperacillin-tazobactam at the OSH. CT scan
showed left-sided colitis, and surgery involved at the OSH, with
no surgical intervention felt to be needed at that time. He was
transferred to ___ for further care. On transfer, vital signs
were stable, on history patient was not delirious and complained
of persistent abdominal pain, not worsening in nature. Labs
showed leukocytosis to 17 and lactate to 1.6 and improved Cr
1.6. Vital signs stable on arrival to ___, so he was
transferred to medicine floor for further work-up. Initially
differential was broad, with concern for infectious versus
ischemic colitis, with possible contribution from urosepsis. He
initially had difficulty having a bowel movement, but then he
had a small one, and c. difficile assay returned positive. At
this time, he was treated for severe complicated c. difficile
infection, colorectal surgery was consulted. KUB was not
concerning for megacolon. Patient was kept NPO initially, and
his diet was advanced slowly. Although his UA came back positive
and grew Pseudomonas/Enterococcus, the primary team, infectious
disease and urology all felt comfortable deescalating antibiotic
treatment for UTI because he is likely a chronic colonizer. He
remained afebrile and hemodynamically stable off antibiotics for
a urinary source. On discharge, patient was having loose bowel
movements less than three times per day, as well as good PO
intake.
# Acute kidney injury: Etiology likely prerenal, improved with
fluid and good PO intake. Admission Cr 1.6, discharge Cr 0.8.
#. Atrial flutter: Noted transiently (minutes) in the setting of
sepsis, resolved without dedicated intervention apart from IV
fluids. In discussion with his daughter/HCP, he has experienced
atrial fibrillation/flutter in the setting of infection and
prior operations and although he has had prior stroke has
declined anticoagulation due to fall risk and the fact that
atrial fibrillation/flutter has occurred only in the context of
physiologic stress. She declined cardiology referral, requesting
that it be made by his primary care physician as needed.
#. Normocytic anemia: Hgb declined gradually from ___ on
admission to 8.3-8.8 and remained stable at the time of
discharge, likely in the setting of infection, antibiotics, and
frequent blood draws. Hemolysis labs reassuring. There were no
signs of active bleeding.
#. Thrombocytopenia: Platelet count nadired in 120s, likely in
the setting of infection and antibiotics and had normalized by
discharge.
Chronic issues:
#CAD/HF: He was without signs of active ischemia and initially
appeared dry on exam, subsequently euvolemic following volume
resuscitation. Continued ASA 325mg. Held furosemide in the
setting of recent hypotension and hypovolemia. Home metoprolol
and isosorbide mononitrate were resumed prior to discharge.
#Seizures: There were no signs of seizure activity throughout
admission. Continued home dose levetiracetam.
Transitional issues:
1. Continue Vancomycin Oral Liquid ___ mg PO/NG Q6H, end date
___
2. Noted eosinophilia on lab work, will need repeat CBC w/diff
in one week to assess for resolution of eosinophilia or further
workup if persistent eosinophilia, as well as to assess for
improving anemia.
3. Follow up with urologist for spanner and foley exchange as
soon as possible
4. Follow up with PCP for ___. difficile colitis and diarrhea
symptoms
5. Please give referral to a cardiologist for new onset
aflutter, only lasting minutes and resolved with 250cc IVF in
setting of sepsis
6. For ___: If patient fails to have a BM for 48 hours while on
his current antibiotics for c. difficile, please call PCP or
bring him in to the ED
7. Incidental lung nodule 5mm or less; repeat CT in ___
8. Incidental kidney lesions noted on CT; pt should follow up
with urology
9. Held furosemide in setting of hypovolemia, ___, and
hypotension. Blood pressure throughout inpatient stay remained
normal to low. Follow up with primary care physician ___
cardiology to restart furosemide
10. Isosorbide mononitrate was held during admission, but was
restarted on day of discharge as SBP was 120s-140s. Please
monitor his BP and consider stopping isosorbide if SBP < 100 or
symptomatic hypotension.
Code: DNR/DNI
Contact: ___, daughter, HCP, MD: ___
___, PoA: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea
3. Furosemide 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
6. Tiotropium Bromide 1 CAP IH DAILY
7. LevETIRAcetam 250 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Aspirin 325 mg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
13. Ranexa (ranolazine) 500 mg oral BID
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every six
(6) hours Disp #*42 Capsule Refills:*0
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Cyanocobalamin 1000 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
8. LevETIRAcetam 250 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Ranexa (ranolazine) 500 mg oral BID
12. Tiotropium Bromide 1 CAP IH DAILY
13. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until you meet with your
primary care doctor. It may cause constipation.
14. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until you meet with your primary care
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C. difficile colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you here at ___. You were
admitted because of significant left sided abdominal pain. Your
blood work and images were concerning for an infection. A sample
of your stool showed that you were positive for the bacteria
Clostridium difficile. We treated your infection with
antibiotics and you recovered nicely. You have some residual
diarrhea which is normal. Please return or tell someone
immediately if you stop having bowel movements while on this
medication for over 36 hours. Meanwhile you will be discharged
with ___ support to your home. Please follow up with your
primary care doctor as well as your urologist, you are over due
for a spanner and foley exchange, and cultures from your urine
are positive for bacteria, so it is important you get those
devices exchanged immediately.
New medications include oral vancomycin and oral metronidazole.
You will continue this until ___.
We are happy to see you are doing much better. We are wishing
you the best and stay warm!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10616548-DS-12 | 10,616,548 | 22,599,703 | DS | 12 | 2158-04-30 00:00:00 | 2158-05-01 13:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Trifluoperazine / Lamictal
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/complicated psychiatric history including
anxiety, mood disorder including MDD vs ? bipolar notable, heavy
EtOH and benzodiazepam use, urinary retention requiring
self-catheterization c/b recurrent UTIs on bactrim suppression
and hyponatremia who presented after fall x2 with altered mental
status and generalized weakness.
Patient was in her USOH until 2 days PTA when states that she
fell out of bed while trying to reach for something at her
nightstand table. The fire department came and helped her up.
This happened again the following night, at which point she was
brought to the emergency department. She fell on her shoulder
once but denies any significant pain. None of the falls were
accompanied by head strike, loss of conciousness, chest pain,
shortness of breath, or palpitations. The patient walks with a
rolling walker at baseline but states she has been too weak to
walk for the past couple days. She has not taken her medications
over the past 48 hours because she has been too weak to reach
them. She recently had diarrhea after starting stool softeners
and had been eating a BRAT diet with decreased PO intake. She
had also been avoiding water over the past day because she was
concerned she would not be able to make it to the bathroom if
she needed to go. Other than the stool softeners she had no
other recent medication exposures or changes.
She had similar symptoms several years ago with weakness and
falls for which she hit her head and was brought to the hospital
where she was diagnosed with hyponatremia which was thought to
be contributing. For workup of her prior hyponatremia, she was
referred to endocrinology for potential adrenal insufficiency
given a low afternoon cortisol. Her morning cortisol was noted
to be in the grey-zone and she responded appropriately to a
___ test. It was recommended to repeat a morning cortisol
which was 19 and it was felt she did not have adrenal
insuffiency. Per OMR, her hyponatremia seems like it was
attributed to SIADH potentially related to her psychiatric
medications and she has been encouraged to limit free water and
increase her salt intake.
She was initially brought to ___ where she had a head CT and CXR
showing no acute abnormality. She was given 2L IVF while there.
She was transferred to the ___ ED because her primary care is
here.
In the ED initial vitals were: 97.9 82 120/58 14 96%
Past Medical History:
Alcohol abuse
Anxiety disorder
Mitral valve prolapse
Synoval cyst
S/p right medial meniscus repair
Urinary incontinence
Metarsalgia
GERD
Left breast basal carcinoma
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals - T: 98.l BP: 125/59 HR: 85 RR: 18 02 sat: 96%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, ?occasional dyskinetic mouth movements
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI systolic murmur at LUSB, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Midline abdominal scar.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. LUE area of erythema over hand at site
of prior IV.
PULSES: 1+ radial and DP pulses bilaterally
NEURO: CN II-XII intact, AAOx3, appropriately conversational,
action tremor present in both arms and neck which patient states
has been present for decades, motor tone normal, decreased bulk,
symmetric ___ weakness in ___ bilaterally. Shoulder ROM intact,
no tenderness to palpation, intact sensation.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Multiple scars from cutting over both UE. Should
ecchymosis.
Discharge Physical Exam:
Vitals - Tm: 98.8 Tc: 98.1 BP: 120/70 HR: 76 RR: 18 02 sat:
95%RA. Weight 63.8 ___, 63.7 ___
I/O: pMN: -/400 p24: 1320/___
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, occasional dyskinetic mouth movements
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI systolic murmur at RUSB and LUSB,
gallops, or rubs
LUNG: inspiratory crackles in bases of posterior lung fields.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Midline abdominal scar.
EXTREMITIES: no cyanosis, clubbing or edema. LUE area of
erythema over hand at site of prior IV.
PULSES: 1+ radial and DP pulses bilaterally
NEURO: L sided facial droop, but face activates symmetrically,
pupils 3mm -> 1.5 mm direct and consensual. Sensation in tact in
branches of V. AAOx3, Strength ___ ___, ___ LUE, ___ biceps RUE. Reflexes 2+ patellar. Sensation diffusely in
tact. Appropriately conversational, action tremor present in
both arms and neck which patient states has been present for
decades.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Multiple scars from cutting over both UE. Should
ecchymosis.
Pertinent Results:
Admission Labs:
___ 06:00PM URINE HOURS-RANDOM CREAT-96 SODIUM-10
POTASSIUM-14 CHLORIDE-22
___ 06:00PM URINE UCG-NEGATIVE OSMOLAL-376
___ 06:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG
___ 06:00PM URINE RBC-4* WBC-65* BACTERIA-FEW YEAST-NONE
EPI-1
___ 06:00PM URINE MUCOUS-RARE
___ 05:00PM GLUCOSE-103* UREA N-11 CREAT-0.5 SODIUM-127*
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-25 ANION GAP-15
___ 05:00PM estGFR-Using this
___ 05:00PM CK(CPK)-1712*
___ 05:00PM cTropnT-<0.01
___ 05:00PM CK-MB-16* MB INDX-0.9
___ 05:00PM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-2.0
___ 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 05:00PM WBC-8.4# RBC-4.04* HGB-13.2 HCT-38.6 MCV-96
MCH-32.7* MCHC-34.3 RDW-12.8
___ 05:00PM NEUTS-70.2* ___ MONOS-10.2 EOS-1.5
BASOS-0.1
___ 05:00PM PLT COUNT-201
Pertinent results:
___ 05:00PM BLOOD CK(CPK)-1712*
___ 07:50AM BLOOD CK(CPK)-790*
___ 05:00PM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Osmolal-259*
Discharge Labs:
___ 07:28AM BLOOD WBC-5.7 RBC-3.71* Hgb-12.2 Hct-35.9*
MCV-97 MCH-32.9* MCHC-34.0 RDW-13.0 Plt ___
___ 07:28AM BLOOD UreaN-9 Creat-0.5 Na-134 K-4.2 Cl-96
HCO3-31 AnGap-11
Imaging:
___ Imaging GLENO-HUMERAL SHOULDER
Three views of the right shoulder provided. There is no acute
fracture or dislocation. There is mild right AC joint
arthropathy with loss of AC joint space. The glenohumeral joint
aligns normally. The imaged right upper ribs appear intact. No
soft tissue calcification.
IMPRESSION:
No acute findings.
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
ENTEROBACTER CLOACAE COMPLEX. ___
ORGANISMS/ML..
___ MORPHOLOGY.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ENTEROBACTER CLOACAE
COMPLEX
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I <=16 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Brief Hospital Course:
Ms. ___ is a ___ w/PMH notable for complicated psychiatric
history including anxiety, mood disorder likely MDD vs ? bipolar
disorder, remote history of alcohol abuse, benzodiazepam abuse,
as well as recurrent UTIs, on tmp/smx prophylaxis, and
hyponatremia who was admitted with fall x2, found to have
Enterobacter UTI and hyponatremia.
ACTIVE PROBLEMS
# Falls: Patient fell x2 overnight requiring assistence of fire
department, no head strike, no LOC. Etiology was felt to be
multifactorial and secondary to hyponatremia, UTI,
benzodiazepine use as below, and baseline gait instability.
Point of impact noted to be the R shoulder, and patient
complained of weakness on admission. Trauma workup of the R
shoulder was negative for fracture, and she was treated with
acetaminophen prn for pain.
# Hyponatremia: Patient's serum Na was 127 on admission. Her
clinical exam was suggestive of euvolemia however urine studies
suggested hypovolemia (Urine Na = 10, FeNa = 0.04%). The patient
was making concentrated urine (Urine osms 380 serum Osm 260)
with stimulus for ADH secretion felt to be from baroreceptors
given her volume status. She was given 2L NS and her Na improved
to 132 over the next ___ hours, and then 134 over the next ___
hours, an appropriate rate of correction. On prior
hospitalizations, she was noted to have ?SIADH ___ to
psychotropic medications however the correction with fluid
rescuscitation and urine electrolytes on presentation supports
hypovolemia as the etiology in this case, although it is still
possible that she may have some ADH secretion from psychotropic
medications. On ___ her serum sodium dipped to 129 in the
setting of poor PO intake, a 2kg decrease in weight from ___,
and she was given 1L of NL for hyponatremia presumed secondary
to hypovolemia. Her sodium responded to IV fluids, and patient
was advised to increase her fluid and solute intake
# Enterobacter UTI: The patient has a history of chronic UTIs
w/tmp/smx suppression at home. She straight catheterizes at home
for urinary retention of unclear etiology and notes that while
down she was unable to properly sterilize her. On admission, her
UA was ___ w/60 wbc/hpf on USed. She was treated empirically
with ceftriaxone. Urine Cx grew Enterobacter cloacae which was
resistant to TMP/SMX but otherwise relatively sensitive. She was
switched to ciprofloxacin with an anticipated 6d course for
cathether associated UTI. To start macrobid suppression ___
after completion of Cipro ___
# Anxiety: The patient takes diazepam 5mg po qAM and qNoon daily
for anxiety. Her urine toxin screen was positive for
benzodiazepines on admission. She was noted to be very somnolent
after receiving her medication and overuse of these medications
was felt to be a factor in her falls.
CHRONIC PROBLEMS
# Depression: Patient was continued on home paroxetine 30mg BID
and trazodone 100mg qd.
# Bipolar Disorder: Patient was continued on home Divalproex
(Valproate) 500 mg TID
# GERD: Patient was continued on home omeprazole for GERD 20mg
po daily
Transitional Issues:
1) Follow-up with outpatient psych re: benzodiazepine regimen,
?abuse vs. overmedication
2) Follow-up of hyponatremia. Initial workup suggested ADH
stimulation secondary to hypovolemia (UOsms 380, Serum Osms 260,
FeNa 0.04%), but given history of borderline am cortisol and
discharge labs with improving but low Na, marginally elevated K,
could revisit the question of adrenal insufficiency vs. SIADH as
an outpatient. Suggest repeat chem 7 in ___ days.
3) Start nitrofurantoin suppression ___ as UTI was resistant
to Bactrim
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 500 mg PO TID
2. Gabapentin 400 mg PO TID
3. Simethicone 40-80 mg PO QID:PRN gas pain
4. Diazepam 5 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Psyllium Dose is Unknown PO Frequency is Unknown
7. Multivitamins 1 TAB PO DAILY
8. Ibuprofen Dose is Unknown PO Frequency is Unknown
9. Omeprazole 20 mg PO DAILY
10. Paroxetine 60 mg PO DAILY
11. TraZODone 100 mg PO HS
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Diazepam 5 mg PO DAILY
2. Diazepam 5 mg PO LUNCH
3. Divalproex (DELayed Release) 500 mg PO TID
4. Gabapentin 400 mg PO TID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Paroxetine 60 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. TraZODone 100 mg PO HS
11. Ciprofloxacin HCl 500 mg PO ONCE Duration: 1 Dose
Last dose ___ of ___. Psyllium 2 PKT PO BID:PRN constipation
13. Nitrofurantoin Monohyd (MacroBID) 100 mg PO HS
for UTI suppression
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
UTI
Secondary Diagnoses:
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization at
___. You were treated for a fall. Xrays of your shoulder were
negative. You were also found to have low blood sodium and a
urinary tract infection which may explain why you felt weak and
fell. The low blood sodium was treated with fluids and resolved.
The urinary tract infection was treated with antibiotics and
your symptoms improved.
Sincerely,
Your ___ team
[] Please follow up with primary care physician after discharge
[] Please follow up with your psychiatrist after discharge
regarding your anxiety medications.
[] Please attend a day program to treat your anxiety
Followup Instructions:
___
|
10617012-DS-17 | 10,617,012 | 28,488,319 | DS | 17 | 2179-09-20 00:00:00 | 2179-09-21 22:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
omeprazole
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: coronary angiography
History of Present Illness:
___ with no significant PMHx who p/w CP x1d and was found to
have
NSTEMI with cardiac cath showing diffuse, non-obstructive CAD
with flow limiting culprit lesion in ___ diag.
Pt states that he developed central chest pain at 11 AM ___
while walking. He describes the pain as a pressure that radiated
down his arms b/l. It persisted throughout the day and kept him
awake last night. He woke up this morning with the pain
continued
and therefore presented to urgent care ___, and was referred to
___ ED.
On arrival, he had ___ chest pain. VSS.
In the ED initial vitals were: 98.0 66 163/77 17 99% RA
EKG: NSR, RBBB, LAFB, LVH. No focal signs of ischemia. At
baseline.
Labs notable for:
- CBC: WBC 10, Hgb 12.8
- Chem7: Cr 0.8
- TropT @ 1530 2.18, MB 81
Images notable for:
- CXR showed no acute cardiopulmonary abnormality.
Patient was given:
___ 16:48 SL Nitroglycerin SL .4 mg ___
___ 16:48 IV Heparin 4000 UNIT ___
___ 16:48 IV Heparin ___ Started 950
units/hr
Card was consulted and pt went to the cath lab.
Cardiac catheterization through RRA
Dominance: Right
* Left Main Coronary Artery
short segment with no angiographically significant disease
* Left Anterior Descending
The LAD has mild proximal disease, ___
The ___ Diagonal appears to be the culprit vessel, slow flow
noted in the distal branch
* Circumflex
The Circumflex has a proximal eccentric 50-60% stenosis across
from the ___ Marginal branch
* Ramus
The Ramus is medium in caliber and has ostial 80% stenosis
* Right Coronary Artery
The RCA is large, dominant and has mild diffuse luminal
irregularities
Impressions:
1. Slow flow in distal segment of a high diagonal branch of the
LAD, likely culprit lesion
2. In light of small caliber branch vessel and clinically
patient
being chest pain free, PCI deferred, would Rx medically
On arrival the floor...
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
Duodenal ulcer in ___
Hemorrhoids
Diverticulosis
Colorectal polyps
Cataract, nuclear sclerotic senile
History of reduction of orbital fracture
Sleep disorder
Social History:
___
Family History:
No family history of CAD
Physical Exam:
Admission Exam:
============
VS: T 98.4, BP 169 / 79, HR 64, RR 17, SpO2 97 ra
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR. Normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Right wrist with pressure band, no surrounding
bleeding or swelling
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Exam:
============
T 98.2 BP 114 / 66HR 65 RR 18SO2 95Ra
General: lying flat, no acute distress
Neck: JVP flat when patient seated at ___ degrees
Heart: RRR no murmurs
Lungs: CTAB, no crackles
Extremities: no peripheral edema
Pertinent Results:
Admission Labs:
============
___ 03:32PM BLOOD WBC-10.1* RBC-3.98* Hgb-12.8* Hct-38.8*
MCV-98 MCH-32.2* MCHC-33.0 RDW-12.6 RDWSD-45.0 Plt ___
___ 03:32PM BLOOD Neuts-75.5* Lymphs-17.8* Monos-5.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.64* AbsLymp-1.80
AbsMono-0.60 AbsEos-0.02* AbsBaso-0.03
___ 03:32PM BLOOD Plt ___
___ 03:32PM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-141
K-4.0 Cl-102 HCO3-27 AnGap-12
___ 03:32PM BLOOD CK(CPK)-995*
___ 03:32PM BLOOD cTropnT-2.18*
___ 03:32PM BLOOD Calcium-9.3 Phos-2.4* Mg-2.1
Discharge Labs:
============
___ 06:05AM BLOOD WBC-10.4* RBC-3.98* Hgb-12.5* Hct-38.4*
MCV-97 MCH-31.4 MCHC-32.6 RDW-12.6 RDWSD-44.8 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD PTT-72.1*
___ 06:05AM BLOOD Glucose-117* UreaN-17 Creat-1.1 Na-144
K-4.2 Cl-105 HCO3-24 AnGap-15
___ 06:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1
Imaging:
======
___:
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the distal anterior
wall and apex (distal LAD territory). The remaining segments
contract normally (LVEF = 50%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
___ Physician ___:
1. Slow flow in distal segment of a high diagonal branch of the
LAD, likely culprit lesion
2. In light of small caliber branch vessel and clinically
patient being chest pain free, PCI deferred, would Rx medically
___ (PA & LAT):
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Mr. ___ is a ___ who presented with chest pain and was
diagnosed with NSTEMI.
#type 1 NSTEMI:
Mr. ___ presented to the hospital with chest pain and was
diagnosed with NSTEMI. He underwent coronary angiography which
disclosed a culprit lesion in a small diagonal branch of the
LAD, to small for intervention. He was treated with IV heparin
for 48h and was started on aspirin 81 mg PO QD, ticagrelor 90 mg
PO BID, atorvastatin 80 mg PO QD. A TTE revealed mild regional
left-ventricular systolic dysfunction. The LVEF was 50%. He was
seen by our Physical Therapy service and outpatient cardiac
rehabilitation was recommended. He was discharged on ASA 81,
Ticagrelor 90 bid (plan for at least 1 month per outpt cards,
then possibly switch to Plavix), atorva 80, metop XL 25.
- outpatient follow-up with Cardiologist Dr. ___
#GERD: omeprazole
Transitional Issues:
====================
[ ] New meds: aspirin 81 mg PO QD, ticagrelor 90 mg PO BID,
atorvastatin 80 mg PO QD, Metoprolol succinate 25 mg PO QD
[ ] F/u with cardiology to determine length of DAPT and possible
switch to Plavix given cost of ticagrelor
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO DAILY
2. LORazepam 0.25 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
Please start on ___
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN severe chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Q5MIN Disp
#*30 Tablet Refills:*0
5. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. LORazepam 0.25 mg PO QHS
7. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI
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 because you had chest pain.
You were found to have had a heart attack. Your heart arteries
were examined (cardiac catheterization) which showed a blockage
of a small branch of one of your heart arteries. This branch was
to small to be opened by placing a tube (stent) in the artery.
Your heart attack was treated medically including IV heparin and
other medications to prevent future blockages.
- It is very important to take your aspirin and ticagrelor (also
known as Brilinta) every day.
- These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and having another
heart attack
- Please do not stop taking either medication without taking to
your heart doctor.
- You are also on other new medications to help your heart, such
as atorvastatin, metoprolol and lisinopril.
- Please weigh yourself daily and contact your doctor if your
weight increases by 3 lbs in 1 day or 5 lbs in 1 week
Please follow- up with your primary care physician and
cardiologist as scheduled below.
It was a pleasure providing care for you! We wish you the best
in your health!
Sincerely,
your ___ CARDIOLOGY team!
Followup Instructions:
___
|
10617255-DS-3 | 10,617,255 | 21,586,668 | DS | 3 | 2110-06-20 00:00:00 | 2110-06-23 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
melena, upper GI bleed
Major Surgical or Invasive Procedure:
___ - EGD by GI
History of Present Illness:
___ y/o M with history alcoholic cirrhosis presenting from ___.
___ with GI bleed. Per his wife, he has had a variceal bleed
in the past, ___. He awoke on ___ morning with increased
fatigue and confusion, and became increasingly confused over the
of the day. He subsequently had several episdoes of melena. No
emesis. Denied pain. No fevers. He was brought to ___ ED
by his wife. On arrival, he was noted to be pale with H/H of
4.___.1. He was given a PPI bolus and gtt, octreotide, 1g
ceftriaxone, and transfused 1U PRBCs prior to transfer to ___.
(Of note, he was written for 2U PRBCs but it is unclear if he
got the 2nd unit). His INR was also noted to be 1.7 but no FFP
was given. On transfer, per EMS he had some blood-streaked and
coffee ground emesis but this was very little.
In the ED, initial VS: T 98.4, HR 86, BP 95/58, RR 18, SaO2 100%
on 3L NC. BP remained in the 100s-110s systolic with HR in the
___. Initial labs notable for H/H 5.1/18.0. He was noted to be
pale, confused, and had guiac postive dark brown stool. He was
evaluated by GI/liver who recommended trending labs, continuing
octreotide, protonix drip, and ceftriaxone.
On arrival to the MICU, initial VS were: 98.1, 127/56, 86, 21,
100% on 2L NC. He is not clear about the course of events over
the past 48 hours, so the majority of this history was verified
by his wife and daughter. Per his family, he is still "not
acting himself".
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, recent URI symptoms. Denies cough,
shortness of breath Denies chest pain or weakness. Denies nausea
or abdominal pain. Denies dysuria. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- EtOH cirrhosis with esophageal varices s/p multiple bleeds and
banding procedures
- H/o Alcohol abuse, quit in ___
- Vocal cord leukoplakia
- Anemia
- Hepatitis A
- Hyperlipidemia
Social History:
___
Family History:
No cirrhosis or liver disease.
Physical Exam:
On Admission:
Vitals: 98.1, 127/56, 86, 21, 100% on 2L NC
General: Alert, oriented to person, hospital, but does not know
why he is hospitalized, cooperative
HEENT: Sclera anicteric, conjunctiva pale, 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: distended, soft, non-tender, normoactive bowel sounds,
no organomegaly, + shifting dullness
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no asterixis, no clonus
On Discharge:
VITALS: 98.8 84/42 70 18 98% on Ra
General: A&Ox3, no asterixis, can recall address, can count the
days of the backwards, difficulty hearting
HEENT: Sclera anicteric, conjunctiva pale, MM are moist w/o
lesions, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTA bilaterally, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, soft, non-tender, bowel sounds are present,
no organomegaly, + shifting dullness
Ext: warm, well perfused, no pedal edema
Neuro: no asterixis, no clonus, speech is fluent, but poor
attention, ___ strength in arms and legs, sensation intact.
Pertinent Results:
On Admission:
___ 12:20AM BLOOD WBC-12.9* RBC-2.25* Hgb-5.1* Hct-18.0*
MCV-80* MCH-22.9* MCHC-28.6* RDW-18.4* Plt ___
___ 12:20AM BLOOD Neuts-78.6* Lymphs-13.5* Monos-7.2
Eos-0.3 Baso-0.3
___ 12:20AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Target-NORMAL
Schisto-OCCASIONAL Tear Dr-1+
___ 12:20AM BLOOD ___ PTT-29.1 ___
___ 12:20AM BLOOD Glucose-138* UreaN-71* Creat-1.2 Na-141
K-4.5 Cl-111* HCO3-19* AnGap-16
___ 12:20AM BLOOD ALT-169* AST-233* AlkPhos-53 TotBili-1.3
___ 12:20AM BLOOD Lipase-517*
___ 12:20AM BLOOD Albumin-3.4*
___ 12:26AM BLOOD Lactate-2.4*
On Discharge:
___ 06:45AM BLOOD WBC-6.2 RBC-3.42*# Hgb-9.0*# Hct-29.0*
MCV-85 MCH-26.2* MCHC-31.0 RDW-17.5* Plt Ct-75*
___ 06:45AM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-6
Eos-1 Baso-0 ___ Myelos-1*
___ 06:45AM BLOOD Plt Smr-VERY LOW Plt Ct-75*
___ 06:45AM BLOOD Glucose-221* UreaN-24* Creat-1.0 Na-137
K-3.6 Cl-104 HCO3-23 AnGap-14
___ 06:45AM BLOOD ALT-378* AST-173* AlkPhos-64 TotBili-2.0*
___ 06:45AM BLOOD Albumin-3.5 Calcium-7.9* Phos-2.9 Mg-2.0
Iron-PND Cholest-PND
Microbiology:
__________________________________________________________
___ 6:45 am Blood (EBV)
___ VIRUS VCA-IgG AB (Pending):
___ VIRUS EBNA IgG AB (Pending):
___ VIRUS VCA-IgM AB (Pending):
__________________________________________________________
___ 6:45 am Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
93 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
__________________________________________________________
___ 6:45 am SEROLOGY/BLOOD
**FINAL REPORT ___
VARICELLA-ZOSTER IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
__________________________________________________________
___ 6:45 am SEROLOGY/BLOOD
**FINAL REPORT ___
RUBELLA IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
__________________________________________________________
___ 6:45 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 6:15 pm SWAB Source: Rectal swab.
**FINAL REPORT ___
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
__________________________________________________________
___ 2:41 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:41 pm SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
__________________________________________________________
___ 9:41 am BLOOD CULTURE Source: Venipuncture #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:26 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 11:53 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Imaging/Studies:
___ CXR
No previous images. The heart is within normal limits and there
is
no evidence of vascular congestion, pleural effusion, or acute
focal
pneumonia.
___ RUQ US
1. Cirrhosis with features of portal hypertension
(splenomegaly). The portal vein is patent with normal
hepatopetal flow demonstrated.
2. Cholelithiasis.
___ EGD
Varices at the extending from the GE junction to 23cm. Varices
at the cardia/fundus. Erythema and mosaic appearance in the
stomach body compatible with moderate-severe portal hypertensive
gastropathy
Ulcers in the antrum. Mild erythema in the duodenal bulb
compatible with mild duodenitis. No evidence of active bleeding
during the procedure.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ with PMHx alcoholic cirrhosis c/b variceal bleed in the past
and ascites who presented to melena and confusion, found to have
severe anemia concerning for upper GI bleeding, transferred to
___ MICU for further care. EGD did not show evidence of active
bleeding but had esophageal and gastric varices, portal
gastropahy, duodenitis, and ulcers.
# Upper GI bleed
H&H on presentation from OSH 5.___. At OSH, H&H on presentation
4.1/13.1. He received 2U pRBC at OSH and total of 3U at ___.
H&H on discharge ___. He was admitted to MICU where an EGD was
done and pt was found to have antral ulcers, duodenitis,
mod/severe portal gastrophathy and esophageal varices. No active
bleeding was observed. H. Pylori was negative. He was initially
started on octreotide gtt and protonix gtt. He was then
transitioned to protonix 40mg po bid and nadolol 40mg daily. He
was treated for SBP prophylaxis with ceftriaxone x3 days (no
ascites on imaging).
# Encephalopathy
He was not clearly appropriate in conversation and had
asterixis, consistent with hepatic encephalopathy. This was
likely precipitated by GI bleed. RUQ ultrasound did not show
portal vein thrombosis. Infectious workup was negative. He was
started on lactulose and rifaximin.
# Child class B alcoholic cirrhosis: c/b variceal bleed,
encephalopathy, and ascites.
- Pt has not been taking any of his medications including
diuretics, rifaximin, and lactulose since ___ because he
"does not believe in western medicine"
- diuretics were held in the setting of GI bleed and the pt has
not been taking them since ___
- resumption of diuretics will be in the discretion of
outpatient hepatologist
- transplant workup was initiated and all laboratory tests were
ordered
- an appointment with a transplant hepatologist was arranged
# Mild ___: Most likely prerenal in the setting of GIB. Trended
down quickly to 1.0 with transfusions.
# H/o Alcohol abuse, quit in ___. Patient would need to be in
alcohol cessation counseling if considering for liver
transplant.
- consult SW
- nutrition consult
# Anemia: Iron studies not useful in setting of multiple
transfusions.
- Iron studies as an outpatient
# Hyperlipidemia: Unclear if patient is on a statin. Follow up
as an outpatient.
TRANSITIONAL ISSUES:
- code status: full code
- pending results: transplant laboratory w/u
- contact: wife ___, ___ daughter is
___
[] monitor H&H one week after discharge on ___
[] transplant workup: labs ordered while inpatient
[] monitor for medication compliance
[] monitor ascites and initiate diuretics prn
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Nadolol 40 mg PO DAILY
3. Magnesium Oxide 400 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*90 Each Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg one tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
5. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg one tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
6. Outpatient Lab Work
Please check CBC, Chem 10, LFT's, coags on ___ and fax results
to ___ and ___.
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE DIAGNOSES:
1. upper GI bleed
2. peptic ulcer disease
3. hepatic encephalopathy
CHRONIC DIAGNOSES:
1. alcohol cirrhosis
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 presented to us with melena. We performed an
EGD (esophagogastroduodenoscopy) to visualize your upper
gastrointestinal tract, and you were found to have duodenal
ulcers and inflammation as well as varices as a result of your
liver disease. We believe your melena was most likely due to
bleeding ulcers. You received multiple blood transfusions due to
severe bleeding. We also started workup for liver transplant.
You will need to be seen by one of our transplant hepatologist
for further workup as instructed below.
Please take your medications as instructed. Please attend all
your follow up appointments.
Followup Instructions:
___
|
10617538-DS-8 | 10,617,538 | 27,286,142 | DS | 8 | 2159-12-15 00:00:00 | 2159-12-15 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Diffuse abdominal and back pain x3 weeks
Major Surgical or Invasive Procedure:
EUS guided biopsy ___
___ liver biopsy ___
PICC placement ___
History of Present Illness:
___ with hx of panic attacks, ___ presenting with three
weeks of diffuse abdominal pain and mid back pain. Pt describes
diffuse, migratory, postprandial abdominal pain with onset 3
weeks prior to presentation. Pain was initially like
"indigestion, heartburn," focused in the LUQ beneath the costal
margin, without clear positional component. Pain was migratory,
dull, at its worst ___ but sometimes ___. ___ tried pepto
bismol and gaviscon without relief. In the week prior to
presentation, pain arrived consistently 40 minutes after eating,
leading to decreased PO intake ___ "food fear." With respect to
his back pain, ___ describes it as midthoracic, between the
scapulae, sometimes radiating around anteriorly, typically R>L,
but similarly migratory in nature. ___ notes that ___ has had pain
related arthritis and pinched nerve in the past; the quality of
this pain was different. ___ did notice associated nausea without
emesis. Ranitidine, started 1 week prior to admission, initially
seemed to provide some relief of his abdominal pain. Denies
fevers, chills, change in stool patterns, dysuria, hematuria,
hematochezia, or melena. ___ called his PCP ___ ___ given
severe back pain, and EGD was scheduled. Pt underwent EGD on
___ which, per his report, was notable only for some
gastritis, and otherwise unrevealing. ___ was directed to ___
for CT torso.
Pt endorses chronic complex migraines without change in baseline
headache pattern. ___ endorses weakness on the day of admission,
but focality to this weakness. ___ denies drenching sweats. ___
has intentionally lost ___ lbs in the ___ months prior to
admission, which ___ accomplished by eliminating sugar and bread
from his diet. ___ has never had a colonoscopy.
His family history is notable for ovarian cancer in a maternal
aunt and a maternal cousin, who apparently died at age ___. ___ is
ethnically ___.
In the ___ ED:
VS 97.6, 61, 126/73, 99% RA
Labs notable for Cr 1.0, WBC 5.2, Hb 13.8, Plt 234, TnT<0.01
ALT 32, AST 21, Alk phos 123, Tbili 0.8, LDH 360, Uric acid 8.1
RUQ u/s with multiple hypoechoic lesions in the liver including
a dominant 4.1 lesion in segment II/III concerning for
malignancy/metastasis. 3.9 cm lobulated hypoechoic structure
along porta hepatis, ?LAD. No e/o cholecystitis.
CT torso with liver lesions, multiple enlarged mesenteric and RP
confluent lymph nodes including 5.8 cm gastrohepatic mass,
retrocural adenopathy, and 8.1 cm RP mass surrounding suprarenal
abdominal aorta, concerning for lymphoma. Heterogenous
appearance of T12 vertebral body concerning for metastatic
involvement.
On arrival to the floor, pt is in no pain. ___ recounts in detail
the findings discovered on his CT torso, the presumptive
diagnosis of malignancy - most likely lymphoma - and that
definitive diagnosis requires biopsy.
Past Medical History:
Anxiety with panic attacks
Hx of tobacco use
?Asthma
___ with hx of CVAs
Sarcoid - diagnosed remotely in the setting of lymphadenopathy.
Biopsy reportedly consistent with sarcoid.
Gout
Complex migraines - typically with visual aura (scotoma),
lasting ___ minutes
Social History:
___
Family History:
Pt has two brothers, ___ and ___, and a sister, ___
has ___ believes ___ and ___ are in good health. ___
has no children. His two nieces, ___ daughters, are in
excellent health. Pt's father died with ___. Mother had one
sister who died from ovarian cancer, as did her daughter. ___ is
not aware of any breast cancer in his family.
Physical Exam:
ADMIT EXAM:
VS T 98.2 BP 124/76 P 69 RR 18 O2 94% RA
Gen: Very pleasant, talkative male, slightly disinhibited, NAD
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera, MMM
Neck/LN: supple, no cervical or supraclavicular adenopathy, no
axillary adenopathy
CV: RRR, no murmurs, rubs or gallops
Lungs: CTAB, good air movement throughout, no wheeze or rhonchi
Abd: soft, nontender, nondistended, normoactive bowel sounds,
liver margin palpated 1 fingerbreadth below costal margin, no
rebound or guarding
GU: No foley
MSK: No spinal tenderness, no tenderness to palpation between
scapula
Ext: WWP, no clubbing, cyanosis or edema
Neuro: CN II-XII intact, strength ___ in UE and ___ bilaterally,
heel to shin limited by chronic L hip pain, gait antalgic,
ambulates with walking stick, apparent weakness of distal RLE,
but strength testing ___ in R hip flexor, knee extension, knee
flexion
Skin: No rash or lesions
DISCHARGE EXAM:
Vitals: Tm 97.9 BP ___ P 40-50 RR 20 O2 95-99% RA
24hr I/O: 2500/1700
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP with several
white lesions scattered on cheeks, tongue, posterior pharynx.
NECK: JVP flat. Normal carotid upstroke without bruits.
LYMPH: No cervical or supraclav LAD
CV: Regular rhythm and rate. Normal S1,S2. II/VI systolic murmur
at RUSB.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: Obese, NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3. CNII-XII grossly intact. Strength ___ in upper and
lower extremities b/l.
LINES: R PICC c/d/I.
Pertinent Results:
ADMISSION LABS
======================
___ 04:20PM GLUCOSE-90 UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-29 ANION GAP-16
___ 04:20PM estGFR-Using this
___ 04:20PM ALT(SGPT)-32 AST(SGOT)-21 LD(LDH)-360* ALK
PHOS-123 TOT BILI-0.8
___ 04:20PM LIPASE-15
___ 04:20PM cTropnT-<0.01
___ 04:20PM ALBUMIN-4.4 CALCIUM-9.5 PHOSPHATE-3.3 URIC
ACID-8.1*
___ 04:20PM WBC-5.2 RBC-4.42* HGB-13.8 HCT-40.4 MCV-91
MCH-31.2 MCHC-34.2 RDW-13.2 RDWSD-44.6
___ 04:20PM NEUTS-61.4 ___ MONOS-9.5 EOS-2.9
BASOS-0.6 IM ___ AbsNeut-3.22 AbsLymp-1.32 AbsMono-0.50
AbsEos-0.15 AbsBaso-0.03
___ 04:20PM PLT COUNT-234
IMAGING
=======================
RUQ u/s ___:
IMPRESSION:
1. Multiple hypoechoic lesions in the liver including a
dominant 4.1 lesion in segment II/III concerning for
malignancy/metastases. Recommend correlation with clinical
history and further evaluation with CT or MRI is recommended.
2. 3.9 cm lobulated hypoechoic structure along the porta
hepatis concerning for lymphadenopathy.
3. No cholelithiasis or sonographic evidence for cholecystitis.
CT torso with contrast ___:
IMPRESSION:
1. Re- demonstration of numerous hypodense lesions throughout
the liver
including a dominant 4.7 cm segment II lesion. These lesions are
amenable for biopsy for further evaluation.
2. Multiple enlarged mesenteric and retroperitoneal confluent
lymph nodes
including a 5.8 cm gastrohepatic mass, retrocrural adenopathy
and a 8.1 cm
retroperitoneal mass surrounding the suprarenal abdominal aorta.
Constellation of findings may reflect lymphoma.
3. Heterogeneous appearance of the T12 vertebral body concerning
for
metastatic involvement.
TTE ___:
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function (biplane LVEF = 68 %). The estimated cardiac
index is normal (>=2.5L/min/m2). There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size for BSA and free wall motion are normal. 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 appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild aortic regurgitation. Mild pulmonary artery systolic
hypertension.
MRI Brain ___:
1. Chronic white matter changes and lacunar infarcts in a
pattern typical for reported history of ___.
2. Numerous punctate bilateral micro hemorrhages predominantly
involving the deep gray nuclei, brainstem, and cerebellum are
characteristic of ___, more likely in a based setting of
superimposed hypertension.
3. No evidence of acute intracranial hemorrhage or acute
infarction.
4. No evidence of mass or mass effect. No abnormal
enhancement.
PATHOLOGY
========================
Fine needle aspiration, Gastrohepatic ligament:
Suspicious for large cell high grade lymphoma.
Flow cytometry ___:
Immunophenotypic findings consistent with involvement by kappa
restricted B cell lymphoma that coexpresses CD10 and CD11c.
Correlation with clinical findings and morphology (see separate
pathology report ___ and other ancillary findings is
recommended.
Flow cytometry ___:
Immunophenotypic findings consistent with involvement by kappa
restricted B cell lymphoma that coexpresses CD10 and CD11c.
Correlation with clinical findings and morphology (see separate
pathology report ___ and other ancillary findings is
recommended.
FISH ___:
POSITIVE for BCL6 REARRANGEMENT and GAIN of MYC. The large
majority of cells examined in this formalin fixed paraffin
embedded left para-aortic lymph node core needle biopsy had
abnormal probe signal patterns consistent with rearrangement of
the BCL6 gene and an extra copy of the MYC gene. There was no
evidence of the IGH/BCL2 gene rearrangement or
rearrangement of MYC. These findings are consistent with
follicular lymphoma or diffuse large B-cell lymphoma.
MICROBIOLOGY
========================
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
___ 7:13 pm VIRAL CULTURE:R/O HERPES SIMPLEX VIRUS
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
___ 3:30 pm THROAT CULTURE
RESPIRATORY CULTURE (Final ___:
HEAVY GROWTH Commensal Respiratory Flora.
___ ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE
GROWTH.
PERTINENT/DISCHARGE LABS
========================
___ 12:00AM BLOOD WBC-5.8 RBC-3.93* Hgb-12.0* Hct-34.6*
MCV-88 MCH-30.5 MCHC-34.7 RDW-12.4 RDWSD-40.0 Plt ___
___ 12:00AM BLOOD Neuts-85.2* Lymphs-12.2* Monos-2.1*
Eos-0.2* Baso-0.0 Im ___ AbsNeut-4.91 AbsLymp-0.70*
AbsMono-0.12* AbsEos-0.01* AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-149* UreaN-24* Creat-0.8 Na-134
K-3.3 Cl-96 HCO3-27 AnGap-14
___ 12:00AM BLOOD ALT-22 AST-14 LD(LDH)-174 AlkPhos-87
TotBili-0.4
___ 12:00AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.4* Mg-2.3
UricAcd-4.5
___ 12:00AM BLOOD %HbA1c-5.3 eAG-105
___ 12:00AM BLOOD Triglyc-148 HDL-32 CHOL/HD-6.1
LDLcalc-134*
___ 06:20AM BLOOD HBsAb-Negative HBcAb-Negative
___ 06:20AM BLOOD HIV Ab-Negative
Brief Hospital Course:
Mr ___ is a ___ year old man with a history notable for
___ syndrome as well as sarcoidosis, who presented with a
subacute onset of worsening abdominal pain. ___ was found to have
multiple hepatic lesions, multiple enlarged mesenteric and
retroperitoneal confluent lymph nodes, and a heterogeneous
appearance of the T12 vertebral body concerning for metastatic
involvement. Initially pathology results available were
consistent with high grade B-cell (non-Hodgkin's) lymphoma.
#B-cell lymphoma. Initial results show cells immunoreactive for
CD10, BCL6 heterogeneous staining), BCL2 (dim subset), and MUM1
(variable staining), concerning for DLBCL vs ___ lymphoma.
Further results as above. Upon admission, concern for TLS given
elevated uric acid and LDH. For this ___ was started on
continuous IVF and Allopurinol. ___ began dose adjusted R-EPOCH
chemotherapy cycle 1 on ___. TTE was obtained prior to
chemotherapy, and showed LVEF 68%. ___ tolerated chemotherapy
well, and finished on ___. ___ did not receive Rituxan while
admitted but arrangement were made for him to receive this as an
outpatient. ___ will also receive Neulasta as an outpatient. CBC
w/diff, electrolytes, LFTs, uric acid were monitored daily. ___
did not require any transfusions.
#Oral candidiasis. On ___, noted to have several small white
lesions on oral mucosa. These were not painful. Rapid strep
negative, viral culture sent with no growth. Lesions then
improved, but reoccurred ___. These were thought to be
consistent with candidiasis, so Micafungin was started ___.
Azole antifungals were advoided during EPOCH chemotherapy.
Fungal gram stain showed no yeast, but culture grew ___
albicans on ___. When chemotherapy was completed, ___ was
discharged on Fluconazole 100mg daily, with plans to stop this 2
days prior to next admission, and switch to Micafungin while
admitted.
___ syndrome. Pt reports a history of basal ganglia stroke
at age ___. ___ was subsequently seen by Dr. ___ in neurology,
who described that ___ almost surely has ___. It does not
appear this has been confirmed with genetic testing, but Mr
___ has been on Aggrenox and Losartan for years. Neurology
was consulted ___ regarding his stroke risk vs risk of
bleeding if ___ is taken off Aggrenox when thrombocytopenic due
to chemotherapy. Per their recommendations, it was felt to be
reasonable to stop Aggrenox as ___ becomes thrombocytopenic,
likely when his platelet count falls below 50. ___ did not become
thrombocytopenic during admission, so Aggrenox was continued. An
MRI was obtained for baseline imaging; A1c and lipids were also
obtained for risk stratification. ___ has previously declined
statin therapy.
#Sarcoidosis. Pt reports history of incidentally discovered
mediastinal lymphadenopathy, with biopsy proven sarcoidosis. ___
also reports a history of uveitis. Both his sarcoid and uveitis
have been followed by his outpatient doctors, and ___ has
received short courses of Prednison, but ___ is not currently on
treatment for this.
#Anxiety. Well controlled at home with Fluoxetine, Alprazolam.
These were continued during admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 20 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Losartan Potassium 50 mg PO DAILY
4. Allopurinol ___ mg PO Frequency is Unknown
5. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
6. ALPRAZolam 0.5 mg PO BID:PRN panic attack
Discharge Medications:
1. Fluconazole 100 mg PO Q24H
Discontinue 2 days prior to next admission for chemotherapy.
RX *fluconazole 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth three
times a day Disp #*30 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. ALPRAZolam 0.5 mg PO BID:PRN panic attack
6. Dipyridamole-Aspirin 1 CAP PO BID
7. FLUoxetine 20 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
High grade B cell lymphoma
SECONDARY:
___ syndrome
Sarcoidosis
Oral candidiasis
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 at ___
___.
Why was I in the hospital?
You were in the hospital because you had worsening abdominal
pain. We found that this was due to lymphoma.
What happened to me while I was in the hospital?
We gave you a cycle of chemotherapy.
What should I do when I leave the hospital?
You should continue to take your medicines and go to your
appointments. We will make appointments for you to receive
injections and get your labs checked.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10617964-DS-10 | 10,617,964 | 27,038,524 | DS | 10 | 2118-11-26 00:00:00 | 2118-11-26 15:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
feculant drainage from abdominal wall
Major Surgical or Invasive Procedure:
Colorectal flushed wound/ECF with 500 cc normal saline. Moderate
amount of necrotic slough removed from bed. Effluent is loose
fecal drainage with blood.
History of Present Illness:
___ year old female with metastatic cervical leiomyosarcoma s/p
ileocolic bypass for malignant obstruction currently on
pazopanib
who presents with feculent drainage of abdominal wound. Her
sarcoma is extremely aggressive. A week ago she had abdominal
bloating and saw her doctor who did an XR with nothing obvious
found at that time. IN the last several days she had worsening
abdominal pain and today she looked down and noted stool
draining
from her lower abdomen which was malodorous so was advised to
come to the ED. Note she has h/o bowel obstruction this past
___ requiring surgical correction. It is known that one of
the
complications of her tumor (or the surgery) was a fistula
between
tumor and bowel, but until now it was thought to be the non
working bowel loop. She started pazopanib on ___. She
was recently admitted in early ___ for diarrhea.
In the ED pt was afebrile with HR int he ___ BP in the
120-130/80s range RR 16 with 97% on RA. In the ED colorectal
surgery saw her and they evacuated a large volume pasty and
liquid stool, no purulence, they felt this could be erosion of
tumor-enteric fistula to skin, effectively distal EC fistula. No
evidence of infection. Ostomy was placed. CT abd/pelvis showed
interval decrease in pulmonary masses, new small left pleural
effusion,k large lower anterior abdominal wall defect with
enterocutaneous fistula involving primarily large bowel, however
small bowel also seen in the region.
UA was not suggestive of infection, lactate 1.4, chem
unremarkable and Hct was 26, near a recent prior value. WBC 5.0
with 83% pmns. She recieved a total of 1.5mg IV dilaudid.
On arrival to the floor she feels well and states her abdominal
pain is reasonably controlled when she lies still but movement
exacerbates it. Denies n/v/sob/diarrhea.
Past Medical History:
OBGYNHx: Gravida 0. Menopausal symptoms of hot flashes for ___
year. Has a history of fibroids. No hx of ovarian cysts, STD's
or
abnormal pap smears. Last pap was in ___ and was normal.
Mammogram in ___ was nml.
PMH: Denies history of asthma, heart disease, diabetes, HTN,
thromboembolic disease and breast cancer.
PSH: Open cholecystectomy in ___
Past Oncological History:
___: Initiated a 9 month period of amenorrhea
-___: Menstrual cycle recommenced with flow similar
to
her previous menstrual cycles. However, as the days went by,
she began experiencing menorrhagia with large blood clots the
size of a tennis ball.
-___: ___ Emergency department. She
underwent a transvaginal ultrasound that showed an 8 x 11 x 9.2
cm uterus with a complex cystic mass in the central uterus
measuring 7.5 x 4.5 cm with multiple septations. She also
underwent a biopsy of the cervix in the emergency department
with
pathology revealing poorly differentiated pleomorphic malignant
neoplasm likely pleomorphic leiomyosarcoma, positive focally for
caldesmon, P16, KI67 increased and negative for melcam, AE1/3,
EMA, P53, P63, inhibin, GATA-3, MelanA, HMB-45, ERG, CD34.
-___: Evaluated by her gynecologist in the office,
Dr. ___. MRI showed a complex 8.2 x 8.8 cm mass.
-___: Established care with Dr. ___. Pelvic exam
revealed the cervix with foul-smelling necrotic tissue, and a
biopsy was performed in clinic.
-___: CT chest, abdomen and pelvis that showed
suspicious left external iliac lymph nodes, two 7 mm periaortic
lymph nodes, a 3-mm left lower lobe nodular atelectasis and a
15.5 x 10.9 x 9.9 cm mass around the lower uterus.
-___: Total abdominal hysterectomy, bilateral
salpingo-oophorectomy, bilateral lymph node sampling, cystoscopy
and omental biopsy. Intraoperatively, the mass extended to the
bilateral pelvic sidewalls with large external bilateral iliac
lymph nodes and a normal omentum.
**PATH: 9.5 cm mass consistent with leiomyosarcoma with
lymphovascular invasion, positive for desmin and ER/PR negative.
The vagina also had fragments of leiomyosarcoma, zero out of
three lymph nodes were positive, but there was involvement of
perinodal fat with leiomyosarcoma. The peritoneal washings were
negative.
-___: Adjuvant radiation therapy started with ___
in ___
-___: CT imaging at ___'s office showed nodules in lung
-___: CT Torso:
*Interval development of multifocal,
multilobuated,heterogeneously -enhancing mass in the pelvis
containing cystic and soft tissue
components with pelvic wall lymphadenopathy, concerning for
disease recurrence.
*Moderate hydroureteronephrosis on the left kidney secondary to
mass effect from above lesion.
*Multiple new pulmonary nodules, predominantly in the lower
lobes
consistent with metastatic disease.
-___: C1D1 Gemcitabine/docetaxel started
-___: C1D8 Docetaxel allergic reaction manifested
as cp, flushing, and dyspnea which resolved with steroids and
benadryl.
-___ to ___ with slow infusion of
docetaxel, well-tolerated
Social History:
___
Family History:
Denies family hx of cancer, heart disease, DM
Physical Exam:
VITAL SIGNS: T 98.5 BP 109/78 HR 94 RR 18 96% RA
General: NAD
GI: BS+, ostomy covering fistula in mid lower abdomen, there is
tenderness to palpation around the ostomy. brown liquid stool in
ostomy bag. there is a strong fecal odor exuding from bag
LIMBS: WWP
SKIN: No rashes
NEURO: Grossly normal
Pertinent Results:
___ 06:30AM BLOOD WBC-3.8* RBC-2.84* Hgb-7.4* Hct-25.0*
MCV-88 MCH-26.1* MCHC-29.7* RDW-22.0* Plt ___
Brief Hospital Course:
___ w/ metastatic cervical leiomyosarcoma s/p ileocolic bypass
for malignant obstruction currently on pazopanib who presents
with open enteroccutaneous fistula
#Enterocutaneous fistula
Pain improved after the fistula opened to skin. It is unclear
whether this fistula is connected to the main colonic outlet.
Colorectal surgery performed a drainage and she was seen by
wound care. Please see page 1 and patient instructions for
detailed wound care. She has home ___ arranged for wound/ostomy
care, and will need to change the pouch every ___.
-- pain control prn with oxycontin and oxycodone
-- f/u colorectal surgery as outpatient
#Cervical leiomyosarcoma
Seems to be responding well to pazopanib as abdominal/chest CT
did not reveal any obvious masses. Cannot resume pazopanib until
enterocutaneous wound heals. Will need repeat imaging early
___ and Dr. ___ will help arrange this as an
outpatient.
#Anemia
Likely from cancer and chemo but there is certainly an element
of bleeding from the fistula. Her CBC was stable at 25 and will
be followed by her oncologist. Since she is not symptomatic and
expect her counts to improve, we did not transfuse.
#Oral ulcers
She was found to have stomitis on admission, potentially related
to pazopanib. She improved quickly with normal saline rinses and
liquid oxycodone. She was instructed to continue oral care TID.
She did not tolerate magic mouthwash)
FEN: Regular
BOWEL REGIMEN: colace/senna
CODE STATUS: Full
CONTACT INFORMATION: ___ husband/HCP
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO QHS:PRN insomani
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. PAZOPanib 800 mg oral daily
4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN severe diarrhea
Discharge Medications:
1. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 ml by mouth every 4 hours as needed
Disp #*500 Milliliter Refills:*0
2. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 12
hours Disp #*60 Tablet Refills:*0
3. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by
mouth q6h prn Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Lorazepam 0.5 mg PO QHS:PRN insomani
8. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN severe diarrhea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic Sarcoma
Enterocutaneous Fistula
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was really a true pleasure to take care of you in the
hospital. You were admitted because of an open enterocutaneous
fistula. You were seen by the colorectal surgeons and the wound
care nurse.
Instruction for Pouch Change:
Please take pain medications ___ minutes before changing your
pouch to help prevent worsening pain.
1. Remove old pouch
2. Cleanse wound and periwound skin with warm water, pat dry.
3. Place clear template over wound.
4. Trace opening with magic marker
5. Replace template to pouch
6. Cut out
7. Apply no-sting barrier wipe ___ wound skin.
8. Remove clear template
9. Place pouch directly over wound - mold wafer to skin gently
with fingers.
10. Close pouch drainable port.
11. Change pouch ___ and ___ and or if leakage occurs.
Wound/ECF Care:
1. apply no-sting barrier wipe to periwound skin. ___ # ___
2. Apply ___ adapt barrier ring directly around wound
opening, ___ # ___
3. Cut out Coloplast 1 piece high output drainable pouch wafer
to
___. ___ # ___
4. Remove wafer and place directly over wound.
5. Mold wafer to skin
6. Apply disposal wash cloth and place warm packet x 5 minutes
over site to assist integrity of pouch.
Change pouch MON and Th schedule or if leakage occurs.
Followup Instructions:
___
|
10618000-DS-17 | 10,618,000 | 28,881,899 | DS | 17 | 2168-04-09 00:00:00 | 2168-04-11 22:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nabumetone / Metformin / Latex / Omeprazole /
Nifedipine / Iodine-Iodine Containing / Oxycodone / Humalog /
Cyclobenzaprine / simvastatin / ibuprofen / bandaid / oxybutynin
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ___ venous insuficiency s/p RFA of the right lesser
saphenous vein who presents for evaluation for PE. She initially
presented to a PCP ___ with complaints of blood clots in her
stools and left pain. She was referred to the ED where stool
guaic were negative and counts were stable, and ___ U/S showed:
Superficial thrombophlebitis of a superficial right calf vein
and left peroneal DVT. She was discharged with decision not to
anticoagulate and to f/u in clinic.
On ___ and ___, patient reported 2 episodes of chest pressure,
and associated nausea. Reports to me she has actually had this
chest tightness daily since her RFA in ___, described as
substernal tightness without clear provoking/palliating factors.
She at first endorsed radiation to the arm but further
questioning revealed she has discrete arm pain since a fall last
year. What was differeant about the discomfort the past 2 days
was the duration: 45 minutes, before self resolving, as well as
the association with nausea. There was mention to the ED and
___ clinic of SOB, but she denies this to me. She had
another ultrasound done by ___ clinic ___ that showed
dilated left proximal peroneal vein. She was referred to the
emergency room for evaluation of her chest pain with concern for
PE.
In the ED intial vitals were: 6 96.8 70 176/80 20 98%
- Labs were significant for Troponin negative x 1. EKG showed
sinus tachycardia.
- Patient was given 1 dose of therapeutic enoxaparin 70mg SC.
- CTA was ordered, but the patient has a contrast allergy so was
admitted to medicine for pre-medication.
Vitals prior to transfer were: 98.0 77 128/44 19 99% RA
On the floor, patient is comfortable but reports she still has
the tightness sensation now. However she declined any
medications, including nitro or pain meds. She also missed her
___ insulin and declined a short acting for her elevated
fingerstick. She does still have ___ pain, L>R in the left calf
especially. No other complaints.
Review of Systems:
(+) per HPI. Also reports feeling cold. Pain in right arm and
feet.
(-) fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, abdominal pain, vomiting,
diarrhea, constipation, melena, dysuria, hematuria.
Past Medical History:
1. Type 2 diabetes mellitus.
2. Chronic HCV
3. HTN
4. Hx of elevated CPKs which normalized after dc of simvastatin
5. Recent admission for chest pain - neg cardiac cath and CTA in
___. Hx of two small (3-4mm) nodules incidentally noted on CTA,
needs ___ CT
7. Status post cholecystectomy.
8. Hx of domestic violence
9. Hx of R Ulnar collateral ligament tear - ___ by Ortho
10. Hx of Glaucoma
11. Bell's palsy.
12. Hyperlipidemia.
13. Positive PPD.
14. Total abdominal hysterectomy.
15. Colonic polyps.
16. Radiofrequency ablation of the right lesser saphenous vein
___.
Social History:
___
___ History:
per OMR
Mother died at age ___ and had HTN
Father died at age ___ of natural causes
has one sister w breast ca and a brother who died of some sort
of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.1 128/62 72 20 99RA ___
GENERAL: NAD and comfortable appearing
HEENT: EOMI, PERRL
CARDIAC: S1, S2 regular. no murmurs/gallops/rubs. No JVD. No
increase in chest tightness to movement/palpation.
LUNG: Clear to auscultration bilaterally without wheezes or
crackles
ABDOMEN: Soft, nontender
EXTREMITIES: trace ___ edema but L>R hyperpigmentation at the
ankles and feet. +pain to posterior left calf
PULSES: 2+ distally in 4 extrems
NEURO: AAOX3, no focal deficits
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 128/62 72 20 99RA FS302
GENERAL: NAD and comfortable appearing
HEENT: EOMI, PERRL
CARDIAC: S1, S2 regular. no murmurs/gallops/rubs. No JVD. No
increase in chest tightness to movement/palpation.
LUNG: Clear to auscultration bilaterally without wheezes or
crackles
ABDOMEN: Soft, nontender
EXTREMITIES: trace ___ edema but L>R hyperpigmentation at the
ankles and feet. +pain to posterior left calf
PULSES: 2+ distally in 4 extrems
NEURO: AAOX3, no focal deficits
Pertinent Results:
ADMISSION LABS
___ 07:30PM BLOOD WBC-5.2 RBC-4.07* Hgb-13.6 Hct-39.3
MCV-96 MCH-33.3* MCHC-34.5 RDW-11.9 Plt ___
___ 07:30PM BLOOD ___ PTT-33.3 ___
___ 07:30PM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-141
K-3.5 Cl-100 HCO3-31 AnGap-14
___ 07:30PM BLOOD cTropnT-<0.01
___ 08:05AM BLOOD cTropnT-<0.01
___ 08:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.7
DISHCHARGE LABS
___ 08:05AM BLOOD WBC-4.4 RBC-4.34 Hgb-14.1 Hct-41.6 MCV-96
MCH-32.5* MCHC-33.9 RDW-11.9 Plt ___
___ 08:05AM BLOOD ___ PTT-37.5* ___
___ 08:05AM BLOOD Glucose-318* UreaN-14 Creat-0.8 Na-138
K-3.7 Cl-98 HCO3-28 AnGap-16
IMAGING
___ Venous duplex bilateral u/s
1. Superficial thrombophlebitis of a superficial right calf
vein. No DVT in
the right lower extremity.
2. Echogenic clot and lack of compressibility in the left
peroneal vein is
consistent with deep venous thrombosis.
___ Venous duplex bilateral u/s
RIGHT: Deep veins are patent, demonstrate full copressibility,
and normal distal augmentation
LEFT: The deep veins are patent, demonstrate full
compressibility, and normal distal augmentation.
___ EKG
Sinus rhythm. Anterolateral T wave abnormalities. Since the
previous tracing
of ___ the rate is somewhat faster. Otherwise, probably no
change. There are
artifact differences which make comparison of ST-T waves
difficiult.
___ CXR
No acute cardiopulmonary abnormality.
___ CTPA
No evidence of a pulmonary embolism or acute aortic injury.
Brief Hospital Course:
___ yo female with ___ venous insufficiency s/p RFA of the right
lesser saphenous vein on ___ who presents for evaluation for PE
given reports of chest pain and shortness of breath. She has a
contrast allergy for which she underwent desensitization and had
a CTPA.
# DISTAL DVT on PRIOR IMAGING (___): CTPA was negative for PE.
Given she had a left peroneal DVT on ___, patient was
initially set for 3 months of anticoagulation but ___ results
from ___ indicated that the left peroneal vein was compressible
and there was no DVT. Thoughts are that either the DVT migrated
(less likely given CT and history), it resolved, or the original
test was a false positive. Recognizing that there is no
evidence, we recommended she be treated for 2 weeks with
anticoagulation and have a f/u ___ to prove resolution. We
discussed treating for 3 months, but recognize that she is also
on ASA and has some gait instability so her bleed/fall risk is
not insignificant. For this reason, patient was sent home with
directions to continue anticoagulation for 2 weeks and have
repeat imaging in 2 weeks to determine if anticoagulation should
be continued.
# Chest Pain: Patient was also complaining of atypical chest
pain. Greatest concerns are pain due to pulmonary embolism
versus cardiac origin, though patient notes she's had this pain
daily for over a month now, so lower suspicion for ACS. Of note,
patient has history of recurrent chest pain in the past with
multiple stress echos that have been negative. roponins x2 were
negative and EKG was unremarkable. An outpatient stress test has
been scheduled for ___ given patient's comorbidities of HTN,
DMII, and hyperlipidemia.
# Diabetes Mellitus: Continued home insulin and cover with
sliding scale.
# Hypertension: Initially hypertensive in the ED but improved on
transfer up. Lisinopril and chlorthalidone held overnight given
consideration for PE and potential for hemodynamic comprimise.
Patient has remained stable with no evidence of hypotension.
Lisinopril and captopril were restarted on discharge.
# Hyperlipidemia: Continued home pravastatin
TRANSITIONAL ISSUES
-continue anticoagulation for at least 2 weeks and then f/u with
PCP
-___ follow up with repeat ___ in 2 weeks and determine if
anticoagulation should be continued
-discharged with lovenox BID and coumadin 5mg daily. Set up with
___ clinic. ___ will check INR starting ___ and
fax to ___ clinic.
-will continue with home ___ and ___ services
-set up for stress ECHO on ___ given her risk factors and
atypical chest pain. Please follow up with the results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Pravastatin 40 mg PO HS
5. Naproxen 250 mg PO DAILY:PRN pain
6. Calcium Carbonate 250 mg PO BID
7. potassium chloride 10 mEq/7.5mL oral Daily
8. Aspirin 81 mg PO DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Glargine 16 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC QAM
Start: ___, First Dose: Next Routine Administration Time
take 60mg in the morning and 80mg at night (12 hours apart).
RX *enoxaparin 60 mg/0.6 mL 60 mg in the morning Disp #*5
Syringe Refills:*0
RX *enoxaparin 80 mg/0.8 mL 80 mg at night, 12 hours apart from
morning dose Disp #*5 Syringe Refills:*0
2. Warfarin 5 mg PO DAILY16
the ___ clinic will be in contact with you about how
to dose this medication
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 250 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Pravastatin 40 mg PO HS
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Glargine 16 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
9. Chlorthalidone 25 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Potassium Chloride 10 mEq/7.5mL ORAL DAILY
12. Enoxaparin Sodium 80 mg SC QPM
take 60mg in the morning and 80mg at night (12 hours apart).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: distal deep venous thrombosis, atypical chest
pain
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 to take care of you here at ___
___. You were admitted for concern of clot
that traveled to your lungs. Preliminary read of the CT showed
that you did not have a clot in your lungs. Repeat imaging of
your legs shows that the clot that was seen just a few days
prior is no longer there. It is unclear if the first study was
not correct or if the clot dissolved on its own. Because there
is a possibility of a clot in your legs that can travel into
your lungs, we started you on anticoagulation which should be
continued for at least 2 weeks. You should take coumadin and
lovenox everyday until told otherwise by your doctor. Your
visiting nurse ___ draw your bloodwork on ___ and fax the
results to the ___ clinic. The clinic will notify you if
you need to change your dosing of coumadin and when to stop
taking the lovenox. In two weeks, your doctor ___ scheduled you
to have repeat imaging of your legs to see if the clot is still
there and if you need to continue anticoagulation medications.
We have arranged for you to have a study of your heart once you
leave the hospital since you were having chest pain though we
think it is less likely that your pain is associated with the
heart. We wish you all the best in your recovery.
**make sure that you take your lovenox shots twice a day and
that ___ nurses check your blood on ___ and fax the results
to the ___ clinic. The ___ clinic will
contact you over the phone to let you know if you need to change
your coumadin dose. Also, call the ___ clinic if you
run out of coumadin or lovenox ___. Also call the
___ clinic if you experience any bloody stools.
** do not take ibuprofen (NSAIDs) while you are taking coumadin
as this can increase your risk of bleeding. You can take tylenol
for pain (do not exceed 2 grams per day).
Sincerely,
Your ___ team
Followup Instructions:
___
|
10618299-DS-10 | 10,618,299 | 25,560,477 | DS | 10 | 2177-09-08 00:00:00 | 2177-09-08 23:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Reglan / morphine
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old with hx of endometriosis, gastroparesis, CRP
syndrome who presents with RUQ abdominal pain.
Patient endorses that pain started on ___ morning as diffuse
abdominal pain associated with nausea and one episode of
vomiting. The pain was then translocated to the RUQ. Patient
went to OSH ED, where she had CT scan with contrast, which
showed "faint calcifications of the gallbladder wall that could
indicate porcelain gallbladder which should be further evaluated
with nonemergent abdominal US." Patient then went to the ED at
___ where US showed "diffusely thicken gallbladder without
evidence of gallstones." Patient went to her PCP on ___
___ who scheduled a HIDAA scan on ___. However, RUQ
pain increased and patient could not tolerate oral intake.
Patient denies similar problems in the past. She denies fever,
chills, night sweats, change in bowel habit, or urinary sx.
She denies similar pain in the past, however, she notes
previously receiving several intramuscular botox injections for
her complex regional pain syndrome. She reports subjective
fevers which resolved since day 1 of her symptoms along w/
nausea & vomiting .
In the ED
BP 120/70- ___, Spo2 96-100%,HR ___
WBC 6.4 Hb 15.6 Plt 336
143 | 104 | 8 AGap=16
_______________/77
4.3 | 23 | 0.8 \
ALT: 76 AP: 73 Tbili: 0.5 Alb:
AST: 46 LDH: 202 Dbili: TProt:
___: Lip: 35
___: 12.0 PTT: 28.1 INR: 1.1
Meds- Hydromorphone 0.5mg x 3, Zofran x1, 2L fluids,
USG liver
1. 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 lesions are
identified.
2. No sonographic evidence to suggest cholecystitis.
3. 4 mm gallbladder wall polyp. No further follow-up is
recommended.
Seen by ACS, recommend HIDA
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Endometriosis
Gastroparesis
"CRP" Complex Regional Pain Syndrome
Lyme disease
Migraines
Social History:
___
Family History:
Noncontributory
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
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge exam
Temp: 98.5 PO BP: 120/81 HR: 73 RR: 18 O2 sat: 97% O2 delivery:
RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, TTP in RUQ. Bowel sounds
present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs
___ 01:58PM BLOOD WBC-6.4 RBC-5.10 Hgb-15.6 Hct-46.8*
MCV-92 MCH-30.6 MCHC-33.3 RDW-11.2 RDWSD-38.0 Plt ___
___ 01:58PM BLOOD Glucose-77 UreaN-8 Creat-0.8 Na-143 K-4.3
Cl-104 HCO3-23 AnGap-16
___ 01:58PM BLOOD ALT-76* AST-46* LD(LDH)-202 AlkPhos-73
TotBili-0.5
___ 09:06AM BLOOD Albumin-4.2
Discharge labs
___ 02:55AM BLOOD WBC-7.7 RBC-4.26 Hgb-13.0 Hct-38.3 MCV-90
MCH-30.5 MCHC-33.9 RDW-11.7 RDWSD-37.5 Plt ___
___ 04:08AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-139 K-4.3
Cl-105 HCO3-24 AnGap-10
Imaging
================================
RUQ US ___
IMPRESSION:
1. 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
lesions are identified.
2. No sonographic evidence to suggest cholecystitis.
3. 4 mm gallbladder wall polyp. No further follow-up is
recommended.
HIDA scan ___
IMPRESSION: Normal hepatobiliary study. Gallbladder ejection
fraction normal.
KUB ___
IMPRESSION:
No radiographic evidence of bowel obstruction.
EGD ___ - antral gastritis with superficial erosion
CT Torso ___
IMPRESSION:
No acute intrathoracic process.
1. No acute abdominopelvic process. No CT findings correlating
to the
reported history of right upper quadrant pain.
2. Please refer to separate same day CT chest report for the
thoracic
findings.
Micro
==================================
UCx ___
___ 2:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ year old with hx of endometriosis, gastroparesis, CRP
syndrome who presents with RUQ abdominal pain, initially
concerning for biliary colic vs. cholecystitis, ultimately
attributed to costrochondritis.
#RUQ pain
#constipation:
Patient presenting with several days of RUQ pain associated with
n/v. Had US at ___ with gallbladder thickening concerning for
cholecystitis. Patient reassuringly without leukocytosis or
fevers on admission. ACS was consulted initially due to concern
for cholecystitis or biliary colic. HIDA scan normal and ACS did
not recommend surgical intervention. GI was consulted. Patient
had EGD with mild antral gastritis and superficial ulceration
but not thought to explain patient's pain. Patient then
developed significant opioid induced constipation which worsened
her pain. She was started on aggressive bowel regimen and . She
had a repeat CT Torso which did not reveal any abnormalites.
Ultimately, after exonerating any dangerous intraabdominal
causes, etiology felt most likely costochronditis with
associated nerve irritation. CPS was consulted and recommended
discharge with baclofen qHS and scheduled for outpatient local
injection of steroids and anesthetic scheduled for ___ AM.
#Endometriosis - continued home OCP
TRANSITIONAL ISSUES:
[] local anesthetic and steroid injection by CPS scheduled for
___ AM. Monitor for clinical improvement of pain symptoms.
> 30 mins spent in coordination of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Norethindrone-Estradiol 1 TAB PO ASDIR
Discharge Medications:
1. Cyclobenzaprine 10 mg PO HS:PRN insomnia/pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth at bedtime Disp
#*20 Tablet Refills:*0
2. Norethindrone-Estradiol 1 TAB PO ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
# costochondritis
# nerve impingement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___. You were
admitted with RUQ abdominal pain. We performed and extensive
workup and luckily no dangerous gastrointestinal etiology of
your pain was found. Given the focality of your symptoms, the
most likely cause is a musculoskeletal process (costochronditis)
with significant irritation of the local nerve root. You were
seen by our chronic pain service and underwent a local nerve
injection to help with symptom control.
You can continue to take Ibuprofen for pain relief and this is
available over the counter. Additionally, you are being
prescribed a muscle relaxant to take at bedtime. This medication
can make you drowsy, so please do not drive or perform any
potentially dangerous activities after taking it until the
effect wears off.
Please continue to take all medications as prescribed and follow
up with the appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10618930-DS-17 | 10,618,930 | 25,063,208 | DS | 17 | 2144-05-15 00:00:00 | 2144-05-17 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Optiray 300 / Adalat CC / Lisinopril / Nortriptyline /
Byetta / Iodine
Attending: ___.
Chief Complaint:
multiple neurologic complaints
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ woman with PMH significant for HTN, HLD,
Bells palsy 20+ years ago, anxiety and depression who presents
for more than 2 months of progressive neurologic symptoms. The
patient's neurologic history start at the end of this past ___.
She was sitting on the couch with her husband with suddenly she
developed a mild room spinning vertigo. She told her husband she
felt like she was suddenly drunk and asked him if her head was
actually spinning. The spinning was accompanied by a mild
headache. The mild vertigo continued more or less unchanged for
about 2 weeks during which time she was able to manage and
continue attending her job. In early ___ the patient was
looking
for a specific file in a file-room. She was moving very large
boxes of files when all of a sudden she felt a sudden "snap" in
her right shoulder as she lifted a box. The pain shot down her
spine an into her left leg. At that moment the vertigo become
considerably worse with faster spinning and more nausea and
associated wooziness. She had to leave work due to the vertigo
which has been more or less ongoing since that time. If she
stays
very still in bed it will quite down enough for her to rest but
otherwise she is always spinning. She was evaluated by her PCP
who prescribed ___ and set up ENT and neuro evaluations.
Initially she was though to have labyrinthitis. The ___
mostly made her sleepy but did help some with her symptoms. Her
ENT workup was reportedly "inconclusive". Her descriptions there
was of more episodic bouts of vertigo. She was found to have
symmetric sensorineural hearing loss with associated bilateral
tinnitus. She was scheduled for vestibular ___ which she
underwent
to day without significant symptom relief. In the afternoon she
saw Dr. ___ in neurology who sent her to the ED for further
evaluation.
The patient did have one episode of vertigo in the past about ___
years ago but none in between. She does endorse a sensation of
ear fullness. She has also been having intermittent diplopia.
The
diplopia is at near and far, with left and right gaze. The
phantom image is up and to the side (diagonal). sometimes images
will appear to be flickering (side to side) like pictures in a
flip book. She has never noted the whole of her visual scene to
shimmer or shake. the symptom comes and goes, it seems worse
when
she is tired. The patient also noted episodes of R face
numbness,
L thigh numbness, R hand parasthesias, and L visual field
graying
out.
On neuro ROS: the pt denies dysarthria, dysphagia, drop attacks,
lightheadedness. Denies difficulties producing or comprehending
speech. 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:
hypertension, diabetes mellitus, hyperlipidemia,
gastroesophageal reflux disease, obstructive sleep apnea with
the use of CPAP, asthma, polycystic ovarian syndrome,
incompetent cervix, and depression.
Social History:
___
Family History:
Her family history is noted for both parents deceased mother age
___ of pancreatic CA; father age ___ with first MI at ___, coronary
artery disease, congestive heart failure, diabetes, stroke and
obesity; she has two sisters and two brothers relatively healthy
with one sister question of benign ovarian tumor; two maternal
aunts and two maternal cousins with history of breast cancer.
Physical Exam:
GENERAL MEDICAL EXAMINATION:
General appearance: alert in no apparent distress
HEENT: Neck is supple, tender R>L. Sclera are non-injected.
Mucous membranes are moist.
CV: Heart rate is regular
Lungs: breathing comfortably on RA.
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and time. Able
to relate history without difficulty. Attentive to conversation.
Language is fluent and appropriate with intact comprehension,
repetition and naming. 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.
Cranial Nerves:
I: not tested
II: visual fields full to confrontation.
III-IV-VI: pupils: R>L by 0.5mm, both round and reactive. EOM
full except for minimal limitation of left abduction. Monocular
diplopia bilaterally which resolves with pinhole. No nystagmus.
V: symmetric sensation to light touch and pin prick.
VII: L peripheral facial weakness noted.
VIII: Hearing intact to finger rub bl. Head impulse test
negative bilaterally.
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ * 5 5 5 5 5 5
R * ___ 4+ 5 5 * 5 5 5 5 5 5
* pain limited
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 3 3 3 2 1
Toes are down going bilaterally.
Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM intact.
Gait: narrow based and steady.
Pertinent Results:
___ 08:30PM WBC-5.7 RBC-4.51 HGB-12.9 HCT-39.3 MCV-87
MCH-28.6 MCHC-32.8 RDW-13.4 RDWSD-42.4
___ 08:30PM GLUCOSE-106* UREA N-12 CREAT-0.8 SODIUM-144
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-28 ANION GAP-16
___ 08:30PM ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-98 TOT
BILI-0.3
___ 06:40AM BLOOD SED RATE-11
___ 06:40AM BLOOD CRP-4.3
___ 06:40AM BLOOD ___
___ 04:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 04:00PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-91
MRI/MRA head and neck ___:
IMPRESSION:
1. No acute infarct or intracranial hemorrhage.
2. A few nonspecific periventricular and subcortical T2/FLAIR
white matter hyperintensities are nonspecific, slightly
increased in number when compared to examination ___, most
commonly seen with chronic microangiopathy in a patient of this
age.
3. Motion degraded MRA of the head. Within these confines, the
circle ___ is grossly unremarkable.
4. Unremarkable MRA of the neck.
MRI C-spine ___:
IMPRESSION:
1. Multilevel multifactorial cervical spondylosis, most
prominent at C3-C4 and C4-C5 where disc bulges remodels the
ventral aspect of the cord and results in moderate right C3-C4
neural foraminal narrowing and bilateral C4-C5 moderate
bilateral neural foraminal narrowing.
2. There is no cord signal abnormality.
MRI brainstem ___:
IMPRESSION:
1. Study is moderately degraded by motion.
2. Question focal 3 mm area of enhancement near left foramen
ovale expected course of left V3 nerve. While finding may be
artifactual in nature, on enhancing mass including schwannoma,
meningioma, or metastatic lesion are not excluded on the basis
examination. Recommend clinical correlation and attention on
followup imaging.
3. Within limits of study, no definite abnormal enhancement or
mass of sixth, seventh or eighth cranial nerves identified.
4. Within limits of exam, no definite brainstem lesion
identified.
5. Probable small vessel ischemic changes as described.
6. Question degenerative changes of left mandibular condyle.
Recommend
clinical correlation.
7. Limited imaging of cervical spine demonstrate degenerative
changes of C2 and C3, with disc protrusions and associated
remodeling of cervical spinal cord, without definite cord signal
abnormality. Recommend clinical correlation. If clinically
indicated, consider dedicated cervical spine MRI.
8. Question degenerative changes of left mandibular condyle.
Recommend
clinical correlation.
RECOMMENDATION(S):
1. Question focal 3 mm area of enhancement near left foramen
ovale expected course of left V3 nerve. While finding may be
artifactual in nature, on enhancing mass including schwannoma,
meningioma, or metastatic lesion are not excluded on the basis
examination. Recommend clinical correlation and attention on
followup imaging.
2. Question degenerative changes of left mandibular condyle.
Recommend
clinical correlation.
3. Limited imaging of cervical spine demonstrate degenerative
changes of C2 and C3, with disc protrusions and associated
remodeling of cervical spinal cord, without definite cord signal
abnormality. Recommend clinical correlation. If clinically
indicated, consider dedicated cervical spine MRI.
4. Question degenerative changes of left mandibular condyle.
Recommend
clinical correlation.
Brief Hospital Course:
The patient was admitted for expedited workup of her symptoms
which was initially worrisome for polycranial neuropathy.
MRI/MRA head and neck did not show evidence of infarct or gross
mass lesion. LP was performed and cell count and protein were
within normal limits. MRI brainstem with thin cuts was grossly
negative although there was a question of a 3mm focal enhacement
near left foramen ovale which was only appreciable on one image.
This was thought most likely artifactual as it was not
corroborated on any other slices but could not exclude small
mass lesion.
Her neurologic exam was also difficult to assess; it was
initially thought she had a left sixth nerve palsy, however she
had diplopia and red-glass test was suggestive of bilateral
third nerve palsy. She also initially had reduced sensation to
pinprick in the R V2-V3 distribution but this normalized during
her admission. Neuro-ophthalmology consult was obtained, which
revealed monocular diplopia bilaterally which resolved on
pinhole and surface ocular disease, which likely explained her
visual symptoms, and NO oculomotor palsy was appreciated. A
possible etiology to explain her symptoms could be cervical
dizziness intermittently affecting facial sensation. She was
discharged in good condition with outpatient Neurology followup
and plan for Neuroradiology conference review of her brainstem
imaging to determine further plans for workup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Meclizine 25 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, cough
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy
symptoms
5. Fexofenadine 180 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lorazepam 0.5 mg PO QHS:PRN insomnia
8. Sertraline 100 mg PO QHS
9. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
10. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral DAILY
11. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, cough
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Cyanocobalamin 500 mcg PO DAILY
4. Fexofenadine 180 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Sertraline 100 mg PO QHS
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
8. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy
symptoms
10. Lorazepam 0.5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical spondylosis
Multiple neurologic symptoms of unclear etiology
Monocular diplopia
Anxiety/depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for multiple
neurologic symptoms including double vision and vertigo. We
performed extensive workup including an MRI of your brain and
cervical spine, a lumbar puncture, and various blood tests.
These did not show any abnormalities of your brain, but did show
some a mild condition of your cervical spine called spondylosis,
which may be directly causing your arm weakness and indirectly
causing your dizziness and facial numbness. We also asked our
neuro-ophthalmology consultants to evaluate you, and they did
not find any problems of the nerves that control your eyes,
which is reassuring.
Some of the laboratory tests we sent from your blood and your
cerebrospinal fluid may take some time to return. If any of
these are abnormal we will call you with results and further
instructions. You should stop the meclizine (antivert) as this
is likely not helping. Otherwise, you should continue with
physical therapy to improve your symptoms and follow up with
your Neurology provider to discuss any further evaluation
needed.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10619088-DS-7 | 10,619,088 | 23,878,625 | DS | 7 | 2187-12-29 00:00:00 | 2187-12-29 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Amoxicillin / Keflex
Attending: ___.
Chief Complaint:
Confusion and agitation following ED observation for unwitnessed
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F w/CAD and dementia s/p unwittnessed fall in nursing
home after receiving Ativan for sleep. Pt had been in usual
state of health but complained of insomnia. Pt was found on
floor by nursing home staff and noted to be lethargic, although
unclear baseline MS. ___ the ED she was worked up extensivly and
there was no infectious etiology for her AMS. She was actually
seen by ___ and cleared to return to her nursing home but became
agitated in the ED where they had to give her 7.5 mg of zyprexa
and she calmed down. She is admitted to medicine for altered
mental status.
.
On the floor she is quiet and ___ but extremey confused. She
believes it is ___ and we are in an apartment. At times she
also thought she was pregnant. She then thanked me for saving
her life and then refused to thank me for saving her life. She
is rediectable.
Past Medical History:
-Coronary artery disease status post 3-vessel CABG (___),
-Myocardial Infarction 20+ years ago
-Hemorroids
-Diverticulosis
-hypertension
-History of DVT
-History of delirium
-Depression
-Anxiety
-Hypercholesterolemia.
-Paroxysmal A-fib
Social History:
___
Family History:
Mother ___ suicide, possible history of depression
Physical Exam:
Admission Exam:
VS 97.4 156/89 83 20 98%RA
GEN Alert, orientedx1 (knows birhtday, but does not know we are
in a hospital or in mass or what year it is)
HEENT MMM EOMI injected conjunctiva b/l, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
.
Discharge Exam:
VS: 97.8 133/63 58 18 98%RA
Gen: No acute distress. Sleeping peacefully
HEENT: NCAT. EOMI. b/l injected conjunctiva. MMM
Resp: CTAB. Good air flow. No rales/rhonchi
CV: RRR. NMRG. NS1&S2.
GI: Very large pannus BS+4. Soft. Non-tender. Non-ditended
Ext: Severe lymphedema of all extremities. Muscle atrophy.
Varicosities throughout lower extremities
Neuro: Oriented x1. Knows her name and birthday, but believes it
is ___ and that she is at home. Rest of neuro exam deferred due
to pt non-compliance.
.
MENTAL STATUS EXAM
APPEARANCE & FACIAL EXPRESSION: patient is obese older
woman
sitting in a ___ chair, she is wearing a hospital gown and has
peripheral edema
POSTURE: sitting in chair
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): got up and pulled
phlebotomist's hair
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): agitated,
oppositional
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC,
ETC.):
somewhat yelling at times, pressured at times
MOOD: irritable
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
angry
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): loose
associations, tangential
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
DELUSIONS, ETC.): somewhat guarded, no formed
delusions
but vaguely paranoid
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): patient did
not
answer question
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
APPETITE, ENERGY, LIBIDO): pt refused to answer
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
I
may jump off tree, and then denied later in the interview
INSIGHT AND JUDGMENT: poor/poor
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: thinks she is ___ at ___ and
it is ___ and she is ___ yrs old
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): unable to
do
MEMORY (SHORT- AND LONG-TERM):unable to do
CALCULATIONS:unable to do
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE):unable to do
PROVERB INTERPRETATION:unable to do
SIMILARITIES/ANALOGIES:unable to do
Pertinent Results:
Admission Labs:
___ 09:20AM BLOOD WBC-5.5 RBC-4.93 Hgb-13.6 Hct-41.0 MCV-83
MCH-27.7 MCHC-33.3 RDW-15.5 Plt ___
___ 09:20AM BLOOD Glucose-97 UreaN-27* Creat-1.4* Na-144
K-4.0 Cl-103 HCO3-31 AnGap-14
___ 09:20AM BLOOD Calcium-10.1 Phos-3.3 Mg-2.1
.
DIscharge Labs:
___ 04:55PM BLOOD WBC-5.7 RBC-4.43 Hgb-12.1 Hct-37.4 MCV-84
MCH-27.2 MCHC-32.3 RDW-15.5 Plt ___
.
Pertinent Labs:
___ 03:35PM BLOOD cTropnT-<0.01
___ 09:20AM BLOOD cTropnT-<0.01
___ 01:05PM BLOOD VitB12-658
___ 01:05PM BLOOD TSH-5.8*
___ 09:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:50AM URINE Color-Straw Appear-Clear Sp ___
.
Microbiology:
___ URINE CULTURE-Negative
.
Studies:
___ CT w/o C: There is no evidence of hemorrhage, edema,
mass, mass effect, or infarction. The ventricles and sulci are
prominent, consistent with age-related volume loss. This is
unchanged from prior exam. The basal cisterns are patent. A
prominent round hypodensity in the left subinsular region is
unchanged from the prior exam and likely a prominent
perivascular space. Alternatively, it could be a prior lacunar
infarct. Stable hypodensities in the left cerebellum likely are
the sequelae of prior infarctions. Mild periventricular
confluent white matter hypodensities are consistent with chronic
small vessel ischemic disease. Atherosclerotic calcifications
are noted in the internal carotid and vertebral arteries. No
fracture is identified. Aerosolized secretions are present in
the left sphenoid sinus. Mild mucosal thickening is present in
the ethmoidal air cells. The frontal sinuses, mastoid air
cells, and middle ear cavities are clear. The soft tissues are
unremarkable.
.
___ CT spine: No acute fracture or malalignment. Moderate
multilevel degenerative changes.
.
___ CXR: No acute cardiopulmonary process. Increased
prominence of
pulmonary vasculature is likely due to low lung volumes.
.
___ KUB: There is no free air below the diaphragm. There
are no dilated bowel loops seen. Overall, the distribution of
bowel and content is unremarkable with no definitive evidence of
stool impaction.
Brief Hospital Course:
___ yo F here for AMS following prolonged stay (~24hours) in the
observation unit. Had unwitnessed fall at ___ facility,
and work-up in ED negative for acute injury. Was cleared by ___
for discharge, but became acutely anxious and was trasnferred to
medicine service after becoming acutely anxious/agitated,
requiring zyprexa 7.5mg. Pt was oriented x0 when evaluated on
admission, and appears to have baseline encephalopathy vs.
dementia per notes in ___. According to her son and ___ notes,
this is worse than baseline for her. No organic cause of altered
mental status demonstrated. Psych consulted and recommended
inpatient ___ evaluation for medication management and
further work-up. Pt son wished her to be treated at ___
___ ward, as this is closer to home.
# AMS: Pt was altered on presentation. Per her son, she was not
at baseline. He states that she can be confused at times with
delusions and hallucinations, but can usually carry on normal
conversation. She was confused during day of admission and
oriented x0. Concentration and attention improved in AM on ___
day of admission, however, this waned as day progressed. She
knew her name, and date of birth. This may represent
polypharmacy as well as being in a disorenting setting. We
discontinued her oxybutynin as the anticholinergic effects
thought to worsen AMS. Checked B12 which was found to be WNL.
TSH slightly elevated, but not to the degree that would cause
such a change in mental status. No infectious source noted on
CXR or urine culture. Monitored on fall precautions and needed
freqent reorientation. Would become frequently agitated and
parnaoid on the floor stating we were going to kill her. Was
given several doses of 7.5mg PO zyprexa with rapid improvement
in symptoms. Both pt and son wished for medication burden to be
decreased. Patient had over 25 medications ordered on her
nursing home records. Evaluated by psychiatry with
recommendation for inpatient ___ treatment for medication
adjustment, and further work-up. Discharged to ___
___ unit.
.
# HTN: Continued anti-HTN meds. Initially held lisinopril in
setting of increased Cr, but this was restarted on discharge
.
# CAD: Continued ASA, BB, Statin
# Hypothyroidism: Continued levothyroxine at same dose
# Depression: Continue psych meds
.
# Gerd: continued PPI
.
Transitional Issues:
#Discontinued oxybutynin in-house. Will need to decide whether
or not to restart
#Responds well to zyprexa 7.5mg PO for anxiety/agitation
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from ___
___ med records.
1. mometasone *NF* unknown Topical as needed
2. Nystatin Ointment 1 Appl TP QID:PRN to mouth corners as
needed
3. Hydrocortisone Cream 2.5% 1 Appl TP BID
apply to ears as directed
4. Preparation H(pe,shark oil,cb) *NF* (PE-shark liver oil-cocoa
buttr) ___ % Rectal as needed
5. Ascorbic Acid ___ mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral QHS
8. Simvastatin 60 mg PO DAILY
9. Oxybutynin 5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
hold for hr<50 or sbp<100
12. FoLIC Acid 1 mg PO DAILY
13. Docusate Sodium 200 mg PO BID
14. Vitamin D 800 UNIT PO DAILY
15. Cyanocobalamin 250 mcg PO DAILY
16. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
hold for sbp<100
17. Duloxetine 40 mg PO DAILY
18. Aripiprazole 2 mg PO DAILY
19. Fish Oil (Omega 3) 1000 mg PO BID
20. Levothyroxine Sodium 100 mcg PO DAILY
21. Lisinopril 2.5 mg PO DAILY
hold for sbp<100
22. Capsaicin 0.025% 1 Appl TP Frequency is Unknown
23. Omeprazole 20 mg PO DAILY
24. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 500-400 mg Oral daily
take three tablets by mouth daily
25. Aspirin 325 mg PO DAILY
26. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Aripiprazole 2 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. Docusate Sodium 200 mg PO BID
6. Duloxetine 40 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
hold for sbp<100
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
hold for hr<50 or sbp<100
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Senna 1 TAB PO BID:PRN constipation
16. Simvastatin 60 mg PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral QHS
19. Lisinopril 5 mg PO DAILY
hold for sbp<100
20. mometasone *NF* 0.1 % TOPICAL AS NEEDED
apply to ears and scalp QOD
21. Nystatin Ointment 1 Appl TP QID:PRN to mouth corners as
needed
22. Preparation H(pe,shark oil,cb) *NF* (PE-shark liver
oil-cocoa buttr) ___ % Rectal as needed
23. Hydrocortisone Cream 2.5% 1 Appl TP BID
apply to ears as directed
24. Capsaicin 0.025% 1 Appl TP Frequency is Unknown unknown
25. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 500-400 mg Oral daily
take three tablets by mouth daily
26. Sarna Lotion 1 Appl TP BID
use twice a day as needed
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
dementia vs. delirium
personality disorder not otherwise specified
Secondary diagnosis:
hypothyroidism
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
after falling at your retirement facility. Nobody was present to
witness your fall, and there was some concern that you may have
injured yourself. You were observed in the emergency department
and had several scans of your body to make sure that there was
no injury. The scans did not show anything abnormal. The
physical therapists evaluated you, and cleared you to go home.
In the emergency department you became very agitated and
anxious, which required us to give you medication by mouth to
ease your anxiety. This helped, but we did not feel it was safe
for you to go home in that state, so you were admitted to
medicine.
On the floor of the medicine service you were very confused, and
at times would become very anxious and upset. For the majority
of the time you sat in a chair in the hallway talking with
staff. We tried to find a medical explanation for your confusion
and anxiety, but could not find one. We tried to stop any
medications that may be contributing to your confusion, so we
discontinued your oxybutynin. You were seen by the psychiatry
service, which recommended that you receive inpatient
psychiatric treatment.
The following medication changes were made.
Medications to STOP
STOP oxybutynin
Followup Instructions:
___
|
10619126-DS-8 | 10,619,126 | 23,873,925 | DS | 8 | 2117-05-29 00:00:00 | 2117-05-29 13:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
aluminum chlorhydrate (in underarm deodorant)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Ultrasound-guided percutaneous cholecystostomy
History of Present Illness:
Mr. ___ is a ___ who p/w abd pain, worse in the RUQ pain,
chills, and fatigue of duration 6 days. He was transferred from
___ for this complaint following CT AP which revealed
perforated cholecystitis and ?pericholecystic fluid cxns vs.
fistulization to the adjacent ascending colon. Of note, Mr.
___ was hospitalized in ___ 1 month ago for complaints of
RUQ pain and fatigue and was found at that time on CT AP to have
some inflammatory stranding surrounding the hepatic flexure,
which at that time was felt to suggest uncomplicated
diverticulitis for which he was treated medically and discharged
home.
Past Medical History:
Diabetes type II
CAD s/p MI in ___ s/p PTCA, DES to LAD, ___
PAD s/p bilateral iliac stenting ___
OSA-CPAP
COPD
hypertension
hyperlpidemia
myringotomy ___
GERD
___ esophagus
osteoarthritis
Social History:
___
Family History:
unknown, patient adopted
Physical Exam:
Admission Physical Exam:
Vitals:
97.0 93 151/59 16 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, moderately distended; minimal RUQ tenderness without
guarding; notable for superficially dilated periumbilical skin
veins; no masses or hernia
Ext: No ___ edema, ___ warm and well perfused
Discharge Physicla Exam:
VS: 98.0, 72, 155/79, 16, 95%ra
Gen: A&O x3, appears comfortable
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, moderately distended; nondistended, perc chole tube
with small amounts tan drainage
EXT: no edema
Pertinent Results:
___ 05:05AM BLOOD WBC-7.2 RBC-3.82* Hgb-10.8* Hct-33.7*
MCV-88 MCH-28.3 MCHC-32.0 RDW-13.2 RDWSD-42.8 Plt ___
___ 07:58PM BLOOD WBC-14.2* RBC-3.90* Hgb-11.0* Hct-34.1*
MCV-87 MCH-28.2 MCHC-32.3 RDW-13.3 RDWSD-42.5 Plt ___
___ 05:05AM BLOOD Glucose-339* UreaN-17 Creat-1.0 Na-133
K-4.6 Cl-94* HCO3-26 AnGap-18
___ 07:58PM BLOOD Glucose-214* UreaN-17 Creat-1.1 Na-130*
K-4.3 Cl-90* HCO3-24 AnGap-20
___ 05:05AM BLOOD ALT-26 AST-19 AlkPhos-126 TotBili-0.4
___ 07:58PM BLOOD ALT-30 AST-25 AlkPhos-135* TotBili-0.4
___ 05:05AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.6
Imaging:
CT ABD & PEL W/ Con ___. Markedly abnormal appearance of the gallbladder which
has progressed significantly compared to the prior study.
There is perforated cholecystitis however the perforation
which extends into the wall of the hepatic flexure of
the colon. The appearances are highly suspicious for a
fistula with the colon. In addition there is a
multiloculated fluid collection at the porta hepatis
tracking into the submucosa of the duodenum.
2. Extensive colonic diverticulosis.
3. Small left kidney likely reflects renal vascular
insufficiency
CT ABD & PEL W/O Con ___
1. Hazy, ill-defined segment of proximal-to-mid ascending colon
likely represents acute uncomplicated diverticulitis, though
colonic neoplasm cannot be definitively excluded. No
pericolonic
abscess or discrete fluid collection identified, within the
limitations of an unenhanced scan. Following resolution of
likely acute diverticulitis, routine screening colonoscopy
should
be performed, if
not already.
2. Distended gallbladder with associated fat stranding, which is
most likely secondary to adjacent diverticulitis, though could
represent acute cholecystitis in the proper clinical context.
If
this is a clinical concern, right upper quadrant ultrasound
would
be recommended for further evaluation.
3. Moderate-to-severe sigmoid diverticulosis.
4. Nonobstructing 2 mm stone in the lower pole of the left
kidney.
5. Extensive atherosclerotic disease.
HIDA ___
No filling of GB, tracer seen to pass through biliary tree and
into duodenum
Brief Hospital Course:
___ M presenting with symptoms and imaging suggestive of acute
on chronic cholecystitis with perforation. He is presently
nontoxic appearing and stable. The patient was made NPO and
started on antibiotics and IV fluid resuscitation.
On HD1, the patient was brought to Interventional Radiology and
underwent an ultrasound-guided percutaneous cholecystostomy
which went well without complication.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. Antibiotics
were converted to oral. 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 with ___ services
for drain care and to complete 7 days of antibiotics. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. He had follow-up scheduled in the ___ clinic to discuss an
interval cholecystectomy.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. 2 puffs po four times a day as needed -
(Prescribed by Other Provider)
CLOPIDOGREL [PLAVIX] - Plavix 75 mg tablet. 1 Tablet(s) by mouth
once a day
EAR DROPS - ear drops . 4 drops in affected ear at onset as
needed for of ear drainage (uses once every 2 months on average)
- (Prescribed by Other Provider)
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. 2 sprays each nostril q a.m. - (Prescribed by
Other Provider: ___ MD)
INSULIN ASPART [NOVOLOG] - Novolog 100 unit/mL subcutaneous
solution. ___ units with breakfast; 6 -10 lunch, ___ dinner
- (Prescribed by Other Provider)
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous
solution. 40-45 units at 10pm managed by endocrine at ___. -
(Prescribed by Other Provider)
LIPASE-PROTEASE-AMYLASE [CREON] - Creon 24,000-76,000-120,000
unit capsule,delayed release. 4 capsule(s) by mouth before each
meal - (Prescribed by Other Provider)
LISINOPRIL - lisinopril 10 mg tablet. 1 Tablet(s) by mouth once
a
day - (Prescribed by Other Provider)
METOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 1
Tablet(s) by mouth twice a day - (Prescribed by Other Provider)
NITROGLYCERIN [NITROSTAT] - Nitrostat 0.3 mg sublingual tablet.
1
Tablet(s) sublingually as instructed for chest discomfort: do
not
use within 24 hours of taking viagra
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
Capsule(s) by mouth twice a day - (Prescribed by Other
Provider)
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet. 1 Tablet(s) by mouth
as needed - (Prescribed by Other Provider)
SIMVASTATIN - simvastatin 80 mg tablet. 1 Tablet(s) by mouth at
bedtime
TRAZODONE - trazodone 50 mg tablet. 1 tablet(s) by mouth at
bedtime - (Prescribed by Other Provider)
Medications - OTC
ASCORBIC ACID (VITAMIN C) [VITAMIN C WITH ROSE HIPS] - Dosage
uncertain - (Prescribed by Other Provider)
ASPIRIN - aspirin 325 mg tablet,delayed release. 1 Tablet(s) by
mouth once a day - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
FISH OIL - Dosage uncertain - (Prescribed by Other Provider)
MULTIVIT-MIN-FA-LYCOPEN-LUTEIN [SPECTRAVITE SENIOR] - Dosage
uncertain - (Prescribed by Other Provider)
NAPROXEN SODIUM - naproxen sodium 220 mg tablet. 2 Tablet(s) by
mouth twice a day - (Prescribed by Other Provider)
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*13 Tablet Refills:*0
3. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Creon 12 4 CAP PO TID W/MEALS
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Lisinopril 10 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. Omeprazole 20 mg PO BID
11. Simvastatin 80 mg PO QPM
12. TraZODone 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ with abdominal pain and were found to
have perforated cholecystitis. You were started on antibiotics
and sent to Interventional Radiology for a drain to be placed
into your gallbladder. Your pain has improved and you are
tolerating a regular diet. Your antibiotics have been switched
to the oral form. You are medically cleared to be discharged
home with a visiting nurse to help you with drain care. You will
follow-up in our Surgery clinic in a few weeks to discuss
planning or surgery to remove your gallbladder once all the
inflammation has subsided. 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.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10619216-DS-8 | 10,619,216 | 23,605,772 | DS | 8 | 2173-10-29 00:00:00 | 2173-10-29 13:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Lower extremity weakness
Major Surgical or Invasive Procedure:
___ Right craniotomy for ___ evacuation
History of Present Illness:
___ is a ___ male, not on anticoagulation, who is
transferred to ___ on ___ with a moderate TBI.
He had a fall 2 weeks ago and developed dull headache and
progressive LLE weakness. He is now "dragging" LLE, so he
presented to ED for evaluation. CT head at OSH showed large R
SDH
with MLS and he was transferred to ___ for neurosurgical
evaluation. He denies nausea, vomiting, numbness, seizure
activity, dizziness or confusion.
Past Medical History:
Asthma
HTN
Social History:
___
Family History:
NC
Physical Exam:
On Discharge:
___: A&Ox3, PERRL, 3-2mm. Face symmetrical. Tongue midline.
No pronator drift. Moves all extremities ___. Staples intact on
crani incision. No redness, swelling or incision.
Pertinent Results:
___ CXR
Hyperinflated lungs, otherwise normal radiograph.
___ ___
Expected postoperative appearance following right craniotomy and
subdural
hematoma evacuation. Postoperative pneumocephalus, extra-axial
fluid and
surgical drain along the right lateral convexity with mild 4 mm
leftward shift of midline structures. Midline shift and mass
effect is significantly improved from preoperative exam.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Mixed density extra-axial collection along the right frontal
convexity
measures 8 mm, decreased in size from CT head ___ the
hyperdense
hemorrhagic components are unchanged in extent. Pneumocephalus
has decreased.
2. Decreased mass effect with 2 mm of leftward midline shift.
3. No new intracranial hemorrhage.
4. Nasal polyps and chronic pansinusitis are again demonstrated.
Superimposed aerosolized secretions in the right maxillary
sinus and aerosolized secretions versus polypoid mucosal
thickening obstructing the right sphenoid ostium may be
secondary to prolonged supine positioning in the inpatient
setting.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman who presented after a fall
and left lower extremity weakness. Imaging revealed a large with
sided subacute subdural hematoma.
#Subdural hematoma
The patient was taken to the OR by Dr. ___ on ___
for craniotomy for subdural evacuation. The procedure was
uncomplicated. Please see operative note for full details. A
drain was left in place to thumbprint suction and removed on POD
#2. Patient tolerated procedure well. Patient's left sided
weakness improved after surgery. Patient was transferred to the
floor. On POD #3, patient had a repeat CT Head which was stable
with decreased collection and improved midline shift. He was
evaluated by physical therapy who recommended home. Incision
care and follow-up were reviewed with patient on day of
discharge. His incision is healing well with staples. No signs
of infection. On admission he was started on Keppra for seizure
prophylaxis and was instructed to continue this medication until
follow-up.
Medications on Admission:
- Lisinopril
- Nasonex
- Singular
- Q-var
- Flomax
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Do not exceed 4GM acetaminophen in 24 hours.
2. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Singulair (montelukast) as prescribed oral as prescribed
4. Lisinopril 20 mg PO BID
5. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Right Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your staples along your incision dry until they
are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
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.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
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 symptoms 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:
___
|
10619466-DS-21 | 10,619,466 | 27,357,813 | DS | 21 | 2187-07-29 00:00:00 | 2187-07-31 12:35:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R parietal scalp laceration s/p mechanical fall
Major Surgical or Invasive Procedure:
___ - scalp laceration repair
History of Present Illness:
___ Yo F with no pertinent medical hx presents to the ED via EMS
for a head injury s/p fall. Pt was about to leave the hotel when
she leaned forward and had a mechanical fall striking her R
parietal region of her head against a bureau. There was
significant blood and EMS was called. Prior to EMS arrival pt's
husband stated that while she did not fully lose consciousness
she had AMS in that while she was talking she seemed very
distracted and out of it. Pt has a poor recall of events. EMS
found pt with significant bleeding and concern for a skull
fracture so she was brought into the ED. Pt had some nystagmus,
but it was unsure if this is because of a concussion or this is
her baseline. Pt denies dyspnea, CP, dysuria, fever, chills, and
any other sxs at this time.
Past Medical History:
PMH:B/L thyroid nodules(R thyroid 3.3cm nodule, L 2.4cm nodule;
R FNA indeterminate, L FNA c/w benign nodule);
hyperparathyroidism from L inferior parathyroid gland adenoma
(dx ___ incidental, Ca ___, PTH 195-235, U/S and sestamibi
left thyroid lobe inferior pole parathyroid adenoma),
nephrolithiasis, osteoporosis, fatigue; arthritis, skin cancer,
obesity, HTN, GERD
PSH:C-section; forehead skin cancer excision, lithotripsy for
neprholithiasis
Social History:
___
Family History:
___
Physical Exam:
Admission:
==========
HR: ___ Resp: 16 O2 Sat: 100 RA
Constitutional: Awake and alert. Uncomfortable. Non-toxic
appearing.
Head / Eyes: Pupils equal, round and reactive to light. No
facial tenderness. No ___ hematoma.
ENT / Neck: No hemotympanum in L ear.
Chest/Resp: Airway intact. Bilateral breath sounds. No crepitus.
Non-localizing chest wall tenderness.
Cardiovascular: Strong radial pulse on L. Palpable pulses on
feet.
GI / Abdominal: Soft, Nontender
Musc/Extr/Back: Bilateral knee tenderness.
Skin: parietal scalp laceration
Neuro: GCS >8. , Speech fluent
Discharge:
==========
Vitals: 97.7 65 117/72 17 99 RA
General: NAD
HEENT: MMM, PERRL, EOMI
CV: RRR
Pulm: no respiratory distress, lungs CTAB
GI: soft, NT/ND
Extremities: WWP
Neuro: AAOx3
Psych: mood, affect appropriate
Pertinent Results:
Admission:
==========
___ 02:16PM BLOOD WBC-6.4 RBC-5.24* Hgb-15.1 Hct-46.4*
MCV-89 MCH-28.8 MCHC-32.5 RDW-13.2 RDWSD-42.9 Plt ___
___ 02:16PM BLOOD ___ PTT-31.7 ___
___ 02:16PM BLOOD UreaN-22* Creat-0.9
Imaging:
========
Portable CXR (___), Impression:
No acute cardiopulmonary process.
CT C-spine w/o contrast (___), Impression:
No acute fracture or traumatic malalignment of the cervical
spine.
CT Head w/o contrast (___), Impression:
1. Right posterior parietal scalp hematoma and laceration
without associated fracture.
2. No acute intracranial hemorrhage or mass effect.
Discharge:
==========
___ 05:45AM BLOOD WBC-7.9 RBC-4.37 Hgb-12.5 Hct-39.3 MCV-90
MCH-28.6 MCHC-31.8* RDW-13.3 RDWSD-44.1 Plt ___
___ 05:45AM BLOOD Glucose-102* UreaN-16 Creat-0.8 Na-142
K-4.4 Cl-105 HCO___ AnGap-14
Brief Hospital Course:
Ms. ___ presented to ___ ED via EMS on ___ for
evaluation of head injury s/p mechanical fall. CT head/cspine
was negative for fracture and intracranial hemorrhage. Trauma
repaired the scalp laceration, and the patient was admitted to
the trauma service for monitoring. On ___, a tertiary
survey was completed, which identified no new symptoms or
injuries. The patient was also seen by physical therapy and
occupation therapy, who both recommended she be discharged home
with a rolling walker. The patient was deemed medical cleared to
be discharged home.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance via a rolling walker, 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. amLODIPine 2.5 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Calcium Carbonate 600 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 6 hours
Disp #*4 Tablet Refills:*0
3. amLODIPine 2.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 600 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10.Rolling Walker
Dx: unsteady gait
Px: good
___: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
scalp laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to ___ a
head injury after a fall. Your scalp laceration was stitched up
and ___ were observed in the hospital overnight. ___ are now
deemed medically cleared to be discharged home. Please read the
following discharge instructions to assist with a successful
recovery.
Diet, Activity, & Medications:
==============================
*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 with assistance from the rolling walker, and drink
adequate amounts of fluids. Avoid lifting weights greater than
___ lbs until ___ follow-up with your surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
Laceration Care:
================
*Please call your doctor or nurse practitioner if ___ have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
___ may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If ___ have stitches, they will be removed at your follow-up
appointment.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
====================================
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
___.
Thank ___ for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10619703-DS-20 | 10,619,703 | 25,298,407 | DS | 20 | 2140-09-06 00:00:00 | 2140-09-06 13:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of Crohn's disease on Humira, depression,
anxiety presenting with refractory, progressive epigastric pain
x1 month. Pt has seen multiple GI MDs, has a known terminal
ileum
stricture, and is now prescribed budesonide and Humira every
other week. She had been scheduled for surgical evaluation with
Dr. ___ on ___. Pt describes pain x1 month,
continuously.
She has some BM with every urination, and has bright red blood
with every BM. She has become fearful of moving her bowels ___
severe pain. She endorses temp to 100 on am of presentation, and
was unable to take anything PO. She describes the pain as ___,
epigastric. She has mild associated nausea. Pain is stabbing in
nature, with associated bloating. She has been unable to eat ___
pain. She has developed a frontal headache, which she says
starts
at the base of her skull, "nonstop aching." Joint paint has been
in her bilateral hips.
She is on Humira every other week. Last injection was ___,
and is self-administered. When she has taken steroids in the
past, her anxiety is amplified, like she "drank 3 pots of
coffee." She tolerates the budesonide, and says she has been
taking it BID. She has had ankles in bilateral ankles.
She has an appointment scheduled with Dr. ___ ___,
but her fiancée brought her to the ED because of worsening
abdominal pain. She is tearful, because she was hoping to attend
her daughter's graduation from preschool on ___. At home,
she
has not been taking any medications for her pain.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
Crohn's disease as per HPI
Depression
Anxiety
C. diff infection in the past
Social History:
___
Family History:
No family history of IBD. Mother is alcoholic.
Father is in good health. Father lives in ___.
Physical Exam:
ADMISSION:
VS: 98.2 PO 143 / 88 93 18 97 RA
GEN: alert, interactive, tearful, frequently shifting, visibly
uncomfortable
HEENT: PERRL, anicteric, conjunctiva pink, small shallow healing
ulcer at inside of L lower lip, moist mucus membranes
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: +guarding, +rebound tenderness, distended, soft on
exhalation
with slow, deep breaths, diffuse TTP is most pronounced at LUQ.
Unable to assess for hepatomegaly ___ pain.
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: grossly intact
PSYCH: tearful, appropriate
DISCHARGE:
VS: 97.9, 106/71, 78, 16, 97% on RA
GEN: asleep in bed but arousable, upon waking is immediately
tearful
HEENT: MMM, NCAT, EOMI, anicteric sclera
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, somewhat distended, TTP of LUQ without rebound but +
anticipatory guarding. Nml bowel sounds
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
Rectal: on external exam, no evidence of hemorrhoids or anal
fissure
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: grossly intact
PSYCH: tearful, anxious
Pertinent Results:
ADMISSION:
___ 09:21PM LACTATE-1.8
___ 08:33PM GLUCOSE-85 UREA N-10 CREAT-0.7 SODIUM-136
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16
___ 08:33PM ALT(SGPT)-28 AST(SGOT)-28 ALK PHOS-69 TOT
BILI-<0.2
___ 08:33PM LIPASE-41
___ 08:33PM ALBUMIN-4.7 IRON-14*
___ 08:33PM calTIBC-443 FERRITIN-7.3* TRF-341
___ 08:33PM CRP-1.0
___ 08:33PM WBC-11.7* RBC-4.50 HGB-11.4 HCT-36.3 MCV-81*
MCH-25.3* MCHC-31.4* RDW-14.6 RDWSD-42.5
___ 08:33PM NEUTS-54 BANDS-0 ___ MONOS-7 EOS-1
BASOS-0 ___ MYELOS-0 AbsNeut-6.32* AbsLymp-4.45*
AbsMono-0.82* AbsEos-0.12 AbsBaso-0.00*
___ 08:33PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 08:33PM PLT SMR-HIGH PLT COUNT-507*
___ 08:33PM ___ PTT-28.2 ___
___ 08:33PM RET AUT-1.1 ABS RET-0.05
___ 07:09PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 07:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
IMAGING/STUDIES:
___ KUB
FINDINGS:
There are no abnormally dilated loops of large or small bowel
with mild to
moderate air and stool throughout the colon and rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
IMPRESSION:
Nonobstructive bowel gas pattern with mild to moderate stool
burden.
___ MRE
MR ENTEROGRAPHY:
There is focal wall thickening, mild wall edema, and some
intramural fat,
involving a short, 3.0 cm segment of the terminal ileum, similar
in severity to CT from ___ but mildly improved in extent
compared to ___. While postcontrast images are limited due
to respiratory motion, there is mild mucosal hyperenhancement of
this segment. In addition, this segment remains narrowed
throughout the examination with the bowel lumen measuring 0.5
cm.
There is no associated pre stenotic dilation. Remainder of the
small bowel is unremarkable. Although not optimized, evaluation
of large bowel is unremarkable.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Views of the liver, spleen, kidneys, pancreas, and adrenal
glands are
unremarkable. The gallbladder is unremarkable. There is no
intra or
extrahepatic biliary duct dilation. There is no mesenteric or
retroperitoneal
adenopathy.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The uterus and ovaries are unremarkable. There is small volume
pelvic free fluid.
IMPRESSION:
Mild acute on chronic terminal ileal inflammation for the distal
3-4 cm, in keeping with known Crohn's disease, similar in
severity compared to ___ but mildly improved when compared to
___. Narrowing lumen noted in this loop throughout the
examination however, in the setting of active disease the
presence of fixed stenosis is uncertain. No upstream bowel
dilation.
DISCHARGE:
___ 07:37AM BLOOD WBC-6.8 RBC-3.82* Hgb-9.6* Hct-31.1*
MCV-81* MCH-25.1* MCHC-30.9* RDW-14.6 RDWSD-42.5 Plt ___
___ 07:37AM BLOOD Plt ___
___ 07:37AM BLOOD Glucose-94 UreaN-9 Creat-0.6 Na-141 K-4.2
Cl-103 HCO3-29 AnGap-13
___ 08:02AM BLOOD ALT-25 AST-24 AlkPhos-69 TotBili-<0.2
___ 07:37AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.8
___ 08:33PM BLOOD calTIBC-443 Ferritn-7.3* TRF-341
___ 08:02AM BLOOD CMV VL-NOT DETECT
___ 09:21PM BLOOD Lactate-1.8
Brief Hospital Course:
Ms. ___ is a ___ PMHx structuring ileocolonic Crohn's who
presents with abdominal pain. She has been followed by
outpatient GI providers at ___ and
underwent colonoscopy with biopsies as well as CTE which
demonstrated chronic inactive Crohn's and mild stricture of the
terminal ileum without evidence of obstruction. Given her
ongoing abdominal pain, she was referred by her outpatient
providers to Dr. ___ and has an appointment on ___
for surgical evaluation. Her evaluation here has been
unrevealing. Labs have been wnl without any evidence of an
infectious process. CRP was only 1.0 and not consistent with an
active Crohn's flare. She had a KUB which was nonobstructive
and showed a mild to moderate stool burden. She also underwent
an MRE which showed very very mild narrowing of the terminal
ileum without any significant active inflammation to explain her
abdominal pain. Per discussion with GI, per presentation could
be consistent potentially with constipation-predominant IBS
although per her providers here and multiple family members,
there was also concern for narcotic pain-seeking behavior. She
was able to tolerate a regular diet during her hospitalization
without any issue. She was ultimately discharged with an
aggressive bowel regimen without any additional narcotic pain
medications and instructed to follow-up with Dr. ___ as
already scheduled.
***TRANSITIONAL ISSUES***
- Pt to see Dr. ___ in clinic on ___
- Patient's iron studies c/w iron deficiency; please consider
iron supplementation as an outpatient when constipation improves
- Would consider weaning off gabapentin as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DICYCLOMine 20 mg PO QID
2. Venlafaxine XR 150 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. HydrOXYzine 50 mg PO BID:PRN anxiety, insomnia
5. Humira (adalimumab) 40 mg/0.8 mL subcutaneous Every other
week on ___
6. Budesonide 3 mg PO BID
Discharge Medications:
1. Bisacodyl ___AILY constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally at bedtime Disp
#*30 Suppository Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO BID constipation
RX *polyethylene glycol 3350 17 gram/dose 17 gm by mouth twice a
day Refills:*0
4. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Budesonide 3 mg PO BID
6. DICYCLOMine 20 mg PO QID
7. Gabapentin 800 mg PO TID
8. Humira (___) 40 mg/0.8 mL subcutaneous Every other
week on ___
9. HydrOXYzine 50 mg PO BID:PRN anxiety, insomnia
10. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
constipation
chronic inactive Crohn's
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for ongoing abdominal pain.
You were evaluated by our GI team and have undergone extensive
work-up of your abdominal pain. Your labs have been
unremarkable and your inflammatory markers were negative. You
had an abdominal X-ray which showed no evidence of intestinal
obstruction. You also had a MRE of your abdomen which showed
very very mild narrowing of your terminal ileum without any
evidence of obstruction and no significant inflammation of your
bowels. This evaluation is consistent with the biopsy results
and CTE you underwent with your outpatient providers at
___ earlier this month which again
showed chronic inactive Crohn's and a very mild stricture of the
terminal ileum that has not caused any obstruction. Per your GI
evaluation, you have constipation predominant-IBS (irritable
bowel syndrome). You were given an aggressive bowel regimen
here in the hospital and will need to continue to take these
medications when you return home. You have also been able to
tolerate a regular diet here in the hospital.
Please follow-up with your outpatient providers as instructed
below.
Thank you for allowing us to participate in your care. All best
wishes for your care.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10619824-DS-12 | 10,619,824 | 24,677,749 | DS | 12 | 2147-06-25 00:00:00 | 2147-07-27 14:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Left inguinal hernia repair with mesh.
History of Present Illness:
Patient is a ___ with history of AL amyloidosis s/p autologous
stem cell transplant ___ years ago, DM2 who presents with left
groin pain. He reports that he has had a reducible right
inguinal hernia for years which has always been easily reducible
and has never been stuck out. He has never had a hernia on the
left that he is aware of. Starting yesterday morning he had a
sudden left inguinal bulge which increased in discomfort
throughout the day with severe pain starting at approximately 3
___. He left work and went home and tried to take a nap to see
if
it would get better but it did not, so he came to the emergency
department. He reports he had a bowel movement yesterday
morning
but has not passed any gas or had a bowel movement since. He
denies nausea/vomiting. He denies fever/chills, chest pain,
dyspnea.
Past Medical History:
1. CKD
2. Diabetes type 2
3. Hyperlipidemia
4. Chronic mild thrombocytopenia
5. Diverticulosis
6. AL amyloidosis s/p autologous stem cell transplant
Social History:
___
Family History:
He has five siblings; three older sisters, one
younger sister and one younger brother, all of whom are well and
healthy to his knowledge.
Physical Exam:
Admission Physical Exam:
Vitals:
99.4 95 122/71 16 95% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: regular, mildly tachycardic
PULM: Breathing comfortably on room air
ABD: Soft, nondistended, moderately tender in the lower
quadrants
with voluntary guarding, left inguinal hernia palpated with hard
bulge, very tender, mild overlying erythema.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.0 BP: 112/71 HR: 89 RR: 18 O2: 95% ra
Gen: A&O x3
Pulm: LS ctab
CV: HRR
Abd: soft NT/ND. Left groin hernia repair site CDI no swelling
or erythema
Ext: WWP no edema
Pertinent Results:
___ 01:40AM BLOOD WBC-10.4* RBC-4.02* Hgb-13.0* Hct-37.1*
MCV-92 MCH-32.3* MCHC-35.0 RDW-12.3 RDWSD-41.5 Plt Ct-92*
___ 01:40AM BLOOD Neuts-65 Bands-22* Lymphs-4* Monos-4*
Eos-0* Baso-0 Atyps-5* AbsNeut-9.05* AbsLymp-0.94* AbsMono-0.42
AbsEos-0.00* AbsBaso-0.00*
___ 01:40AM BLOOD Glucose-167* UreaN-21* Creat-0.9 Na-138
K-3.9 Cl-107 HCO3-22 AnGap-9*
Imaging:
CT Abd/Pelvis:
Left inguinal hernia with heterogeneous indeterminate
components.
There does
appear to be a tubular structure within the hernia sac with a
hyperenhancing
rim concerning for incarceration/strangulation
Brief Hospital Course:
___ with hx of AL amyloidosis s/p autologous stem cell
transplant, chemotherapy in remission, DM2, presenting with an
incarcerated left inguinal hernia, unable to be reduced at
bedside. The patient was hemodynamically stable. The patient
underwent left inguinal hernia repair with mesh, 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.
.
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:
Acyclovir
Atorvastatin
Lisinopril
Metformin
Aspirin
Cholecalciferol
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*25 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*5 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth once a
day Refills:*0
4. Acyclovir 400 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left incarcerated inguinal hernia
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 abdominal pain. CT scan
revealed a left inguinal hernia. You were taken to the operating
room and had a left inguinal hernia repair with mesh. 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 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:
___
|
10620077-DS-14 | 10,620,077 | 27,462,506 | DS | 14 | 2175-12-08 00:00:00 | 2175-12-08 17:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ibuprofen / Strawberry / Pineapple / Tree Pollen / Tussionex /
Penicillins / Avelox
Attending: ___.
Chief Complaint:
Word finding difficulty, memory loss
Major Surgical or Invasive Procedure:
___ L stereotatic brain biopsy
History of Present Illness:
___ F found on MRI to have L frontal and temporal brain mass.
Pt has been increasingly forgetful over past few weeks.
Daughter
noticed issues with remembering events, but also naming everyday
items. This has been worse int he past few days. Patient has
noticed some of this, but daughter was mainly concerned. PCP
ordered MRI which shows 2 brain lesions (L frontal and temporal
brain) with some midline shift. Pt received 10 mg IV Decadron
at
___ and was transferred to ___ for neurosurgery
eval.
Of note, pt was found to have a 9 mm x 9mm x 6mm enhancing
lesion
in the right cerebellar peduncle found in ___. Seen in brain
tumor clinic transiently, but spontaneously resolved on
subsequent MRI. She was being followed by Dr. ___.
Past Medical History:
Depression, GERD, Seasonal allergies
Social History:
___
Family History:
There is no family history of malignancy. Her
mother had diabetes ___, MI, and a stroke at age ___. Her
father had diabetes ___.
Physical Exam:
PHYSICAL EXAM:
O: 98.7 66 118/63 18 97%
Gen: WD/WN, comfortable, NAD.
HEENT: EOM-I
Neck: Supple.
Lungs: no resp distress
Cardiac: reg
Abd: Soft, NT, ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension with occasional
naming errors (easily resolved)
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch,
Pertinent Results:
___ MRI brain done at BIN
___ CTA Brain
___ CT Torso
___ 06:00AM BLOOD WBC-8.9 RBC-3.96* Hgb-11.6* Hct-36.0
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.0 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-125* UreaN-14 Creat-0.7 Na-140
K-3.5 Cl-100 HCO3-34* AnGap-10
___ 04:45AM BLOOD ALT-51* AST-39 AlkPhos-49 TotBili-0.3
Brief Hospital Course:
Ms. ___ was evaluated in the emergency department and after
review of her brain MRI which showed to foci on enhancement she
was admitted to Neurosurgery for further workup.
She underwent a CTA of the brain and on ___ went to the
Operating room for a stereotatic Biopsy. Biopsy was successful
and patient was transferred to the PACU for recovery. Post
operative head CT was performed and showed small punctate
hemorrhage at the biopsy site. She remained intact post
operatively. She was started on decadron 4mg Q6H. On ___, she
was stable on exam. She was ambulating independently and an echo
and 24hr urine was sent for preparation for chemotherapy.
The patient was then transferred to 11R to start therapy for
primary CNS lymphoma (high grade B cell)
Her active medical problems during the hospitilization were the
following:
1.Primary CNS lymphoma: Pt received her 1st dose of methotrexate
3.5gm/m2
on ___ received a low dose of the high dose methotrexate
since there was concern that her creatinine clearance maybe low.
She tolerated the chemotherapy well. Her methotrexate level is
0.7 (___) and was 0.04 on ___, at the time of discharge.
She was told to continue dexamethasone 4mg PO daily at home. She
will be readmitted on ___ for her next cycle of HD
methotrexate. She will be premedicated with sodium bicarbonate
tablets 24 hours prior to next admission. Pt was given contact
information for neurosurgery as an outpatient to have her
sutures removed.
2. GERD: symptoms were well controlled with omeprazole.
3. Depression: well controlled on current regimen of gabapentin
and mirtazapine.
Pt and plan discussed with Dr. ___ concurs with above
mentioned plan
Medications on Admission:
All: Ibuprofen / Strawberry / Pineapple / Tree Pollen /
Tussionex / Penicillins / Avelox
Medications prior to admission:
gabapentin 100 mg capsule 1 Capsule(s) by mouth tid and hs (pt
to
drop hs dose)
lorazepam 0.5 mg tablet ___ tablet(s) by mouth tid prn
mirtazapine 7.5 mg tablet TAKE 1 TABLET ONCE DAILY AT BEDTIME
omeprazole 20 mg capsule,delayed release TAKE ONE CAPSULE EVERY
MORNING 30 MINUTES BEFORE BREAKFAST
Zyrtec 10 mg capsule oral 1 capsule(s) Once Daily
Discharge Medications:
1. Gabapentin 100 mg PO BID
2. Mirtazapine 7.5 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 50 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*2
6. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*30
Capsule Refills:*0
7. Lorazepam 0.5 mg PO HS:PRN insomnia, anxiety
8. ZyrTEC (cetirizine) 10 mg ORAL QD
9. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*12
Tablet Refills:*0
10. Sodium Bicarbonate 1300 mg PO Q6H
Start 1 day prior to next admission (start on ___
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth every 6 hours
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L frontal lobe lesion
L temporal lobe lesion
Primary CNS Lymphoma
Discharge Condition:
Stable.
Alert and orientated
ambulating
Discharge Instructions:
x
*Have a friend/family member check your incision daily for signs
of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
**Your wound was closed with staples or non-dissolvable sutures
then you must wait until after they are removed to wash your
hair. You may shower before this time using a shower cap to
cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
Clearance to drive and return to work will be addressed at your
post-operative office visit.
Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101° F.
Followup Instructions:
___
|
10620252-DS-10 | 10,620,252 | 22,273,102 | DS | 10 | 2149-06-20 00:00:00 | 2149-06-21 08:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilantin / phenobarbital / levetiracetam
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with history of type 2 DM and HTN who presented with 1
day of epigastric pain. Pain started on ___ evening at 5:00 pm,
after several episodes of dry heaving and emesis. At ___
noted to be hypertensive to 160s, equal in both arms. Given
concern for esophageal tear with history of initiation of pain
after vomiting, he was given a dose of zosyn. Had CTA chest
which demonstrated no evidence of esophageal perforation or
dissection dissection, and no other abnormalities. Pt was
initially transferred to ___ for esophagram, but lipase
subsequently came back elevated, increasing concern for
pancreatitis as etiology for pain.
Of note, pt has no h/o gallstones, but does have a history of
moderate to heavy beer drinking (has had 2 episodes of syncope
previously I/s/o drinking 8 beers).
In ED initial VS: 100.4 ___ 20 100% RA
Exam: "Abdomen is distended and tender to palpation, most so in
periumbilical area. Lower extremities without swelling or
tenderness to palpation. Skin is warm and well perfused
distally. Alert and oriented"
Labs were notable for: Lipase 677 at ___ here, WBC 22.1
(83% PMNs), ALT 50 (other LFTs wnl), Lactate 5.3 -> 3.2, anion
gap about 21, chem7 glucose 381, Trops negative x 2, VBG with pH
7.42, pCO2 31
Patient was given: 2 L LR, 4 L NS, IV Dilaudid 1 mg x2, IV
morphine 4 mg x1, IV Tylenol ___ mg x1
Imaging notable for: CT A/P c/w pancreatitis, concerning for
possible necrosis of pancreatic tail
Consults: none
Given persistent tachycardia and tachypnea, he was admitted to
the ICU for severe pancreatitis.
VS prior to transfer: 98.7 139 160/89 25 94% Nasal Cannula
On arrival to the MICU, pt is tachycardic to the 130s but
otherwise hemodynamically stable. He is in NAD, but does endorse
ongoing abdominal pain, worst in the epigastrium and the
suprapubic area. His last drink was ___.
Past Medical History:
type 2 DM
HTN
HLD
obesity
?___
Recurrent syncope
Seizures in childhood
No surgical histories
No history of any gallstones
Social History:
___
Family History:
His father had a TIA at age ___, also suffers from hypertension
and CHF. There is no family history of sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99.2 ___ 22 95% RA
GENERAL: overweight gentleman in NAD, able to answer questions
appropriately, does appear moderately uncomfortable ___
abdominal pain
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally in frontal fields
CV: tachycardic, regular rhythm, normal S1 S2, no murmurs
ABD: distended, diffusely tender, hypoactive BS
EXT: Warm, well perfused, 2+ pulses, trace ___ edema
SKIN: no rashes
NEURO: AAOx3, moving all extremities
Discharge Exam:
Gen: Sitting in chair, in no apparent distress, on RA, bearded
obese gentleman
Vitals: Afebrile, BP 140/70, HR 105, RR 18, 94 on RA%:
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: tachycardic no MRG, nl. S1 and S2
Pulmonary: Lung fields largely clear with occasional wheeze save
for diminished breath sounds at left base.
Gastroinestinal: Soft, no tap tenderness, mild tenderness to
deep
palpation in epigastric region, non-distended, bowel sounds
present, no HSM, protuberant abdomen
MSK: trace edema bilaterally,
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
==============
___ 01:10PM ___ PTT-24.1* ___
___ 01:10PM WBC-21.8* RBC-5.31 HGB-16.2 HCT-47.5 MCV-90
MCH-30.5 MCHC-34.1 RDW-13.5 RDWSD-43.5
___ 01:10PM PLT COUNT-311
___ 01:10PM NEUTS-83.5* LYMPHS-7.5* MONOS-8.1 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-18.19* AbsLymp-1.64 AbsMono-1.76*
AbsEos-0.00* AbsBaso-0.06
___ 01:10PM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.2
MAGNESIUM-1.2*
___ 01:10PM cTropnT-<0.01
___ 01:10PM LIPASE-813*
___ 01:10PM ALT(SGPT)-45* AST(SGOT)-17 ALK PHOS-46 TOT
BILI-0.8
___ 01:10PM GLUCOSE-381* UREA N-17 CREAT-1.2 SODIUM-136
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-18* ANION GAP-25*
___ 01:28PM LACTATE-5.3*
STUDIES
=======
-CT A/P ___
IMPRESSION:
1. Marked fat stranding and fluid surrounding the body and tail
of the
pancreas consistent with pancreatitis. There is suggestion of
hypoenhancement
of the pancreatic tail, concerning for pancreatic necrosis. No
evidence of
splenic vein thrombosis or pseudoaneurysm formation. Associated
focal ileus.
2. Extensive fluid extending along the descending colon and into
the pelvis is
likely secondary. Small amount of fluid within ___'s pouch.
3. Filling defect within the distal right anterior portal vein,
concerning for
a nonocclusive thrombus. Remaining portal vein is patent.
4. Mild focal anterior bladder wall thickening, nonspecific, and
could be
related to the urinary bladder not being fully distended.
Correlate with
urine analysis and consider nonurgent urology ___.
5. Hepatic steatosis.
Discharge Labs:
___ 07:30AM BLOOD WBC-17.5* RBC-3.93* Hgb-11.8* Hct-35.4*
MCV-90 MCH-30.0 MCHC-33.3 RDW-13.9 RDWSD-45.5 Plt ___
___ 07:30AM BLOOD Glucose-216* UreaN-13 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-24 AnGap-17
___ 07:30AM BLOOD ALT-29 AST-21 AlkPhos-41 TotBili-1.2
___ 07:30AM BLOOD Lipase-38
___ 01:10PM BLOOD Lipase-813*
___ 12:30AM BLOOD Lipase-470*
___ 07:00AM BLOOD Albumin-3.0* Calcium-8.1* Phos-1.7*
Mg-2.0
___ 07:00AM BLOOD Triglyc-250*
Brief Hospital Course:
___ yo M with history of type 2 DM and HTN who presents with
epigastric pain, found to have pancreatitis and with anion gap,
admitted to ICU because of persistent tachycardia despite fluid
resuscitation.
#Acute Pancreatitis with Necrotizing features: Pt with
epigastric pain, elevated lipase and white count, and CT A/P c/w
pancreatitis, concerning for possible necrosis of pancreatic
tail. Precipitant though to be EtOH. Lactate improved with 8L
IVF resuscitation. Initially admitted to ICU given hemodynamic
instability (hypoxemia, need for aggressive IVF, and ongoing
tachycardia) as well as imaging finding of possible necrotizing
pancreatitis. Improved steadily with IVF, pain control. Was
tolerating clears at the time of transfer out of ICU on ___.
Quickly advanced to regular diet that he tolerated well upon
discharge. Patient was counseled to avoid alcohol altogether
given its likely impact on his possible seizure d/o, risk of
pancreatitis, and nutritional status. His depakoate was stopped
given case reports of depakoate contributing to necrotizing
pancreatitis and given it is unclear whether the patient has a
seizure d/o at all.
-D/c depakoate
-Alcohol Cessation
-PCP ___
-Continue low fat diabetic diet
-Continue Atorvastatin for elevated triglycerides
#Leukocytosis likely reactive from pancreatitis. Intermittent
low-grade temps in ICU and upon transfer to the ward, however,
afebrile with improving HD status on discharge. No localizing
source. WBC 20-->17.5 on day prior to and day of discharge.
#Hyperglycemia
#Type 2 DM: Sugar elevated in the 300s in ED with anion gap of
21 and trace ketones in urine. Unclear whether gap due to DKA vs
elevated lactate. Fingerstick on arrival 263. Gap closed within
24 hours. Home metformin and glyburide were held and restarted
on discharge.
-Reassess fasting glucose as outpatient and provide glucometer
if elevated
#Tachycardia: Pt persistently tachycardic to 130s despite
aggressive fluid resuscitation. CTA at ___ negative for
PE or dissection. EKG showed sinus tach. Was not scoring on CIWA
scale. His tachycardia steadily improved and was thought
secondary to SIRS responsive from severe pancreatitis.
#?Portal Vein Thrombus: CT showing possible nonocclusive
thrombus in right anterior portal vein. Thought to be a
complication of pancreatitis. No evidence of hepatic compromise
or ischemia.
-Repeat RUQUS with Doppler as outpatient as may have self
resolved
#ETOH Abuse: Pt has a binge drinking pattern. No h/o withdrawal
and was not scoring on CIWA scale. Started on Thiamine/folate
and social work consulted.
-Counseled on complete alcohol cessation
-declined naltrexone
#Recent recurrent syncope
#Concern for seizure d/o: Pt has had several episodes of syncope
over the past year, cardiac and neuro workup unrevealing,
including ambulatory monitoring. Does have a history of seizures
in childhood for which he was on antiepileptics until the age of
___. Keppra was restarted recently, switched to valproate in ___
because of rash. Valproate held given case reports it can cause
pancreatitis. Upon further history two of these episodes have
occurred in the last year have been at the bar he frequents in
___ and the patient notes preceeding diaphoresis and
light-headedness. He thinks he was down for a total of 30
seconds during these episodes and was not witnessed to be
shaking. He does not recall having a true seizure since the age
of ___. I suspect he has vaso-vegal episodes in the context of
vasodilation and dehydration from alcohol.
-Neurology ___ for consideration of whether he needs AED at all
and which type given several allergies and now pancreatitis in
the context of depakoate
-Avoidance of alcohol
-Cardiology ___ as planned
-Consider carotid U/S to assess for carotid insufficiency
=================
CHRONIC ISSUES
=================
#HLD, Carotid Disease: Continued home aspirin, statin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Divalproex (EXTended Release) 500 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. GlyBURIDE 5 mg PO BID
Discharge Medications:
1. Acetaminophen 650 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:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. GlyBURIDE 5 mg PO BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
-Acute Nectrotizing pancreatitis
-Hypoxemia
-Alcohol abuse d/o
-DMII with hyperglycemia
Discharge Condition:
Good
Alert and oriented x3
Ambulatory without assistance
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with severe acute pancreatitis
that is likely from excess alcohol usage. This episode made you
quite ill and it is extremely important that you stop alcohol
use all together when you leave the hospital or this will happen
again and perhaps be worse. You should see your primary care
physician for ___ you should also see your neurologist to
determine whether you should continue anti-seizure medication.
You have had adverse reactions (hives) to several seizure
medications. We have discontinued your depakoate because there
is a small chance it contributed to your pancreatitis. You
should also re-check your blood glucose (sugars) in the clinic
to determine you have appropriate control of your diabetes. You
should know that pancreatitis makes controlling your diabetes
Followup Instructions:
___
|
10620300-DS-11 | 10,620,300 | 20,242,867 | DS | 11 | 2135-12-13 00:00:00 | 2135-12-13 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Nausea, Vomiting, Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of recent CCY, type I DM c/b gastroparesis
who presents with ___ colicky, non-radiating abdominal pain.
He was recently admitted to ___ from ___ with
symptomatic cholelithiasis and cholecystitis. He underwent ERCP
on ___ which revealed sludge in the CBD. He underwent lap
chole on ___. Since discharge on ___, he had been
feeling well and not stopped using pain medication on ___. He
had been tolerating a normal diet. The morning of ___, he
woke up with nausea and began to have several episodes of yellow
emesis. He then developed right sided abdominal pain, worsened
with movement, and abdominal sorenss diffusely. The pain is
similar to before his surgery. He continues to pass flatus and
has normal BMs. This feels different than his usual
gastroparesis flares which are characterized by severe,
unrelenting nausea. The most pressing symptom for him is the
pain. During this time, he has also been experiencing hot/cold
flashes, which are at his baseline.
In the ED, initial vitals were: 97.4 95 150/103 18 99% RA
- Labs were significant for WBC 13.4, H&H 13.7/43.0, plts 395,
ALT 262/AST 134, Tbili 0.5, alk phos 103. BUN/Cr ___.
- CT ab/p didn't reveal any fluid collection and no acute
process was identified.
- The patient was given zofran, reglan, pantoprazole,
hydromorphone, insulin IV, lorazepam IV, and viscous lidocaine.
Vitals prior to transfer were: 98.0 93 134/72 18 98% RA
Upon arrival to the floor, he is c/o significant amount of
abdominal pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Type 1 DM
- c/b gastoparesis
GERD
Social History:
___
Family History:
DM1
gallbladder disease (cholecystitis in several relatives)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5 142/97 99 20 100% RA BG 155
General: Alert, oriented, appears uncomfortable
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, TTP diffusely, worse over LUQ/RUQ, laprascopic
scars appear well-healed, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6, 127/80, 79, 18, 96% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, bowel sounds present, tender surgical
scar, no tap tenderness, rebound, or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, able to get out of bed and walk to
bathroom independently.
Pertinent Results:
ADMISSION LABS:
===================
___ 04:35PM BLOOD WBC-13.4* RBC-4.83 Hgb-13.7 Hct-43.0
MCV-89 MCH-28.4 MCHC-31.9* RDW-14.2 RDWSD-45.8 Plt ___
___ 04:35PM BLOOD Neuts-88* Bands-1 Lymphs-7* Monos-3*
Eos-0 Baso-0 ___ Myelos-1* AbsNeut-11.93*
AbsLymp-0.94* AbsMono-0.40 AbsEos-0.00* AbsBaso-0.00*
___ 04:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
___ 04:35PM BLOOD Plt Smr-NORMAL Plt ___
___ 04:35PM BLOOD Glucose-205* UreaN-10 Creat-0.8 Na-141
K-4.5 Cl-102 HCO3-23 AnGap-21*
___ 04:35PM BLOOD ALT-262* AST-134* AlkPhos-103 TotBili-0.5
___ 07:22AM BLOOD ALT-190* AST-65* AlkPhos-86 Amylase-37
TotBili-0.6
___ 04:35PM BLOOD Lipase-23
___ 04:35PM BLOOD Albumin-4.4
___ 09:00PM BLOOD Calcium-9.2 Phos-3.7 Mg-1.7
___ 09:04PM BLOOD ___ Temp-36.7 FiO2-20 pO2-71*
pCO2-35 pH-7.43 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
___ 09:04PM BLOOD Glucose-352* Lactate-3.1*
DISCHARGE LABS:
================
___ 07:15AM BLOOD WBC-9.9 RBC-4.47* Hgb-12.6* Hct-39.2*
MCV-88 MCH-28.2 MCHC-32.1 RDW-14.0 RDWSD-44.8 Plt ___
___ 07:15AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-139
K-3.9 Cl-100 HCO3-25 AnGap-18
___ 06:40AM BLOOD ALT-161* AST-44* LD(LDH)-193 AlkPhos-91
TotBili-0.7
___ 06:40AM BLOOD Calcium-9.3 Phos-5.6* Mg-2.1
RELEVANT LABS:
===============
___ 07:22AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 07:22AM BLOOD Acetmnp-NEG
___ 07:22AM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY:
===============
___ Blood Cultures NGTD
IMAGING:
===========
CT ABD PEL ___:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent. CBD stent is seen.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
Bilateral ureteral jets are seen.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Soft tissue thickening in the subcutaneous
tissues of the right upper quadrant and at the umbilicus are
compatible with recent laparoscopic surgery.
IMPRESSION:
No fluid collection. No acute process.
___ MRCP: ! WET READ !
Enhancement and restricted diffusion along CBD, intrahepatic
ducts and
gallbladder fossa (series 8, image 7, 11 and series 15: Im 51)
can be
infection ascending cholangitis in appropriate clinical setting,
or related to recent procedure. No stones or intra/extra hepatic
ductal dilatation. No visible collections.
Brief Hospital Course:
___ hx DM I c/b severe gastroparesis, s/p CCY on ___ who
presented with colicky, severe abdominal pain.
# Abdominal Pain/Vomiting:
Concerning for stent dysfunction or retained stones given
uptrending LFT's post-operatively. Post-cholecystectomy syndrome
was on differential including possible retained stones however
felt to be less likely given normal biliary morphology on CT
abdomen. Patient was evaluated by ___ team who felt symptoms
were not consistent with post-cholecystectomy complication.
Other etiologies including hepatitis and acetaminophen toxicity
considered though ultimately these tests were negative. Also
patient's gastroparesis was also considered though transaminitis
was inconsistent with this. MRCP was also obtained with wet read
that showed question of ascending cholangitis but that was
inconsistent with the stable, afebrile, improving clinical
picture of the patient. Lastly, discussion of the ERCP team it
was also noted that findings post-stent placement can often
times appear as ascending cholangitis commonly without it being
present. Given resolution of patient's symptoms it was
determined that he would have biliary stent removed on ___
at 2 ___ with the ERCP team.
# Transaminitis:
___ be post-CCY inflammation or stent dysfunction or retained
stones. Tylenol toxicity and viral hepatitis ruled out given
negative Tylenol level and negative hepatitis serologies. See
above discussion.
# Hyperphosphatemia:
Patient noted to have some hyperphosphatemia this
hospitalization. CK was below normal, ruling out rhabdomyolysis.
Also consideration for post-procedural inflammation in the
setting of stent placement and transaminitis. Should be followed
up as outpatient.
# Type 1 Diabetes:
Patient was managed with fixed dose insulin, lantus, and insulin
sliding scale.
Inconsistent DM management history, last A1c in ___ was 7.0.
The patient estimated pre-prandial insulin based upon
carbohydrate load of meals and proved to be appropriately
estimating his insulin requirements.
# Gastroparesis: Metoclopramide given before meals.
# GERD: Continued Omeprazole and Ranitidine.
TRANSITIONAL ISSUES:
=======================
-Arranged for patient to have biliary stent removal as an
outpatient on ___ at 2:00 ___
-Patient prescribed with limited oxycodone for pain until PCP
follow up
-___ patients abdominal pain symptoms. Consider writing for
ongoing oxycodone if patient has ongoing symptoms as he was
provided with limited oxycodone prescription this
hospitalization.
-Final read of MRCP pending at time of discharge
-recommend close follow for management of diabetes ongoing as
outpatient with PCP and ___
#Code: full
#Communication: ___
Relationship: FATHER
Phone: ___
Other Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO DAILY
2. esomeprazole magnesium 40 mg oral DAILY
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Docusate Sodium 100 mg PO BID
6. Glargine 65 Units Bedtime
7. Acetaminophen ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Glargine 65 Units Bedtime
3. Ranitidine 150 mg PO DAILY
4. Acetaminophen ___ mg PO Q4H:PRN pain
5. esomeprazole magnesium 40 mg oral DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastroparesis
Abdominal Pain
Secondary:
Type 1 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 ___ due to uncontrollable vomiting and
severe abdominal pain. It was felt that this was most likely a
flare of your gastroparesis, potentially caused by elevated
blood sugars. Your pain and nausea were controlled and you were
able to eat regular meals by the time of discharge.
It was recommended that you have your stent removed and this was
arranged to happen on ___ at 2:00 ___ on ___
___ floor. Please do not eat or drink anything after
midnight tonight.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
10620300-DS-12 | 10,620,300 | 25,446,280 | DS | 12 | 2136-01-06 00:00:00 | 2136-01-06 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
nausea, emesis, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with a PMHx of T1DM complicated
by gastroparesis who is presenting with nausea, vomiting, and
abdominal pain. He felt like a flu was coming on 3 days ago,
when he began throwing up bile in the morning, then had an itchy
throat and subjective fever. He had a recent cholecystectomy and
since then he had only thrown up bile in the morning ___ times
until 3 days ago. It has been non-stop for the past several
days.
He states that since his CCY he can consistently taste bile in
his stomach and up his esophagus but he feels "technically
better." His vomiting had decreased after the surgery up until
his ERCP stent got backed up with sludge. After the stent came
out he improved again until his current symptoms began. He feels
like his stomach and esophagus are on fire from bile and
vomiting. It is not a similar pain as when he had gallstones. He
thinks the abdominal tenderness is from throwing up constantly.
He also feels like he is being "crushed with the flu." Some
coughing and body aches. A lot of fatigue. No diarrhea.
He does note that his symptoms are much better when taking a hot
shower.
Past Medical History:
Type 1 DM c/b gastoparesis
GERD
Social History:
___
Family History:
DM1
gallbladder disease (cholecystitis in several relatives)
Physical Exam:
PHYSICAL EXAM on ADMISSION:
Vitals: 98.6, 163/106, 99, 22, 96/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, non-labored breathing
Abdomen: +BS, obese, soft, diffusely tender to light palpation,
non-distended
Ext: WWP, no ___ edema
Neuro: Normal gait, moving all extremities
PHYSICAL EXAM on DISCHARGE:
Vitals: Tm 99.2 BP 130s-140s/80s-90s P ___ R ___
SatO2 96-99/RA
General: Alert, oriented, feeling nauseous
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, reduced breath sounds bilaterally
Abdomen: +BS, obese, soft, non-tender to palpation over all
quadrants, non-distended
Ext: WWP, no ___ edema
Neuro: Normal gait, moving all extremities
Pertinent Results:
LABS on ADMISSION:
___ 04:20PM BLOOD WBC-13.7* RBC-5.02 Hgb-14.1 Hct-43.6
MCV-87 MCH-28.1 MCHC-32.3 RDW-13.9 RDWSD-43.8 Plt ___
___ 04:20PM BLOOD Neuts-82.6* Lymphs-12.8* Monos-3.6*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.29* AbsLymp-1.75
AbsMono-0.49 AbsEos-0.02* AbsBaso-0.04
___ 04:20PM BLOOD Plt ___
___ 04:20PM BLOOD Glucose-151* UreaN-11 Creat-0.7 Na-141
K-4.3 Cl-106 HCO3-21* AnGap-18
___ 04:20PM BLOOD ALT-73* AST-39 AlkPhos-87 TotBili-0.6
___ 04:20PM BLOOD Lipase-15
___ 04:20PM BLOOD Albumin-4.7
___ 08:05AM BLOOD IgM HAV-NEGATIVE
___ 09:50AM BLOOD Calcium-9.6 Phos-3.1# Mg-1.9
PERTINENT STUDIES:
- CT abdomen/pelvis (___):
1. Status post cholecystectomy without evidence of acute
intra-abdominal process. Normal appendix.
2. Colonic diverticulosis without diverticulitis.
- Liver U/S (___):
Status post cholecystectomy without biliary ductal dilatation.
No focal hepatic lesion. Trace perihepatic fluid.
LABS on DISCHARGE:
___ 08:00AM BLOOD WBC-10.4* RBC-4.38* Hgb-12.4* Hct-38.2*
MCV-87 MCH-28.3 MCHC-32.5 RDW-13.5 RDWSD-42.8 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-141
K-3.4 Cl-102 HCO3-25 AnGap-17
___ 08:00AM BLOOD ALT-95* AST-50* LD(LDH)-198 AlkPhos-72
TotBili-1.4
___ 08:00AM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.3 Mg-2.0
Brief Hospital Course:
Mr. ___ has a history of T1DM c/b gastroparesis and
cholecystectomy (___) s/p biliary stent removal (___) who
presents with several days of nausea, vomiting, and abdominal
pain likely due to a gastrointestinal viral illness in the
setting of longstanding gastroparesis.
ACUTE ISSUES:
#Nausea/Vomiting/Abdominal Pain: Unclear etiology, but this has
been a chronic problem and he has already had a CCY ___
biliary stent (removed ___ with only short term relief of his
symptoms. The patient's symptoms most likely due to upper
respiratory viral illness causing nausea and vomiting in the
setting of longstanding history of gastroparesis. LFTs do not
suggest a biliary etiology. CT Abd/pelvis unremarkable, with low
suspicion for obstruction or abscess. Liver U/S was also normal,
with scant perihepatic fluid. Overall on ___ patient has
subsided nausea, no emesis, no abdominal pain on exam. Patient
was NPO while having acute nausea/emesis, and was given IVF
therapy. He was on ondansetron 8 mg IV Q8H:PRN, briefly on
metoclopramide 10 mg IV Q6H; Pantoprazole 40 mg IV Q24H, and
maalox/ Diphenhydramine/ Lidocaine cocktail was given for
symptomatic relief. The patient's symptoms and abdominal pain
resolved with supportive care by day of discharge.
#Flu-like symptoms: Several-day history of viral illness with
myalgias and subjective fevers. Negative for influenza. Complete
resolution of myalgias by day of discharge.
#Leukocytosis: Downtrending 13.7 --> 10.3 --> 11.9 -> 10.4. No
clear source of infection, no suspicion for PNA (normal CXR),
and no abscess noted on abdominal CT. Possibly ___ viral process
or stress reaction. Monitored and trended daily CBC.
CHRONIC ISSUES:
#DM Type I: Continued home glargine 65U QHS, and ISS.
#Marijuana Use: Patient reports marijuana use on weekends.
TRANSITIONAL ISSUES:
- Please follow up with your PCP (see appointment at ___ above).
- Please follow up with your GI doctor, ___, on ___
(see above).
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ranitidine 150 mg PO BID
2. esomeprazole magnesium 40 mg oral DAILY
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Glargine 65 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. esomeprazole magnesium 40 mg oral DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Ranitidine 150 mg PO BID
4. Glargine 65 Units Bedtime
5. other med
patient reports taking domperidone 20 QID at home which he will
continue
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastroenteritis
Secondary:
Gastroparesis
Diabetes Mellitus Type I
S/p cholecystectomy and biliary stent removal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had worsening nausea, vomiting, and abdominal pain,
as well as several days of upper respiratory viral illness
consisting of fevers and itchy throat. You were tested for flu
and found to be negative. While you were hospitalized, we gave
you anti-nausea medications and fluids by IV. Imaging of your
abdomen and liver did not reveal any identifiable signs of
infection. Your symptoms improved and you were deemed safe for
discharge home with outpatient GI follow-up.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10620300-DS-14 | 10,620,300 | 28,225,733 | DS | 14 | 2138-11-13 00:00:00 | 2138-11-13 23:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ginger / Reglan / Compazine
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
Ecdoscopic botox injection
History of Present Illness:
Mr. ___ is a ___ with DM1 c/b gastroparesis managed with
endoscopic botox therapy and Domperidone, prior diagnosis of MJ
induced hyperemesis, GERD, treated H pylori, biliary tract
disease s/p ERCP with prior stenting and CCY, recurrent
bronchitis, vocal cord polyps, who presents with worsening N/V/
and abdominal pain consistent with prior flares of
gastroparesis.
He reports that over the past few weeks he has had greatly
worsening symptoms. He says he has required hospitalization
frequently at ___ and that each time he is
hydrated and given antiemetics along with other supportive care
and is ultimately discharged feeling better. He reports that his
frequent symptoms have prevented him from following up with his
outpatient providers including ___ and ___. He states that he
knows he is overdue for endoscopy and botox injections.
In the ED, vital signs were stable. Laboratory studies
unremarkable. Admission was requested as it was thought he would
require inpatient GI consultation given his multiple recent
hospitalizations and failure to follow up outpatient.
Past Medical History:
Type 1 DM c/b gastoparesis
GERD
Biliary tract disease
Recurrent bronchitis
Vocal cord polyps
S/p CCY with ERCP, papillotomy, stent placement, and removal
Social History:
___
Family History:
Mother and father are healthy. Brother, maternal cousin,
maternal aunt, with Type 1 ___ Mellitus.
Physical Exam:
ADMISSION EXAM:
Gen: initially diaphoretic, still appears uncomfortable,
nauseous
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: Soft, mild diffuse tenderness, non specific, no guarding or
rebound tenderness, no rigidity, BS sluggish. No HSM.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Thought linear.
GU: No foley
DISCHARGE EXAM:
Gen: Lying in bed, unhappy appearing but NAD
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: Soft, mild tenderness in epigastrium without guarding or
rebound tenderness, no rigidity, BS sluggish. No HSM.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Thought linear.
GU: No foley
Pertinent Results:
ADMISSION LABS:
___ 02:05AM GLUCOSE-189* UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
___ 02:05AM ALT(SGPT)-12 AST(SGOT)-13 ALK PHOS-63 TOT
BILI-0.5
___ 02:05AM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-4.6*
MAGNESIUM-2.2
___ 02:05AM LIPASE-15
___ 02:05AM WBC-11.0* RBC-4.80 HGB-13.7 HCT-41.8 MCV-87
MCH-28.5 MCHC-32.8 RDW-14.0 RDWSD-44.8
___ 02:05AM NEUTS-67.4 ___ MONOS-6.4 EOS-1.8
BASOS-0.4 IM ___ AbsNeut-7.41* AbsLymp-2.59 AbsMono-0.70
AbsEos-0.20 AbsBaso-0.04
___ 02:05AM PLT COUNT-285
___ 02:08AM LACTATE-1.7
___ 03:00AM URINE RBC-0 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:00AM URINE HYALINE-3*
OTHER PERTINENT TESTING:
EGD ___:
Normal mucosa in esophagus, stomach and duodenum. Botox
injected into 4 quadrants into the pylorus. Botox injection was
successfully applied for sphincter relaxation.
Brief Hospital Course:
This is a ___ with DM1 c/b gastroparesis previously managed with
endoscopic botox therapy, prior diagnosis of MJ induced
hyperemesis, GERD, treated H pylori, biliary tract disease s/p
ERCP with prior stenting and CCY, recurrent bronchitis, vocal
cord polyps, who presents with worsening N/V and abdominal pain
consistent with flare of gastroparesis.
# Gastroparesis flare
- Symptoms most consistent with gastroparesis flare.
- A CT abdomen was normal, lipase negative, denies recent MJ use
- He was seen by Gastroenterology who recommended an EGD with
boxtox
- He underwent EGD with pyloric botox injections on ___
- He was treated with antiemetics PRN (Zofran and Phenergan)
- Bentyl was added
- Narcotic pain medication were initially given but subsequently
tapered off.
- Patient was counseled on gastroparesis diet and following-up
with GI. Given his good response to botox injections, he may
benefit from a G-POEM procedure as an outpatient.
# GERD: History of GERD with esophagitis.
- He was continued on his home PPI, H2, Carafate
- He was counseled to take the PPI 30 min before meals on an
empty stomach.
# DM1:
- The patient uses lantus and Humalog at home.
- He does carb counting for his ISS.
- While hospitalized with poor PO intake, his nighttime lantus
was decreased to lantus 50 mg qHS (normally on 60 units)
- He will follow-up with Endocrinology for discussion of insulin
pump and further management options
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nexium 40 mg Other DAILY
2. Ondansetron 8 mg PO Q8H:PRN Nausea
3. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Ranitidine 300 mg PO DAILY
5. Promethazine 12.5 mg PR Q6H:PRN Nausea
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Domperidone 10 mg PO QID
Discharge Medications:
1. DICYCLOMine 20 mg PO QID
RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
2. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Domperidone 10 mg PO QID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Nexium 40 mg Other DAILY
6. Ondansetron 8 mg PO Q8H:PRN Nausea
7. Promethazine 12.5 mg PR Q6H:PRN Nausea
8. Ranitidine 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Type1 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented with severe nausea, vomiting and abdominal pain
and were believed to have a flare of your gastroparesis. You
were seen by the gastroenterology team and underwent endoscopic
injection of botox into your stomach muscles. Your diet was
advanced and blood sugars monitored. You slowly improved and we
think are safe to go home today. It will be very important for
you to follow-up with your GI and Endocrinology doctors. We
have scheduled you for follow-up with your primary care doctor.
Please note, while you are recovering and not eating as much as
usual, please take a decreased dose of your home lantus 50 units
each night.
______________________________________________________________
GASTROPARESIS DIET
___ 4 to 5 small meals during the day instead of 2 or 3
big ones.
___ food through the blender before eating it.
___ down on foods that have a lot of fat, such as cheese
and fried foods.
___ down on foods that have a lot of "insoluble" fiber,
such as some fruits, vegetables, and beans.
___ fizzy drinks, like soda, as they can cause more
bloating and gas
___ alcohol and smoking
If you have diabetes, it's also very important to keep your
blood sugar as close to normal as possible.
Followup Instructions:
___
|
10620446-DS-15 | 10,620,446 | 22,371,463 | DS | 15 | 2167-09-12 00:00:00 | 2167-09-12 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Right Neck Swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with history of depression,
presenting to ED from urgent care with r-sided neck swelling in
setting of recent URI. Patient noticed swelling that began day
prior to admission in the morning. Noted that around his R
neck/chin noted swelling increased quickly, and has been stable
the past day. Initially associated with slight sore throat which
has since improved. When he visited urgent care, noted some ear
aches around the swelling, and felt as though voice was muffled.
Additionally, patient notes ___ weeks of URI-type symptoms with
rhinorrhea, congestion, and some sinus fullness/congestion.
Notes initially may have had slightly elevated temperature, but
has not experienced this recently. Has felt increased fatigue.
Notes no trauma to R neck. Has been able to eat/drink,
tolerating secretions with minimal pain. No head/neck stiffness.
No current cough, sore throat, abd pain, nausea, vomiting,
diarrhea. Patient notes being fully immunized. He notes some
testicular discomfort a few weeks ago in setting of not
ejaculating, but no swelling or significant pain, and this
resolved.
In the ED, initial vitals were: 98.2 ___ 18 97% RA
- Exam notable for: unremarkable oropharynx, very mild
tenderness to palpation, R submandibular swelling, no focal
intra-oral swelling, clear lungs, FROM neck
- Labs notable for: Normal BMP, normal CBC (WBC 5.2), normal
lactate
- Imaging was notable for:
US: Prominent right submandibular gland, consider CT to further
assess.
CT: (prelim): Sialoadenitis involving the right submandibular
gland with no associated abscess or visualized sialolith.
- Patient was given: IV clinda, NS, tylenol
Transfer vitals: 98.4 91 134/86 18 100% RA
Upon arrival to the floor, patient reports he still feels some
discomfort from R neck, but has no fevers, throat pain. Does
continue to feel somewhat dry. No dizziness/lightheadedness,
change in vision.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Depression
h/o recurrent HSV outbreaks
h/o syphilis
HLD
h/o scrotal pain
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
=======================
VITAL SIGNS: 97.7 PO 124/79 75 20 96 RA
GENERAL: Patient appears comfortable, in NAD
HEENT: clear OP, no visible swelling intra-orally. No visible
draining. some R sub-mandibular swelling, about 3-4cm, round.
face is somewhat asymmetric. minimal tenderness on palpation of
R submandibular area.
NECK: no cervical lymphadenopathy
CARDIAC: RRR, normal s1 and s2, no additional heart sounds, no
m/g/r
LUNGS: CTAB, no w/c/r
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: BLE wwp, ___
NEUROLOGIC: CN II-XII intact. very mild muffling of his voice
Discharge Physical Exam
=======================
VITAL SIGNS: 97.7 PO 124/79 75 20 96 RA
GENERAL: Patient appears comfortable, in NAD
HEENT: clear OP, no visible swelling intra-orally. No visible
draining. Erythema and minimal swelling of R neck in
submandibular area with mild TTP. No respiratory compromise or
distress.
NECK: no cervical lymphadenopathy
CARDIAC: RRR, normal s1 and s2, no additional heart sounds, no
m/g/r
LUNGS: CTAB, no w/c/r
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: WWP, pulses 2+
NEUROLOGIC: CN II-XII intact.
Pertinent Results:
Admission Labs
===============
___ 01:00PM BLOOD WBC-5.2 RBC-4.92 Hgb-15.3 Hct-43.4 MCV-88
MCH-31.1 MCHC-35.3 RDW-12.9 RDWSD-41.5 Plt ___
___ 01:00PM BLOOD Neuts-75.6* Lymphs-13.8* Monos-9.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.94 AbsLymp-0.72*
AbsMono-0.50 AbsEos-0.01* AbsBaso-0.01
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-106* UreaN-12 Creat-1.0 Na-134
K-4.1 Cl-97 HCO3-22 AnGap-19
___ 01:27PM BLOOD Lactate-1.8
Discharge Labs
==============
___ 01:00PM BLOOD WBC-5.2 RBC-4.92 Hgb-15.3 Hct-43.4 MCV-88
MCH-31.1 MCHC-35.3 RDW-12.9 RDWSD-41.5 Plt ___
___ 01:00PM BLOOD Neuts-75.6* Lymphs-13.8* Monos-9.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.94 AbsLymp-0.72*
AbsMono-0.50 AbsEos-0.01* AbsBaso-0.01
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-106* UreaN-12 Creat-1.0 Na-134
K-4.1 Cl-97 HCO3-22 AnGap-19
___ 01:27PM BLOOD Lactate-1.8
Imaging & Studies
==================
CT neck ___
FINDINGS:
There is asymmetric enlargement of the right submandibular gland
with
overlying fat stranding and thickening of the platysma. Edema
in the
parapharyngeal fat effaces the right piriform sinus, however
there is no
obstruction of the airway. There is no lymphadenopathy. No
sialolith is
appreciated along the course of the submandibular duct.
Tonsilliths are noted
bilaterally. The tonsils are not enlarged. The parotid glands
are normal.
There is moderate mucosal thickening and fluid in the maxillary
sinuses as
well as the anterior ethmoid air cells bilaterally. The mastoid
air cells and
middle ear cavities are clear. There is no periapical lucency
or evidence of
periodontal disease. The vessels of the neck enhance normally
and the
skullbase appears normal. The thyroid gland is homogeneous.
The great
vessels of the aortic arch are unremarkable. The imaged lung
apices are clear
bilaterally.
IMPRESSION:
Sialoadenitis involving the right submandibular gland with no
associated
sialolith.
Parotid U/s ___
FINDINGS:
Transverse and sagittal images were obtained of the superficial
tissues of the
right neck in the region of the right parotid and right
submandibular glands.
The right parotid gland appears normal. There is mild
prominence of the right
submandibular gland. No drainable fluid collection is seen.
IMPRESSION:
Prominent right submandibular gland, consider CT to further
assess.
Microbiology
=============
__________________________________________________________
___ 1:00 pm SEROLOGY/BLOOD
MUMPS IgG ANTIBODY (Pending):
__________________________________________________________
___ 1:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Mumps IgM - pending
Brief Hospital Course:
___ year old male with r-sided neck swelling c/w sialoadenitis
with no abscess or visualized sialolith on CT scan.
# R submandibular sialoadenitis
Patient with swelling for 2 days prior to admission and imaging
c/w sialoadenitis. There was no visible sialolith on imaging,
but may be present d/t viral infection vs decreased PO intact
from viral URI. Potential viruses include ___,
parainfluenza, EBV, FluA. Patient was started on treatement for
bacterial etiolog with clindamycin and then Keflex. Keflex was
transitioned to augmentin prior to d/c due to improved adherence
given less frequent dosing. Patient last had HIV testing in
___, which was negative. Unlikely due to HIV given unilateral
nature, although no current HIV testing. Will plan for 7 day
treatment course of Augmentin followed by apt with patient's PCP
___ ___ extend course for an additional 3 days depending on
clinical improvement. Mumps antibody was still pending. Patient
instructed to avoid public spaces, pregnancy women, and teaching
until mumps ab is reported negative.
# Depression: He was continued on fluoxetine daily.
Transitional Issues
====================
[] Continue augmentin 875/125 for 7 day treatment course ___ -
___. Patient will followup with his PCP ___ ___ for assessment
and consideration of extension of abx course
[] Needs HIV testing as outpatient given last tested in ___ and
infection may be related to HIV infection
[] Mumps IgM/IgG pending at time of discharge. Instructed
patient to not have contact with pregnant women,
immunocompromised individuals or young children until he gets a
call confirming Mumps are negative.
[] Patient should avoid public places, pregnancy women, and
teaching until mumps IgM negative.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 60 mg PO DAILY
2. ValACYclovir 500 mg PO Q12H 3 days, for recurrent HSV
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
2. FLUoxetine 60 mg PO DAILY
3. ValACYclovir 500 mg PO Q12H 3 days, for recurrent HSV
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Right submandibular sialadenitis
Secondary Diagnosis
===================
Depression
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 swelling on
the right side of your neck that was concerning for infection
after recent upper respiratory infection. Given swelling in your
submandibular gland, the emergency room doctors were concerned
about a mumps infection and impingement of your airway so you
were admitted to the hospital.
You were started on antibiotics and you improved quickly. You
will continue taking these antibiotics for 7 days, when you will
follow up with your primary doctor at ___. Please **do
not** return to work or have any contact with pregnant women,
children, or public spaces until you have learned that the mumps
test is negative. You should continue to drink copious fluids.
If you experience any new fevers, difficulty breathing, or neck
pain, you should follow up immediately with your doctor and
return to the hospital.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10620832-DS-12 | 10,620,832 | 28,537,983 | DS | 12 | 2110-12-29 00:00:00 | 2110-12-30 00:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough, chest pressure
Major Surgical or Invasive Procedure:
none this admission
History of Present Illness:
___ w/ type B dissection extending to both iliacs recently
discharged yesterday after undergoing right external iliac
artery stent placement on ___. He states he had a new cough
come on last night around midnight with post-tussive emesis and
some mild hemoptysis. He denies fevers and chills. He did have
some "chest pressure" during these coughing episodes. There was
no dizziness, paresthesias, low urine output or change in bowel
movements during this time.
Past Medical History:
HTN
smoking
Social History:
___
Family History:
Mother and brother living, father died at young age
Physical Exam:
Alert and oriented x 3
VS:98.9 BP 138/64 HR 81 RR 21 SaO2 94% RA
Carotids: 2+, no bruits or JVD
Resp: Lungs with diffuse expiratory crackles bilaterally, worse
right middle lung field
Abd: Soft, non tender
Ext: Pulses:
Left Femoral palpable, DP palpable, ___ palpable
Right Femoral palpable, DP palapble, ___ palapable
Feet warm, well perfused. No open areas
Incisions c/d/i
Groin puncture site: Dressing clean dry and intact. Soft, no
hematoma or ecchymosis
Pertinent Results:
___ 07:00AM BLOOD WBC-13.0* RBC-3.70* Hgb-11.8* Hct-35.5*
MCV-96 MCH-31.9 MCHC-33.3 RDW-13.1 Plt ___
___ 10:30AM BLOOD WBC-15.8* RBC-3.85* Hgb-12.3* Hct-36.6*
MCV-95 MCH-31.9 MCHC-33.5 RDW-13.0 Plt ___
___ 06:04AM BLOOD WBC-17.4* RBC-3.62* Hgb-11.6* Hct-34.5*
MCV-95 MCH-32.1* MCHC-33.6 RDW-13.1 Plt ___
___ 06:15AM BLOOD WBC-14.2* RBC-3.51* Hgb-11.4* Hct-33.8*
MCV-96 MCH-32.4* MCHC-33.7 RDW-13.3 Plt ___
___ 10:30AM BLOOD Neuts-88.9* Lymphs-5.5* Monos-4.3 Eos-1.1
Baso-0.1
CTA chest ___
IMPRESSION:
1. Diffuse bilateral opacities with air bronchograms compatible
with multi
focal pneumonia.
2. Small bilateral pleural effusions.
3. Re- demonstration of known type B dissection with extension
into the left subclavian artery.
4. No pulmonary embolism allowing for suboptimal bolus
contrast.
Brief Hospital Course:
Mr. ___ was admitted with cough and shortness of breath s/p
right external iliac stent ___ for type B aortic dissection.
On CTA his dissection was visible, extending into the left
subclavian artery, and he was found to have multifocal pneumonia
and small bilateral pleural effusions, likely nosocomial
pneumonia. Antibiotic therapy was initiated with intravenous
vancomycin and cefepime for empiric treatment. Sputum cultures
were not obtained. He was afebrile. WBC was elevated to 15.8
on admission and peaked at 17.4 on HOD2. ECG was within normal
limits, negative for any acute process or changes. BP was
within normal limits. Respiratory therapy provided nebulizer
treatments and patient was encouraged to use IS. Prior to
discharge to home, vancomycin and cefepime were discontinued,
and levaquin PO was initiated. SaO2 was stable, >90% on RA.
For discharge planning, Mr. ___ met with ___, LICSW,
who helped patient devise a plan for obtaining financial
counseling, appropriate medical insurance coverage, and primary
care provider. The patient has follow-up already scheduled with
Dr. ___ surgeon at ___. He was
discharged to home in good condition, tolerating a regular diet,
with prescriptions for nicotine patch and antitussive, and he
will complete a 7 day course of levaquin as an outpatient.
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___ mg PO DAILY:PRN CONSTIPATION
4. Clopidogrel 75 mg PO DAILY
5. Fluconazole 200 mg PO ___ Duration: 3 Doses
6. Labetalol 800 mg PO TID
7. Losartan Potassium 50 mg PO BID
8. HydrALAzine 75 mg PO Q6H
9. Phenoxybenzamine HCl 20 mg PO BID
10. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___ mg PO DAILY:PRN CONSTIPATION
4. Clopidogrel 75 mg PO DAILY
5. Fluconazole 200 mg PO ___ Duration: 3 Doses
6. Labetalol 800 mg PO TID
7. Losartan Potassium 50 mg PO BID
8. HydrALAzine 75 mg PO Q6H
9. Phenoxybenzamine HCl 20 mg PO BID
10. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply transdermal qday
Disp #*21 Patch Refills:*2
11. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin [Cheratussin AC] 100 mg-10 mg/5 mL ___
ml by mouth every six (6) hours Refills:*1
12. Docusate Sodium 100 mg PO BID
13. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
health care associated pneumonia
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted with pneumonia following a recent hospital
stay. You have been given antibiotics and are now deemed stable
for discharge home with oral antibiotics.
Followup Instructions:
___
|
10620832-DS-13 | 10,620,832 | 22,090,317 | DS | 13 | 2111-01-17 00:00:00 | 2111-01-18 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
In brief, Mr. ___ is a ___ y/o male with a past medical history
of HTN, type B aortic dissection in both iliacs s/p right
external iliac artery stent placement (___) and multifocal
pneumonia (___) treated with vanc/cefepime and
transitioned to levofloxacin who presented to the ED on ___ with
dyspnea, hypoxia and tachypnea. At this time, he presented to
his PCP with ___ complain of worsening dyspnea, SOB and cough with
sats in the mid ___. He was placed on a NRB and then on CPAP
with improvement in his oxygenation. Received NTG spray x1 and
paste x 1 inch. He was ultimately transferred to ___ for
further management. Of note, at this PCP visit he was going to
be evaluated for an adrenal mass concerning for pheochromocytoma
given poor controlled hypertension, aortic dissection, and
incidental finding of adrenal mass. Interestingly, in his
admission from ___ for a type B aortic dissection, the
patient had urine metnephrines elevated at 3600.
In the ED, VS on arrival were T 98.0, HR 24, BP 125/71, 93% 15L
CPAP. CXR showed worsening multifocal opacities suggesting
pneumonia in addition to increased right side pleural effusion.
CTA was performed and showed an increased in consolidative
airspace opacities, no pulmonary emboli, and evidence of
bilateral pleural effusions. Patient was evaluated by vascular
and per report the dissection appeared stable.
On arrival to the MICU, T 98.6, HR 76, BP 135/85, HR 96, RR 21,
97% FiO2 80% CPAP PEEP 5. Patient appeared comfortable, was
speaking in full sentences and was not using accessory muscles.
At admission, treated with antibiotic for suspected pneumonia on
CPAP. Patient decompensated that prompt intubation with
subsequent bronchoscopy. On blood work elevation of WBC and
eosinophilia. Evaluation for eosinophilia negative for HIV, high
suspicion of strogyloides (results pending) with administration
of one dose ivermectin. Bronchoscopy and BAL with no DAH and
positive for eosinophils. Started with steroids for suspected
eosinophilic pneumonitis. Stable at MICU and extubated 3 days
ago with normal SaO2 at rest, improving respiratory status with
SaO2 of 88% prior to transfer to medical floor. Endocrinology
was consulted given his incidental finding in CT of adrenal mass
+ positive metanephrine, negative renal doppler done suggesting
pheocromocytoma. An MRI w/o contrast of adrenal glands was
ordered (pending result) to assess adrenal mass prior to
consider a surgical approach. Management of his pheocromocytoma
has been done primarily with alpha blockade with
phenoxybenzamine started at 20 increased to 30 BID and beta
blocker with labetalol decreased slowly from 800 to 600 mg with
a BP goal of 140. Per vascular consult during his MICU admission
echo showed mildly dilated thoracic aorta; EF 60-65%; mild
symmetric LVH.
On transfer to the floor, patient presents with productive cough
"spells" lasting approximately 30 seconds to 1 minute with clear
mucous secretions, similar cough "spells" in MICU. Patient on
oxygen 4 lts with no signs of respiratory distress, no use of
accesory muscles. Denies SOB or chest pain. No nausea, vomiting
or epigastric pain. No chills or clammy skin.
Of note, today the patient went for an evaluation regarding an
adrenal mass. Given poorly controlled hypertension, arotic
dissection, and adrenal mass there was concern for
pheochromocytoma. Due to the patient's acute illness a thorough
evaluation was not performed in clinic; however per our records,
patient has urine metnephrines during last admission which were
elevated.
Review of systems: in addition to the above, patient endorses
chest pain that occurs with cough but not with exertion,
shortness of breath, cough with sputum production. Denies
abdominal pain, dysuria, diarrhea, nausea or vomiting.
Past Medical History:
HTN
type B aortic dissection b/l iliacs s/p right external iliac
artery stent ___
multifocal pneumonia ___
Social History:
___
Family History:
Mother and brother living, father died at young age
Physical Exam:
=============================================================
PHYSICAL EXAM AT ADMISSION
=============================================================
Vitals- T 98.6, HR 76, BP 135/85, HR 96, RR 21, 97% FiO2 80%
CPAP PEEP 5
GENERAL: Alert, oriented, able to speak in full sentences, no
accessory muscle use
HEENT: EOMI, sclera anicteric, MMM, tongue midline
NECK: supple, unable to appreciate JVD due to neck size
LUNGS: Clear anteriorly, bibasilar crackles laterally, no
wheezes or rhonchi
CV: distant heart sounds, normal S1 and S2, regular, no MRG
ABD: soft, non-tender, non-distended, bowel sounds present,
obese
EXT: Warm, well perfused, ___ pulses, no clubbing, cyanosis; 1+
peripheral edema bilateraly to shins
NEURO: CNII-XII grossly intact, moving arms/legs spontaneously,
sensation intact to soft touch
=============================================================
PHYSICAL EXAM AT DISCHARGE
=============================================================
Vitals- VS - T:98 BP:125/80 P:88 R:18 SaO2:95%RA and
90-93% on deambulation.
GENERAL: Alert, oriented, able to speak in full sentences, no
accessory muscle use
HEENT: EOMI, sclera anicteric, MMM, tongue midline
NECK: supple, unable to appreciate JVD due to neck size
LUNGS: Clear anteriorly, bibasilar crackles laterally, no
wheezes or rhonchi
CV: distant heart sounds, normal S1 and S2, regular, no MRG
ABD: soft, non-tender, non-distended, bowel sounds present,
obese
EXT: Warm, well perfused, ___ pulses, no clubbing, cyanosis; 1+
peripheral edema bilateraly to shins
NEURO: CNII-XII grossly intact, moving arms/legs spontaneously,
sensation intact to soft touch
Pertinent Results:
=============================================================
AT ADMISSION
=============================================================
___ 05:27PM BLOOD WBC-19.4* RBC-3.60* Hgb-11.4* Hct-32.4*
MCV-90 MCH-31.8 MCHC-35.4* RDW-12.7 Plt ___
___ 05:27PM BLOOD Neuts-86.5* Lymphs-5.4* Monos-3.7
Eos-4.2* Baso-0.2
___ 05:27PM BLOOD ___ PTT-31.8 ___
___ 08:45PM BLOOD ESR-96*
___ 05:27PM BLOOD Glucose-128* UreaN-14 Creat-0.9 Na-118*
K-6.7* Cl-89* HCO3-20* AnGap-16
___ 12:42AM BLOOD Glucose-138* UreaN-12 Creat-0.9 Na-130*
K-4.7 Cl-95* HCO3-25 AnGap-15
___ 05:27PM BLOOD cTropnT-<0.01
___ 12:42AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0
___ 11:50AM BLOOD ANCA-NEGATIVE B
___ 11:50AM BLOOD ___
___ 04:42AM BLOOD HIV Ab-NEGATIVE
___ 01:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:33AM BLOOD IGE-negative
___ Anti-GBM - negative
___ 04:33AM BLOOD IGE-Test
___ 04:42AM BLOOD Plt ___
___ 04:42AM BLOOD Glucose-107* UreaN-20 Creat-0.8 Na-136
K-4.6 Cl-98 HCO3-32 AnGap-11
___ 04:42AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.1
___ 02:28AM BLOOD WBC-13.4* RBC-3.55* Hgb-10.9* Hct-33.0*
MCV-93 MCH-30.7 MCHC-33.0 RDW-12.7 Plt ___
___ 02:28AM BLOOD Glucose-112* UreaN-23* Creat-0.9 Na-137
K-4.5 Cl-95* HCO3-30 AnGap-17
___ 02:28AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1
___ 07:45AM BLOOD Glucose-118* UreaN-17 Creat-0.9 Na-138
K-4.4 Cl-97 HCO3-30 AnGap-15
___ 07:45AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1
___ 07:45AM BLOOD WBC-12.5* RBC-3.62* Hgb-11.1* Hct-33.8*
MCV-93 MCH-30.7 MCHC-32.9 RDW-13.0 Plt ___
___ 07:29AM BLOOD Glucose-106* UreaN-19 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-26 AnGap-15
___ 07:29AM BLOOD estGFR-Using this
___ 07:29AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.9
CT CHEST/ABDOMEN
1. No evidence of large central or segmental pulmonary
embolism.
2. Unchanged appearance of a type B aortic dissection.
3. Interval increased bilateral consolidative airspace
opacities suggesting
worsening multifocal pneumonia.
4. Moderate right and small left pleural effusions, increased
in size as
compared to the prior examination.
5. Status post right internal iliac artery stent placement
without evidence
of occlusion.
6. 1.9 cm left adrenal nodule. Further evaluation can be
performed with
adrenal protocol CT or MRI to characterize further or
alternatively six month
follow-up examination is suggested for surveillance.
TTE
The left atrium is elongated. The right atrium is moderately
dilated. 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 with normal
cavity size and regional/global systolic function (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic arch is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mildly dilated thoracic aorta. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Suggestion of elevated left ventricular
filling pressure
RENAL US
Normal renal ultrasound and normal renal Doppler study.
CHEST XRAY ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have
further
decreased. The extent of the bilateral parenchymal opacities has
slightly
increased. Moderate cardiomegaly with mild pulmonary edema
persists in almost
unchanged manner.
CHEST XRAY ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have
increased,
likely reflecting improved ventilation of the lung parenchyma.
However, the
bilateral parenchymal pre-existing opacities are still clearly
visualized and
are overall, not substantially changed as compared to the
previous image. No
new opacities. No pleural effusions. Borderline size of the
cardiac
silhouette without pulmonary edema.
MRI w/o CONTRAST ___
IMPRESSION:
2.4cm left adrenal nodule consistent with adenoma. No
concerning features.
Aortic dissection, not fully evaluated on this examination but
grossly
unchanged from recent CTAs.
=============================================================
AT DISCHARGE
=============================================================
___ 07:10AM BLOOD WBC-16.8* RBC-3.92* Hgb-12.1* Hct-36.7*
MCV-94 MCH-30.8 MCHC-32.9 RDW-13.2 Plt ___
___ 07:10AM BLOOD Glucose-123* UreaN-17 Creat-1.0 Na-140
K-4.4 Cl-100 HCO3-26 AnGap-18
___ 07:10AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a past medical history of HTN,
type B aortic dissection in both iliacs s/p right external iliac
artery stent placement (___) who presented to the ED on
___ with dyspnea and hypoxia and was diagnosed with acute
eosinophilic pneumonia. Hospital course is outlined below by
problem:
# Hypoxemic respiratory failure ___ acute eosinophilic
pneumonia: His presentation was initially concerning for HCAP v.
pulmonary edema, however CT imaging revealed a more atypical
process concerning for a vasculitis v. DAH v. acute interstitial
pneumonia. Patient was initially maintained on CPAP however
underwent intubation for bronchoscopy. He was placed on
vanc/cefepime empirically and received diuretics as he looked
volume overloaded on exam. Bronch studies revealed an
eosinophilia and in the setting of a peripheral eosinophilia,
the patient was diagnosed with acute eosinophilic pneumonia.
Antibiotics were discontinued and steroids were started. HIV
antibody was negative. Patient received a dose of ivermectin
while his strongy antibody was pending. Strongy antibody
negative, no need for second dose of ivermectin in 2 weeks.
Patient was successfully extubated and improved from an
oxygenation standpoint while in the ICU. He was transferred to
the floor on 4L NC. In the floor patient was succesfully weaned
of oxygen with ___ of 95% RA and between 90-93% while walking.
# Concern for pheochromocytoma: Patient was recently admitted
for an aortic dissection and workup revealed elevated urine
metanephrines and an incidental adrenal mass. At that time,
patient was discharged on 5 antihypertensives. Endocrinology was
consulted during this hospitalization and recommended obtaining
an MRI adrenal protocol which showed a 2.4cm left adrenal nodule
consistent with adenoma. Endocrinology also recommended a iodine
in urine given history of CT scan w/ contrast that could render
a false positive result if a MIGB scan needed in the future.
Endocrinology suggested that initial chemical evaluation of pheo
could be confounded by the use of medications that patient was
previously on including phenoxybenzamine, labetalol and
amlodipine. Other causes that could cause increase levels of
metanephrines includes stress produced by recent history of
aortic dissection.
# Hypertension: Patient was maintained on 5 antihypertensives.
Blood pressure was closely monitored, with a goal SBP <140 in
the setting of his recent dissection. Patient became
hypertensive during intubation and extubation, ultimately
requiring additional prn antihypertensives and nitroglycerin
gtt. Otherwise, his blood pressure was well controlled. Patient
at admission to the floor was on phenoxybenzamine started BID on
___ and increased to TID on ___, switch again to BID as
suggested by endocrinology. Patient's goal for hypertensive
control is a SBP <120 with either ACEI or ARBs that do not
caused false positive results in both plasma and urine
metanephrines. As discussed with endocrinology the patient will
need to be monitor closely and once his BP goal is reached, a
repeated level of metanephrines will be needed.
CHRONIC ISSUES:
# Type II dissection extending to b/l illiac s/p stent placement
___. At admission, vascular consulted. CT scan showed unchanged
appearance of type B aortic dissection extending into the L
subclavian artery and inferiorly through the bilateral iliac
arteries, s/p right internal iliac artery stent w/o evidence of
occlusion. On Echo Mildly dilated thoracic aorta; EF 60-65%;
mild symmetric LVH, suggestion of elevated LV filling pressure;
similar to prior. Aspirin and plavix continued per vascular
recommendations.
TRANSITIONAL ISSUES
- consider further testing for MEN syndrome
- patient needs f/u with vascular surgery after discharge at ___.
___ with Dr. ___
- ___ up with pulmonary for eosinophilic pneumonitis.
- Chest Xray 2 weeks after discharge.
- close monitoring of BP and alternative anti-hypertensive
regimen prior to new metanephrine test.
-- Preferably clonidine, ACEI or ARBs since labetalol, sotalol,
phenoxybenzamine can cause a falsely elevated levels of
metanephrines in plasma and urine.
--Blood pressure goal <120.
- Follow up with endocrinology for suspected pheocromocytoma.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___ mg PO DAILY:PRN CONSTIPATION
4. Clopidogrel 75 mg PO DAILY
5. Fluconazole 200 mg PO ___
6. Labetalol 800 mg PO TID
7. Losartan Potassium 50 mg PO BID
8. HydrALAzine 75 mg PO Q6H
9. Nicotine Patch 14 mg TD DAILY
10. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
11. Docusate Sodium 100 mg PO BID
12. Phenoxybenzamine HCl 20 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. HydrALAzine 75 mg PO Q6H
RX *hydralazine 25 mg 3 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
4. Labetalol 600 mg PO TID
RX *labetalol 300 mg 2 tablet(s) by mouth three times a day Disp
#*60 Tablet Refills:*1
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
RX *albuterol 2 puff four times a day Disp #*1 Inhaler
Refills:*0
9. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
10. Calcium Carbonate 500 mg PO DAILY
Take this medication with ___ hour interval with pantoprazole.
RX *calcium carbonate [Calci-Mix] 500 mg calcium (1,250 mg) 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*20
Tablet Refills:*0
12. Phenoxybenzamine HCl 30 mg PO BID
RX *phenoxybenzamine [Dibenzyline] 10 mg 3 capsule(s) by mouth
once a day Disp #*60 Capsule Refills:*0
13. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
14. Ipratropium Bromide MDI 2 PUFF IH QID
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 puff
four times a day Disp #*1 Inhaler Refills:*0
15. Outpatient Lab Work
Please have a Chem7 (Na, K, Cl, HC30, BUN, Cr and glucose)
checked by ___ and have results faxed to Dr ___ Dr
___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
* Eosinophilic pneumonitis
* Adrenal mass, suspected pheochromocytoma
* Hypertension
* s/p type II aortic dissection extending to b/l illiac s/p
stent placement ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure taking care at your recent admission at
___. You were admitted on
___ after experiencing difficulty breathing and cough
after a recent admission for pneumonia from ___. Your
oxygen delivery was innapropiate despite oxygen therapy. To
manage your breathing and maintain an adequate respiratory
status, your were admitted to the MICU (medium intensive care
unit). In the MICU you were intubated and at the same time we
were able to take samples of your airway that showed eosinophils
(a specific type of cell). At the same time, a chest Xray from
your chest was performed showing opacities and liquid in the
right side of your chest suggesting pneumonia that was suggested
to be eosinophilic pneumonitis. The causes for this type of
pneumonia are still unclear. You started the treatment with
steroids that help your respiratory status and progressively you
were weaned of the ventilator and started to breath by yourself.
You will need to maintain the steroids (prednisone) at least 2
weeks after your discharge. Steroids can cause several side
effects including increased appetite and glucose levels, loss of
bone mass and prompt you to infections. For this reason, you
will need to take vitamin D and calcium to prevent bone loss and
bactrim to prevent infections. You will continue with your
inhalers as prescribed in the hospital. You will follow with
pulmonology in 2 weeks. Prior to your consult you will need to
have a repeated chest X ray to check your progress.
One day prior to your admission, you were seen by the vascular
service to follow up on your aortic dissection and stent. Since
you presented with shortness of breath, we performed tests to
confirm that your aortic dissection was not the caused for your
symptoms. An ECHO and EKG were non revealing for any vascular
compromised. Given your history of aortic dissection, poorly
controlled hypertension and adrenal mass the diagnosis of
pheocromocytoma (adrenal mass that produce a hormone that
controls blood pressure) was suspected. On further evaluation
with an MRI the adrenal mass was consistent with adrenal
adenoma. Endocrinology has participate in your care and you will
need to follow up with Dr. ___ at ___
___. Your aortic dissection and stent will need to be
closely follow by vascular and you will need to continue on
aspirin and plavix.
Your uncontrolled hypertension will need to be closely follow by
your PCP, ___. In the meantime, you will continue
to take 4 medications to control your blood pressure.
Sincerely,
Your inpatient team.
Followup Instructions:
___
|
10620882-DS-18 | 10,620,882 | 20,746,007 | DS | 18 | 2155-07-19 00:00:00 | 2155-07-20 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
throat pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a lovely ___ year old gentleman recently diagnosed with
Stage ___ SCC (per patient felt to have ~90% chance of
cure) now s/p chemo (cisplatin ___, and planned
___ and recent XRT who is presenting with worsening throat
pain failing outpatient narcotics.
He and his wife explain that he been having a very difficult
time in general over the last few weeks as he has been
completing his XRT. His most recent and final treatment was this
past ___ (they are stopping a cycle short due to his side
effects). Across this time his throat pain has gotten
progressively worse. He had previously been able to control his
pain (at least to a greater degree) with a combination of
fentanyl patches and roxicet. Last week, however, he developed a
diffuse rash which they were concerned was due to his roxicet.
As a result of this they stopped his roxicet and increased his
fentanyl patch from 1 to 2 patches (25mcg). They also started
him on standing ibuprofen. Neither of these have managed to
effectively control his pain however. Earlier today he had a few
particularly severe episodes of throat pain and coughing one of
which was followed by vomiting. No preceding nausea. He and his
wife noticed a small amount of blood during this episode
although they are unsure if it was in his sputem or emesis. They
estimate that the total amount of blood was less than one
teaspoon and they only noticed this once. His wife called the
covering oncology resident who requested that he come in to the
ED for evaluation.
The throat pain is closely accompanied by frequent coughing with
thick clear secretions which have been worsening over the last
few weeks. He has beens tarted on guiafenasin and more recently
home suctioning for his secretions. He describes the pain and
coughing as coming together in waves but it is not clear which
comes on first (ie, the pain does not only start after the
coughing). The coughing has at times been followed by brief
episodes of vomiting. He explains that during his chemotherapy
he was nauseated and vomiting frequently but now he is not
nauseated and only occasionally vomiting in the setting of
severe coughing spells.
Over the last few days he has also noticed some night sweats and
intermittent feeling of shakiness (not specifically chills)
which he thinks might be due to having stopped the Roxicet. No
actual fevers prior to presentation (Tmax at home was 99.0). He
has also noticed some increased twitchiness in his legs and
sometimes arms over the past few days which he also feels is
related to going off of the roxicet. No witnessed sustained
shaking or jerking movements and no LOC, tongue biting or
incontinence. Other than his worsening throat pain and cough he
has had no other focal signs of infection. He has no shortness
of breath. He denies any dysuria or change in the color or odor
of his urine. He notes increased urinary frequency only in the
setting of aggressive IV hydration at the outpatient ___
clinic.
Of note he also had a PEG tube placed recently to bridge him
through his pain and difficulty swallowing post XRT. He was not
tolerating the tube feeds well however they recently started him
on a pump which he feels is working better. He has also been
coming in to the outpatient ___ clinic several times a week
for IV hydration. He has no irritation or pain around the site
of his PEG tube. He has no other focal pain.
As for the rash, it started last week and has spread over most
but not all of his body (legs from the knees to thighs, entire
torso, some on arms but sparing palms). It was previously very
itchy but is less so now. It is not specifically painful. They
have been treating it with benadryl as well as loratadine and it
has remained stable over the last few days.
Of note contrary to prior notes he and his wife do not have any
current or recent concerns about him being over-sedated from his
pain medications; they are much more concerned with adequately
controlling his symptoms.
In the ED initial VS were 100.7 113 130/72 15 98%. He was given
tylenol, nebulized and topical lidocaine, ketorolac and
morphine. A UA was borderline and so he was started on
ceftriaxone. Labs were notable for a WBC of 1.5 with 73%
neutrophils. He is being admitted for pain management,
management of his secretions, and completion of his infectious
workup.
Past Medical History:
PAST MEDICAL HISTORY
squamous cell cancer of the tonsil
s/p vasectomy
Social History:
___
Family History:
FAMILY HISTORY:
There is history of head and neck cancer on his maternal side
with a grandfather and another person with larynx cancer. A
maternal aunt had bone cancer.
Physical Exam:
ADMISSION EXAM:
VS: 99.1 118/71 81 16 96/ra Pain ___
GENERAL: fit-appearing gentleman in obvious discomfort,
intermittently coughing with thick clearish secretions
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, oropharynx
diffusely erythematous, no evidence of bleeding, I do not
appreciate any clear evidence of thrush on his exam at the
moment
NECK: supple
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, PEG tube site without evidence of infection or
drainage
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE EXAM:
GENERAL: fit-appearing gentleman, coughing with thick clearish
secretions
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, oropharynx
diffusely erythematous, no evidence of bleeding, I do not
appreciate any clear evidence of thrush on his exam at the
moment
NECK: supple
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, PEG tube site without evidence of infection or
drainage
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
ADMISSION LABS:
___ 10:10PM BLOOD WBC-1.5* RBC-2.93* Hgb-8.9* Hct-26.3*
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.4 Plt ___
___ 10:10PM BLOOD Neuts-73* Bands-2 Lymphs-9* Monos-12*
Eos-1 Baso-0 Atyps-3* ___ Myelos-0
___ 10:10PM BLOOD ___ PTT-28.1 ___
___ 08:47AM BLOOD ___ ___
___ 08:47AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.5*
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-3.6*# RBC-2.87* Hgb-9.1* Hct-26.8*
MCV-93 MCH-31.6 MCHC-33.8 RDW-15.0 Plt ___
___ 07:40AM BLOOD Neuts-82.1* Lymphs-9.9* Monos-5.6 Eos-2.1
Baso-0.3
___ 07:40AM BLOOD ___ ___
___ 07:40AM BLOOD Glucose-97 UreaN-22* Creat-0.8 Na-143
K-3.8 Cl-104 HCO3-30 AnGap-13
___ 07:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.4*
Brief Hospital Course:
___ with stage ___ SCC s/p chemo and recent XRT
presenting with worsening throat pain, cough, and secretions.
# Throat Pain: Likely due to mucositis in the setting of recent
chemo exacerbated by tissue damage from his XRT. No thrush
appreciated on exam. He recently completed a course of nystatin
oral suspension. He and his wife are interested in further
exploring the possibility of him starting on methadone however
we agreed that we would postpone such a decision until we had
the chance to discuss the plan and expected duration of his
symptoms further with his primary oncologist. Patient was
managed with fentanyl patch 50mcg/hr + dilaudid for breakthrough
pain. He was discharged per his outpt oncologists request with
fentanyl 75mcg/hr with dilaudid breakthrough.
# Febrile neutropenia: Patient neutropenic given ANC of 728 and
downtrending. He was febrile in the ED to 100.7 and reporting
night sweats and possible chills for the last few days as well
as low-grade fevers noted at his clinic visits. He remains
normotensive, has a normal lactate, is mentating well, making
excellent urine and appears nontoxic on exam. He was started on
ceftriaxone (___) in the ED for a possible UTI and was
discharged on ciprofloxacin to complete a ___espite
an unimpressive UA and negative cultures.
# Hemoptysis: He had a single episode of hemoptysis vs
hematemesis with a small (< 1 teaspoon) amount of blood earlier
today in the setting of a severe coughing spell. His hematocrit
is 26.3 in the setting of recent chemotherapy. This is most
likely mucosal ___ his radiation therapy and not otherwise
significant however we will continue to monitor this closely. We
will also type and cross him in case he requires a transfusion.
He has a mildly elevated INR (1.2) in the setting of poor
nutrition. His platelets are normal.
# Secretions: He presents with several weeks or worsening thick
clearish secretions without evidence of a PNA on CXR or exam. I
suspect these secretions are due to his mucositis and XRT and
not to an underlying infection. He continued to have clear
secretions throughout his admission.
# Tube Feeding: Patient takes neutrin 2.0 at home, and was
transitioned to two cal HN while in the hospital. He was
discharged on his home nutrition regimen.
# SCC: Stage ___ SCC of the tonsil now s/p chemo and XRT.
-primary oncologist is dr. ___ saw the pt on ___,
primary management for his SCC is deferred to the outpatient
provider.
TRANSITIONAL ISSUES:
-he will need his narcotic regimen re-titrated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 10 mg PO Q8H:PRN nauisea
2. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
3. diphenhydrAMINE HCl *NF* ___ ml Oral Q8H:PRN allergy
4. Fentanyl Patch 50 mcg/h TP Q72H
2x 25 mcg patches
5. Cetirizine *NF* 10 mg Oral daily
6. ___ *NF* 200-25-400-40 mg/30 mL
Mucous Membrane Q4H:PRN pain
one tablespoon by mouth 10 - 15 minutes before meals and at
bedtime as needed for sore throat, pain with swallow may use up
to 6 ___ daily
7. Ibuprofen Suspension 200-400 mg PO Q8H:PRN pain
Discharge Medications:
1. Cetirizine *NF* 10 mg Oral daily
2. Fentanyl Patch 75 mcg/h TP Q72H
3x 25 mcg patches
3. ___ *NF* 200-25-400-40 mg/30 mL
Mucous Membrane Q4H:PRN pain
one tablespoon by mouth 10 - 15 minutes before meals and at
bedtime as needed for sore throat, pain with swallow may use up
to 6 ___ daily
4. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
5. Aquaphor Ointment 1 Appl TP QID:PRN xrt burn
RX *white petrolatum [Aquaphor with Natural Healing] 41 % apply
to skin three times a day Disp #*1 Unit Refills:*0
6. Guaifenesin 10 mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 10 ml by mouth q6 Disp #*200
Milliliter Refills:*0
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H pain
8. diphenhydrAMINE HCl *NF* ___ ml Oral Q8H:PRN allergy
9. Prochlorperazine 10 mg PO Q8H:PRN nauisea
10. Ibuprofen Suspension 200-400 mg PO Q8H:PRN pain
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin [Cipro] 500 mg/5 mL 5 ml by mouth twice a day
Disp ___ Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Stage ___ SCC
Mucositis
UTI
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 mouth pain caused by mucositis.
We started a pain medication called hydromorphone. You should
continue to take this via your PEG tube as needed. You should
also continue to take your numbing mouthwash for your mucous
pain. It was unclear whether you had a urinary infection,
however we gave you antibiotics and you should continue them for
4 more days. Please follow up with your outpatient providers.
Followup Instructions:
___
|
10621049-DS-15 | 10,621,049 | 25,587,644 | DS | 15 | 2130-01-03 00:00:00 | 2130-01-04 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status; dypnea
Major Surgical or Invasive Procedure:
___: Intubation
___: Extubation
History of Present Illness:
___ w/ h/o Pickwickian syndrome, OSA, gout and HTN transferred
from ___ for hypercarbic respiratory failure. The patient
was in her usual state of health until this morning, when her
brother noticed that she was sleepier than normal. At that time
he placed her on her home nasal cannula with improvement in her
oxygen saturations into the ___. However, she continued to be
somnolent and altered and was then transferred to ___.
She presented to OSH with altered mental status, was found to be
hypercapnic with ABG with pH 7.2, CO2 107, O2 76, CO3 44. She
was started on BiPAP with significant improvement in her
mentation. CXR revealed ? infiltrate, so pt was given CTX.
Trop was negative. Due to lack of ICU beds at ___, pt was
transferred to ___. Of note, pt has history of hypercarbic
respiratory failure in past requiring intubation (last document
occurance in ___. Per review ___ records, baseline
pCO2 is ___.
On arrival to ___ ED, initial vitals: HR 104 BP 132/68 O2 91%
on BiPAP. Pt denied chest pain, recent fever, cough, or any
additional symptoms. States she has been complaint with her
medications. Pt's ABG continued to improve while on BiPAP in
the ED. EKG showed deep T-wave inversions in both inferior leads
and V1-5 (per ___ ___ d/c summary: in the inferior leads
the patient has some T-wave inversions which are unchanged from
prior.) Pt was also given azithro for CAP coverage and admitted
to the ICU for hypercarbic respiratory failure and CAP requiring
BiPAP.
On arrival to the MICU, vitals: T 98.3, HR 91, BP 127/73, RR 19,
O2 93% on BiPAP FiO2 100%. Pt was placed on NC O2 shortly after
arrival and was doing well, mentating clearly. ABG was obtained
about 45 minutes after weaning from BiPAP, which found pH 7.22,
pCO2 118, pO2 83, HCO3 51. Due to worsening hypercapnia and
increased somnolence, pt was placed back on BiPAP.
Past Medical History:
Obesity hypoventilation syndrome
Obstructive sleep apnea
Hypertension
dCHF
Gout
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PE:
Vitals- T: 100.9 BP: 127/73 P: 91 R: 19 O2: 93% on BiPAP
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Quiet breath sounds, Clear to auscultation, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no visible ecchymoses or wounds
NEURO: alert and oriented to person, location, month/year
DISCHARGE PE:
Vitals: Tc:97.7 Tm:99.1 HR:82(71-100) BP:101/55(101/55-132/75)
RR:18 O2:91 on 3L
I/O: Incontinent; Weight:87.9<-88.4kg<-88.9kg (standing)
General: Elderly female sitting up in bed in NAD; appears to be
breathing more comfortably; occasional cough with secretions
requiring self-suction; Able to speak in full sentences
HEENT: MMM; OP clear
Lymph: Thick neck; unable to appreciate LAD
CV: S1S2 RRR; no appreciable murmurs or rubs
Lungs: Improved air flow, with scattered crackles.
Abdomen: Soft, nondistended, nontender, +BS, reducible ventral
hernia
Ext: no lower extremity edema, extremities warm to touch
Neuro: Alert and oriented x 3; Thought process organized; Moving
all four extremities with purpose
Pertinent Results:
ADMISSION LABS:
___ 10:20PM BLOOD WBC-8.5 RBC-5.39# Hgb-16.5*# Hct-52.3*#
MCV-97# MCH-30.6 MCHC-31.5 RDW-16.3* Plt ___
___ 10:20PM BLOOD Neuts-76.1* Lymphs-14.0* Monos-7.5
Eos-2.2 Baso-0.3
___ 10:20PM BLOOD Plt ___
___ 10:20PM BLOOD Glucose-113* UreaN-25* Creat-0.7 Na-142
K-5.6* Cl-97 HCO3-36* AnGap-15
___ 10:20PM BLOOD CK(CPK)-54
___ 05:16AM BLOOD cTropnT-<0.01 ___
___ 05:16AM BLOOD Calcium-8.8 Phos-4.5# Mg-2.1
___ 05:16AM BLOOD Triglyc-90
___ 10:36PM BLOOD ___ pO2-41* pCO2-119* pH-7.22*
calTCO2-51* Base XS-14 Intubat-NOT INTUBA Comment-O2 DELIVER
___ 10:36PM BLOOD Lactate-1.9
___ 10:36PM BLOOD O2 Sat-68
___ 11:30PM BLOOD freeCa-1.19
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-6.3 RBC-5.54* Hgb-15.5 Hct-51.2*
MCV-93 MCH-28.0 MCHC-30.3* RDW-15.3 Plt ___
___ 06:00AM BLOOD Glucose-116* UreaN-23* Creat-0.6 Na-140
K-3.7 Cl-89* HCO3-45* AnGap-10
___ 06:00AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.9
STUDIES/IMAGING:
ECHO (___):
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with Valsalva maneuver. The estimated right atrial pressure is
___ mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with hypokinesis of the mid
to apical free wall. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.
IMPRESSION: Dilated right ventricle with mild hypokinesis of the
mid-distal free wall and mild pulmonary hypertension. Mild
symmetric left ventricular hypertrophy with normal
global/regional systolic function.
CXR (___):
As compared to the previous radiograph, the patient has been
extubated and the nasogastric tube was removed. Moderate to
severe cardiomegaly as well as moderate pulmonary edema persists
in almost unchanged manner. No pleural effusions. Moderate
retrocardiac atelectasis. No evidence of pneumonia.
CXR (___):
Moderate to severe cardiomegaly, tortuous aorta and enlarged
pulmonary
arteries are unchanged. ET tube is in standard position. NG tube
tip is out of view below the diaphragm. Mild interstitial edema
is stable. There is no pneumothorax or large effusions
ECG (___):
Sinus rhythm. Right bundle-branch block. Right axis deviation.
Prolonged Q-T interval. Anterior myocardial infarction of
indeterminate age. Marked diffuse T wave inversion. Compared to
the previous tracing of ___ multiple abnormalities as
previously described persist without major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 ___ 64 95 -34
MICROBIOLOGY:
___ 09:13AM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
___ 4:19 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
___ 4:19 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:23 pm BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:40 pm BLOOD CULTURE Source: Venipuncture #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:55 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 10:20 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ yo F w/ h/o obesity hypoventilation syndrome, OSA, prior
episodes of respiratory failure requiring intubation, p/w
altered mental status, hypoxemic and hypercarbic respiratory
failure requiring intubation found to be Flu positive.
# Hypoxia - Pt presenting hypoxic to the ___ on RA with
hypercarbic respiratory failure as outlined below. CXR with a
possible focal consolidation, with moderate pulmonary edema. Pt
received CTX/Azithro for presumed CAP (finished ___.
Influenza PCR positive. Required intubation on ___ for one day,
and then improved with BiPap at night. Multiple factors
contributing to hypoxia including restrictive component to her
respiratory status from obesity, and hypoxia worsened with
influenza and fluid overload. ECG and current Echo consistent
with right heart strain likely from pulmonary hypertension. No
tachycardia to suggest PE. TTE demonstrated that she did not
have a shunt. She was diuresed throughout her hospitalization
for fluid overload with lasix 40mg IV boluses, and satted well
on 3L NC and BiPap at night. On discharge she was transitioned
with 80mg po BID for continued diuresis, and plan for
pulmonology follow-up.
# Acute hypercarbic respiratory failure and hypoxemia: Pt with
known restrictive lung disease secondary to habitus as well as
inciting event from influenza. This admission required
intubation for somnolence and hypercarbic respiratory failure
with pCO2 as high as 129. Also started on CTX/Azithromycin for
presumed CAP (Last Dose ___ for 5 day course). Monitored ABGs.
Patient was volume overloaded on exam so given 40mg IV lasix
boluses during ICU admission as well as on the floor. Patient
tolerated extubation without difficult, however had a persistent
night time BiPAP requirement. Sleep consult was placed and BiPap
settings were titrated. An attempt was made at conducting a
sleep study to titrate the pressures required, however the
patient was unable to tolerate trilolgy mask throughout the
night. She was tolerating bilevel ventilation. She will follow
up as an outpatient in the sleep clinic as outlined below. The
patient was discharged to rehab on furosemide 80mg po BID and
labs should be checked on ___ to evaluate renal function.
Weight at discharge:87.9kg down from 97kg on presentation.
# Metabolic encephalopathy secondary to acute hypercarbic
respiratory failure- mental status cleared after intubation and
reduction in CO2. Somnolence associated with higher CO2 levels.
With improved mental status, the patient's HCO3 remained in the
___, which is likely her baseline.
# Influenza: Pt found to have positive influenza PCR, likely
trigger for hypercarbic respiratory failure as above. Was given
oseltamavir for a few doses, although likely started therapy >48
hours of onset. Saline nebs were given to help mobilize her
secretions as well as fluticasone nasal spray to help with nasal
congestion.
# Diastolic CHF- pt on daily lasix 40mg po daily at home.
Reports compliance with home medications. Given fluid overload
as outlined above, the patient was bolused with lasix 40mg IV
BID. Transitioned to lasix 80mg po BID with continued diuresis.
TTE demonstrates preserved EF with ventricular hypertrophy.
# ECG changes- pt with document TWIs in inferior leads per ___
note, however TWIs in V1-5 are new, but of unknown acuity/onset.
First trop negative. Pt w/o complaints of CP, dyspnea, ___
pain, nausea. ECG most consistent with pulmonary hypertension
and increased right heart strain. No evidence of ACS throughout
admission.
CHRONIC ISSUES:
# Morbid obesity- likely contributing to pt's poor respiratory
status as above. Pt should follow-up with PCP as restrictive
process from obesity may be contributing to her respiratory
status.
# Gout - Stable during admission and continued on home
allopurinol
# Hyperglycemia - Pt with no reported history in our system of
diabetes. Her sugars were persistently elevated blood sugars
during hospitalization and possibly carries the diagnosis of
diabetes mellitus. She was continued on insulin sliding scale
during hospitalization with sugars ranging from ___.
***TRANSITIONAL ISSUES***
-After release from rehab, the patient should call ___ Home
Care at ___ to set up BiPAP (an order will be placed
with them). The patient should then call ___ and ask to
speak with ___ to have her booked with Sleep Medicine.
-BiPap Settings:
Auto Bilevel
max IPAP 18
min EPAP 8
max PS 8
(If only set bilevel is used, please use ___
- Pt should follow up with Dr. ___ from pulmonology as
listed above
- Please weight the patient daily
- Acetazolamide was held on admission as it was unclear this was
helping her respiratory status
- Continue to take furosemide 80mg po BID and monitor BUN/Cre
every 3 days. (Next draw on ___ Decrease furosemide once
Cre>0.6.
- Pt may benefit from PFTs as outpatient
- Please check A1c >3 months after acute hospitalization for
diabetic screening.
- Code: Full
- Contact: Brother ___ ___,
___.
- Weight on discharge: 87.9kg (admission weight 97kg)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Klor-Con 10 (potassium chloride) 10 mEq oral daily
3. Furosemide 40 mg PO DAILY
4. AcetaZOLamide 125 mg PO Q24H
5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral Daily
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Furosemide 80 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze/sob
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU BID
7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheeze
8. Ipratropium-Albuterol Neb 1 NEB NEB Q1H:PRN wheeze/sob
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 8.6 mg PO BID constipation
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral Daily
12. Klor-Con 10 (potassium chloride) 10 mEq ORAL DAILY
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Influenza pneumonia
Secondary Diagnosis: Exacerbation of diastolic congestive heart
failure; obstructive sleep apnea; obesity hypoventilation
syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you were found to be very confused and somnolent at
home. On presentation you were found to have influenza, and you
were transferred to the ICU for your persistent confusion. In
the ICU you required a breathing tube for one day to help with
your breathing. You were also treated with a medication called
oseltamavir for your influenza. Your mental status improved so
the breathing tube was removed. Your confusion was caused from
not being able to breath well at home. This was likely due to a
combination of having influenza, obstructive sleep apnea, and
having extra fluid on your body. You were placed on a BiPap at
night which helped your breathing and confusion. You were also
placed on oxygen during the day. We gave you IV furosemide to
help get rid of the extra fluid, which was transitioned to oral
medication prior to your discharge.
Please continue to take furosemide 80mg twice per day to help
keep fluid out of your lungs. You should continue to take this
medication until you follow-up with your outside providers.
During your hospitalization you were evaluated by physical
therapy, and it was felt that you would benefit from rehab.
Please make an appointment with the pulmonologist Dr. ___
___ as listed below. Your primary care would like you to
follow with him for further work-up of your respiratory issues.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10621125-DS-20 | 10,621,125 | 21,451,546 | DS | 20 | 2181-05-06 00:00:00 | 2181-05-12 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cymbalta / Prednisone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ history of postherpetic neuralgia presented
to outside hospital after receiving sudden onset of left sided
abdominal pain at 4 am. The pain is localized to the dermatomal
T8-T10 region and is similar in character to previous
exacerbations of postherpetic neuralgia. She took 2 oxyodone
without relief x 2, following this she presented to ___
___. The patient is s/p ablation of dorsal root ganglia for
post-herpetic neuralgia ___. At the OSH, she received
dilaudid with improvement in pain. There was concern for
complication from this procedure, so patient transfered to ___
for MRI.
The patient also c/o exertional shortness of breath ongoing
since ___ and unchanged. OSH CXR was unrevealing.
.
In the ED, initial vitals pain 6 Temp 98 70 140/60 18 97%. Labs
notable for WBC 24 with diff of 92% PMN's, lactate 2.7. UTI with
RBC 4, WBC 9, few bacteria, nitrite positive. Blood cultures and
urine cultures pending. She received Cipro 250mg po x 1 at 6pm.
The pt underwent a CT which showed no changes to explain acute
abdominal pain. She received dilaudid x1, 1L NS up and hanging@
150cc/hr.
Vitals prior to transfer: BP 114/60 HR 77 RR 18 T98.
.
Currently, More comfortable with ___ pain.
.
ROS: denies fever, chills, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Post-herpetic neuralgia x ___ (w/ chronic abd pain T9-T10
distribution on the left side s/p x-lap at ___)
----Radiofrequency Neurotomy - Left T8 and T9 Dorsal Root
Ganglia
Hypothyroidism
Hypertension
s/p appendectomy
s/p oopherectomy & hysterectomy
s/p bladder suspension
CAD - patient reports having MI in ___ underwent PTCA
at ___ in ___
thyroid surgery ___ years ago
Anxiety in past
depression (documented passive SI on previous records, refused
psych referral)
Social History:
___
Family History:
Significant for heart disease. Son died at ___ from MI, another
son with ___ lymphoma (but in remission). Father died
from MI, mother died from brain cancer.
Physical Exam:
Admission Physical:
VS - Temp 99.6F, BP 144/64 , HR 66 , R 18, O2-sat 96% RA 165lbs/
74.84kg
GENERAL - Well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, pupils small, EOMI, sclera anicteric, MMM, OP
clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air mvmt, resp a little
labored, hunched over
HEART - RRR, no MRG, nl S1 S2
ABDOMEN - NABS, distended at baseline, NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, some actinic keratosis
LYMPH - no cervical LAD
NEURO - awake, A&O x 3, CN II-XII intact, muscle strength ___
throughout, sensation grossly intact throughout, vibration sense
intact in lower extremities, DTRS 2+ and symmetric, cerebellar
exam intact, steady gait
Discharge Physical:
VS - Tm 99.6 Tc 98.7 BP 138/62 HR 60 RR18 97%
GENERAL - Well-appearing woman in a large amount of pain,
appropriate
HEENT - NC/AT, pupils small, sclera anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air mvmt, resp a little
labored, hunched over
HEART - tachy RR, no MRG, nl S1 S2
ABDOMEN - NABS, distended at baseline, NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, some actinic keratosis
LYMPH - no cervical LAD
NEURO - awake, A&O x 3, CN II-XII grossly intact, steady gait
Pertinent Results:
Admission Labs:
___ 01:08PM BLOOD WBC-24.0*# RBC-3.75* Hgb-12.0 Hct-38.5
MCV-103*# MCH-32.1* MCHC-31.3# RDW-13.2 Plt ___
___ 01:08PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.3 Eos-0.1
Baso-0.1
___ 01:08PM BLOOD Glucose-119* UreaN-18 Creat-0.9 Na-141
K-4.3 Cl-104 HCO3-24 AnGap-17
___ 07:45AM BLOOD Calcium-9.5 Phos-2.5* Mg-2.0
Discharge Labs:
___ 07:45AM BLOOD WBC-13.0* RBC-3.65* Hgb-11.8* Hct-36.8
MCV-101* MCH-32.4* MCHC-32.2 RDW-13.3 Plt ___
___ 07:45AM BLOOD Glucose-82 UreaN-22* Creat-0.9 Na-142
K-3.6 Cl-103 HCO3-27 AnGap-16
___ 07:45AM BLOOD Calcium-9.5 Phos-2.5* Mg-2.0
Pertinent Labs
___ 07:45AM BLOOD VitB12-514 Folate-6.6
___ 01:15PM BLOOD Lactate-2.7*
___ 3:00 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Studies:
CTAP ___:
IMPRESSION:
1. No acute abdominal process or bowel pathology.
2. Mild intrahepatic biliary dilation, stable since ___.
Brief Hospital Course:
Ms. ___ is an ___ year old F with history of chronic post
herpetic neuralgia with pain management treatment and depression
who presented from ___ with ___ L abdominal pain.
.
# L sided abdominal pain:
Patient's symptoms most consistent with flare of postherpetic
neuralgia. There was initially concern for hemorrhagic
complication from ablation of dorsal root ganglia performed the
day prior to admission, however, CT abdomen and pelvis
unremarkable. She reports that she does get an exacerbation of
her pain following RFA but then later has some improvement. The
patient was treated with prn oxycodone and her dose of
gabapentin was increased. The patient was discharged with follow
up to her PCP and instructed to call the pain management clinic
for an urgent follow up appointment.
.
# leukocytosis:
WBC of 24 on admission, improved to 13 on day of discharge.
Patient had dexamethasone injection on ___, so could be
secondary to steroids. Patient was also found to have a UTI with
pansensitive E.coli. She was treated with one dose of
ciprofloxacin in the ED. The patient declined further treatment
as she was asymptomatic.
.
# anemia:
Borderline anemia with Hgb 12 Hct 38.5 and macrocytosis. B12 and
folate were WNL.
Medications on Admission:
Docusate Sodium 100 mg PO BID
Metoprolol Tartrate 12.5 mg PO/NG BID
Gabapentin 300 mg PO/NG QID
Levothyroxine Sodium 100 mcg PO/NG DAILY
Aspirin 81 mg PO/NG DAILY
Lactulose 30 mL PO/NG EVERY 5 days
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
Isosorbide mononitrate 10mg po daily?
Discharge Medications:
1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q5mins as needed for chest pain: if pain continues,
call your doctor or 911.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO EVERY
OTHER DAY (Every Other Day): as directed.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day): do NOT take this medication while doing heavy
activity as this can cause sedation.
Disp:*180 Capsule(s)* Refills:*0*
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. oxycodone 10 mg Tablet Sig: One (1) Tablet PO five times a
day as needed for pain: do NOT take this while doing heavy
activity as this can cause sedation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Postherpectic neuralgia
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you this admission. You were
admitted for severe abdominal pain, similar to your postherpteic
neuralgia. We treated you with some IV pain medications and you
got some relief. We think it would be most helpful to increase
your dose of gabapentin, as this medication works well for your
type of pain. We are quite concerned that your pain is so
severe. Please follow up with the pain doctors as ___ as
possible. Please call the pain clinic and ask for an emergency
appointment with Dr ___.
You also may have had a urinary tract infection. You were
started on antibiotics in the emergency department, and the
urine culture showed E. coli, though the antibiotic
sensitivities were not yet back. We offered you treatment for
the UTI which you politely declined. Should you experience
symptoms of pain with urination, incontinence, or blood in your
urine, please contact your doctor or go to the emergency room.
The following medications were changed:
- INCREASE the dose of Gabapentin to 600mg three times daily
-We were unclear what dose of isosorbide you were taking. Please
confirm this with your primary care doctor at your appointment
tomorrow.
Please continue the other medications you were taking prior to
this admission.
Followup Instructions:
___
|
10621393-DS-20 | 10,621,393 | 24,873,752 | DS | 20 | 2120-01-20 00:00:00 | 2120-01-20 18:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine
Attending: ___
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
___: Trans-esophageal echocardiogram
___: ___ guided axillary lymph node core biopsy
History of Present Illness:
___ yo male with a PMH of HTN, CHF, severe TR, CKD, Cirrhosis
(presumed due to R-sided HF, has not seen GI yet), a-fib
(Coumadin) who presents with fatigue/FTT and hyponatremia.
The patient has been declining lately. His family notes a slow
decline starting after ___, following by a more sudden
decline since ___. He has been progressively more weak
fatigued. Now he is having difficulty walking ___ fatigue and
weakness. Found to be hyponatremic today at 124 (130 on ___
at ___'s office, and was sent for eval.
He has dyspnea on exertion but not at rest. He has low back
pain. Per his daughter, he has had fevers (as high as 102),
chills, and night sweats - but none of these ___ the past week.
Blood cultures were sent by PCP as outpatient and no growth,
fungal cultures as well an no growth to date. When asked about
weight loss, the family is unsure as providers have been
actively titrating diuretics to attempt to lose weight/edema.
Of note, PCP has been extensively working up a number of
symptoms and problems as an outpatient. Would recommend
reviewing Atrius chart for full details. These include (1)
adenopathy (noted on CT done at ___ during a
hospitalization), anemia/thrombocytopenia (recent bone marrow
biopsy with equivocal results), (3) CHF/Tricuspid Regurg and
volume status, (4) cirrhosis (based on imaging findings,
presumed due to R Heart Failure), and (5) fever/chills/night
sweats. Of note, ESR was 138 on ___, and CRP was 16.7 ___ ___lso of note, plan was for outpatient PET scan to better
eval the adenopathy.
At PCP visit today, family weas concerned about missing his
scheduled evaluations (PET ___ and TEE ___ but the PCP
reassured them that these studies could happen as an inpatient.
___ the ED, initial vitals were: 97.4, HR 82, BP 107/59, RR 18,
96% RA
Labs showed: Na
Imaging showed:
- CT Head no abnormality
- CXR mild interstitial pulm edema
Received: 500cc NS
Past Medical History:
HTN
T2DM
Atrial fibrillation on coumadin
CAD
Thrombocytopenia/Anemia
Severe TR
dCHF
? Cirrhosis
Surg Hx:
L Carotid endarterectomy
___: Lymphoproliferative disorder
___: Staph Aureus Pneumonia
Tonsillectomy
R Inguinal hernia repair
Social History:
___
Family History:
Reviewed and non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
Vital Signs: 97.6, 108/75, HR 105, RR 18, 96 RA
General: Alert, chronically ill appearing, pleasant
HEENT: Sclerae anicteric, MMM
NECK: Supple, no adenopathy
CV: Irregular, no murmur
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, NTND
GU: No foley
Ext: Warm, well perfused, 1+ ___ edema
Neuro: CNII-XII intact grossly
DISCHARGE PHYSICAL EXAM
======================
Pertinent Results:
ADMISSION LABS
=============
___ 10:47PM BLOOD WBC-7.6 RBC-3.27* Hgb-10.1* Hct-30.7*
MCV-94 MCH-30.9 MCHC-32.9 RDW-17.7* RDWSD-57.5* Plt ___
___ 10:47PM BLOOD Neuts-78* Bands-1 Lymphs-5* Monos-6 Eos-5
Baso-0 Atyps-5* ___ Myelos-0 AbsNeut-6.00 AbsLymp-0.76*
AbsMono-0.46 AbsEos-0.38 AbsBaso-0.00*
___ 11:33PM BLOOD ___ PTT-36.1 ___
___ 10:47PM BLOOD Glucose-152* UreaN-35* Creat-1.6* Na-127*
K-4.8 Cl-89* HCO3-22 AnGap-21*
___ 10:47PM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.9* Mg-2.3
Iron-82
___ 10:47PM BLOOD ALT-12 AST-22 LD(LDH)-317* CK(CPK)-40*
AlkPhos-59 TotBili-1.7*
DISCHARGE LABS
=============
CARDIOLOGY LABS
==============
___ 10:47PM BLOOD cTropnT-<0.01 proBNP-5368*
___ 07:23PM BLOOD CK-MB-<1 cTropnT-<0.01
ANEMIA EVALUATION
================
___ 10:47PM BLOOD calTIBC-248* Ferritn-143 TRF-191*
___ 10:47PM BLOOD Iron-82
___ 10:47PM BLOOD Ret Aut-4.1* Abs Ret-0.13*
TSH
===
___ 05:23AM BLOOD TSH-1.8
CORTISOL
========
___ 05:23AM BLOOD Cortsol-20.3*
URINE STUDIES
============
___ 05:56AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:56AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:56AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 05:56AM URINE CastHy-7*
___ 05:56AM URINE Hours-RANDOM UreaN-520 Creat-113 Na-<20
___ 05:56AM URINE Osmolal-354
___ 12:47
HISTOPLASMA ANTIGEN
Test Result Reference
Range/Units
HISTOPLASMA GALACTOMANNAN <0.5 ng/mL
MICROBIOLOGY
============
___: BLOOD CULTURE X 2: NO GROWTH (FINAL)
___ 11:08 am SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
___ 2:07 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
IMAGING
======
___: CT HEAD WITHOUT CONTRAST
IMPRESSION:
1. No acute intracranial abnormality.
2. Involutional changes.
3. Mild degenerative changes of the left temporomandibular
joint.
___: CHEST X-RAY PA AND LATERAL
IMPRESSION:
Mild interstitial pulmonary edema.
___: FDG TUMOR IMAGING (PET SCAN)
IMPRESSION: 1. Extensive FDG-avid cervical, intrathoracic,
abdominal and pelvic lymphadenopathy, consistent with
lymphoproliferative disorder (SUVmax 14.9, D5). 2. Bilateral
inguinal lymph nodes measure 20 mm on the right, and 15 mm on
the left. 3. Enlarged spleen with diffusely increased tracer
uptake, compatible with splenic involvement. 4. Moderate right,
and small left pleural effusion. 5. Small volume ascites.
___: TRANSESOPHAGEAL ECHOCARDIOGRAM
The left atrium is dilated. Mild spontaneous echo contrast is
seen ___ the body of the left atrium and left aztrial appendage.
No mass/thrombus is seen ___ the left atrium or left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No spontaneous echo contrast or
mass/thrombus is seen ___ the right atrium or right atrial
appendage. The right atrial appendage ejection velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). There is considerable beat-to-beat
variability of the left ventricular ejection fraction due to an
irregular rhythm. The right ventricular cavity is dilated with
depressed free wall contractility. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] There are simple atheroma ___ the
aortic arch and descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. Mild
to moderate (___) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve. No
mitral valve abscess is seen. Mild (1+) mitral regurgitation is
seen. There is no abscess of the tricuspid valve. Severe [4+]
tricuspid regurgitation is seen. On 3D echocardiography, the
tricuspid leaflets do not appear to fully coapt. The estimated
pulmonary artery systolic pressure is normal. ___ the setting of
at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
UNDERestimated due to a very high right atrial pressure.] No
vegetation/mass is seen on the pulmonic valve. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe tricuspid regurgitation ___ the setting of
incomplete tricuspid leaflet coaptation and a dilated right
ventricle with depressed free wall contractility. Normal left
ventricular systolic function. Mild to moderate mitral
regurgitation. Mild aortic regurgitation.
___: CHEST X-RAY (PORTABLE AP)
IMPRESSION: Hypoinflated lungs with minimal interval improvement
___ mild perihilar interstitial pulmonary edema since ___.
___: CHEST X-RAY (PA AND LATERAL)
IMPRESSION:
___ comparison with the study of ___, there are continued
low lung volumes. There is increasing pulmonary edema with
worsening bilateral pleural effusions with underlying
compressive atelectasis at the bases. No definite evidence of
acute focal pneumonia, though this could be obscured by the
extensive pulmonary changes on plain radiography. .
Brief Hospital Course:
___ with a h/o PMH of HTN, CHF, severe TR, CKD, Cirrhosis
(presumed due to R-sided HF), a-fib (Coumadin), and possible
lymphoproliferative disorder (bone marrow biopsy performed as
outpatient) who presents with fatigue, FTT, and hyponatremia.
# Fatigue Secondary to Lymphoproliferative Disorder: Patient was
evaluated for lymphoproliferative disorder as an outpatient. He
initially had a CT Abdomen and Pelvis at ___ which showed
lymphadenopathy. He subsequently underwent a bone marrow biopsy
on ___ which showed "hypercellular bone marrow for age with an
abnormal interstitial and paratrabecular infiltrate concerning
for the involvement of a lymphoproliferative disorder."
When patient was admitted, ___ Oncology was contacted. They
recommended PET scan as an inpatient. PET scan performed and
showed "extensive FDG-avid cervical, intrathoracic, abdominal
and pelvic lymphadenopathy, consistent with lymphoproliferative
disorder...Enlarged spleen with diffusely increased tracer
uptake, compatible with splenic involvement."
To evaluate the underlying lymphoproliferative process,
Interventional Radiology was consulted who performed a core
biopsy of right axillary lymph node. Results of the biopsy
showed "atypical populations of T cells: CD3(+)/CD5(+)/CD2dim
cells with CD4 predominance and expanded population of
double-negative (CD4-, CD8-) cells AND CD3(-)/CD2(+)/CD5(+)
cells with CD4 predominance". Pathology felt that the diagnostic
yield of an ___ tact lymph node would be greater, so the patient
was taken by ___ for an excisional biopsy of an axillary lymph
node. Initial results were concerning for T-cell lymphoma, but
additional molecular studies are needed to make a diagnosis.
Given the anticipated results and the patient's significant
burden of comorbid conditions, ___ Oncology recommended not
pursuing aggressive treatment. After discussing the situation
with the primary team, oncology and palliative care, the patient
and his family decided that the best option was to be
transferred home on hospice.
# Staphylococcus Aureus Pneumonia: During hospitalization,
patient was noted to have a cough. He was initially treated with
doxycycline, which was transitioned to vancomycin. When sputum
culture grew MSSA, he was transitioned to nafcillin and
completed a 1 week course. He remained afebrile with stable
oxygen saturation and improvement ___ his chest X-ray for several
days after discontinuation of antibiotics, but continued to have
a productive cough.
# ___: Creatinine rose after attempts to diurese more
aggressively, likely secondary to ATN. Diuretics were held for
several days and creatinine improved.
# Right Heart Failure/Severe Tricuspid Regurgitation: Patient
has a history of severe tricuspid regurgitation complicated by
cirrhosis likely secondary to right sided heart failure. During
hospitalization, patient underwent a TEE to evaluate the
structure of the tricuspid valve. Results showed "severe
tricuspid regurgitation ___ the setting of incomplete tricuspid
leaflet coaptation and a dilated right ventricle with depressed
free wall contractility." ___ Cardiology was involved ___ the
care who contact the Interventional Cardiologist about possible
tricuspid valve clip. Decision was made not to intervene on the
tricuspid valve. The patient was stabilized on a regimen of
torsemide 10md daily. Given ___, his atenolol was discontinued
and metoprolol was started.
# Hyponatremia: On admission Na was 127. Urine Na was <20. As
patient had decreased PO intake prior to admission ands as
continuing with torsemdide 40 mg PO daily, there was concern
that patient was hypovolemic. Diuretics were initially held and
patient was encourage to take ___ PO's. Throughout
hospitalization diuretic regimen was managed as below ___
"Chronic Diastolic Heart Failure."
# Atrial Fibrillation: He was rate controlled initially with
atenolol 25 mg PO daily. This was changed to metoprolol ___ the
setting of ___. Anticoagulation was achieved with warfarin
during hospitalization.
# Hyperlipidemia: Continued simvastatin 5 mg PO QPM.
# Cirrhosis: Thought to be from right-sided heart failure ___ the
setting of severe tricuspid regurgitation. He will benefit from
outpatient management of cirrhosis with Hepatology for variceal
screening.
TRANSITIONAL ISSUES
=================
#Transferred home on hospice
#Axillary lymph node biopsy final pathology pending at the time
of discharge
#Discharging on warfarin per patient request. Re-address
discontinuation with patient once settled ___ at home
#DNR/DNI
#Contact Information: ___ (Daughter/HCP): ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 40 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Simvastatin 5 mg PO QPM
4. Potassium Chloride 20 mEq PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Warfarin 3.75 mg PO 5X/WEEK (___)
7. Warfarin 5 mg PO 2X/WEEK (MO,TH)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
3. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*3
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN throat pain.
5. Docusate Sodium 100 mg PO BID
6. GuaiFENesin ___ mL PO Q6H:PRN cough
7. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth pain
RX *lidocaine HCl [Lidocaine Viscous] 2 % apply to painful areas
___ mouth three times a day Refills:*0
8. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*3
9. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth three times a day
Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
12. Torsemide 10 mg PO DAILY
RX *torsemide [Demadex] 10 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*3
13. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
-Lymphoproliferative process
-Severe tricuspid regurgitation
-Hyponatremia
SECONDARY DIAGNOSIS
==================
-Atrial fibrillation
-Diastolic Heart Failure
-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 ___ due to
fatigue. You were previously being worked up for a possible
lymphoma as an outpatient. During this hospitalization, you
underwent a PET scan which showed areas of concern for lymphoma.
You were also found to have pneumonia and improved with a week
long course of IV antibiotics. You underwent a biopsy of one of
the lymph nodes which revealed a likely lymphoma. The final
diagnosis was still pending at the time of discharge. The
oncologist felt that there would not be any worthwhile treatment
options from any of the diagnoses we might expect. After
considering this, talking with our palliative care team and
discussing matters with your family, you elected to go home on
hospice. Dr. ___ ___ ___ will be ___ touch with
you when the final results of your biopsy return. It was a
pleasure taking care of you.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10621477-DS-11 | 10,621,477 | 29,516,080 | DS | 11 | 2181-06-05 00:00:00 | 2181-06-05 22:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Aleve / Morphine / Ranitidine / Paxil
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of ___ disease, OA, GERD presenting to
the ED following syncopal episode while having a bowel movement.
The pt states that she was sitting on the toilet earlier today
and had some lower abdominal pain. She was straining trying to
have a BM as she has chronic constipation and passed out. The pt
denies preceding cp, sob, palipiations. She awoke to her
daughter pressing on her chest attempting chest compressions. Of
note, she had a similar episode a few months ago when she also
syncopized while having a BM. At the time she was found to have
some hematochezia and sigmoidoscopy demonstrated ischemic
colitis.
In the ED, initial vital signs were 98.2 62 133/59 18 98%. Exam
was notable for benign abdomen and unremarkable cardiopulmonary
examination. CXR showed no acute process. Patient was given 1L
NS. On attempted transfer vitals are: 97.4 72 218/97 18 97%. The
pt was given lopressor 5mg IV x1, metop tartrate 25mg PO x1, and
oxycodone-acetaminophen 1tab PO x1 with improvement of bp to
161/79.
On the floor, VS 98.3 ___. Pt was given
metoprolol 25mg PO x1 (home dose 50mg PO BID) with improvement
to 160/62. The pt denies any symptoms currently, no
lightheadedness, dizziness, cp, sob, palpitations. She denies
blood in her stool or black stools. SHe does endorse
constipation for which she takes colace prn (but has not been
taking it) and straining. She says she tries to drink a lot of
water but never seems to drink enough. She endorses only L
muskuloskeletal chest pain at the site of chest compression.
Denies current ab pain.
Past Medical History:
-___ disease, on sinemet
-GERD
-HLD
-HTN
-B/l total hip replacements
-OA
-Incontinent of urine
-Right total knee replacement
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission PE:
Vitals- 98.3 ___
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, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- non focal.
MSK: L chest mild TTP
Discharge PE:
Vitals: T97.6 ___ overnight. HR range ___. BP
229/73 HR 67 RR18 97-99RA
General: elderly woman, NAD
HEENT: EOMI, clear oropharynx
Lungs: CTAB, no rales, rhonchi or wheezes
Cardiovascular: No bruises, TTP lateral to L breast, RRR w/o
m/r/g
Abdomen: soft, non tender, non distended BS present no HSM
GU: no CVAT
Extremities: warm, 2+ pulses, no c/c/e
Neuro: alert, oriented, strength ___ bilat, ___ intact and
equal bilat.
Pertinent Results:
Admission labs:
___ 01:00PM WBC-7.1 RBC-4.11* HGB-12.9 HCT-39.9 MCV-97
MCH-31.3 MCHC-32.3 RDW-12.8
___ 01:00PM NEUTS-68.9 ___ MONOS-5.7 EOS-1.2
BASOS-0.6
___ 01:00PM PLT COUNT-190
___ 01:00PM ___ PTT-36.2 ___
___ 01:00PM GLUCOSE-113* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13
___ 01:04PM LACTATE-1.2
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:30PM URINE COLOR-Straw APPEAR-Clear SP ___
EKG: sinus bradycardia without q waves, or ST changes.
CXR: No acute cardiopulm process
Brief Hospital Course:
___ yo F with a history of ___ disease presenting with
syncopal event.
# Syncope- Consistent with vasovagal event as patient was
strainging prior to syncopizing. She was monitored on telemetry
and had no events, EKG was at baseline, and patient was not
orthostatic. Patient encouraged to monitor BPs closely at home,
increase laxative use to ensure soft bowel movements and to
avoid straining with bowel movements.
# Hypertension- BP elevated on arrival to ED and next morning
despite home regimen of losartan 50mg daily and metoprolol
tartrate 50mg BID. With IV medications, patient's pressures
dropped sharply from >200 systolics, to 140s. Losartan was
changed to twice daily dosing (25mg BID) to avoid the high blood
pressures, and hopefully therefore prevent the sharp drops. She
was discharged with ___ to assist in blood pressure monitoring
and appropriate medication dosing.
# Goals of care- Patient expressed wish to be DNR/DNI during
this admission. On further discussion, family, including HCP,
acknowledged patient's wishes and code status was changed.
Family was assisted in completeing HCP paperwork as they had
misplaced their prior copy.
# Transitional issues-
- ___ for assistance with BP monitoring and medications
- ___ evaluated patient and felt she would benefit from home ___
to assist with stability
- losartan changed from 50mg daily to 25mg BID
- patient now DNR/DNI per her wishes, family in agreement
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Losartan Potassium 50 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Simvastatin 20 mg PO DAILY
5. Carbidopa-Levodopa (___) 1.5 TAB PO TID
6. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Metoprolol Tartrate 50 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Carbidopa-Levodopa (___) 1.5 TAB PO TID
5. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Losartan Potassium 50 mg PO DAILY
Take 25mg in morning, and 25mg at night.
RX *losartan 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Simvastatin 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*30 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Vasovagal syncope
Hypertension
Secondary diagnosis:
___ disease
Discharge Condition:
Stable, alert and oriented, ambulating.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___
___. You were brought into the hospital for losing
consciousness while in the bathroom at home. This is likely due
to straining while you were on the toilet and poor blood
pressure regulation due to your ___ disease.
You were also found to have high blood pressure levels during
your hospitalization, which was treated with medications. Your
losartan prescription has been changed to 25mg twice daily.
Please pick up your new prescriptions and discard your old
medication.
Please measure and record your blood pressures at home three
times a day, and bring them to your next PCP visit at the
gerontology office. You will have a visiting nurse to help you
with this.
We are giving you additional laxatives to help your bowel
movements and advise you not not strain while having a bowel
movement.
Followup Instructions:
___
|
10621477-DS-13 | 10,621,477 | 29,077,770 | DS | 13 | 2184-04-10 00:00:00 | 2184-04-11 10:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Ranitidine / Paxil / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / duloxetine / tramadol
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is an ___ year old woman with a history of
___ disease with multiple falls and gait disorder,
hypertension, hyperlipidemia, osteoarthritis, mild cognitive
impairment, peripheral neuropathy, depression, insomnia, and
osteopenia. She is admitted to ___ with cough.
ED COURSE
In the ED, initial vital signs were: 98.3 126 148/72 16 95% RA
Labs were notable for nl U/A, nl CHEM/CBC, lactate 1.6 and flu
neg
Imaging notable for negative CT
Patient was given 2L NS, albuterol/ipratrop and APAP.
On Transfer Vitals were: 98.2 90 167/78 18 97% RA.
FLOOR COURSE
She describes 3 days of non-productive cough, normal PO intake,
no fall since last hospitalization. She had one episode of loose
non-bloody stool at home. In speaking with daughter, family
concerned about pneumonia or flu, as well as inability to
provide safe medications for cough symptom control given
___ disease. Received one dose of Coricidin at home.
She denies dyspnea, chest pain, abdominal pain. Endorses nasal
and throat congestion.
Past Medical History:
-___ disease, on sinemet
-GERD
-HLD
-HTN
-B/l total hip replacements
-OA
-Incontinent of urine
-Right total knee replacement
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3 168/71 88 22 98%RA Bed wt 65.2kg
General: Thin, no acute distress, laying comfortably in bed
HEENT: NCAT, MMM, false teeth in place
Lymph: no LAD
CV: RRR, no m/r/g
Lungs: Diffuse wheezes throughout, no crackles
Abdomen: soft, nontender, nondistended
GU: no foley
Ext: warm, no peripheral edema
Neuro: A&Ox3, gait deferred
Skin: no rashes or lesions
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 ___ 18 95%RA;
General: Thin, no acute distress, laying comfortably in bed
HEENT: NCAT, mucous membranes dry, false teeth out
Lymph: no LAD
CV: RRR, no m/r/g
Lungs: Diffuse wheezes throughout, no crackles
Abdomen: soft, nontender, nondistended
GU: no foley
Ext: warm, no peripheral edema
Neuro: A&Ox3, gait deferred
Skin: no rashes or lesions
Pertinent Results:
ADMISSION LABS:
==============
___ 10:54PM BLOOD WBC-7.9 RBC-4.11 Hgb-12.7 Hct-39.1 MCV-95
MCH-30.9 MCHC-32.5 RDW-13.6 RDWSD-47.6* Plt ___
___ 10:54PM BLOOD Neuts-74.2* Lymphs-15.7* Monos-8.9
Eos-0.3* Baso-0.6 Im ___ AbsNeut-5.85 AbsLymp-1.24
AbsMono-0.70 AbsEos-0.02* AbsBaso-0.05
___ 10:54PM BLOOD Glucose-113* UreaN-16 Creat-0.9 Na-135
K-5.0 Cl-100 HCO3-24 AnGap-16
___ 10:54PM BLOOD CK(CPK)-174
___ 06:39AM BLOOD ALT-5 AST-34 LD(___)-219 AlkPhos-90
TotBili-0.6
___ 10:54PM BLOOD Calcium-10.0 Phos-3.0 Mg-1.7
___ 11:13PM BLOOD Lactate-1.6
___ 01:10AM URINE Color-Straw Appear-Clear Sp ___
___ 01:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:10AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 01:10AM URINE Mucous-RARE
OTHER PERTINENT/DISCHARGE LABS:
============================
___ 06:39AM BLOOD WBC-9.9 RBC-3.45* Hgb-10.6* Hct-33.6*
MCV-97 MCH-30.7 MCHC-31.5* RDW-13.8 RDWSD-49.4* Plt ___
___ 06:39AM BLOOD Glucose-87 UreaN-21* Creat-1.0 Na-141
K-3.4 Cl-105 HCO3-25 AnGap-14
___ 06:39AM BLOOD ALT-5 AST-34 LD(LDH)-219 AlkPhos-90
TotBili-0.6
IMAGING/STUDIES:
==============
CT chest ___
1. The radiographic abnormality corresponds to a large hiatus
hernia
containing almost the entire stomach without evidence of
obstruction or
volvulus. There is mild adjacent left lower lobe subsegmental
atelectasis
without lobar consolidation.
2. Multi nodular thyroid gland, a 0.7 cm left thyroid lobe
nodule is larger
than from ___. Consider nonemergent thyroid ultrasound.
3. Extensive atherosclerotic calcification of the coronary
arteries and
thoracic aorta.
CXR PA/LAT ___
No convincing radiographic evidence of pneumonia. Pulmonary
vascular
congestion.
MICROBIOLOGY:
==============
___ - blood cultures x2 - pending, no growth to date as of
___ 10:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Brief Hospital Course:
Mrs ___ is an ___ year old woman with a history of
___ disease, gait disorder, peripheral neuropathy, and
frequent falls who presents to ___ with cough. Family brought
pt in with concern for flu vs pneumonia. Negative flu swab and
no evidence of pneumonia on CXR or CT chest in ED.
ACUTE ISSUES:
# Cough - concern for viral illness, duration prior to admission
3 days, non-productive, no fevers/chills, nausea, change in PO
intake. Responded well to benzonatate 100mg TID and guaifenisen.
No detromethorphan due to carbidopa/levidopa in pt with
___ disease. Reactive airway component likely with
diffuses wheezes, improved with albuterol nebs, discharged with
albuterol inhaler. Pt to complete 5 day azithromycin course
(___). instructed to call her doctor should she develop
productive cough, shortness of breath, fever, chills or any
concerns.
# Falls / Gait Disorder: fall in ___ with fracture, d/c
from ___ in ___. Per daughter, pt in wheelchair at
home, walks with assistance and walker. Evaluated by physical
therapy who recommended home with home ___.
# Peripheral Neuropathy- continued home gabapentin 200mg AM,
400mg ___
# ___ Disease - continued home Rytary *NF*
(carbidopa-levodopa) 23.75-95 mg oral 5X/DAY
# GERD- no home meds
# HLD-no home meds
# HTN- continued home losartan 37.5mg daily and metoprolol
succinate 100mg daily, felodipine 10mg ER
# Primary prevention- continued home ASA 81mg
# Osteoarthritis-continued home acetaminophen 650mg TID
# Stress Incontinence -monitored no foley needed
# Mild Cognitive Impairment -at baseline
# Depression -continue home venlafaxine, holding nonformulary
melatonin
# Insomnia -continued home trazodone 50mg qHS
# Osteopenia -no evidence of fracture, continue home vitamin D3
and calcium
TRANSITIONAL ISSUES:
- Pt to complete 5 day azithromycin course (___).
instructed to call her doctor should she develop productive
cough, shortness of breath, fever, chills or any concerns.
-CT scan showed multi nodular thyroid gland, a 0.7 cm left
thyroid lobe nodule is larger than from ___. Consider
nonemergent thyroid ultrasound.
- Pt also given inhalers course for use while ill
- Rx for benzonatate and guaifenisen had significant improvement
in her cough symptoms.
- Close follow-up with geriatrics pending
- Code: DNR/DNI
- Contact: Daughter, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Rytary (carbidopa-levodopa) 23.75-95 mg oral See Below
2. Felodipine 10 mg PO DAILY
3. Gabapentin 200 mg PO BID
4. Losartan Potassium 37.5 mg PO BID
5. Metoprolol Succinate XL 100 mg PO DAILY
6. TraZODone 50 mg PO QHS
7. Venlafaxine XR 37.5 mg PO DAILY
8. Acetaminophen 650 mg PO Q8H
9. Aspirin 81 mg PO DAILY
10. Calcium Carbonate 300 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Docusate Sodium 100 mg PO QHS
13. melatonin 10 mg oral QHS
14. Gabapentin 200 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 300 mg PO BID
4. Docusate Sodium 100 mg PO QHS
5. Felodipine 10 mg PO DAILY
6. Gabapentin 200 mg PO BID
7. Losartan Potassium 37.5 mg PO BID
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Rytary (carbidopa-levodopa) 23.75-95 mg oral 5X/DAY
RX *carbidopa-levodopa [___] 23.75 mg-95 mg 1 capsule(s) by
mouth 5x per day Disp #*150 Capsule Refills:*0
10. TraZODone 50 mg PO QHS
11. Venlafaxine XR 37.5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*30
Capsule Refills:*0
14. Gabapentin 200 mg PO QPM
15. melatonin 10 mg oral QHS
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ PUFF INH Q4H PRN
Disp #*2 Inhaler Refills:*0
17. Guaifenesin ___ mL PO Q6H
RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL
100-200 mg by mouth every 6 hours Refills:*0
18. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Upper respiratory tract infection
Frailty
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 caring for you at the ___
___. You were recently admitted with concern for
frailty in the setting of an upper respiratory tract infection.
You underwent testing which was negative for influenza ("flu")
and a CT scan which showed no evidence of pneumonia. You were
started on cough medication and your symptoms improved.
Please continue to take your home medications and keep your
follow-up appointments.
We will also discharge you with a script for antibiotics. Please
do not take this medication unless your symptoms worsen with a
productive cough, fevers, shortness of breath, falls or other
signs that make you concerned for an infection. If this
situation occurs, please also call your doctor. Otherwise,
please discard the medication.
The CT scan you had in the emergency department showed a small
change in the size of a nodule in your thyroid gland in your
neck. You should talk to your doctor about the role of an
ultrasound to evaluate this in the future.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10621477-DS-14 | 10,621,477 | 26,465,572 | DS | 14 | 2185-04-27 00:00:00 | 2185-04-27 14:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Morphine / Ranitidine / Paxil / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / duloxetine / tramadol
Attending: ___
Chief Complaint:
Lethargy, slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ right-handed woman with a past medical history
significant for ___ disease on Rytary, hypertension,
arthritis with multiple joint replacements, frequent episodes of
'vasovagal' syncope who presents to the emergency room after her
family noted her to have very slow slurred speech as well as
left-sided weakness. She walks with a ___ + 1 person assist
at baseline, cannot pay her own bills or do groceries, and lives
at home with her ___ husband. She has 2 daughters, one
lives in the same building as her and one that comes to stay
with
her during the day. The daughter she lives close to noticed
that
she was not eating as much as normal last night and seemed
lethargic. This persisted into the morning. She has a nurse
that comes to the ___ in the morning who also thought that she
looked unwell and lethargic. When her other daughter came to
the
___ around 10 AM, she found the patient on the toilet, her
husband was trying to help her go to the bathroom. She has not
had a bowel movement in many days. Her husband thought that she
was not doing particularly well and told his daughter this. He
was unable to quantify a time when she became more ill. To her
daughter however, she appeared to have very slow labored speech
with decreased verbal output although she was making
understandable words. She also appeared to have much more
difficulty walking than baseline, and her daughter felt that she
was dragging her left side. The patient will state that she had
an acute change around 7 AM this morning. She was transported
to
the ED where a code stroke was called on arrival.
Past Medical History:
-___ disease, on sinemet
-GERD
-HLD
-HTN
-___ total hip replacements
-OA
-Incontinent of urine
-Right total knee replacement
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL EXAM:
- Vitals: 98 67 151/67 18 98% room air
- General: Drowsy, but awakes readily
- HEENT: NC/AT
- Neck: Increased axial tone
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft
- Extremities: no edema
NEURO EXAM:
- Mental Status: Drowsy but awakes readily when her name is
called. Knows that it is ___, does not know the date.
Able
to name ___ but not ___. Knows she is in a hospital. Can
tell me the days of the week forward but not backwards. Able to
repeat phrases with no errors including "it is always sunny in
___ and "no ifs, ands or buts". Able to name high frequency
objects such as thumb, watch, knuckles. Names all the objects
on
the stroke card except hammock and feather. Can only register
___ of my words on multiple attempts, does not remember any
words
after 5 minutes. Decreased verbal output, but no evidence of
dysarthria or paraphasias. Speaks mostly in ___ word answers.
- Cranial Nerves:
PERRL 1.5mm->1mm. VFF to confrontation and number counting.
Decreased up and down gaze. Facial sensation intact to light
touch. Facial asymmetry, but activates equally. Hearing intact
to room voice. Tongue protrudes in midline and to either side
with no evidence of atrophy or weakness.
- Motor: Decreased bulk with increased tone throughout. With
arms extended, marked pronation and cupping of the left arm but
significant pain on passive movement suggesting a frozen
shoulder; no drift. No axial or appendicular tremor
appreciated.
Delt Bic Tri WrE WrF FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 4
R 5 ___ ___ 5 5 5 5 5 5
- Sensory: Reports 50% sensation to pinprick in the left V1 and
V2, 100% in V3. 100% in the left arm, 100% in the left thigh,
50% in the left leg. No extinction to DSS.
- DTRs:
- Coordination: No dysmetria on FNF; although these movements
are
much slower on the left, she is able to hit target.
- Gait: Deferred as she uses a ___ with assistance at
baseline
and no ___ at bedside.
DISCHARGE PHYSICAL EXAM:
- General: Awake, in no acute distress
- HEENT: NC/AT
- Neck: Increased axial tone
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: non-distended
- Extremities: no edema
Neuro:
Mental Status: Awake, alert, oriented to self, place, date. Some
difficulty keeping eyelids open bilaterally. Fluent, speaking in
full sentences. Able to participate in multistep commands. No
evidence of dysarthria or paraphasias.
Cranial nerves: PERRL, EOMI with some slight decreased up and
downgaze. Intact to LT over facies ___. Slight L NLFF (chronic)
w/ relatively symmetric activation. Hearing intact ___. Palate
elevates symmetrically and tongue protrudes in midline without
apparent weakness.
Motor: Decreased bulk throughout w/ paratonia in both upper
extremities. Very slight weakness (___) over L hemibody at
triceps and TA.
Reflexes: deferred
Sensory: Intact to LT in UEs and ___
Coordination: deferred
Gait: deferred
Pertinent Results:
___ 05:35AM BLOOD WBC-7.2 RBC-3.81* Hgb-11.9 Hct-35.8
MCV-94 MCH-31.2 MCHC-33.2 RDW-12.4 RDWSD-42.8 Plt ___
___ 12:15PM BLOOD WBC-7.4 RBC-4.19 Hgb-13.1 Hct-40.4 MCV-96
MCH-31.3 MCHC-32.4 RDW-12.6 RDWSD-45.2 Plt ___
___ 05:30AM BLOOD ___ PTT-34.2 ___
___ 12:15PM BLOOD ___ PTT-32.2 ___
___ 05:35AM BLOOD Glucose-94 UreaN-15 Creat-0.8 Na-141
K-4.3 Cl-107 HCO3-25 AnGap-13
___ 12:15PM BLOOD Glucose-123* UreaN-19 Creat-0.9 Na-142
K-4.5 Cl-104 HCO3-24 AnGap-19
___ 05:30AM BLOOD cTropnT-<0.01
___ 05:35AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.6
___ 12:15PM BLOOD Calcium-9.8 Phos-3.0 Mg-1.9
___ 05:30AM BLOOD %HbA1c-5.7 eAG-117
___ 05:30AM BLOOD Triglyc-127 HDL-56 CHOL/HD-3.5
LDLcalc-113
___ 05:30AM BLOOD TSH-0.05*
___ Brain Perfusion
1. No evidence of new large territorial infarction or
intracranial hemorrhage.
2. Extensive anterior circulation atherosclerotic disease
including severe
stenoses of the bilateral M1 and M2 segments and left A1
segment. No definite
arterial occlusion. No aneurysm.
3. Unchanged chronic microangiopathy.
4. Heterogeneous and multinodular thyroid gland, no largest
greater than 1.5
cm. Per ACR guidelines on incidentally discovered thyroid
nodules, no specific
follow-up imaging is recommended FOR INCIDENTAL THYROID NODULE.
___
Symmetric LVH with normal global and regional biventricular
systolic function. Mild pulmonary hypertension.
___ Head w/o
1. Late acute to early subacute right frontoparietal infarction
in the
distribution suggestive of right MCA distribution, although some
areas may be in the watershed distribution between the right ACA
and MCA (05:23). No associated hemorrhage.
2. Small chronic infarctions within bilateral cerebellar
hemispheres.
3. Diffuse parenchymal volume loss with probable chronic small
vessel ischemic disease.
Brief Hospital Course:
Ms. ___ is an ___ R-handed woman with a past medical
history significant for ___ disease, cognitive impairment,
vascular risk factors including HTN and HLD and frequent
episodes of syncope who is admitted to the Neurology stroke
service with decreased verbal output/anomia secondary to an
acute ischemic in the ACA/MCA watershed zone. Her stroke was
most likely secondary to significant atherosclerotic disease of
of the anterior cerebral circulation with hypoperfusion as a
potential contributor. We considered this a failure of ASA. She
underwent Echo with no suggestion of cardioembolic source. Her
deficits improved greatly prior to discharge with only mild
anomia to low-frequency objects, partial sensory loss on the L
face and L leg, and no significant weakness.
She was started on dual antiplatelet therapy of ASA 81 and
clopidogrel (Plavix) 75mg daily to reduce risk of future
strokes. She was started on Atorvastatin 80mg qpm for elevated
cholesterol level. Her blood pressure medications were held
(with the exception of halve her Metoprolol at 25mg BID) to
reduce risk of hypotension. She was seen to have a urinary tract
infection (culture pending at time of discharge) and was treated
with Ceftriaxone 1g q24 with plan for 7 day course. She was
evaluated by Swallow and determined to be appropriate for
regular diet with thin liquids by cup (no straws). She was also
evaluated by ___ and recommended for discharge to acute rehab.
Her stroke risk factors include the following:
1) Extensive anterior circulation atherosclerotic disease
2) Hyperlipidemia: well controlled on atorvastatin 80mg with LDL
113
3) Hypertension
4) Advanced age
An echocardiogram did not show a PFO on bubble study.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed â () 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 = 13 ) - () No
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 - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - ASA/Plavix () 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. Rytary (carbidopa-levodopa) 23.75-95 mg oral 7am, 1pm, 6pm
___ Disease
2. Docusate Sodium 100 mg PO Frequency is Unknown
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown
4. Chlorpheniramine-Hydrocodone 5 mL PO Frequency is Unknown
5. Acetaminophen 650 mg PO Frequency is Unknown
6. Aspirin 81 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. diclofenac sodium 1 % topical BID shoulder pain
10. Felodipine 10 mg PO DAILY
11. Losartan Potassium 37.5 mg PO BID
12. Metoprolol Succinate XL 100 mg PO DAILY
13. TraMADol 25 mg PO DAILY
14. TraZODone 75 mg PO QHS
15. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. CefTRIAXone 1 gm IV Q24H
Please continue for 3 more days to complete 7 day course of
antibiotic therapy
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN increased
secreations
6. Docusate Sodium 100 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. diclofenac sodium 1 % topical BID shoulder pain
10. Felodipine 10 mg PO DAILY
Please start BP meds gently to reduce risk of hypotension
11. Losartan Potassium 37.5 mg PO BID
Please start BP meds gently to reduce risk of hypotension
12. Metoprolol Succinate XL 100 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown
14. Rytary (carbidopa-levodopa) 23.75-95 mg oral 7am, 1pm, 6pm
___ Disease
15. TraMADol 25 mg PO DAILY
16. TraZODone 75 mg PO QHS
17. Venlafaxine XR 75 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of slurred and slowed
speech and difficulty walking 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
High cholesterol
We are changing your medications as follows:
Please start taking Clopidogrel 75mg daily. Please continue
taking Ceftriaxone 1g q24 for 3 more days to treat urinary tract
infection. Please start taking Atorvastatin 80mg at bedtime.
Please hold Felodopine ER 10mg and Losartan 37.5mg BID for now
and restart each slowly to reduce risk of abnormally low blood
pressure in the future.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10621477-DS-15 | 10,621,477 | 29,391,231 | DS | 15 | 2185-05-05 00:00:00 | 2185-05-05 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Morphine / Ranitidine / Paxil / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / duloxetine / tramadol
Attending: ___
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ right-handed woman with a past medical history
significant for recent strokes thought secondary to
hypoperfusion
of her anterior circulation in the setting of marked
atherosclerosis as well as hypotensive events, ___
disease on Rytary, hypertension, arthritis with multiple joint
replacements, frequent episodes of vasovagal syncope who
represents to the emergency room from rehab after worsening
left-sided weakness and facial droop noticed by the nurse at the
facility. Her daughter and son at the bedside report that she
started seeming off to them yesterday. Her daughter gave her
some watermelon yesterday around 10 AM and she seemed okay and
enjoyed it very much. She then went to physical therapy at 11
AM
and when she came back she seemed confused. She is stated that
she wanted to lie down and thought that she was at church. Her
son then saw her at 7:30 ___, and he also thought that she was
acting a little bit strange. She was confused and did not
really
interact with him like normal. He let her get some rest and
went
home. Today, she was noted by the nurse at the facility to have
an episode of syncope after going to the toilet. She lost
consciousness, became lethargic, and when she woke up she had a
recurrence of her left facial droop with dysarthria as well as
left-sided weakness. 911 was called and she was brought to the
emergency room. A code stroke was called on arrival.
Past Medical History:
-___ disease, on sinemet
-GERD
-HLD
-HTN
-B/l total hip replacements
-OA
-Incontinent of urine
-Right total knee replacement
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
- General: Drowsy, but awakes readily
- HEENT: NC/AT, masked facies
- Neck: Increased axial tone
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft
- Extremities: no edema
NEURO EXAM:
- Mental Status: Drowsy but awakes readily when her name is
called. States that it has ___, does not know the date.
Knows that she is at ___. Able to
repeat phrases with no errors including "it is always sunny in
___ " and "no ifs, ands or buts" but does sound mildly
dysarthric from her left facial droop. Able to name high
frequency objects such as thumb, watch. Only names feather and
glove on the stroke card. Will not describe the cookie theft
picture. Decreased verbal output. Speaks mostly in ___ word
answers. When asked to count the number of people in the room,
states 3, which is correct, with people on both sides of the
bed.
- Cranial Nerves:
PERRL 1.5mm->1mm. VFF to confrontation and number counting.
Decreased up and down gaze, will not bury the sclera to the
left.
Facial sensation intact to light touch. Left facial droop.
Hearing intact to room voice. Tongue protrudes in midline and to
either side with no evidence of atrophy or weakness.
- Motor: Decreased bulk with increased tone throughout, L>R.
With arms extended, pronation and cupping of the left arm; no
drift. No axial or appendicular tremor appreciated.
Delt Bic Tri WrE WrF FFl FE IP Quad Ham TA ___
L 5 ___ ___ 4 5 5 5 5 4
R 5 ___ ___ 4 5 5 5 5 4
*Dystonic appearing posturing of the left foot
- Sensory: To pinprick, states that both sides are equal in the
face arms and legs. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 1+ 0
R 2 1 1 1+ 0
Plantar response was flexor bilaterally
- Coordination: No dysmetria on FNF; although these movements
are
much slower on the left, she is able to hit target.
- Gait: Deferred
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, lying in bed NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic Examination:
- Mental status: Awake, alert, oriented to person, place, and
date. Able to relate history without difficulty. Speech is
fluent with full sentences,
intact repetition, and intact verbal comprehension. Naming
intact
to items on stroke card. No paraphasic errors. Normal prosody.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 2->1 brisk. VF full to confrontation.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
speech. Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No tremor or asterixis.
[___]
L 4+ 5 5- 4+ 4 4 4- 5 4 4+ 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [___]
L 2+ 2+ 2+ 2+ 0
R 2+ 2+ 2+ 2+ 0
Plantar response mute on left, extensor on right.
- Sensory: No deficits to light touch, proprioception, or cold
sensation. No extinction to DSS.
- Coordination: On left, + dysmetria on FNF and slowed finger
tapping
- Gait: Not able.
Pertinent Results:
___ 05:50AM BLOOD WBC-8.3 RBC-3.63* Hgb-11.4 Hct-34.3
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.4 RDWSD-43.1 Plt ___
___ 02:00PM BLOOD WBC-11.4*# RBC-4.29 Hgb-13.3 Hct-41.6
MCV-97 MCH-31.0 MCHC-32.0 RDW-12.7 RDWSD-45.1 Plt ___
___ 02:00PM BLOOD ___ PTT-28.1 ___
___ 05:50AM BLOOD Glucose-83 UreaN-9 Creat-0.7 Na-140 K-4.2
Cl-106 HCO3-24 AnGap-14
___ 10:20AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-25 AnGap-14
___ 02:00PM BLOOD ALT-<5 AST-15 AlkPhos-111* TotBili-0.3
___ 02:00PM BLOOD Lipase-63*
___ 02:00PM BLOOD cTropnT-<0.01
___ 05:35AM BLOOD Calcium-9.4 Phos-2.7 Mg-1.5*
___
1. No evidence of hemorrhage or acute large territory
infarction.
2. Multiple bilateral chronic lacunar infarcts, one of which has
occurred
since ___. ___. Subcortical white matter hypodensities
of the right
frontal lobe are chronic in appearance but new since ___ as
well.
___ H&N
1. Multifocal atherosclerotic calcifications as described above
resulting in
multifocal irregularity and narrowing of the proximal middle
cerebral artery
branches bilaterally. The circle of ___ and its major
branches are patent.
2. Calcified atherosclerotic disease at carotid bifurcations
without
significant internal carotid artery stenosis by NASCET criteria.
3. Atherosclerotic disease at the origin of the right vertebral
artery results
in moderate focal luminal narrowing, more prominent compared to
prior
examination. The vertebral arteries are patent bilaterally.
4. A hypodensity in the right lentiform nucleus corresponds to
known acute
infarcts seen on subsequent MRI. Additional small scattered
right hemisphere
infarcts seen on MRI are poorly visualized on CT.
___ Head w/o
New late acute infarcts in the right globus pallidus, right
frontal cortex and
subcortical white matter in addition to previously seen
scattered evolving
late acute infarcts in the right MCA and right MCA/ACA watershed
distribution.
Brief Hospital Course:
Pt presented to ___ from acute rehab due to worsening left
sided weakness and facial droop concerning for new stroke. She
underwent NCHCT which was unremarkable and was admitted to the
Stroke Service. She was continued on dual antiplatelet therapy
with Aspirin and Plavix as well as Atorvastatin 80mg qpm and
Metoprolol 25mg BID. She was monitored on telemetry and blood
pressure was allowed to autoregulate. She underwent MRI which
showed new strokes in right globus pallidus, frontal cortex, and
subcortical white matter in similar distribution to strokes
found on previous admission, likely related to hypoperfusion
event in setting of significant anterior circulation
atherosclerosis as well as possible syncopal event at rehab. Her
BP parameters were adjusted for maintenance between 140-200 and
she was started on Midodrine 2.5mg in morning and afternoon due
to being seen to be orthostatic positive (with drop of SBP from
170 to 120s from sitting to standing). She was started on
lowered dose of home Losartan at 25mg daily. Pt was evaluated by
___ and recommended to return to acute rehab.
Transition Issues:
-Pt will need to continue taking dual anti-platelet therapy with
Aspirin and Plavix for ___s Atorvastatin for
secondary stroke prevention
-Pt should continue on Metoprolol 25mg twice daily and restart
home blood pressure medications slowly (at home pt takes
Losartan 37.5mg twice daily and Felodopine 10mg daily) to ensure
no significant hypotensive event; appropriate to maintain pt at
high normal or slightly elevated SBP
-Pt should continue Midodrine 2.5mg twice daily in morning and
afternoon
-Pt will need to be moved from supine, sitting, and standing
positions slowly when with family and/or ___ to ensure no
cerebral hypoperfusion; if new neurologic symptoms develop,
recommend laying pt supine with head of bed flat (and
potentially placing in ___ position) and providing
hydration; provided family with these instructions
-Pt should follow up with Neurology and primary care provider in
near future
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed â () 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 = 113) - () No
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 - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
Medications on Admission:
1. Atorvastatin 80 mg PO QPM
2. CefTRIAXone 1 gm IV Q24H
Please continue for 3 more days to complete 7 day course of
antibiotic therapy
3. Clopidogrel 75 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN increased
secreations
6. Docusate Sodium 100 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. diclofenac sodium 1 % topical BID shoulder pain
10. Felodipine 10 mg PO DAILY
Please start BP meds gently to reduce risk of hypotension
11. Losartan Potassium 37.5 mg PO BID
Please start BP meds gently to reduce risk of hypotension
12. Metoprolol Succinate XL 100 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown
14. Rytary (carbidopa-levodopa) 23.75-95 mg oral 7am, 1pm, 6pm
___ Disease
15. TraMADol 25 mg PO DAILY
16. TraZODone 75 mg PO QHS
17. Venlafaxine XR 75 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
2. Midodrine 2.5 mg PO BID
3. Losartan Potassium 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN increased
secreations
7. Clopidogrel 75 mg PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. diclofenac sodium 1 % topical BID shoulder pain
10. Docusate Sodium 100 mg PO BID
11. Felodipine 10 mg PO DAILY
12. Gabapentin 100 mg PO BID
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
unknown
14. Rytary (carbidopa-levodopa) 23.75-95 mg oral 7am, 1pm, 6pm
___ Disease
15. TraMADol 25 mg PO DAILY
16. TraZODone 75 mg PO QHS
17. Venlafaxine XR 75 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke in R MCA distribution
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left sided weakness and
facial weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol with significant intracranial atherosclerosis
Prior strokes
We are changing your medications as follows:
Please start taking Midodrine 2.5mg twice daily in morning and
in early afternoon (DO NOT give in evening or at night)
Please decrease home Metoprolol to 25mg twice daily
Please restart pt's home blood pressure medications slowly
(Felodopine 10mg daily and Losartan 37.5mg twice daily) with
goal to maintain SBP at high normal or mildly above average to
reduce risk of intracranial hypoperfusion
Please take your other medications as prescribed.
Please be careful when moving from supine, sitting, and standing
positions to ensure no cerebral hypoperfusion; if new neurologic
symptoms develop, recommend laying supine with head of bed flat
(and potentially lifting up legs) and providing hydration
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:
___
|
10621477-DS-16 | 10,621,477 | 24,139,105 | DS | 16 | 2185-11-14 00:00:00 | 2185-11-14 21:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Ranitidine / Paxil / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / duloxetine / tramadol
Attending: ___.
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ CVA (L-sided weakness), ___, HTN, arthritis p/w
recurrent vasovagal syncope and unresponsive episode.
Per documentation, patient was reportedly found on the toilet by
her family. She was sitting on the toilet (aided by her
daughter) and then lost consciousness. She was placed on the
ground and a pulse was checked and CPR was initiated for a few
minutes. Her teeth were clenched (bit her mouth) and she was
incontinent, but no other overt signs of seizure (shaking). When
EMS arrived, patient was alert and oriented but it is unclear if
she is back to baseline.
Patient denies any CP, SOB, abdominal pain, n/v/d. Family noted
that she was groggy when she came through. She was a little
confused (did not seem like herself).
Speaking with her daughter, the patient lives with husband and
youngest daughter. They mobilize her in a spryte. She
periodically looses consciousness which seems to be related to
going to the bathroom. She wears TEDS at home and mobilizes
slowly with assistance. Lately, she doesn't know where she is
and is more confused. She is A+Ox1-2 at baseline.
In the ED, initial VS were: 98.2 64 123/77 16 98% RA
Exam notable for: mild right gaze deviation but able to move her
eyes in all directions. Clear lungs and normal heart sounds.
Past Medical History:
#Bilateral total hip replacements
___ disease
#Left knee replacement
#Gait instability
#Ischemic stroke
#Hypertension
#Dysphagia
#Major Depression
#Hx of Falls
#Major Neurocognitive Disorder
Social History:
___
Family History:
No family history of seizures, arrhythmias. Daughters have
cardiac stents and mother with CHF/CAD.
Physical Exam:
ADMISSION PHYSICAL:
VS: T 98.7 BP 177/79 HR 112 93% room air
Gen: NAD, A/O x2 (does not know year, knows she's in the
hospital)
HEENT: Anicteric, PER, EOM intact, MMM, oropharynx without
erythema or exudate, cannot move eye beyond midline to the right
side.
Neck: no JVD
CV: RRR, S1/S2 noted, no murmurs/gallops
Pulm: CTAB, breathing comfortably
GI: NTTP, ND, NBS
GU: No foley
Skin: no lesions
MSK: Warm, no edema, 2+ pedal pulses
Neuro: left sided stroke with contracture of her left hand and
leg. Minor cogwheeling, no rigidity or tremores noted. Gait
unassessed
Psych: Alert
DISCHARGE PHYSICAL:
Vitals: 98.4 146/64 80 18 95 RA
Gen: NAD, AAOx3, laying back in bed
HEENT: AT/NC, EOM cannot move right eye beyond midline with
preferential upward gaze, no JVD, neck supple
CV: RRR, S1/S2 noted, no murmurs/gallops/rubs appreciated
Pulm: CTAB
Abd: +BS, non-tender
Ext: Pulses present, no edema
Neuro: No rigidity or worsening tremors noted, motor strength
preserved in upper extremities with grip and lower extremities
with ROM
Pertinent Results:
ADMISSION LABS:
___ 10:00AM GLUCOSE-125* UREA N-18 CREAT-0.7 SODIUM-144
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12
___ 10:00AM CALCIUM-9.6 PHOSPHATE-2.5* MAGNESIUM-1.6
___ 10:00AM WBC-9.3 RBC-3.84* HGB-10.9* HCT-34.8 MCV-91
MCH-28.4 MCHC-31.3* RDW-14.0 RDWSD-45.7
___ 10:00AM PLT COUNT-192
___ 10:00AM ___ PTT-38.1* ___
___ 10:43PM cTropnT-<0.01
___ 09:58PM URINE HOURS-RANDOM
___ 09:58PM URINE UHOLD-HOLD
___ 09:58PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:58PM URINE RBC-4* WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 09:58PM URINE HYALINE-3*
___ 09:58PM URINE MUCOUS-RARE*
___ 06:31PM LACTATE-2.2* K+-5.2*
___ 06:25PM GLUCOSE-174* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-6.7* CHLORIDE-101 TOTAL CO2-22 ANION GAP-15
___ 06:25PM estGFR-Using this
___ 06:25PM cTropnT-<0.01
___ 06:25PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-1.8
___ 06:25PM TSH-0.39
___ 06:25PM WBC-9.1 RBC-4.13 HGB-11.6 HCT-37.7 MCV-91
MCH-28.1 MCHC-30.8* RDW-13.9 RDWSD-47.0*
___ 06:25PM NEUTS-67.4 ___ MONOS-8.6 EOS-1.3
BASOS-0.7 IM ___ AbsNeut-6.15* AbsLymp-1.98 AbsMono-0.78
AbsEos-0.12 AbsBaso-0.06
___ 06:25PM PLT COUNT-193
___ 06:25PM ___ PTT-34.3 ___
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-9.3 RBC-3.71* Hgb-10.7* Hct-33.2*
MCV-90 MCH-28.8 MCHC-32.2 RDW-13.9 RDWSD-45.1 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-94 UreaN-22* Creat-0.8 Na-144
K-4.0 Cl-105 HCO3-25 AnGap-14
___ 05:40AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.8
IMAGING:
___ CT Chest w/o con:
1. Large hiatal hernia, increased in size since the prior study
from ___
2. Increased left basilar atelectasis likely secondary to the
hiatal hernia.
A superimposed infection cannot be excluded.
3. Multinodular thyroid gland similar to the prior study.
___ CT Head & C-spine w/o con:
No acute intracranial process common no hemorrhage.
No fracture or malalignment.
___ EEG:
This is continuous video EEG monitoring study captured no
pushbutton activations, no definite epileptiform discharges, and
no
electrographic seizures. The background demonstrates a sharply
contoured
alpha rhythm.
___ Video Swallow:
Penetration without aspiration of nectar thickened and pureed
liquids.
Significant vallecular residue was not easily cleared. Patient
did not
initiate mastication adequately with barium coated ___
crackers.
MICRO:
___ Blood Cx x2: PND
___ 9:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:00 pm URINE Source: Catheter.
URINE CULTURE (Pending):
Brief Hospital Course:
___ w/ CVA (L-sided weakness), ___, HTN, arthritis p/w
recurrent vasovagal syncope and unresponsive episode.
ACUTE ISSUES:
#Syncope event:
Syncopated on toilet and had 2 min of CPR for reported
pulselessness. Unlikely true asystole since labs and Tn
negative. Had teeth clenching and loss of bladder control so
concern for seizure. Neuro exam unchanged from prior in OMR. DDx
also includes vasovagal (all prior events occur around bathroom)
or medication effect (recently increased morphine). Her home
morphine was held during her stay. Underwent NCHCT in addition
to c-spine CT to r/o acute hemorrhagic stroke or compression
fractures which returned negative. She then underwent EEG for 24
hours, which was not remarkable for concerning epileptiform
tracings. She did not have acute episodes of neurological
deficits during her stay. Discussed case with family including
likely vasovagal event and need for close care. Decreased home
trazodone to 12.5mg QHS. Per S/S evaluation, did have increased
cough at risk for aspiration with mixed tasks of eating and
drinking, which would necessitate monitoring while feeding at
home with caution.
#Dysuria:
Endorsed right prior to d/c on ___. Planned for straight cath
w/ UA and UCx.
CHRONIC ISSUES:
#Insomnia:
-Decreased home trazodone 75 mg qhs to 25 mg qhs
#History of CVA:
#Vascular dementia:
A+Ox1-2 at baseline.
-Continued aspirin/Plavix
-Continued atorvastatin 80 mg qd
___ disease:
-Continued home Rytary (carbidopa-levodopa) 23.75-95 mg oral
7am, 1pm, 6pm ___ Disease
#Autonomic dysautonomia:
-Increased home midodrine from 2.5 mg BID to TID
-Continued home felodipine 10 mg qd
-Continued home metoprolol 25 mg BID
#Code status:
Was DNR/DNI at last hospitalization, but family initiated CPR
once she became pulseless. Family endorses it being her wishes
and they want to continue DNR/DNI once she leaves.
TRANSITIONAL ISSUES:
#New Medications:
-Lactulose 15mL PO daily to prevent constipation (thought to be
a contributor to vaso-vagal syncope)
-Bactrim DS BID for 3 days for uncomplicated UTI (___)
#Stopped Medications:
-Morphine Sulfate ___ 7.5 mg PO BID
#Medication changes:
-Trazodone decreased from 75mg to 25mg PO QHS
-Midodrine increased from 2.5 mg PO BID to TID
-Senna increased from 17.8mg PO daily to BID
[]Questionable UTI: Patient had dysuria on the day of discharge
with concerning UA so she was started on bactrim for 3 days.
Please follow-up urine culture and symptoms upon discharge.
[]Please follow up urine cultures sent to ensure appropriate
antibiotic treatment for a potential UTI.
[]Delirium precautions at home with frequent re-orientation
given reported increase in hallucinations
[]Minimize doses of trazodone necessary for adequate sleep and
morphine necessary for pain control
[]Please consider restarting pain medication for her left
shoulder which does not significantly impact BP
[] Constipation: Thought to be a significant contributor to
vaso-vagal syncope. Please evaluate for regular bowel movements
and consider uptitrating bowel regimen to prevent frequent
episodes of syncope.
[] Orthostatic hypotension and vaso-vagal syncope. Increased
midodrine. Goal SBP is 160-200 to prevent orthostatic symptoms.
[] Labs on discharge: hgb was 10.7 and cr was 0.8. Consider
rechecking a hgb to ensure stability.
#Code status: DNR/DNI confirmed
#Contact: ___, Relationship: daughter,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN increased
secreations
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Gabapentin 100 mg PO BID
7. Rytary (carbidopa-levodopa) 23.75-95 mg oral 7am, 1pm, 6pm
___ Disease
8. Venlafaxine XR 75 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. Midodrine 2.5 mg PO BID
11. diclofenac sodium 1 % topical BID shoulder pain
12. Felodipine 10 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
14. TraMADol 25 mg PO QHS
15. TraZODone 75 mg PO QHS
16. Vitamin D 1000 UNIT PO DAILY
17. Senna 8.6 mg PO BID:PRN constipation
18. Morphine Sulfate ___ 7.5 mg PO BID
Discharge Medications:
1. Lactulose 15 mL PO DAILY
RX *lactulose 10 gram/15 mL 15 mL by mouth once a day Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
3. Midodrine 2.5 mg PO TID
Please take at 8AM, 12 noon, and 4PM daily
RX *midodrine 2.5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
4. Senna 17.2 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*120 Tablet Refills:*0
5. TraZODone 12.5 mg PO QHS
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth once at
night Disp #*15 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN increased
secreations
9. Clopidogrel 75 mg PO DAILY
10. Cyanocobalamin 100 mcg PO DAILY
11. diclofenac sodium 1 % topical BID shoulder pain
12. Felodipine 10 mg PO DAILY
13. Gabapentin 100 mg PO BID
14. Metoprolol Tartrate 25 mg PO BID
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
16. Rytary (carbidopa-levodopa) 23.75-95 mg oral 7am, 1pm, 6pm
___ Disease
17. TraMADol 25 mg PO QHS
18. Venlafaxine XR 75 mg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
20. HELD- Morphine Sulfate ___ 7.5 mg PO BID This medication was
held. Do not restart Morphine Sulfate ___ until confirming her
blood pressure with your primary doctor and considering other
medications
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Vasovagal syncope
Autonomic dysfunction
SECONDARY:
___ Disease
Cerebrovascular disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized to work up potential neurological
conditions which may have caused you to lose voluntary control
and consciousness when using the toilet.
What was done while I was in the hospital?
- Pictures were taken that showed you did not have a sudden
bleed in your brain which may have caused a stroke or did not
have a fracture in your spinal cord in your neck.
- A brain wave recorder was used to determine if you are
actively having seizure like brain activity, which did not
return such tracings.
- You were regulated on your home medications to help you
avoid potential doses which may cause delirium or changes in the
consciousness of patients, especially the elderly.
- You had a urine test done that was concerning for a urinary
tract infection so you were started on an antibiotic called
bactrim.
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor.
- If you have seizures or further loss of voluntary motor
function, please tell your primary doctor or go to the emergency
room.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10622931-DS-12 | 10,622,931 | 25,813,977 | DS | 12 | 2156-09-19 00:00:00 | 2156-09-24 08:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / pravastatin / Zetia
Attending: ___
Chief Complaint:
fever, altered mental status
Major Surgical or Invasive Procedure:
Arthrocentesis on ___ of Left first MCP, dry tap
History of Present Illness:
___ s/p L4-L5 laminectomy POD#5 (___), HTN, IDDM ___ years) who
presents with intermittent fevers, nausea, constipation and
weakness.
He was discharged home the day after his surgery. Since
discharge, he has experienced fevers intermittently that his
wife reports have reached 101.5. He was told to start walking
immediately, but he can't because he feels unbalanced. He says
that "it's not that the scenery is spinning", but that he feels
like he's going to have a mistep. He has not showered because he
worries about needing to stand. Neurosurgery at ___ instructed
incentive spirometry. Patient reports he has not had a BM since
his surgery. Believes last BM was just prior to his surgery
(about 1 week ago). Has been taking senna/Colace without effect.
He also reports that he has had increasing nausea. He has eaten
very little since the surgery. Even when he is hungry, food is
not appealing. His wife notes he has become confused in the last
day. Denies chest pain, dyspnea, abdominal pain,
dysuria/frequency/urgency/retention. Denies neuropathic pain or
pain at his surgical incision site. Last BM normal and reports
normally has BMs daily. The patient has no sick contacts.
Of note, the patient has been having left thumb pain since he
stopped his Celebrex on ___ for his surgery. He is unable to
grasp anything. There was no trauma.
In the ED, the patient received:
- 2 x 1L NS
- 2 x 4mg Morphine sulfate
- Vancomycin 1000 mg IV once
- Lorazapam 1 mg IV once
In the ED, initial VS were
Tm 102.8 Tc 99.5 HR ___ BP 131/46-162/67 RR ___ 02Sat 98%
Glucose 267 Pain ___
Exam notable for:
Gen: well-appearing, NAD
CV: RRR, no m/r/g
Resp: CTAB
Abd: +BS, distended, non-tender
Back: surgical incision with staples in lumbar spine. no
surrounding erythema or purulence
Ext: warm and well perfused, pitting edema bilaterally in legs
Neuro: grossly intact, fluent speech
Labs showed
WBC 19.0 Hgb 10.9 Hct 33.3 Plt 392 N 63.6 L 17.4 M 16.6 E 0.2
Bas 0.5 ___ 1.7 Absneut 12.09 Abslymph 3.32 Absmono 3.16
Abseos 0.04 Absbaso 0.09
Na 130 K 4.3 Cl 90 HCO3 25 BUN 23 Cr 1.7 (baseline) Glucose 272
pO2 42 pCO2 43 pH 7.42
Lactate 1.2
Dipstick: Blood SM Nitrate Neg Protein 100 Glucose 300 Ketone 10
Bilirub Neg Urobiln Neg pH 6.0 Leuks Neg
UA: RBC 2 WBC 2 Bacteria None Yeast None Epi 0 CastHy 1
Imaging showed
1. MRI L-Spine W & W/O Contrast: A heterogeneous fluid
collection at the site of the patient's L4-5 laminectomy likely
represents post operative changed but underlying infection
cannot be excluded. Moderate degenerative changes are stable
from the prior examination.
2. CT Abd/Pelvis W/O Contrast: Postsurgical changes in the
lumbar spine from recent L4 laminectomy with small locules of
gas in the surgical bed. No definite fluid collection though.
Evaluation limited without IV contrast.
3. Wrist X-Ray: Small well corticated density projecting just
dorsal to the proximal carpal row which may represent a chronic
triquetral fracture. Please correlate clinically. Mild
degenerative disease of the basal and triscaphe joint noted.
4. CXR (PA & Lat): No acute intrathoracic process.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that he feels cold and
that his fevers are still mild. He is in no acute pain. The only
pain he has is from his incision site, but it is no worse than
it has been and feels to be getting better each day. He reports
that the incision is itchy.
Past Medical History:
- IDDM Type 2 ___ years)
- HTN
- HLD
- Bell's Palsy (3 weeks ago)
- Shingles
- Legally blind
- Bilateral cataract surgery (___)
Social History:
___
Family History:
Father, ___, deceased: Heart Attack (third one)
Mother, ___, deceased: lung cancer (smoker)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Tc 100.3 BP 152/73 HR 95 RR 18 O2Sat 98% RA
GENERAL: Well-appearing gentlemen only making eye contact when
speaking in no acute distress.
HEENT: AT/NC, L eye lags with adduction, Non-reactive pupils
bilaterally, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S3, no murmurs, gallops, or rubs
LUNG: Decreased breath sounds at the R lower base, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing. 2+ symmetrical pitting
edema.
PULSES: 2+ DP pulses bilaterally
NEURO: AOx3 CN II-XII intact, pupils are non-reactive. Resting
tremor. No tremor on finger to nose test. Normal rapid
alternating movements. Normal heel to shin bilaterally. ___
Strength throughout except with the left thumb - ___. Swelling
and warmth of the L thumb MCP joint. Mild diffuse swelling of
the right hand. Bilateral 2+ pitting edema. Reflexes 1+,
symmetric bilaterally.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. Surgical site is not erythematous or purulent.
DISCHARGE PHYSICAL EXAM
VS - T 98.8 BP 124/74-143/78 HR ___ RR 18 O2Sat 95% RA Sugars
210-265
Gen: well-appearing, NAD
CV: RRR, no m/r/g
Resp: CTAB
Abd: +BS, distended, non-tender
Back: surgical incision with staples in lumbar spine. no
surrounding erythema or purulence
Ext: warm and well perfused, pitting edema bilaterally in legs
R>L (less than yesterday)
Left thumb - no erythema, mild swelling over the right thumb. No
warmth.
Neuro: AOx3, alert, grossly intact, fluent speech. Answering
questions appropriately.
Pertinent Results:
ADMISSION LABS:
___ 07:45PM BLOOD WBC-19.0*# RBC-4.08* Hgb-10.9* Hct-33.3*
MCV-82 MCH-26.7 MCHC-32.7 RDW-14.3 RDWSD-41.9 Plt ___
___ 07:45PM BLOOD Neuts-63.6 Lymphs-17.4* Monos-16.6*
Eos-0.2* Baso-0.5 Im ___ AbsNeut-12.09*# AbsLymp-3.32
AbsMono-3.16* AbsEos-0.04 AbsBaso-0.09*
___ 07:45PM BLOOD Glucose-272* UreaN-23* Creat-1.7* Na-130*
K-4.3 Cl-90* HCO3-25 AnGap-19
___ 07:50PM BLOOD Lactate-1.2
___ 07:50PM BLOOD ___ pO2-42* pCO2-43 pH-7.42
calTCO2-29 Base XS-2 Comment-GREEN TOP
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-15.3* RBC-4.55* Hgb-12.2* Hct-37.9*
MCV-83 MCH-26.8 MCHC-32.2 RDW-14.7 RDWSD-44.4 Plt ___
___ 07:30AM BLOOD Glucose-254* UreaN-24* Creat-1.4* Na-134
K-4.6 Cl-94* HCO3-24 AnGap-21*
___ 07:30AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0
___ 10:28AM BLOOD CRP-217.1*
MRI:
1. Status post L5 laminectomies. Slightly heterogenous small
nonenhancing
fluid collection in the laminectomy beds, without mass effect on
the thecal
sac, which is contiguous with a nonenhancing fluid collection in
the
subcutaneous fat from L4 through S1, may represent a
postsurgical seroma.
Superimposed infection cannot be excluded by imaging.
2. Apparent residual or recurrent nonenhancing left paracentral
disc
herniation at L5-S1 extending inferiorly, with mass effect on
the left S1
nerve root. Unchanged moderate right and mild left L5-S1 neural
foraminal
narrowing with deformation of the right L5 nerve root and
abutment of the left
L5 nerve root.
3. Stable appearance of postsurgical and degenerative changes at
L4-L5.
4. Severe spinal stenosis at L3-L4 appear slightly worse than on
___. Moderate right and severe left neural foraminal narrowing
is unchanged.
AXR: No evidence of constipation. A single loop of mildly
dilated small bowel in
the left abdomen is consistent with a focal ileus.
LENIs: Deep venous thrombosis of the left peroneal veins.
Brief Hospital Course:
___ s/p L4-L5 laminectomy POD#5 (___), HTN, IDDM ___ years) who
presents with intermittent fevers, nausea, constipation and
weakness.
#Fever: The patient was admitted with intermittent fevers up to
102.8 since his surgery. Possibly etiologies included incision
site infection, spinal cord infection, septic joint vs. gout vs.
cellulitis, Post-surgical UTI or PNA, constipation, drug fever
or DVT. The patient's incision site was clean, non-erythematous,
non-purulent and no neurological deficits were seen on exam.
While MRI showed a heterogenous fluid collection, per
neurosurgery, this was a post-operative change consistent with
post-surgical seroma. UA was negative. CXR showed no new
atelectasis or consolidation. The patient was not on any new
medications, nor any classic causes of drug fever such as
anti-convulsants, antimicrobials, allopurinol or heparin. U/S
showed left peroneal DVT, however the patient never endorsed any
calf pain.
The patient has a history of gout (not documented) and had an
erythematous, warm, swollen L first MCP joint. Patient was
treated for gout flare and possible cellulitis of first finger
as below. Patient was afebrile over 24 hours before being
discharged.
#Constipation: The patient had not had a bowel movement since
the day before his surgery (10 days total). He had been passing
gas the whole time. He had been taking senna/Colace with no
success. The most likely etiology is ___ oxycodone. KUB did not
show obstruction. Bisacodyl and miralax were added to the
patient's bowel regimen and he eventually had a bowel movement.
#L Thumb Pain: The patient had increasing thumb pain since he
stopped his celecoxib on ___ for his surgery. Joint was
erythematous, swollen and warm to the touch. There was no
associated trauma. The most likely etiology was septic arthritis
vs. Crystal arthropathies (gout, pseudogout) vs. cellulitis. Of
these, gout and cellulitis were most likely. Hand surgery was
consulted to tap the joint but it was dry tap. The patient was
started on colchicine, empiric vancomycin/ceftriaxone and
Acetaminophen to treat gout and infection. The
Vancomycin/Ceftriazone was switched to Keflex and colchicine was
continued. NSAIDs were added for pain and potential gout. The
patient's swelling, erythema and pain continued to resolve prior
to discharge.
#Encephalopathy: The patient had waxing and waning paranoia and
confusion on admission. There were several factors that could
have caused delirium in him, including pain, constipation,
fever, infection. Prior to discharge, he was back to his
baseline mental status.
#Left Peroneal DVT: ___ showed a left, non-extending peroneal
DVT. ___ said that while the patient is beyond post-op day 5,
they would prefer not anticoagulating him until 2 weeks post-op.
A discussion was had with the family regarding low risk of DVT
extension and PE and higher risk of bleeding in immediate
post-op period. The family elected to not start
anti-coagulation. Patient should follow up with outpatient to
monitor DVT and discuss anticoagulation after immediate post-op
period.
TRANSITIONAL ISSUES:
- New medications: Naproxen 500 mg BID x 5 days total (last day
___, colchicine 0.6 mg daily, Keflex ___ mg q6h x 7 days
total course (last day ___
- Please evaluate right leg for erythema, worsening swelling at
next PCP ___. Legs appeared equal upon discharge. Consider
doing follow up ultrasound in 2 weeks to r/o propagation of
right peroneal DVT. Not on anticoagulation as above.
- Patient needs to follow up with neurosurgeon Dr. ___ at
___.
- Patient started on colchicine for gout. Consider stopping in
outpatient follow-up.
>30 minutes spent in coordination of care and counseling on day
of discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Furosemide 20 mg PO DAILY:PRN severe peripheral edema
3. Glargine 53 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 50 mg PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO BID:PRN pain
6. Pravastatin 10 mg PO Frequency is Unknown
Discharge Medications:
1. TraMADol 50 mg PO Q6H:PRN pain
if oxycodone too strong and not needed. call surgeon is pain is
getting worse, please!
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*1
2. amLODIPine 10 mg PO DAILY
3. Glargine 53 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 50 mg PO DAILY
5. OxyCODONE (Immediate Release) 2.5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q3h Disp
#*21 Tablet Refills:*0
6. Pravastatin 10 mg PO EVERY OTHER DAY
7. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
RX *acetaminophen [Pain Reliever] 500 mg 2 capsule(s) by mouth
every eight (8) hours Disp #*60 Capsule Refills:*2
8. Cephalexin 500 mg PO Q6H Duration: 4 Days
last day ___
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
9. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 tablet(s) by mouth daily Disp #*21
Tablet Refills:*0
10. Naproxen 500 mg PO Q12H Duration: 3 Days
Stop taking on ___
RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*7
Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
12. Senna 17.2 mg PO HS
RX *sennosides 8.6 mg 2 tablets by mouth at bedtime Disp #*28
Tablet Refills:*2
13. Furosemide 20 mg PO DAILY:PRN severe peripheral edema
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
Gout flare
Cellulitis
Delirium
Constipation
Deep Vein Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to ___ with fevers, nausea, constipation and
confusion. ___ were found to have a cellulitis (skin infection)
vs. gout flare of your left thumb as well as a DVT (blood clot)
in your right calf.
WHAT WAS DONE?
==============
-___ had an MRI of your spine to make sure there was no
post-surgical infection. We did not see any signs of infection.
-___ had an ultrasound of your legs to look for a clot. We found
one clot in the right calf. We discussed the pros and cons of
starting anticoagulation for this blood clot. ___ were not
started on anticoagulation due to the risk of bleeding after
your surgery.
-___ received antibiotics, first through IV and then pill form,
as well as colchicine and Naproxen for your left thumb infection
and possible gout flare.
WHAT TO DO WHEN I LEAVE THE HOSPITAL
====================================
-For pain: try acetaminophen 1 gram every 8 hours first. Do not
exceed 3 grams of acetaminophen per day. If acetaminophen does
not work, try 50 mg tramadol every 6 hours. If tramadol does not
help your pain, try 2.5 mg oxycodone every 3 hours (split 5 mg
pills in half). Do not combine tramadol with oxycodone.
- If your pain is getting worse, please call your neurosurgeon
and primary care doctor immediately
- Take your antibiotic (Keflex/cephalexin) for 4 more days (last
day ___ for your skin infection.
- ___ were started on colchicine for possible gout flare. Please
take one daily until ___ see your PCP.
- ___ were started on Naproxen 500 mg two times per day. Please
take with food. ___ should only take this for 3 more days (last
day ___. This medication treats gout and pain from your
surgery.
-Follow up with your PCP and neurosurgeon as scheduled.
-Call your doctor if ___ develop fevers, your hand swelling does
not resolve, or your back pain worsens.
-Work with physical therapy and continue to be mobile.
Wishing ___ the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
10623220-DS-9 | 10,623,220 | 22,458,922 | DS | 9 | 2123-05-01 00:00:00 | 2123-05-02 13:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ wound
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ w/ hx of HTN, hypothyroidism who presents
to the ED after suffering traumatic abrasion to L ___, now
with draining and erythema.
She states that she had a ___ kneeler come down and scrape
her shin a little over a week ago. At the time, she went home
and soaked it in warm cloths. It had a large hematoma, which
burst a day or two ago. Given that the skin over the wound came
off and it was draining so, she asked her taxi to bring her to
the ED today for further eval.
In the ED, initial VS were 98.4 88 173/63 17 98%RA. Received
a wound consult in the ED. Chem 7 and CBC normal with elevated
CRP at 7.9. Cultures were taken from wound, the area was
abraded.
On arrival to the floor, no pain in the wound. She relates a
good history.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
*S/P TOTAL ABDOMINAL HYSTERECTOMY
CERVICAL SPONDYLOSIS
DYSHIDROTIC ECZEMA
EDEMA
GASTROESOPHAGEAL REFLUX
HYPOTHYROIDISM
LEG ULCERS
OBESITY
OSTEOARTHRITIS
HYPERTENSION
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 169/58 74 18 97%RA
General - pleasant, NAD
HEENT - anicteric sclerae
CV - RRR no m/r/g
Lungs - CTAB
Abdomen - soft, nt nd
GU - no foley
Ext - ___ edema L>R. DP pulses palpable b/l. ___ pulses
dopplerable, less strong on L
Neuro - AOx3, fluent speech, normal strength in all extremities
Skin - 3.5cm dark maroon depressed ulcer on the L shin that was
covered with clean dry wrapping (removed to examine).
Nontender. Surrounding erythema and edema. Draining clotted,
necrotic material.
DISCHARGE PHYSICAL EXAM:
VS - 98.1 135/49 75 18 96%RA
General - pleasant, NAD
HEENT - anicteric sclerae
CV - RRR no m/r/g
Lungs - CTAB
Abdomen - soft, nt nd
Ext - ___ edema L>R. DP pulses palpable b/l. ___ pulses
dopplerable, less strong on L
Neuro - AOx3, fluent speech, normal strength in all extremities
Skin - 3.5cm x 3cm dark depressed ulcer on the L shin with some
white tissue over top. Slightly tender around edges.
Surrounding erythema and edema. Draining clotted, necrotic
material.
Pertinent Results:
Admission Labs:
___ 04:44PM BLOOD ___
___ Plt ___
___ 04:44PM BLOOD ___
___
___ 04:44PM BLOOD ___
___
___ 07:15AM BLOOD ___
___ 04:47PM BLOOD ___
STUDIES:
___ ___
IMPRESSION:
1. No left lower extremity deep venous thrombosis.
2. 3.5 cm left ___ cyst.
L Tib/Fib Xray ___
There is an ulceration anteriorly at the level of the lower
shaft of the tibia and fibula. However, there is no evidence of
fracture. The ankle and knee are not adequately evaluated.
ABI ___
No evidence of significant arterial insufficiency to the right
lower extremity.
Significant left superficial femoral and tibial arterial
insufficiency at
rest.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY: ___ w/ hx of HTN, hypothyroidism who
presents to the ED after suffering traumatic abrasion to L
___, now with draining and erythema. The lesion was likely
a hematoma that has since opened into a draining ulcer. She was
discharged to home on antibiotics for 7 d course with home wound
care.
ACTIVE CLINICAL ISSUES:
# wound: Appears to be a ruptured hematoma +/- surrounding
cellulitis. Vascular surgery has been consulted, who would like
to follow this patient as L pulses are diminished. ABIs
demonstrated decreased flow in L leg. She will complete
augmenting and bactrim (DS BID) therapy for a total course of
7d. Her dressings were recommended by wound care RN and
vascular surgery team. She will elevate the leg, change
dressings, be discharged to home w/ wound care visiting RN and
___ w/ PCP and ___.
INACTIVE CLINICAL ISSUES:
# HTN: normotensive on discharge
# Hypothyroidism: continued home levothyroxine.
TRANSITIONAL ISSUES:
- continue amox/clavulanic acid and bactrim (DS BID) for total
course of 7d
- ___ w/ PCP
- ___ w/ ___ clinic
- home ___ for wound
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluocinonide 0.05% Ointment 1 Appl TP BID affected area
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Acetaminophen 650 mg PO TID
4. Fluocinonide 0.05% Ointment 1 Appl TP BID affected area
5. ___ Acid ___ mg PO Q12H
RX ___ clavulanate 875 ___ mg 1 tablet(s) by
mouth twice a day Disp #*7 Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX ___ 800 ___ mg 2 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnoses: L lower leg ulceration, cellulitis
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.
You were admitted to the hospital for an ulceration on your left
leg. We treated this with dressing changes. We also had our
wound nurse and our vascular surgeons evaluate them and followed
their guidance. You have been treated with antibiotics for a
surrounding infection.
It is important for you to keep your ___ appointments.
The following changes were made to your medications:
-START Bactrim 2 tablets twice a day
-START Amoxicillin 2 tablets twice a day
The last day of these antibiotics will be on ___.
Followup Instructions:
___
|
10623751-DS-19 | 10,623,751 | 22,971,148 | DS | 19 | 2181-12-02 00:00:00 | 2181-12-05 13:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Admit for positive flu test
Major Surgical or Invasive Procedure:
Port replacement since his Port was in his RIJ.
History of Present Illness:
Mr. ___ is a ___ male with multiple myeloma,
chronic kidney disease, poorly controlled hypertension,
diastolic
CHF, renal insufficiency, sleep apnea currently undergoing
chemotherapy (last carfilzomib ___ who presents with fever.
Patient reports feeling sick since yesterday morning. He notes
symptoms including nasal congestion, sore throat, muscle aches,
shortness of breath, dry cough, and chills. He denies sick
contacts and recent travel. He did not receive the flu shot this
year.
Came in to clinic today for scheduled chemo, had temp 101 and up
to 102 (fever x 2 days but hadn't reported it). Given Tylenol at
1630 and 1 hour later was 102.5. Nasopharyngeal swabs done. CXR
negative for pneumonia, but reported that port is in jugular.
Given a dose of Azithromycin 500.
Today labs showed: chem reassuring other than BUN/cr 43/6.6 (at
baseline) WBC 7 with 67% pmns, Hct stable at 24, plts WNL.
calcium and LFTs also WNL. Positive fluA PCR. Resp viral panel
pending. CXR with No focal evidence of pneumonia. 2. Severe
stable cardiomegaly.
3. Right-sided Port-A-Cath with the terminal tip projecting in
the right jugular vein.
In the ED, T was 101.1 BP 182/89, HR 84. RR 18 94%RA. Patient
was
given Tamiflu 30mg PO and 1L NS. Vitals prior to transfer were
100.5 82 151/73 18 98% RA.
On arrival to the floor, he denies pain. He denies headache,
vision changes, dizziness/lightheadedness, chest pain,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
dysuria,
and hematuria.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia
2. CARDIAC HISTORY: None
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
OBSTRUCTIVE SLEEP APNEA
OBESITY
RENAL INSUFFICIENCY
Social History:
___
Family History:
His mother is alive, age ___ with hypertension
and back pain. His father died at age ___ of cancer. His
brother
is alive at age ___ with diabetes and hypertension. His sister
is
alive at age ___ with hypertension.
Physical Exam:
VS: Temp 100.8, BP 150/90, HR 79, RR 18, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, scattered end
expiratory wheezes.
ABD: Normal bowel sounds, obese, soft, nontender, nondistended,
no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused. 2+ bilateral lower extremity edema.
NEURO: Alert, oriented, good attention and linear thought, CN
II-XII intact, FTN and HTS intact. Strength full throughout.
SKIN: No significant rashes.
Pertinent Results:
___ 05:06AM BLOOD WBC-8.0 RBC-2.83* Hgb-7.1* Hct-23.2*
MCV-82 MCH-25.1* MCHC-30.6* RDW-20.9* RDWSD-62.1* Plt ___
___ 05:06AM BLOOD Glucose-76 UreaN-53* Creat-7.1* Na-139
K-4.3 Cl-103 HCO3-24 AnGap-16
___ 05:06AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ male with
multiple myeloma, chronic kidney disease, poorly controlled
hypertension, diastolic CHF, renal insufficiency, sleep apnea
currently undergoing chemotherapy (last carfilzomib ___ who
presents with fever, his fever quickly defervesced after
initiation of Tamiflu (renally dosed) and was able to be
dhischarged home in 2 days in stable condition
# Fever
# Influenza A Positive
No pneumonia on CXR
blood culture- NGTD
Sent home with total 5 days of Tamiflu total
# chronic kidney disease/ proteinuria: Creatinine stably
elevated
in 6 range today. CKD mostly secondary to long standing
uncontrolled HTN as demonstrated by prior renal biopsy, rather
than felt related to myeloma. Being followed by renal. BP still
remains an issue see below.
- Renally dose medications
- Continue calcium acetate
# Port malplacement - CXR today reveals that port terminates in
right jugular vein.
- d\w ___. port replaced with proper positioning this time.
# HTN -
per recent PCP ___ "Complicated by possible cognitive
impairment and severe renal failure. Will consider clonidine
patch 0.1 mg if persists."
- cont home labetalol 600mg po BID, home hydral, torsemide,
amlodipine
# Myeloma - missed carfilzomib (due today) due to sx and admit,
on carfilzomib/rev/dex
- d\w ___ , MM medications to be held until next appointment
with them.
- cont ___, Bactrim
- cont ASA while on revlimid
# Back pain: Recent MRI showing spinal stenosis.
- Continue oxycodone
TRANSITIONAL ISSUES
Pt requested scripts for oxycodone before discharge as he had
run out of medications. Gave 14 days worth of oxycodone
prescriptions. However pharmacy (___) called me adn told me that
he had picked up >100 pills of oxycodone 3 days ago prior to
admission. I spoke with the patient about this, and he mentioned
that he does have the medications but now he cannot go to his
home to access them as he is staying with his mother at her
place. Discussed with pharmacy, they were not comfortable
prescribing pills for concerns of diversion. They told me they
would give 4 pills for emergency needs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO QPM
2. Atorvastatin 80 mg PO QPM
3. Calcium Acetate 667 mg PO TID W/MEALS
4. HydrALAZINE 100 mg PO Q8H
5. Labetalol 600 mg PO BID
6. Lenalidomide 5 mg po QOD
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
8. Acyclovir 400 mg PO DAILY
9. Clotrimazole Cream 1 Appl TP BID
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Torsemide 80 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. OSELTAMivir 30 mg PO Q24H
RX *oseltamivir [Tamiflu] 30 mg 1 capsule(s) by mouth daily Disp
#*3 Capsule Refills:*0
2. Acyclovir 400 mg PO DAILY
3. amLODIPine 10 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium Acetate 667 mg PO TID W/MEALS
7. Clotrimazole Cream 1 Appl TP BID
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. HydrALAZINE 100 mg PO Q8H
10. Labetalol 600 mg PO BID
11. Lenalidomide 5 mg po QOD
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*40
Tablet Refills:*0
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Torsemide 80 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza type A
Chronic kidney disease
HTN
Multiple Myeloma
Discharge Condition:
stable, afebrile
Alert and clear mental status
Ambulates independently
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
DEar ___,
You were admitted since you had fevers and you tested positive
for Flu. You received treatment with Tamiflu while you were in
the hospital. Please continue to take this medication as
directed below. your other follow up appointments are set up as
below, please follow up with them. I discussed with your
oncologist about your medications and they will stop for now and
they will discuss with you about this at the next appointment
Your port was not in the right place so you had to undergo the
procedure to replace your port during this visit.
Please call your primary care providers office if you have any
questions.
Sincerely,
___ MD
Followup Instructions:
___
|
10623751-DS-22 | 10,623,751 | 29,594,748 | DS | 22 | 2183-09-03 00:00:00 | 2183-09-05 07:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Clotted AV graft
Major Surgical or Invasive Procedure:
Temporary HD catheter in R internal jugular vein, now removed
Recanalization of AV graft
History of Present Illness:
___ male with past medical history significant for ESRD
on HD ___, smoldering multiple myeloma (not
on active chemo), hypertension, hyperlipidemia, chronic back
pain, and congestive heart failure who presented to the ED 2
days
ago as a referral from AV care with a chief complaint of clotted
LUE graft. Patient remained in the ED on ___ and ___ during
which time he had a temporary HD catheter placed (RIJ) and
underwent dialysis on ___ with removal of 3 L UF. He had been
planned to undergo attempted recanalization with ___ and
anesthesia on ___ but this did not happen. Hence, he was
admitted to the medical service after being in the ED for 48
hours. Patient's last dialysis session prior to ___ was on
___. Otherwise, patient reports that he is in his usual state
of health and does not have any other complaints apart from left
upper extremity pain. Denies fevers, chills, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, lightheadedness, dizziness. Does report increased
lower extremity edema that improved after dialysis yesterday.
Past Medical History:
- Hypertension
- Congestive Heart Failure
- Obstructive Sleep Apnea
- ESRD on HD ___
- Obesity
- Knee Pain s/p right knee surgery
Social History:
___
Family History:
Mother with hypertension and back pain. His father died at age
___ of cancer. His brother is alive at age ___ with diabetes and
hypertension. His sister is alive at age ___ with hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Head/ Eyes: NC/AT
Neck: Supple
ENT: OP WNL
Resp: CTAB
Cards: RRR. s1,s2. no MRG.
Abd: S/NT/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c, LUE with trace edema, LUE AVF with palpable
pulse, no audible thrill.
Neuro: speech fluent, MAE with no gross focal lateralizing
neurologic deficit
Psych: normal mood
DISCHARGE PHYSICAL EXAM
=======================
T 99.0, BP 136-165/68-91, HR 63-66, 94%RA
GENERAL: NAD, lying comfortably in bed
HEENT: AT/NC, anicteric sclera, MMM, proptotic both eyes
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: 1+ lower extremity edema, LUE fistula with palpable
thrill, bruit
PULSES: 2+ DP pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 01:10PM BLOOD WBC-7.0 RBC-3.68* Hgb-10.1* Hct-32.3*
MCV-88 MCH-27.4 MCHC-31.3* RDW-14.0 RDWSD-45.1 Plt ___
___ 01:10PM BLOOD Glucose-81 UreaN-87* Creat-11.3* Na-139
K-5.2 Cl-101 HCO3-22 AnGap-16
___ 01:10PM BLOOD Calcium-9.0 Phos-6.3* Mg-1.9
PERTINENT LABS
===============
___ 07:40AM BLOOD WBC-7.4 RBC-3.71* Hgb-10.4* Hct-32.7*
MCV-88 MCH-28.0 MCHC-31.8* RDW-13.6 RDWSD-43.8 Plt ___
___ 07:40AM BLOOD Glucose-90 UreaN-72* Creat-10.4* Na-139
K-4.8 Cl-98 HCO3-23 AnGap-18
___ 11:37AM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND RDW-PND RDWSD-PND Plt Ct-PND
___ 07:00AM BLOOD Glucose-82 UreaN-55* Creat-8.0*# Na-140
K-4.1 Cl-98 HCO3-25 AnGap-17
IMAGING
========
Temp HD line (___)
Successful placement of a temporary triple lumen catheter via
the right internal jugular venous approach. The tip of the
catheter terminates in the distal superior vena cava. The
catheter is ready for use.
Fistulogram (___):
The patient has a left forearm loop graft. Occlusion of the
brachial vein with opacification of multiple collateral veins.
Brief Hospital Course:
___ yo male with PMH significant for ESRD on HD (___), HTN,
smoldering multiple myeloma who presented with clotted AV
fistula s/p ___ based recannulization on ___.
ACUTE ISSUES:
=============
#ESRD on HD ___
#Occluded LUE Graft
Patient in the ED for 2 days after referral from AVcare for
occluded AV graft. s/p temporary HD catheter placement (RIJ) on
___. Last dialysis ___ with 3L UF removed. Patient was very
upset that 3 L were removed, rather than his usual ___ (he is
very particular about amount of fluid removal during HD due to
concern for cramping). Pt is s/p ___ recannulization of AV
graft on ___. Although we would have preferred for patient to
have HD again here before discharge, patient refused and wanted
to return to outpatient HD on ___. The
risks/benefits/alternatives were communicated and patient
understood complications of missing HD including fluid overload,
shortness of breath, cardiac arrhythmias, and death. On
discharge, Na 139, K 4.8, Cr 10.4, Ca 8.7, Mg 2.0, P 6.4
CHRONIC ISSUES:
===============
# Smoldering Myeloma: Received chemotherapy in the past with no
current plans except monitoring.
# Normocytic Anemia: Hgb 10.7 at baseline Hgb ___.
# HLD: Continue home atorvastatin
# HTN: Continue amlodipine and labetalol
# Spinal Stenosis/Chronic back pain: Continue home oxycodone
# Insomnia: Held home zolpidem while in house
TRANSITIONAL ISSUES:
====================
#ESRD
#Occluded LUE Graft
[] Outpatient HD on ___, pt understands risks of not getting HD
here
[] PCP ___ on ___
>30 minutes spent coordinating discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sodium Bicarbonate 1300 mg PO BID
2. Zolpidem Tartrate 5 mg PO QHS
3. Labetalol 200 mg PO BID
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. OxyCODONE (Immediate Release) 5 mg PO DAILY
7. Calcium Acetate 667 mg PO TID W/MEALS
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
9. sildenafil 100 mg oral PRN
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Labetalol 200 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO DAILY
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. sildenafil 100 mg oral PRN
8. Sodium Bicarbonate 1300 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Clotted AV graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why was I admitted to the hospital?
===================================
Your AV graft of your left forearm was found to be clogged at
your dialysis center on ___, and you were transferred to the
BI so they could fix it.
What happened while I was in the hospital?
==========================================
While you were waiting for the interventional radiologists to
unclog the graft, you got a temporary dialysis line in your neck
and got dialysis on ___. You got your AV graft fixed on ___.
What should I do after leaving the hospital?
============================================
Please continue all your home medications and return to dialysis
next ___.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10623883-DS-14 | 10,623,883 | 27,359,600 | DS | 14 | 2140-07-10 00:00:00 | 2140-07-12 12:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Appendectomy
History of Present Illness:
___ healthy recently delivered baby in ___ presents to
ED with 2 day history of worsening RLQ pain and fevers. +
Nausea.
+flatus/normal BM. No dysuria.
Past Medical History:
ObHx: 6 weeks post partum
MedHx: none
SurgHx: none
Meds: none
All: NKDA
Social History:
___
Family History:
NC
Physical Exam:
98.2 98.1 92 100/69 18 98RA
AAOX3 NAD
RRR
CTAB
INCISION CDI
NO EDEMA
Pertinent Results:
CTA/P
IMPRESSION: Acute appendicitis. No extraluminal gas or
drainable fluid
collection.
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 appendicitis. The
patient underwent laparoscopic appendectomy, which went well
without complication (refer to the Operative Note for details).
After a brief, uneventful stay in the PACU, the patient arrived
on the floor tolerating sips, on IV fluids, and oxycodone for
pain control. The patient was hemodynamically stable. She was
maintained on 24hrs of antibiotics for concern of intrabdominal
pus.
.
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 spirrometry, 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. She was advised to pump/dump for 48 hours. 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 ___ mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*10 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive while taking narcotics
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours Disp
#*30 Tablet Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
Hold for loose stools
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Please pump and dump for 48 hours after surgery
Followup Instructions:
___
|
10623984-DS-10 | 10,623,984 | 25,097,439 | DS | 10 | 2156-06-18 00:00:00 | 2156-06-21 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status, ?seizure
Major Surgical or Invasive Procedure:
placement of triple lumen catheter in right IJ
History of Present Illness:
___ PMH of ETOH abuse (c/b severe withdrawal, seizures, DTs,
requiring ICU admission and intubation in past), Seizure
disorder? (on keppra BID, unclear if compliant), who was
transferred from OSH s/p potential seizure. As per report from
OSH, pt had last drink night of seizure. Pt's father then heard
a loud crash in patient's room, found him on ground,
awake/confused, incontient of urine. Given pt's hx, and
suspected seizure, he was then brought to ___.
.
At ___, pt was found to have a lactate of 4.6 and left
humurus fx so was placed in sling. He also had RIJ CVL placed,
was given ASA, Ativan (1mg x2), Keppra, and 1L IVF. Pt was then
transferred to ___ due to need for ICU care and no bed
availability at ___ ICU.
.
In the ___, initial VS were 99.3 136 128/87 18 99% RA. Pt was
very agitated/tremulous initially, and later was febrile to
103.5, and tachycardia persisted >120 (EKG sinus tach)
throughout ___ course. Labs were significant for WBC 5.6 (74%N),
Hg 12.8, Plt 93, PT13.1, INR 1.2, ALT 41, AST 77, TBili 1.6, Alb
3.7, Ca 7.5 ,Phos 1.6, K3.2, Trop 0.05, UA (1WBC, sm bld, 30
prot, trace ketones), Serum/Urine tox negative, CSF7WBC, 2RBC,
40 protein, 82 glucose). Imaging significant for CT HEAD
negative for intracranial abnormality, CT-CSpine w/o contrast no
fracture in spine but surgical fx of humerus noted on scout
film, CT upper extremity pending but Xray showed
comminuted/impacted fracture of the surgical neck of the left
humerus w/out dislocation.
.
Pt was felt to be possibly withdrawing from ETOH given hx, so
was given 2mg Ativan, 20 mg Valium. In light of fever, pt given
Tylenol PR, Vancomycin/Ceftriaxone/Ampicillin/Acyclovir and had
LP.
.
On arrival to the MICU, VS were: T98, ___, BP139/100, R23,
O295%RA. Pt was noted to be AOx3, NAD, asymptomatic
.
Review of systems:
(+) Per HPI
(-) Sore throat, rhinorrhea, abd pain, nausea, vomiting, SOB,
photo/phonophobia, neck pain, diarrhea, dysuria, itching
Past Medical History:
-ETOH abuse (c/b severe withdrawal, seizures, DTs, requiring ICU
admission and intubation in past),
-Seizure disorder? (on keppra BID, unclear if compliant)
-Reported history of cirrhosis without clear evidence
-Upper GI Bleeding - s/p EGD ___ revealing lower esophageal
ulcers
-Small bowel obstruction ___ bezoar
-Intra-abdominal abscesses ___
-HTN
-Reported history of chronic pancreatitis without clear evidence
-Seizures
-QT prolongation
-Opioid addiction
-h/o C-diff ___
-Homelessness
-Medication non-compliance
-3rd degree burns on feet as child
-Positive Hepatitis C antibody but no detectable viral load
.
PAST SURGICAL HISTORY:
1. ___ - Exploratory laparotomy with enterotomy for ___
revealing SB fruit bezoar
2. Tonsillectomy
3. Eye surgery as a child for strabismus
.
Social History:
___
Family History:
Father is living in ___. Mother died in ___ of "a bad heart",
no fmaily hx of seizures
Physical Exam:
================================
ADMISSION EXAM ON ADMISSION:
================================
Vitals: T98, ___, BP139/100, R23, O295%RA.
General- AOx3 (name, ___, hospital, date), pleasant affect,
NAD
HEENT-no photo/phonophobia, PERRL, slight scleral icterus, neck
supple, neg lhermitte's sign, dry MM, OP clear, tongue
non-tremulous
Lungs-CTA b/l except for slight wheeze over R base. no incr WOB,
no accessory muscle use, speaking in full sentences
CV-tachycardic, RR, normal S1/S2, no m/r/g
Abdomen-Soft, NT/ND, central adiposity, no HSM, no caput
medusae, no spider angiomata,
GU-Foley in place
Ext-no palmar erythema, no lesions in webs of fingers, no
asterixis
Neuro-AOx3, PERRL, EOMI, no asterixis
Skin - scabbed circular lesions 2-3mm in diameter, predominantly
in inguinal folds, extending superiorly and inferiorly. Webs of
fingers and axilla are clear of any lesions.
Pertinent Results:
ADMISSION LABS:
===============================
___ 09:40AM BLOOD WBC-5.6 RBC-4.24* Hgb-12.8* Hct-38.6*
MCV-91 MCH-30.3 MCHC-33.3 RDW-15.2 Plt Ct-93*#
___ 09:40AM BLOOD ___ PTT-34.2 ___
___ 09:40AM BLOOD Glucose-114* UreaN-13 Creat-1.0 Na-137
K-3.2* Cl-99 HCO3-24 AnGap-17
___ 09:40AM BLOOD ALT-41* AST-77* AlkPhos-80 TotBili-1.6*
___ 05:45PM BLOOD CK(CPK)-572*
___ 09:40AM BLOOD cTropnT-0.05*
___ 09:40AM BLOOD Albumin-3.7 Calcium-7.5* Phos-1.6* Mg-1.6
___ 08:12AM BLOOD Phenoba-12.6
___ 09:56AM BLOOD Lactate-1.7
___ 07:00PM BLOOD freeCa-0.94*
CARDIAC ENZYMES
================================
___ 09:40AM BLOOD cTropnT-0.05*
___ 05:45PM BLOOD CK-MB-4 cTropnT-0.05*
___ 03:12AM BLOOD CK-MB-5 cTropnT-0.03*
CSF STUDIES:
==========================
___:
Tube 1: 12WBC 67RBC 78POLYS 6LYMPHS ___ MONOS
Tube 2: 7WBC 2RBC 76POLYS 6LYMPHS ___ MONOS
Total Prot 40, Total Glc 82
Herpes Simplex PCR: NEGATIVE
PERTINENT MICRO:
================================
___: Blood Cx NGTD x 2sets Prelim
___: Urine Cx No growth (FINAL)
___: CSF
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
___: MRSA SCREEN NEGATIVE
___ Rapid Respiratory Viral Screen & Culture - NEGATIVE
___ C. diff assay - NEGATIVE
___ Blood culture x 1 set
___ Blood culture x 1 set
PERTINENT STUDIES:
================================
___: CT HEAD
No acute intracranial abnormality.
.
___: CT CSPINE:
No acute fracture or malalignment.
.
___: GLENOHUMERAL SHOULDER X-RAY
Comminuted, impacted fracture of the surgical neck of the left
humerus. No dislocation is identified.
.
___: CT UPPER EXTREMITY:
1. Three-part fracture of the surgical neck of the humerus.
2. Multiple old rib fractures and an old fracture of the left
clavicle with nonunion.
.
___ PCXR
Right IJ line ends in the mid to low SVC. No pneumothorax,
pleural effusion or mediastinal widening. New peribronchial
opacification at the base of the right lung could be returning
atelectasis or early aspiration. Clinical followup advised.
Left rib fractures are chronic. Normal cardiomediastinal and
hilar silhouettes and pleural surfaces.
.
___ Renal US
1. No hydronephrosis in either kidney.
2. Stable renal cysts.
3. Mildly echogenic liver, similar to prior, most consistent
with hepatic steatosis.
.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
=============================================
___ PMH of ETOH abuse (c/b severe withdrawal, seizures, DTs,
requiring ICU admission and intubation in past), Seizure
disorder? (on keppra BID, unclear if compliant), who was
transferred from OSH s/p potential seizure who p/w fever and
tachycardia
.
ACTIVE ISSUES:
=============================================
# ENCEPHALOPATHY:
Pt is not known to be altered at baseline but was found
awake/confused and incontinent of urine by his father. In ___ pt
was tremulous, agitated, AOx1-2. Post-ictal period possible,
given resolution of AMS by time pt transferred to MICU. Given hx
of ETOH abuse (AST>ALT), acute intoxication and ETOH withdrawal
were high on differential but serum/urine tox were negative and
timecourse wasn't appropriate for withdrawal. Trauma, cranial
bleed, or mass lesion unlikely given negative CT head in ___.
CHEM panel unremarkable. Corrected Ca low (7.5) which can
account for AMS and seizures. Encephalopathy ___ liver disease
also possible given history of cirrhosis but no asterixis/AMS on
exam. The fever of 103 in the ___ was concerning for possible
meningitis. Lumbar puncture had slightly elevated WBC (despite
normal protein and glucose). The patient was started on
Vancomycin, Ampicillin, Ceftriaxone, and Acyclovir. Once the CSF
gram stain was negative and CSF cultures were negative x24hrs,
antibiotics were discontinued. Acyclovir was continued until
HSV PCR also returned negative. Given hx of ETOH withdrawal, pt
was started on phenobarbital protocol and appeared comfortable
throughout the MICU course. He was also given
MVI/Folate/Thiamine. Sedating medications - quetiapine Fumarate
and TraZODone were held.
.
#Seizure
It is unclear if pt has primary seizure disorder, or has just
had seizures associated w/ ETOH withdrawal. As per OSH records,
pt is non-compliant w/ BID Keppra dosing. Pharmacy confirmed
that pt is out of medication at home. Pt has hx of being found
down, incontinent of urine, w/ elevated lactate 4.5 at OSH, and
confusion c/w post-ictal state is convincing of seizure
occurrence. Possible etiologies of seizure include medication
non-compliance (most likely), ETOH withdrawal (no evidence on
exam), acute head injury (CT Negative), infection (given CSF
studies), or metabolic derangement (hypocalcemia). Keppra was
continued at home dose for seizure prophylaxis and pt did not
have any events during hospitalization. ETOH withdrawl was
treated successfully w/ phenobarbital protocol. Meningitis was
considered given fever and altered mental status - CSF had only
slightly elevated WBC (but normal protein/glucose) and patient
was emperically treated w/ Vancomycin, Ampicillin, Ceftriaxone,
and Acyclovir. Once the CSF gram stain was negative and CSF
cultures were negative x24hrs, antibiotics were discontinued.
HSV PCR then returned negative and Acyclovir was ___ as well.
.
# EtOH dependence / intoxication / withdraw
Pt has long standing history of significant EtOH abuse. Unclear
what attempts have been made for voluntary treatment. Pt
reports the last time he was sober was while incarcerated. He
was placed on phenobarbital taper for withdraw risk. He was
also placed on MVI, thiamine, folate. In discussion with him
during this hospitalization, he initially agreed to be evaluated
for placement at an inpatient treatment program, however, he has
since refused. Given that he has had recurrent admissions for
similar presentation and concern that his alcoholism is
preventing him from being medically compliant with his seizure
medications, Section 35 was considered. In terms of his risk,
this does not appear to be an acute change and he has been
admitted several times in the past ___ years for similar
presentation.
.
# Humeral Fracture
On CT head scout films, pt was noted to have a Left humeral head
fracture. X-ray here showed that fracture was
comminuted/impacted but without dislocation. Orthopedics saw pt
and recommended a sling, no weight bearing w/ LUE, starting
pendulum exercises in ___, and ROMAT through elbow. He was
instructed to make an appointment to follow up in ___
in 4 weeks. Seen by ___.
.
# Acute Kidney Injury / Acute renal failure
Pt with normal Creatinie at baseline. During hospitalization
had sudden increase in Cr from 0.6 to 1.9. He continued to make
good UOP, renal US did not show obstruction, UA was bland and
Urine Eos were negative. We suspect this may be side effect
from IV Acyclovir. After stopping Acyclovir, his creatinine
returned to baseline.
.
# Thrombocytopenia
Likely ___ ETOH use or liver disease as chronic and nadir in
___ in past as per OMR review. No e/o active bleeding. Count
remained relatively stable, so no acute intervention ocurred,
and platelet count since returned to within normal limits.
.
# Rash / Scabies
Pt had rash in inguinal area with sparing of other areas of
body. Given poor hygeine, scabies was high on differential, but
dermatitis also possible. ___ w/ lindane cream once and rash
improved dramatically. He also received 1 dose of ivermectin
PO.
.
# Cirrhosis
Patient is reportedly Hep C positive, and carries a diagnosis of
cirrhosis, though the details are unclear. AST>ALT x2 on this
admission. Given hx of extensive ETOH abuse, it is most likely
etiology. Exam reveals no stigmata of liver disease or
encephalopathy.
.
# Diarrhea
Initially concerning for C. diff, due to history of C. diff in
the past, as well as broad spectrum antibiotic use during
hospitalization. However, C. diff assay returned negative and
pt's diarrhea resolved spontaneously.
.
# Renal cyst: stable on imaging
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. QUEtiapine Fumarate 25 mg PO DAILY
6. TraZODone 25 mg PO Q4H:PRN agitation
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Acetaminophen 650 mg PO Q8H:PRN fever/pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
EtOH intoxication / dependence / withdraw
Seizure disorder
Left humerus fracture
Acute renal failure / Acute kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ after being found unconscious
by your father, with either alcohol intoxication or seizure.
You were then transferred to ___ and admitted to the ICU
initially for close monitoring due to concern for severe alcohol
withdraw. You underwent a spinal tap to rule out meningitis,
with current results showing no evidence of meningitis. Your
symptoms improved. You were seen by the Physical and
Occupational Therapists and they recommend home services. We
recommended that we help place you in an alcohol treatment
program, which you initially agreed to, but then declined.
.
Do not resume drinking alcohol. If you do use alcohol, please
know that you were given a medication in the hospital that makes
you more sensitive to the effedcts of alcohol with greater
potential
intoxication at number of beverages than you are used to
.
You were also found to have a left humerus (arm) fracture. You
were seen by the Orthopedic surgeons and they recommend
conservative management with a sling. You will need to call the
Orthopedic surgeons to schedule a follow up appointment.
.
Please take your medications as listed.
.
Please see your physicians as instructed.
.
Followup Instructions:
___
|
10623984-DS-14 | 10,623,984 | 25,863,300 | DS | 14 | 2157-06-21 00:00:00 | 2157-06-22 08:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of polysubstance abuse (EtOH, IV opiates), alcohol
related withdrawal seizures, HCV, sCHF (EF ___,
polysubstance abuse who presents with altered mental status.
Patient was in usual health until 1d PTA when his father noted
he was having "seizure like activity" (no further clarification
available) for about two hours. He was transported to ___
___, where he was febrile to 102, tremulous, tachycardic and
hypertensive; he was apparently alert to name and following
basic commands.
- Initial labs notable for lactate 18. Tox screen performed and
+for barbiturates, ETOH 64.
- Imaging: head CT was obtained and neg for acute intracranial
process.
- Interventions: 2L IVF, banana bag, and acetaminophen. Diazepam
20 mg x3 for withdrawal. Lyte repletion 40meq KCl for K=3.1, Mg
2gm IV. Given fevers and report of last IVDU 1wk PTA, pt was
started on vanc/ceftriaxone.
- R IJ was placed due to inability to obtain peripheral access.
- Repeat lactate was 2.8.
He was then transferred to ___ for ICU-level management of
ETOH withdrawal. VS at transfer were AF 128 146/68 16 98%2L.
In ___ ED, initial VS were ___ 19 96%. Given a
question of altered mental status in setting of IVDA, LP was
performed to eval for meningitis. Acyclovir x1 given. CTX 1g
given (for 2g total, to achieve meningitic dosing). CXR obtained
and neg for acute intrathoracic process. He was then txf to ___
for management of ETOH withdrawal and seizures. VS at transfer
129 166/94 16 98% RA.
On arrival, the patient reports feeling tired and endorses the
history above. He denies fevers, chills, chest discomfort,
shortness of breath, abdominal pain. Most recent IVDA 1 week
ago. Most recent ETOH was the day prior to admission.
Past Medical History:
-sCHF LVEF= ___ %
-ETOH abuse (c/b severe withdrawal, seizures, DTs, requiring ICU
admission and intubation in past)
-Seizure disorder? (on keppra BID, non-compliant)
-Reported history of cirrhosis
-Upper GI Bleeding - s/p EGD ___ revealing lower esophageal
ulcers
-Small bowel obstruction ___ bezoar
-Intra-abdominal abscesses ___
-HTN
-Reported history of chronic pancreatitis without clear evidence
-Seizures
-QT prolongation
-Opioid addiction
-h/o C-diff ___
-Positive Hepatitis C antibody but no detectable viral load
Social History:
___
Family History:
Father is living in ___, also suffers from alcoholism. Mother
died in ___ of "a bad heart", no family hx of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.9 ___ 35 98%RA
General: Alert, oriented, no acute distress. Disheveled.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardia, regular, no murmurs. RIJ in place.
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
Pertinent Results:
LABS:
___ 07:00PM GLUCOSE-117* UREA N-6 CREAT-0.8 SODIUM-137
POTASSIUM-2.9* CHLORIDE-98 TOTAL CO2-23 ANION GAP-19
___ 07:00PM CALCIUM-7.5* PHOSPHATE-1.8*# MAGNESIUM-2.4
___ 07:15PM NEUTS-64.6 ___ MONOS-8.3 EOS-0.1
BASOS-0.2
___ 07:15PM WBC-5.6 RBC-4.29* HGB-13.1* HCT-37.4* MCV-87
MCH-30.7 MCHC-35.1* RDW-14.6
___ 07:17PM LACTATE-1.7
___ 07:17PM ___ PO2-40* PCO2-36 PH-7.47* TOTAL
CO2-27 BASE XS-2
___ 09:06PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-38 ___ ___ 09:15PM URINE RBC-2 WBC->182* BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:18PM NEUTS-61.7 ___ MONOS-9.6 EOS-0.5
BASOS-0.4
___ 11:18PM WBC-4.9 RBC-4.21* HGB-12.7* HCT-36.8* MCV-88
MCH-30.1 MCHC-34.4 RDW-14.1
___ 11:18PM TOT PROT-7.0 ALBUMIN-3.6 GLOBULIN-3.4
CALCIUM-7.5* PHOSPHATE-2.0* MAGNESIUM-1.8
___ 11:18PM ALT(SGPT)-43* AST(SGOT)-134* LD(LDH)-261* ALK
PHOS-89 TOT BILI-0.9
___ 06:17AM BLOOD WBC-4.8 RBC-3.93* Hgb-11.7* Hct-34.4*
MCV-87 MCH-29.6 MCHC-33.9 RDW-15.2 Plt Ct-47*
___ 06:17AM BLOOD Glucose-94 UreaN-8 Creat-0.8 Na-139 K-3.4
Cl-104 HCO3-23 AnGap-15
CXR ___ 03:28PM URINE Color-Orange Appear-Clear Sp ___
___ 03:28PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 03:28PM URINE RBC-8* WBC-57* Bacteri-FEW Yeast-NONE
Epi-0
FINDINGS:
AP portable upright view of the chest. Right IJ central venous
catheter is again seen with its tip in the region of the low
SVC. Lungs are clear. Multiple old rib cage deformities as well
as deformities of both clavicles again noted. No pleural
effusion or pneumothorax. Cardiomediastinal silhouette stable.
IMPRESSION:
Right IJ central venous catheter tip in the low SVC.
Brief Hospital Course:
___ hx of polysubstance abuse (EtOH, IV opiates), alcohol
related withdrawal seizures, HCV, sCHF (EF ___,
polysubstance abuse who presents with altered mental status.
# Seizures: Patient with hx of seizure disorder on
levetiracetam and history of ETOH withdrawal seizures.
Re-presents with seizure-like activity in the setting of
recently discontinuing alcohol and non-adherence to AED,
elevated lactate to 18 c/w seizure. Patient loaded per
phenobarbitol protocol. Restarted home dose Keppra. No further
seizures witnessed.
# ETOH withdrawal: Per patient, recent alcohol consumption
several days. Father admits to buying alcohol for the patient
and states that he drinks up to a liter of vodka a day. Father
states that without alcohol, the patient has the "shakes" and
that alcohol consumption stops the shaking. Father notes that
his son has "an addictive personality" and that leads him to
smoke and drink heavily. I counselled the father extensively on
the heavy damage that alcohol was inflicting on his son's health
and urged him not to buy alcohol for his son, to which his
father responded "You try living with an alcoholic". Patient
himself shows no desire to stop drinking alcohol. He is able to
articulate the risk to his health of ongoing drinking.
# Altered mental status: No leukocytosis, no localizing
hx/exam/studies (CXR/NCHCT neg, LP negative). Patient's mental
status returned to baseline (per father) over the course of the
hospitalization.
# Hypokalemia/hypophosphatemia: ? secondary to refeeding
syndrome. Repleted while in house.
# Thrombocytopenia: Unclear etiology. HIV test pending.
Peripheral smear ordered and pending.
# Substance abuse:
Abuses ETOH and opiates. Long history of abuse. Continued on
thiamine and folate.
# LFTs abnormalities: c/w recent alcohol use. No
hyperbilirubinemia. Pt with history of HCV
# Sterile pyruria: Noted during this hospitalization and prior
ones as well. Advised PCP ___ to have urine tests repeated and
consider GC/Chlamydia testing.
#Self care: Patient with prior history of guardianship, was
deemed last ___ admission ___, to FICU then floor for
ETHO withdrawal seizures) to have capacity. Review of
medication history reveals that he is inconsistent about having
medications filled and taking them.
# Hypertension: Started on captopril, and then converted to
lisinopril during hospitalization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sarna Lotion 1 Appl TP TID:PRN rash, itch
2. Nicotine Patch 14 mg TD DAILY
3. Thiamine 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. LeVETiracetam 500 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
8. Acetaminophen 650 mg PO Q8H:PRN pain
9. Docusate Sodium (Liquid) 100 mg PO BID
10. Senna 8.6 mg PO BID:PRN Constipation
11. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Thiamine 100 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
9. Sarna Lotion 1 Appl TP TID:PRN rash, itch
10. Acetaminophen 650 mg PO Q8H:PRN pain
11. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
1. Seizure disorder
2. Alcohol Abuse
3. Smoking use
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after a seizure which we believe is related to
alcohol withdrawal. You received medications to treat your
alcohol withdrawal. We advise you not to drink alcohol. Please
take your keppra or levacetiram for your seizure disorder. I am
discharging you with a medication for your high blood pressure.
It is called lisinopril. Please take one tablet daily.
Followup Instructions:
___
|
10623984-DS-16 | 10,623,984 | 20,718,890 | DS | 16 | 2158-04-05 00:00:00 | 2158-04-05 20:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure, tachycardia
Major Surgical or Invasive Procedure:
1) ICU stay with intubation and mechanical ventilation.
2) Endoscopic evaluation of his esophagus which revealed food
impaction (removed), severe structuring, and significant
ulceration.
History of Present Illness:
Mr. ___ is a ___ man with h/o cardiomyopathy with recent
normal EF ___ ___, ETOH abuse c/b seizures/DTs, active IVDU,
hepatitis C c/b cirrhosis, and seizure disorder who p/w
seizures.
Per report and the father, patient was at home with his father
and had a witnessed seizure by his dad. Father reports his last
drink was about 2 days ago. EMS activated and patient reportedly
no longer seizing when EMS arrived at scene, but he was
confused. When EMS arrived on scene, pt had a HR ___ 200s and was
found to be ___ SVT. He then had a witnessed tonic/clonic seizure
by EMS and was given 10mg IV diazepam en route with resolution
of seizure. He was also given 6 mg adenosine without effect.
He was initially brought to ___ where he was given
diltiazem with continued tachycardia to 130s. He was
unresponsive on presentation and was thus intubated for airway
protection and became hypotensive to SBP ___. For this, he was
given a total of 2.5L NS and subsequently started on levophed.
Labs significant for lactate of 15 and pH of 7.05. His ABG
showed pH 7.0, lactate 15. He was also given 2 gm CTX, 2mg
ativan, 1gm dilantin, 5mg valium, and a banana bag. He was then
transferred to ___ for further management. Per report, he was
weaned off levophed en route.
Of note, patient was recently admitted to ___ ___ -
___ for dilation of known chronic esophageal stricture. He did
not score on CIWA and did not require any benzodiazepines during
that hospitalization.
___ the ED, VS: 99.2 131 152/98 18 100% on ventilator
- Notable labs: WBC 14.7 (83.6% N), Lactate 4.7, negative serum
and urine tox screens
- CT head was negative for intracranial process
- CXR showed multiple old rib fractures and ETT terminating
approximately 6 cm above the carina
- ETT advanced 1cm
- Patient given midazolam/fentanyl for sedation and 10mg IV
diazepam x 2 for tachycardia/hypertension and was admitted to
___ for further care.
On arrival to the ___, pt intubated and agitated on sedation
and thus required some boluses of sedation. He subsequently
became hypotensive to SBP ___ for which he received 1L NS bolus
and started on neosynephrine given tachycardia.
Past Medical History:
-sCHF ___
-ETOH abuse (c/b severe withdrawal, seizures, DTs, requiring ICU
admission and intubation ___ past)
-Seizure disorder (on keppra BID, ___
-Upper GI Bleeding - s/p EGD ___ revealing lower esophageal
ulcers
-Small bowel obstruction ___ bezoar
-___ abscesses ___
-HTN
-Chronic pancreatitis
-h/o ___ ___
-Positive Hepatitis C antibody with undetectable VL
-? history of cirrhosis
Social History:
___
Family History:
Father is ___ years old, healthy.
Patient reports family hx of alcohol use.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 100.5 BP: 142/128 P: 139 R: 28 O2: 98% (___)
GENERAL: intubated, sedated
HEENT: No JVD
LUNGS: Ventilatory breath sounds
CV: RRR, S1 and S2, no m/r/g
ABD: BS+, soft, NT, ND
EXT: No ___ edema
SKIN: R lateral thigh with large hyper and hypopigmented patch
c/w scar
.
.
DISCHARGE PHYSICAL EXAM
VS: T 98 BP 118/56 HR 84 RR 18 pOx 98% on RA
Gen: NAD, lying comfortably ___ bed
HEENT: large ___ scar over left forehead, EOMI, sclera
anicteric, poor dentition
Neck: supple, no LAD, no JVD
Chest: normal work of breathing, able to speak ___ full
sentences,
no accessory muscle use, on auscultation: mild rhonchi and
moderate crackles remain prominent ___ bilateral lower lobes, no
wheezing or prolonged expiratory phase
Cardiovasc: RR, s1 and s2 quiet, no m/r/g, 2+ peripheral pulses
bilaterally, no ___ edema
Abd: soft, nontender, nondistended, BS+
MSK: laying flat ___ bed, but able to sit upright without
assistance, moving all 4 extremities spontaneously
Skin: no rashes noted
Neuro: awake, alert, and responsive to questions; able to follow
follows commands; oriented to person and place, but not to time
(but able to read calendar across the room) or reason for
hospitalization; no facial droop, slurred speech, or tremor;
remote memory seems generally intact; recent/working memory
remains extremely poor
and does not seem to be improving to any meaningful degree.
Psych: calm, cooperative
Pertinent Results:
ADMISSION LABS
___ 03:50PM BLOOD ___
___ Plt ___
___ 03:50PM BLOOD ___
___ Im ___
___
___ 03:50PM BLOOD ___ ___
___ 03:50PM BLOOD ___
___
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD ___
___
___ 03:52PM BLOOD ___
___ Base XS--8
___ 04:12PM BLOOD ___
___ 10:48AM BLOOD O2 ___
___ 03:10AM BLOOD ___
___ 03:39PM URINE ___ Sp ___
___ 03:39PM URINE ___
___
___ 03:39PM URINE ___
___
___ 04:40AM CEREBROSPINAL FLUID (CSF) ___
___ 04:40AM CEREBROSPINAL FLUID (CSF) ___
___ 04:40AM CEREBROSPINAL FLUID (CSF) ___
___
.
.
DISCHARGE AND PERTINENT LABS
.
___ ___ Plt ___
___ ___
___
.
MICROBIO:
___ 3:52 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
___ 4:05 pm BLOOD CULTURE #2 SOURCE: VENIPUNCTURE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
___ 9:34 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
.
___ 4:40 am CSF;SPINAL FLUID Source: LP #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
.
___ 4:53 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
ASPERGILLUS ___. SPARSE GROWTH.
.
___ 10:20 am URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
___ 10:16 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
.
NOTABLE IMAGING AND DIAGNOSTICS
.
Head CT (noncontrast) ___ - No acute intracranial
abnormality.
.
Brief Hospital Course:
ICU Course:
.
Mr. ___ is a ___ year old man with history of current ETOH
abuse c/b w/d sz and DT, sCHF, IVDU, HCV who presented intubated
from ___ after having witnessed seizure at home ___
setting of decreased ETOH intake.
.
# Respiratory Failure: Pt transferred to ___ s/p intubation
after having a seizure and with concern for protection of his
airway. At ___, ABG 7.34/42/498 on 100% FiO2, Rate 20, PEEP 5.
Vent settings were weaned appropriately, as was sedation. Once
patient awoke after weaning of sedation, he was extubated and
able to maintain his own airway. Speech and swallow was
consulted, and based on their bedside exam, looks like pt
aspirating likely due to oropharyngeal dysphagia, but they are
unable to eval esophageal issues.
.
#Seizures: patient had witnessed seizure, and after discussion
with the patient, he was not taking his seizure medications
consistently. He did share that he is still an active drinker
and typically drinks a pint a day, but was unable to remember
when his last drink was. Likely cause of his seizure was not
taking AED, but EtOH withdrawal on the differential as well. EEG
was done prior to extubation and patient was not seizing at that
time. He was restarted on home AED regimen of Keppra, and placed
on phenobarbital protocol for prevention of alcohol withdrawal.
.
# Hypotension: Pt on admission SBPs 60. Likely ___ sedation vs
sepsis; cardiogenic shock less likely although patient does have
history of cardiomyopathy. PE also less likely but given
tachycardia was included ___ differential. He was volume
resuscitated and initially on pressors, but eventually weaned
off pressors and BP was normalized by the time he was called out
of the ICU. Cultures were taken and a spinal tap was done to r/o
meningitis given his altered mental status and the fact that he
did have a fever at one point. Empiric vanc/zosyn/acyclovir were
started on admission, along with azithromycin. This was narrowed
to Zosyn and Azithromycin by the time of transfer out of the
ICU.
.
# Lactic acidosis: initial lactate of 15 with pH 7.05. Improved
quickly following fluid resuscitation and pressors. Most likely
etiology is seizure given the very high initial value and abrupt
return to normal. Less likely etiology is sepsis.
.
# ETOH Withdrawal: Pt uses significant ETOH, has had w/d with
seizures and DTs previously. Unclear on admission as to when the
last EtOH was, given the inability to obtain accurate history.
Phenobarbitol protocol was started, along with folate, thiamine,
MVI. Social work was consulted.
.
# Leukocytosis/fever: T 100.5 on admission. No localizing signs
of infection. Low grade fever likely ___ recent seizure. DTs
may also cause fevers. Leukocytosis also could be reactive.
Last drink unknown on admission, so unclear if he was ___ DTs
window. UA shows no e/o infection, CXR shows no e/o
consolidation. BCx were sent. Meningitis is also a possible
etiology of fevers, seizures, and AMS, so LP was done, w/o any
evidence of infection. Infectious treatment and shock management
were done as described above.
.
# Elevated Troponin: Troponin 0.02 on arrival. ECG sinus.
Likely type II demand ischemia. CKMB normal.
.
# Systolic CHF: LV EF ___. Held beta blocker and lisinopon
admission given hypotension
.
# HTN: Chronic issue, held antihypertensives on admission given
hypotension on admission.
.
# HCV c/b cirrhosis: Reportedly undetectable VL. Currently not
being treated.
.
.
.
Medicine Floor Course:
.
___ ETOH abuse c/b w/d sz and DT, sCHF, IVDU, HCV presents as a
transfer from ___ to floor following admission to ___ for
hypotension, septic shock, and respiratory failure from ___
___ after having witnessed seizure at home ___ setting of
recently decreased ETOH intake.
.
# Poor PO intake w/ known esophageal stenosis and recent
mechanical dilation at ___. Was unable to tolerate
meaningful amounts of PO since transfer from ___.
- per review of ___ records:
-- ___ - EGD with biopsies of esophageal stricture, they were
unable to pass scope.
-- ___ - EGD with dilatation of esophagus
- GI consulted:
** EGD on ___ removed impacted food, revealed severe stricture
w/ ulceration
** maintained on a liquid only diet w/ no pills (liquid meds
only)
** PPI BID (lansoprazole dissolving tablet) - prior
authorization for this medication was obtained, and the patient
was able to pick it up at his pharmacy
** Scheduled for f/u ___ GI clinic ___ 1 month
** GI is planning for EGD ___ 2 months (to allow esophageal ulcer
to heal)
- Nutrition consulted:
** Ensure TID + Magic Cup w/ meals and liquid multivitamin
.
# Respiratory Failure & aspiration PNA/pneumonitis: Was
extubated on ___. Cough productive of copious sputum has
resolved since EGD with removal of impacted food from his
esophagus. Treated with zosyn for empiric coverage of gram
negative and anaerboic organisms given the severity of his
presenting illness. Briefly on vancomycin (started ___ ICU), but
no suggestion of ___ infection, so this was
discontinued. Zosyn was discontinued after an 8 day course
(___) with no fever, chills, cough or recurrence ___ his
pulmonary symptoms for 24 hours of further observation.
.
# Seizure: Likely ___ ETOH w/d given report of ___
daily ETOH use with negative serum ETOH. Pt started on IV
diazepam ___ ED. Pt also may have primary seizure disorder, so
it is possible that the seizure is ___ seizure disorder, and he
was likely not compliant with AED's. EEG ___ FICU was negative
for seizure activity.
- completed phenobarbitol protocol for ETOH withdrawal
- has had no evidence of clinical seizures since transfer from
ICU
- continued home keppra 500mg BID (liquid form only) upon
discharge
.
# ETOH Withdrawal: Pt uses significant ETOH, has had withdrawal
seizures and DTs previously. Unclear when the last dose of EtOH
was prior to admission.
- Completed phenobarb protocol
- Given thiamine 100 mg IV x3 days (since unable to take pills
PO)
- SW saw patient several times during hospitalization
.
# Persistent memory deficits - severely impaired
___ memory, overall is improving, but per
corroborative history, is a chronic issue with significant
impaired baseline. Per his Father, who visited him several
times during this hospitalization, his memory deficits are
significant at baseline, have been a problem for the past couple
of years, and began after the patient was hit by a motor vehicle
and suffered significant head trauma. Social work, case
management, and physical therapy evaluated the patient and
provided support where possible. His memory deficits provide a
severe impediment to his following ___
instructions for any period. He is being discharged into the
care of his father, who has agreed to look after him and help
him get to his appointments, take his meds and avoid pills and
solid foods.
.
# Chronic systolic CHF: LV EF ___
- Initially held BB/ACEi given hypotension ___ setting septic
shock.
- Had restarted lisinopril to good effect after ICU, but forced
to hold for now given patient's inability to take pills ___
esophageal stricture.
- Lisinopril and beta blocker should be restarted once patient
able to tolerate pills PO.
.
# HTN: Chronic - not having significant hypertension at this
time
- home lisinopril on hold per above
- was mostly normotensive ___ the days prior to discharge
.
# HCV with ? of cirrhosis (patient reports hx of cirrhosis):
Reportedly undetectable VL. Currently not being treated. No
evidence of decompensated cirrhosis on exam or laboratory
studies (normal PLT, normal INR, normal bilirubin)
- most recent inpatient LFTs were relatively unremarkable
- f/u as outpatient as needed
.
# PCP - ___ of ___ / ___
___.
.
# Code status - Full Code (confirmed with patient)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Thiamine 100 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
7. Docusate Sodium 100 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. Sarna Lotion 1 Appl TP TID
10. Acetaminophen 650 mg PO Q8H:PRN pain
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*3
2. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
3. LeVETiracetam Oral Solution 500 mg PO BID
RX *levetiracetam [Keppra] 100 mg/mL 5 ml by mouth twice a day
Disp ___ Milliliter Milliliter Refills:*3
4. Multi Vitamin (multivit ___ fum) 9 mg iron/15
mL oral DAILY
RX *multivit ___ fum [Complete
___ 9 mg iron/15 mL 15 ml by mouth daily
Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal seizure
Aspiration pneumonitis/PNA
Severe Esophageal stricture with ulceration
Severe ___ memory defect
Alcohol abuse and dependence - chronic
IV drug abuse - intermittent
Housing insecurity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: T 98 BP 118/56 HR 84 RR 18 pOx 98% on RA
Gen: NAD, lying comfortably ___ bed
HEENT: large ___ scar over left forehead, EOMI, sclera
anicteric, poor dentition
Neck: supple, no LAD, no JVD
Chest: normal work of breathing, able to speak ___ full
sentences,
no accessory muscle use, on auscultation: mild rhonchi and
moderate crackles remain prominent ___ bilateral lower lobes, no
wheezing or prolonged expiratory phase
Cardiovasc: RR, s1 and s2 quiet, no m/r/g, 2+ peripheral pulses
bilaterally, no ___ edema
Abd: soft, nontender, nondistended, BS+
MSK: laying flat ___ bed, but able to sit upright without
assistance, moving all 4 extremities spontaneously
Skin: no rashes noted
Neuro: awake, alert, and responsive to questions; able to follow
follows commands; oriented to person and place, but not to time
(but able to read calendar across the room) or reason for
hospitalization; no facial droop, slurred speech, or tremor;
remote memory seems generally intact; recent/working memory
remains extremely poor
and does not seem to be improving to any meaningful degree.
Psych: calm, cooperative
Discharge Instructions:
You were admitted to the hospital because you had a seizure
resulting from alcohol withdrawal. You were very sick
initially, requiring intubation and treatment ___ the intensive
care unit. You were treated for pneumonia and alcohol
withdrawal. You also have severe esophageal narrowing that
makes it difficult for you to swallow solid foods and pills.
You underwent an endoscopy of the esophagus, which showed
narrowing of the esophagus and ulceration ___ the same area where
you had previously had an esophageal dilation procedure at ___
___. The ___ doctors recommended that ___ avoid all
solid foods and all pills until you ___ with them ___
clinic.
1) DO NOT EAT ANY SOLID FOODS. CONSUME LIQUIDS ONLY. Examples
include Ensure, Magic Cup, juices, and water.
2) DO NOT TAKE ANY SOLID PILLS OR CAPSULES. TAKE ONLY LIQUID
MEDICATIONS AND THE ORAL DISINTEGRATING TABLET WE HAVE
PRESCRIBED FOR YOU.
3) DO NOT DRINK ALCOHOL, BECAUSE ALCOHOL WILL MAKE YOUR
ESOPHAGEAL ULCER WORSE AND HAS RESULTED ___ YOU HAVING SEIZURES.
4)Follow up with the ___ doctors ___ ___ at your scheduled
appointment, listed below, on ___.
Followup Instructions:
___
|
10623984-DS-20 | 10,623,984 | 25,576,657 | DS | 20 | 2159-10-15 00:00:00 | 2159-10-15 17:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
intoxication
Major Surgical or Invasive Procedure:
EGD x 3 with dilation
History of Present Illness:
Mr. ___ is a ___ PMHx HFrEF (LVEF ___, HCV, EtOH and
IVDA abuse with h/o of withdrawal seizures, possible seizure
disorder ___ ?TBI, PUD and chronic anemia who was transferred
from ___ for vascular surgical evaluation for possible
SMA stenosis.
He was initially brought to ___ for intoxication after he
was found wandering on the streets in ___ by police. He
reported that his father (whom he lived with) recently passed
away. His initial evaluation in the ___ showed wnl VSS
and the patient appeared intoxicated. However, his labs showed
severe hypokalemia 2.9 and lactate elevated to 9.8. His labs
otherwise showed Na 137, Cr 0.7 (baseline 0.5), WBC 4.9, Hgb
14.5 (baseline ~10), Plt 236. He was given 2L NS there. He
also had multiple episodes of NBNB emesis there so underwent CT
torso which showed concern for L SFA occlusion (new compared to
prior imaging in ___ and possible high grade stenosis of his
SMA of unclear chronicity. His CT torso also showed fluid
filled esophagus, new vertebral compression fractures and
possible pulmonary nodules. He was transferred for vascular
surgical evaluation.
In the ___ at ___, his initial VS 97.9, 90, 123/74, 18, 99% on
RA. He initial labs showed wnl chemistries with Cr 0.7. LFTs,
lipase were wnl. WBc 4, Hgb 10.9, Plt 168. Repeat lactate was
1.6. Troponin was negative. His serum tox screen was negative
but his urine tox screen was positive for barbiturates and
opiates. He was evaluated by Vascular Surgery who felt that
given his benign abdominal exam, high grade stenosis of the ___
was unlikely; they recommended no acute intervention and
outpatient f/u with Dr. ___ as needed. They also felt
that his LLE exam was unremarkable and that he likely has
chronic PVD of his LLE which does not require acute
intervention. While in the ___, the patient became tachycardic
to the low 100s, felt to be ___ EtOH withdrawal. He was given
10 IV and them 10 PO valium prior to transfer to the floor.
Upon arrival to the floor, the patient reports feeling very
overwhelmed because of the recent death of his father. He
states that he has no place to live at this time. He does not
recall the circumstances of his being brought to ___ and now
to ___. He states that he has not been binge drinking, but
has been drinking about 0.5 pint of vodka daily; he believes his
last drink was on ___. He denies any leg pain, abdominal pain,
and has no current n/v. He has no other acute medical
complaints.
Of note, the patient was most recently admitted to the Neurology
service on ___ for confusion in the setting of EtOH
intoxication. However, he was found to have venous sinus
thrombosis which was felt to be chronic. He was initially
anticoagulated with heparin and then transitioned to
rivaroxaban. The patient himself has no idea of what these
medications are and cannot recall taking any of his listed home
medications.
Past Medical History:
-sCHF ___ per chart, though last TTE (___) shows EF 55%
and patient without recent symptoms of heart failure
-ETOH abuse (c/b severe withdrawal, seizures, DTs, requiring ICU
admission and intubation in past)
-Seizure disorder (on keppra BID, non-compliant)
-Upper GI Bleeding - s/p EGD ___ revealing lower esophageal
ulcers
-Small bowel obstruction ___ bezoar
-Intra-abdominal abscesses ___
-HTN
-Chronic pancreatitis
-h/o C-diff ___
-Positive Hepatitis C antibody with undetectable VL
-? history of cirrhosis
-Chronic venous sinus thrombosis
Social History:
___
Family History:
+ family history of EtOH abuse
+ grandfather with CAD
Physical Exam:
Vitals- 98.4 137 / 72 85 16 98 RA
GENERAL: disheveled elderly male in NAD
HEENT: MMM, poor dentition, NCAT, EOMI, anicteric sclera
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: CTAB, no w/r/r, unlabored respirations
ABDOMEN: soft, NTND, no rebound/guarding, nml bowel sounds
EXTREMITIES: No clubbing, cyanosis, or edema, no ulcers of his
BLE, BLE are wwp.
SKIN: no rash or lesions
NEUROLOGIC: AOx2 (to self and place), states that it is ___, states that ___ is the president, but when
prompted that ___ is currently the president states "I keep
thinking that is a bad dream". Able to do months of the year
backwards. Following all commands and fluent speech. No
tremors.
Psych: nml affect and appropriately interactive
DISCHARGE EXAM
VS 97.9 130 / 84 83 18 98 RA
Gen: Alert, NAD
HEENT: NC/AT
Cardiovascular: RRR, no m/r/g.
Respiratory: Breathing comfortably, lungs CTAB
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present
MSK: No edema
Skin: minimal excoriations on LUE without underlying rash
Neurological: Alert, oriented x 3, interactive, speech fluent,
moving all extremities, attentive
Psychiatric: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 03:51PM ___ PO2-41* PCO2-40 PH-7.43 TOTAL CO2-27
BASE XS-1
___ 03:51PM LACTATE-1.6
___ 03:51PM O2 SAT-70
___ 03:40PM GLUCOSE-77 UREA N-10 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18
___ 03:40PM ALT(SGPT)-10 AST(SGOT)-27 CK(CPK)-52 ALK
PHOS-65 TOT BILI-0.5
___ 03:40PM LIPASE-58
___ 03:40PM cTropnT-<0.01
___ 03:40PM ALBUMIN-3.2* CALCIUM-8.1* PHOSPHATE-2.5*
MAGNESIUM-2.5
___ 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:40PM URINE bnzodzpn-NEG barbitrt-POS* opiates-POS*
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:40PM WBC-4.0 RBC-3.48* HGB-10.9* HCT-31.8* MCV-91
MCH-31.3 MCHC-34.3 RDW-13.2 RDWSD-43.6
___ 03:40PM NEUTS-63.6 ___ MONOS-12.0 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-2.54# AbsLymp-0.95* AbsMono-0.48
AbsEos-0.00* AbsBaso-0.01
___ 03:40PM PLT COUNT-168#
___ 03:40PM ___ PTT-31.7 ___
___ 03:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Micro:
___ BCx pending
___ UCx pending
Imaging/Studies:
___ CT TORSO W/CONTRAST
IMPRESSION:
1. Atherosclerotic calcifications with possible
high-grade stenosis of the proximal SMA and occlusion of the
left superficial femoral artery. MR angiogram can be
considered.
2. Indeterminate left renal lesion for which MRI or ultrasound
can be performed.
3. Fluid-filled esophagus with wall enhancement distally.
Endoscopy should be considered.
4. Fat containing ventral hernia.5. Multiple compression
fractures some of which are new compared to ___ but are age
indeterminate.
6. Stable lucency in the L3 vertebral body.
7. Peribronchial opacities in the left lower lobe which are
presumably inflammatory or infectious.
___ EGD
Impression:Stricture of the distal esophagus (dilation)
Severe esophagitis esophagitis in the for 2-3 cm above stricture
in lower esophagus
Food in the esophagus (foreign body removal)
Otherwise normal EGD to third part of the duodenum
CTH ___:
FINDINGS:
There is no evidence of acutely large vascular territorial
infarctionhemorrhage,edema,or mass. An old left parietal
infarct is
identified with ex vacuo dilatation of the left lateral
ventricle. There is
prominence of the ventricles and sulci suggestive of
involutional changes.
Periventricular and subcortical white matter hypodensities are
nonspecific but
likely reflect sequelae of chronic small vessel ischemic
disease.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Chronic left parietal infarct.
3. Parenchymal atrophy and changes due to chronic small vessel
ischemic
disease.
LUE US ___:
FINDINGS:
There is normal flow with respiratory variation in the bilateral
subclavian
vein.
The left internal jugular and axillary veins are patent, show
normal color
flow and compressibility. The left brachial and basilic veins
are patent,
compressible and show normal color flow and augmentation. The
left cephalic
vein was not visualized. There is atherosclerotic plaque in the
left common
carotid artery, not well evaluated on this scan, and could be
further assessed
with dedicated carotid imaging.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
The left
cephalic vein was not visualized.
EGD ___:
Impression:Stricture of the distal esophagus (dilation)
Small hiatal hernia
Not visualized as seen on prior scopes
Otherwise normal EGD to stomach
Recommendations:- Continue pureed diet for 24 hours and advance
to soft solids if tolerated
- Continue PO Omeprazole 40 mg BID for at-least ___ weeks
- Continue Carafate 1 gram TID *14 days
- OK to re-start anticoagulation today
- Repeat EGD as clinically indicated
- F/u in GI Clinic
___ CAROTID ULTRASOUNDS
IMPRESSION:
1. Moderate bilateral homogeneous atherosclerotic plaque
involving the common carotid arteries. Mild atherosclerotic
plaque in the right ICA. There is no resultant hemodynamically
significant stenosis (<40%) bilaterally.
2. Bilateral antegrade vertebral flow.
___ TTE:
Conclusions
The left atrium and right atrium are normal in cavity size. The
interatrial septum is aneurysmal. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Aneurysmal interatrial septum.
Brief Hospital Course:
___ y/o M with PMHx of EtOH abuse (cb withdrawal seizures), HCV,
venous sinus thrombosis (on Rivaroxiban), h/o CVA, PAD, prior hx
of ___ (EF wnl in ___, prior hx of heroin abuse, who
presented ___ to ___ with EtOH intoxication (etoh level
86; barb+), transferred to ___ for evaluation of elevated
lactate (9.8) and eval of ?SMA stenosis. Found to have
esophageal stricture sp dilation ___ and ___ and ___.
# EtOH withdrawal
# EtOH abuse.
Patient with multiple hospitalizations for EtOH intoxication and
withdrawal; has had withdrawal seizures in the past and has
required phenobarb taper. The patient had fairly minimal
withdrawal symptoms on this presentation. He was successfully
managed with valium per CIWA. He also received IV fluids,
folate, thiamine, MVI, and repletion of K and Mg.
# Toxic-metabolic encephalopathy.
Head CT was unremarkable for acute pathology. Sensorium improved
to baseline in the setting of sobering up and receiving fluids
and electrolyte repletion. The patient has history of a stroke,
head trauma, and would also be at risk for alcohol dementia, so
he does have baseline cognitive impairment.
# esophageal stricture
Patient has a well-known h/o esophageal stricture requiring
serial EGDs and dilations. Multiple esophageal biopsies have
been negative for malignancy. EGD with esophageal dilation
performed ___. Lumen of esophageal < 1 cm at area of stricture
post-procedure. Also noted to have severe esophagitis proximal
to stricture. Diet liberalized from full liquid diet to
mechanical soft after patient able to verbalize risks but he did
not tolerate this and was returned to full liquids. He was
started on lansoprazole ODT 30 mg po bid. Repeat endoscopy
performed ___ with successful dilatation. Per formulary, PPI
changed to pantoprazole for a ___ week course. Pt also rec'd a
course of carafate. Recurrent symptoms required a repeat EGD and
dilation on ___. with good results.
-Follow-up with GI as scheduled
# Homelessness/Inability for self-care
# cognitive impairment
# alcoholic dementia
# h/o traumatic brain injury
Patient had been living with his ___ father who managed
his money and affairs, but his father has recently passed away.
This leaves the patient with no place to live and no social
support. The patient is an only child. Cognitive eval showed
impairment in executive functioning and short term memory. OT
recommended supervision for higher level cognitive tasks.
Psychiatry was consulted and determined that pt did not have
capacity and a guardian was appointed. He failed to name anyone
so a court appointed guardian was assigned. However, the courts
did not feel that he needed long-term care as he did not have
any nursing needs. He did not qualify for rest home or
placement in ___ house. After discussion with his
court appointed guardian he was discharged to a shelter at ___.
# Venous sinus thrombosis.
Continued rivaroxaban 20 mg daily. Held prior to EGD per GI recs
(Neurology confirmed this was acceptable temporarily).
# SMA stenosis/SFA occlusion:
Per Vascular, no need for any acute intervention. Continued
atorvastatin 40 mg daily, ASA 81 mg daily
# Seizure disorder:
Continued levetiracetam 500 mg BID
# Contact dermatitis:
Pt with bl erythema in antecubital region. No response to
Keflex. No warmth, fever or leukocytosis. Likely contact
dermatitis. sp Keflex trial (___). UENI neg. Improved with
steroid cream. He had a recurrent episode on the anterior aspect
of the LUE later in admission.
# Prior history of HFrEF: Repeat TTE here showing normal EF
without wall motion abnormalities, no signs of heart failure.
# interatrial septal aneurysm: may be incidental, but given his
history of thrombosis, anticoagulation and aspirin seem
reasonable.
- rivaroxaban and ASA
# Transitional:
- New vertebral compression fx. Would obtain DEXA and start
appropriate therapy. On MVI with vitamin D and calcium.
- Repeat CT for pulmonary opacities as outpatient
- Recommend hepatology follow-up; consider repeat HCV viral load
as outpatient
- Repeat TFTs post-discharge
- Consider follow up with cardiology as outpatient for
interatrial septum aneurysm
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. LevETIRAcetam 500 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Pantoprazole 40 mg PO BID
RX *pantoprazole [Protonix] 40 mg 1 granules(s) by mouth twice a
day Disp #*28 Packet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*14 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
6. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
8. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
esophageal stricture s/p dilation
Acute alcohol withdrawal
cognitive impairment
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted and treated for alcohol intoxication and
withdrawal and an esophageal stricture for which you had a
dilation procedure. We helped you obtain a guardian, however the
courts did not feel that you needed to stay in a nursing home so
we discharged you to XXX.
Followup Instructions:
___
|
10623984-DS-8 | 10,623,984 | 27,033,628 | DS | 8 | 2155-09-02 00:00:00 | 2155-09-03 07:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ Patient with h/o EtOH abuse and withdrawal seizure presents
to ___ after being found down by his father with concern for
recent seizure. Patient endorses daily intake of approximately 1
pint vodka and reports prior EtOH withdrawl and seizures in
setting of withdrawal. Reports last drink was last night/this
AM. Taken to ___ where he appeared to be in EtOH
withdrawal scoring in low teens on CIWA, was reportedly treated
with ativan and valium though serum benzos and EtOH here were
negative, and EtOH and ___ negative as well. Upon arrival to
___, patient was without acute complaints, no anxiety, auditory
hallucinations, visual hallucinations. No other complaints.
In the ___, initial VS were: 98.8 113 128/82 19 94%
Mucus membranes dry. Patient mildly tremulous.
Patient received Thiamine 100mg po, FoLIC Acid 1 mg po,
Multivitamins po, Diazepam 10 mg po, and Magnesium Sulfate 2g
IV.
Received fluids, 5L documented between ___ and ___ here
though not clear how much was received. Has 2 20 gauges, 1 in
hand and 1 in foot.
On arrival to the MICU, patient's VS 106, 113/36, 76, 14, 95%RA
Patient does not recall the events preceding his arrival but is
otherwise alert, interactive, and cooperative. Denies any
current complaints.
Past Medical History:
PAST MEDICAL HISTORY:
# Reported history of Hepatitis C without clear lab evidence
# Reported history of cirrhosis without clear evidence
# Upper GI Bleeding - s/p EGD ___ revealing lower esophageal
ulcers
# Small bowel obstruction ___ bezoar
# Intra-abdominal abscesses ___
# systolic CHF - EF ___, presumably alcohol-induced
vs tachycardia-induced CMP
# HTN
# Reported history of chronic pancreatitis without clear
evidence
# Seizures
# QT prolongation
# Opioid addiction
# h/o C-diff ___
# Homelessness
# Medication non-compliance
# 3rd degree burns on feet as child
PAST SURGICAL HISTORY:
# ___ - Exploratory laparotomy with enterotomy for SBO
revealing SB fruit bezoar
# Tonsillectomy
# Eye surgery as a child for strabismus
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Vitals: 98.8 113 128/82 19 94%
General: Alert, appropriate, interactive. Elderly male appearing
older than stated age, disheveled in appearance, no acute
distress.
HEENT: Sclera anicteric, mucus membranes moist
Neck: supple, JVP difficult to assess due to full beard
CV: distant heart sounds. tachycardic, difficult to discern
whether extra heart sounds are present. no obvious murmurs or
rubs.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, minimal non-localizing tenderness, non-distended,
bowel sounds present, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Dirt underneath fingernails.
Neuro: CNII-XII grossly intact, moving extremities equally. ___
beat clonus on achilles bilaterally. gait deferred.
Pertinent Results:
ADMISSION LABS
==============
___ 09:20PM BLOOD WBC-5.5 RBC-3.73*# Hgb-13.1*# Hct-38.7*#
MCV-104*# MCH-35.0*# MCHC-33.7 RDW-15.5 Plt ___
___ 09:20PM BLOOD Neuts-65.6 ___ Monos-6.4 Eos-0.1
Baso-0.4
___ 10:18PM BLOOD ___ PTT-35.6 ___
___ 09:20PM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-131*
K-3.9 Cl-98 HCO3-23 AnGap-14
___ 09:20PM BLOOD ALT-43* AST-127* AlkPhos-119 TotBili-1.4
___ 09:20PM BLOOD Albumin-3.5 Calcium-7.8* Phos-2.2*
Mg-1.5*
___ 09:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
INTERVAL LABS
==============
___ 03:32AM BLOOD HCV Ab-POSITIVE*
___ 04:42AM BLOOD WBC-3.0* RBC-3.26* Hgb-11.0* Hct-34.3*
MCV-105* MCH-33.8* MCHC-32.1 RDW-15.2 Plt ___
___ 04:42AM BLOOD Glucose-120* UreaN-10 Creat-0.7 Na-136
K-3.8 Cl-104 HCO3-25 AnGap-11
___ 04:42AM BLOOD ALT-34 AST-85*
___ 04:42AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.6
___ 03:32AM BLOOD TSH-3.1
DISCHARGE LABS
==============
___ 07:45AM BLOOD WBC-3.9* RBC-3.38* Hgb-11.5* Hct-35.7*
MCV-106* MCH-34.2* MCHC-32.4 RDW-15.1 Plt ___
___ 07:30AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-133
K-3.9 Cl-97 HCO3-27 AnGap-13
___ 07:30AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.4*
MICROBIOLOGY
============
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___
8:50AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___: MRSA SCREEN (Pending).
IMAGING/REPORTS
===============
TTE ___: Normal global and regional biventricular systolic
function.
CXR ___: AP single view of the chest has been obtained with
patient in
semi-upright position. The heart size is within normal limits.
No
configurational abnormality is identified. Thoracic aorta
mildly widened with some calcium deposits in the wall at the
level of the arch. No local contour abnormalities are present.
Pulmonary vasculature is not congested. No signs of acute or
chronic parenchymal infiltrates are seen, and the lateral
pleural sinuses are free. No evidence of pneumothorax in the
apical area. Extensive rib deformities are seen in the left
hemithorax representing apparently old deformities of multiple
rib fractures. Acute injuries are not identified on this
portable chest examination.
MR ___ ___: 1. No acute infarct or hemorrhage. 2. Old
hemorrhagic contusions in the right frontal and left temporal
lobes. Generalized global cerebral volume loss including the
bilateral temporal lobes without evidence of abnormal signal or
enhancement within the temporal lobes. 3. Possible slow flow vs
calcified plaque in the left vertebral artery, clinical
correlation, and an MRA could be helpful for further evaluation
EEG ___: This is a normal awake and drowsy EEG. There are no
epileptiform discharges, seizures, or focal slowing recorded.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Ms. ___ is a ___ year old gentleman with history of EtOH abuse
and withdrawal seizures admitted for EtOH withdrawal with
concern for recent seizure activity. He was stable during
admission. No evidence of seizures, and CIWA scale was
discontinued as he had not been scoring for 24 hours. He was
noted to be tachycardic and have loose stools, found to be c.
diff positive, discharged on a 14 day course of PO
metronidazole.
ACTIVE ISSUES
=============
# EtOH withdrawal: He was stable on admission, notable for mild
tremulousness, mild tachycardia (though eventually as high as
140s), and mild agitation. He had no hypertension, other
adrenergic symptoms, or hallucinosis. Given his history of
withdrawal seizures and question of recent ___ mal seizure
activity prior to presentation, there was a low threshold for
benzo administration to keep CIWA score low (<10) and to monitor
him closely in the ICU. He was maintained on diazepam as needed
per CIWA (though this was rapidly stopped due to absence of
scoring), and supplementation with thiamine, folate, MVI was
continued.
# Seizures: Unclear whether strictly related to alcohol
withdrawal or whether also has underlying seizure disorder. In
the past per ___ records, he has had seizures when he missed
his medications. If reported ___ mal seizure truly occurred on
the morning of admission, it may be related to non-compliance
with home levetiracetam dosing in addition to withdrawal. He
was continued on home levetiracetam 500mg po BID. ___ MRI was
performed which showed old hemorrhagic contusions which could be
predispose him to seizures, but no active process. EEG was done
and was normal.
# C diff colitis: He was noted to be tachycardic with loose
stools and C diff returned positive. He will complete 14 days
of oral metronidazole.
# Left vertebral artery MR finding: His MRI found "possible slow
flow vs calcified plaque in the left vertebral artery." He did
not have any signs of symptoms of vertebral artery insufficiency
and it was felt to be be unlikely to be related to his current
presentation. This should be followed up in the outpatient
setting and MRA could be considered.
# HTN: He was started on Metoprolol XL 50mg daily for
persistent hypertension.
# Hyponatremia, hypovolemic: Na 131 on arrival, likely in the
setting of decreased PO intake. Supporting evidence includes
tachycardia and presumed hemoconcentration in setting of
hyponatremia and malnutrition. He was given normal saline with
improvement.
# Hypomagnesemia: Likely due to malnutrition in setting of
alcoholism. History of QT prolongation, though no reported
history of prolonged QT-induced arrythmia. He was repleted
aggressively and monitored with EKGs closely. His QTc on ___
was 423.
# Prior systolic CHF (previously reported EF ___, now 55%):
No current evidence of volume overload. He had a TTE in ___,
which showed EF ___. However, it was unclear if he had CHF
during that admission (regardless of cause - alcohol-induced or
tachycardia-induced). He underwent another TTE this admission,
which showed EF 55% and normal biventricular systolic function.
# Abnormal EKG: Revealed stable inferior lead ST seg elevation
without clinical sx of angina and flat enzymes. EKG remained
unchanged ___ and ___ suggesting these are not new
findings. He was started on a beta blocker for HTN.
# Pancytopenia, and macrocytic anemia: Macrocytosis is stable,
likely secondary B12/folate deficiency from malnutrition
secondary to alcoholism. He was continued on vitamin
supplementation. If his pancytopenia does not resolve (with
current clinical picture, most likely due to malnutrition, bone
marrow suppression in the setting of chronic alcohol abuse), he
warrants further workup.
# Medical history reconciliation: By ___ documentation in
discharge summaries, he is reported to have a history of
cirrhosis, Hepatitis C, and chronic pancreatitis. CT torso
imaging in ___ commented specifically on normal appearing
liver, spleen, and pancreas without any noted sequelae of these
conditions - however, RUQ ultrasound at ___ in ___
showed echogenic liver. His HCV antibody was positive on this
admission, confirming previous history. No abdominal pain during
this admission.
- Needs liver work-up: ___ records: No
hepatitis B Core antibody on record, though HbSAb was positive
at ___.
- He would benefit from HVC viral load and HIV.
- Needs second dose of Hepatitis A series (got first dose
___.
TRANSITIONAL ISSUES:
====================
- Code: Full code, confirmed.
- Emergency contact: Father, ___, ___.
- Studies pending at discharge: None
- Got first Hepatitis A series in ___, needs second
Hep A immunization.
- Please check HbcAb (not done at ___, though HbSAb positive),
HCV viral load, HIV.
- Needs follow-up with Hepatology and would recommend Neurology
follow-up given seizure history
- Needs outpatient PFTs (has evidence of COPD on exam, long
smoking history), started on long acting tiotropium during
admission
- Currently not interested in alcohol detox or partial
hospitalization, but will consider it in the future - please
re-address.
- Discharged on a 14 day course of PO metronidazole for c. diff.
- QTc was 423 on the day of discharge (___).
- Last EF from ___ in ___ was ___ repeat cardiac echo
___ with EF 55% and normal global and regional biventricular
systolic function.
- If pancytopenia does not resolve with nutrition, consider
further hematologic workup.
- Consider MRA to evaluate possible slow flow seen in vertebral
artery on MRI
- A copy of this discharge summary was faxed to ___,
NP, at ___ at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 500 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Nicotine Patch 21 mg TD DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*2
3. Multivitamins 1 TAB PO DAILY
4. Nicotine Patch 21 mg TD DAILY
5. Thiamine 100 mg PO DAILY
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
RX *metronidazole 500 mg one tablet(s) by mouth every 8 hours
Disp #*36 Tablet Refills:*0
7. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg one
puff(s) inhaled daily Disp #*30 Capsule Refills:*2
8. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Seizure, possibly due to alcohol withdrawal
Secondary: Chronic Alcohol, Chronic Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because of a reported seizure and possible alcohol withdrawal.
You were stable during admission and no longer required
monitoring for withdrawal. You underwent MRI which showed
previous locations of bleeding (from possible prior falls) but
no active bleeding. This could cause you to be more likely to
have seizures in the future. You also had an EEG that was
normal.
We discussed your alcohol use and believe it is imperative that
you stop drinking alcohol. You were also found to have a C.
difficile infection (GI infection), and were started on
antibiotics for this, for which you need to complete the full
course of therapy.
In addition, you should follow up with your NP ___ after
discharge, and with a neurologist and liver specialist. You
should make sure to get your next hepatitis A immunization.
Followup Instructions:
___
|
10624280-DS-10 | 10,624,280 | 27,226,962 | DS | 10 | 2141-01-06 00:00:00 | 2141-01-06 21:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lithium / Heparin Analogues
Attending: ___
Chief Complaint:
Percutaneous cholecystectomy tube fallen out
Major Surgical or Invasive Procedure:
Insertion of percutaneous cholecystectomy tube via
interventional radiology (___)
History of Present Illness:
___ with history of trach s/p respiratory failure, c. diff,
biliary obstruction s/p ERCP with stent removal and
sphincterotomy yesterday presenting today with Perc tube falling
out today and found by staff at ___. He was transferred to
the FICU as he requires night-time ventilation.
Mr. ___ initially had an episode of cholecystitis ___
___, had perc chole placed on ___ it fell out once on
___. RUQ USS showed cholecystitis and was tube was replaced on
by ___ ___. During that time, he has also received cipro and
flagyl despite being afebrile and no leukocytosis. He is s/p
ERCP yesterday ___ which his G tube internal bumper was found to
have migrated to the duodenum, a migrated biliary stent was
removed, and a sphincterotomy, sphincteroplasty and balloon
sweep was performed with the removal of at least three 3-4 mm
stones from CBD. CBD, CHD, R+L hepatic ducts and cystic duct
all filled with contrast
Of note, patient was admitted ___ with septic shock with
work-up revealing for C-diff and sputum positive for Klebsiella
oxytoca, briefly requiring pressors ___ the ICU and completed
course of flagyl and ceftriaxone at LTAC, respectively. Also
recent ___ admission with hypercarbic respiratory failure.
Pt initially with somnolence felt to be ___ hypercarbic resp
failure, but due to pressor-requiring hypotension, he was
treated with 7 days of vancomycin + aztreonam + metronidazole
for possible aspiration event given his history of aspiration
and taking POs at rehab. Pt put on vent at night for CO2 removal
during this admission and subsequently uses vent each night.
___ the ED, initial vs were 103.2, pulse 105, BP 141.60, RR 16
and 98% RA: Labs were remarkable for troponin of 0.10,
leukocytosis of 15, Hb of 9 . Patient was given Acetaminophen
(Rectal) 650mg, Ciprofloxacin IV 400mg, MetRONIDAZOLE (FLagyl)
500mg, Vancomycin 1g, Morphine 5 mg.
Past Medical History:
-MSSA PNA c/b respiratory failure and chronic ventilation at
___ ___
-CVA ___ with residual L hemiparesis
-DM2
-HTN
-OSA
-atrial fibrillation on coumadin
-heparin induced thrombocytopenia
-CKD, baseline Cr 1.2
-ASD vs PFO
-systolic heart failure with EF 35%
-CAD s/p CABG ___
-AVR ___ at time of CABG
-bipolar
# Displaced right femoral neck fracture ___ ___)
.
Past Surgical History:
-trach ___ and replacement ___,
-PEG ___
-CABG, AVR (bioprosthetic) ___
-right hip replacement
Social History:
___
Family History:
Diabetes mellitus
Physical Exam:
PHYSICAL EXAM ON ADMISSION
General- Calm, Alert, oriented to place and year and name, ___ no
acute distress
HEENT- Tracheostomy tube site clean, dry and intact. No
bleed/exudate.
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, RUQ tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. PEG site
clean.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
------------------
Discharge physical:
General- A+Ox3, NAD
HEENT- PERRL, MMM, trach site c/d/i
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB, no w/r/r
CV- IRIR, slight tachycardia, no m/r/g
Abd- Soft, mild tenderness ___ RUQ, non-distended, BS present, no
rebound/guarding, G-tube c/d/i.
Ext- WWP, no c/c/e
Neuro- CNs intact, moving all extremities equally
Pertinent Results:
ADMISSION LABS:
___ 05:15PM ___ PTT-32.3 ___
___ 05:15PM PLT COUNT-112*
___ 05:15PM NEUTS-83.0* LYMPHS-10.0* MONOS-5.4 EOS-1.2
BASOS-0.4
___ 05:15PM WBC-14.2*# RBC-3.67* HGB-10.9* HCT-33.1*
MCV-90# MCH-29.8 MCHC-33.0 RDW-15.3
___ 05:15PM ALBUMIN-2.8*
___ 05:15PM LIPASE-123*
___ 05:15PM ALT(SGPT)-86* AST(SGOT)-357* ALK PHOS-717*
TOT BILI-4.4*
___ 05:15PM GLUCOSE-96 UREA N-27* CREAT-1.0 SODIUM-145
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-33* ANION GAP-14
___ 05:15PM estGFR-Using this
___ 05:29PM LACTATE-1.2
___ 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 06:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
STUDIES:
___: ___ G-tube replacement- Insertion of a 16 ___
low profile MIC - G with 4 cm stomal length. Feeding tube is ___
the stomach and ready for use.
___: CXR
Tracheostomy is ___ place. Large bilateral, right more than left
pleural
effusion and associated bibasal atelectasis are re-demonstrated.
No
appreciable pulmonary edema is seen.
___: EKG
Atrial fibrillation with a controlled ventricular response.
Diffuse
non-specific ST-T wave abnormalities. Compared to the previous
tracing the
ventricular rate is better controlled. ST-T wave abnormalities
are mild and
similar.
___: Abdominal US
Small amount of complex fluid surrounding the extraperitoneal
course of the
gastrostomy catheter. Infection cannot be excluded.
___ EKG
Atrial fibrillation with a rapid ventricular response.
Non-specific ST-T wave
changes, similar to that recorded on ___. There is again low
limb lead
voltage. No diagnostic interim change.
___ CXR
IMPRESSION:
1. Increased right pleural effusion.
2. Retrocardiac opacification may be due to atelectasis,
however, underlying
pneumonia cannot be excluded.
___ KUB
IMPRESSION:
Dilated colon may be cecum or sigmoid colon and most likely
represents ileus.
There is no evidence of volvulus or obstruction.
___ EKG
Atrial fibrillation with moderate ventricular response with
slowing of the rate
as compared to the previous tracing of ___. There are
non-specific
inferior ST-T wave changes. Ventricular ectopy is absent.
Otherwise, no
diagnostic interim change.
___ CXR
IMPRESSION:
1. Tracheostomy tube remains ___ place. There is elevation of
the right
hemidiaphragm with volume loss suggesting that there may be
collapse of the
right middle and lower lobes has worsened since the prior study.
The left
lung appears well inflated without evidence of focal airspace
consolidation.
There is no evidence of pulmonary edema. There is some crowding
of the
vasculature, particularly on the right. There is likely a
layering right
effusion. Right subclavian PICC line has been removed. There
has been a
prior median sternotomy with aortic valve replacement and the
heart remains
stably enlarged. No pneumothorax is appreciated.
___
FINDINGS: As compared to the previous radiograph, there is an
increase ___ extent of the known right pleural effusion. Also
increased are the subsequent areas of atelectasis at the right
lung base. On the left, signs of fluid overload are more
evident than on the previous image. Tracheostomy tube and right
PICC line are unchanged.
___ CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Low lung volumes. Moderate right pleural effusion with
areas of
atelectasis at the right lung bases. Moderate cardiomegaly. On
the left,
areas of mild retrocardiac atelectasis are visualized. The
sternal wires show
unchanged alignment. Unchanged course of the right PICC line
and the
tracheostomy tube.
MRCP ___
IMPRESSION:
1. Cholelithiasis, with persistent moderate gallbladder
inflammation
consistent with cholecystitis. Multiple stones ___ the
gallbladder neck and
cystic duct, likely causing obstruction. Multiple areas of mural
irregularity/ulceration of gallbladder wall, relates to multiple
episodes of
cholecystitis.
2. No obstructing CBD stones. No intrahepatic bile duct
dilation.
The above findings were discussed with ___ on ___ at 9:50
a.m.
Liver GB USS ___:
. Gallbladder wall thickening with pericholecystic fluid and an
echogenic focus external to the gallbladder, which could be
secondary to gallbladder contents or air. If there is further
clinical concern, a CT would be recommended for further
evaluation.
2. Small right pleural effusion.
ERCP (___):
The previous PEG tube (Foley catheter) was found ___ the stomach
body with the internal bumper through the pylorus and within the
duodenal bulb.
The PEG tube was pulled back into proper position ___ the
stomach.
Few erosions ___ the duodenal bulb, possibly related to migration
of the PEG tube bumper into the duodenal bulb.
Previous plastic biliary stent was found having migrated
distally into the duodenum.
The previous plastic biliary stent was removed using a snare.
Successful pancreatic cannulation with the sphincterotome.
Limited pancreatogram ___ the head of the pancreas was normal.
Successful biliary cannulation with the sphincterotome.
A few (at least 3) round 3-4mm stones were seen ___ the lower
common bile duct.
Mild dilation was seen of the biliary tree with the CBD
measuring 10 mm.
A sphincterotomy was successfully performed.
Balloon sphincteroplasty was successfully performed using an
8-10mm wire-guided CRE dilation balloon ___ the major papilla.
A few (at least 3) stones and some debris were extracted
successfully with multiple sweeps of the extraction balloon.
Otherwise normal ERCP to third part of the duodenum.
MRCP (___):
Multiple gallstones/sludge ___ a mildly distended gallbladder,
with
persistent gallbladder inflammation. No intra or extrahepatic
biliary
dilatation. Non-obstructing tiny stones/ sludge ___ the CBD. No
obstructing mass identified
Micro:
All blood and urine cultures negative.
___ 5:00 pm BILE
ACUTE CHOLECYSTITIS//PERCUTANEOUS CHOLECYSTOSTOMY.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 9:30 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 1:01 pm ABSCESS PERCUTANEOUS CHOLE DRAINAGE BAG.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
ENTEROCOCCUS SP.. MODERATE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ =>32 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>___ R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ =>32 R 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
DISCHARGE LABS:
___ 05:28AM BLOOD WBC-5.6 RBC-2.37* Hgb-7.2* Hct-24.2*
MCV-102* MCH-30.5 MCHC-29.9* RDW-19.2* Plt ___
___ 05:28AM BLOOD ___ PTT-31.9 ___
___ 05:28AM BLOOD Glucose-101* UreaN-23* Creat-0.8 Na-139
K-3.6 Cl-95* HCO3-38* AnGap-10
___ 05:28AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ with history of trach s/p respiratory
failure, c. diff, biliary obstruction s/p ERCP with stent
removal and sphincterotomy presenting for evaluation of perc
tube falling out, treated for cholecystitis, with course
complicated by MRSA PNA, UTI, volume overload, and hypercarbic
respiratory failure requiring nocturnal ventilation.
#Respiratory acidosis with metabolic alkalosis: On the morning
of ___, Mr. ___ was noted to have a respiratory acidosis
with excessive metabolic compensation. CO2 retention likely
caused by pt being off nocturnal ventilation while on the
medicine floor. Secretions were not excessive, ruling that out
as a cause of his hypercarbic resp failure. He was also diuresed
with lasix, helping to improve respiratory status. He was
transferred to the ICU on ___ to receive overnight
ventilation. ___ the ICU, pt received nocturnal ventilation on
MMV/PSV (Vt set to 500, RR set to 10, with PS 10, PEEP5, and
FiO2 40%). Pt reached respiratory goal of PCO2 ___ to ___ as
well as bicarb goal of 38-40, and remained stable subsequently
with nocturnal ventilations. He should continue on nocturnal
ventilation while at rehab. He should also continue on lasix
100mg PO BID, with f/u lytes ___ ___ days. Daily weights should
be trended.
#Pleural effusion: Likely from pulmonary edema. Noted to be
worsening on ___ and IP recommended diagnostic
thoracentesis once his INR is <2.0. Warfarin held on ___.
Ultimately, the pleural effusion was not felt to be large enough
to tap, and his warfarin was restarted.
#Hypotension: Mr. ___ blood pressures frequently trended
from the 80-90's with improvement to the 100-110's with
administration of NS. Unclear etiology but bp also notably
reduced with each administration of metoprolol. Holding
parameters were placed for his metoprolol and he was
occasionally administered his metoprolol along with NS boluses.
His metoprolol was decreased to 12.5mg QID and should remain
that way upon discharge to avoid hypotension. His SBPs were ___
the 110s-120s by time of discharge. His ACE-i was held, since
BPs were too low to restart it during his hospitalization.
# Atrial Fibrillation Patient has a CHADS score of 5. Home dose
of coumadin is 7.5mg daily. Continued metoprolol for rate
control. Coumadin was held for the procedure and patient was
placed on argatroban drip given heparin intolerance. Home dose
of metop tartrate is 37.5 mg qid but had been reduced to 12.5
bid given brief episode of hypotension while ___ the FICU. He was
initially well-controlled but began to have bursts of A-fib to
the 150's on the evening of ___. He was placed back on his home
dose of 37.5 mg metop tartrate with stable blood pressure and
well-controlled heart rate. ___ the MICU, pt's metoprolol
tartrate was divided into 12.5 mg QID. After G-tube exchange,
pt was restarted on argatroban and warfarin, with plan to
subsequently discontinue argatroban once INR hits 4 per protocol
and recheck pt's INR on warfarin alone. Pt's INR took quite a
while to reach goal, and it was ultimately decided that since pt
does not have mechanical valve, it was safe to continue his
anticoagulation without an argatroban bridge. INR on day of
discharge was 1.4. Pt was up to 10mg warfarin daily dosing. His
INR should be watched closely while ___ rehab and warfarin
adjusted accordingly, for goal INR ___.
# ACUTE CHOLECYSTITIS/RUQ pain: Previous episodes of
cholecystitis. Underwent ERCP with sphincterotomy and stone
removal day before admission. Perc tube fell out and needed to
be replaced: MRCP showed thickening of the gallbladder. Surgery
was consulted and they believed given the patient's multiple
medical comorbidities, he was not a surgical candidate and thus
tube was replaced. Patient's coumadin was held and he was
placed on an argatroban drip prior to procedure of tube
placement on ___. His LFTs trended downwards during the course
of his admission. He was initially treated with ceftriaxone and
flagyl. His RUQ pain was treated with prn morphine. The RUQ pain
persisted, however, and he was noticed to have erythema and
drainage around his perc chole tube site. Abdominal CT showed no
acute processes. He was already on bactrim for S. aureus ___ his
sputum and was switched to doxycycline when he experienced ___
from the bactrim. He was subsequently noticed to have erythema
and drainage from his G tube site. Patient noted to have a
small, complex fluid collection ___ the abdomen at the site of
his G tube insertion- ___ did not feel this needs to be drained.
___ addition, he had an isolated episode of 50 mL bloody
discharge from his perc chole tube; culture of the fluid grew
enterococci sensitive to linezolid. ID was consulted and
recommended a course of linezolid/ciprofloxacin. Of note, on
abdominal CT the patients G-tube was noted to be abutting the
duodenal bulb; ___ initially did not feel that the tube needed to
be retracted. However, pt self-discontinued G tube on ___,
and it was subsequently replaced by ___ on ___ without
complications. He underwent an ultrasound on ___ and the
perc chole drain was capped. This should remain capped for the
next ___ days. The pt has a RUQ ultrasound ordered at ___
___. Instructions for
scheduling this appointment can be found ___ the attached
discharge worksheet. If output is minimal at the time of
ultrasound, the radiologist will d/c the perc chole tube.
#CHEST PAIN: Early on ___ the hospital course, patient
experienced a small amount of chest pain. Reports many like
this ___ the past as per previous discharge summaries. His pain
was reproducible on exam, resolved spontaneously. EKG shwoed no
new changes: A-fib, some PVCs and inferolateral T wave
inversions. Troponin .10 and CKMB 3. Troponin down-trended ___
the next hours of admission. Patient was already on 325mg
aspirin, 10mg Rosuvastatin and 37.5mg Metoprolol tartrate.
Patient's rosuvastatin was initially held whilst he was an
___ given rising LFTs. His chest pain subsequently
resolved. When LFTs downtrended, statin was resumed.
#MRSA pneumonia/respiratory status: Contacted Kindred, where
patient's home regimen was usually on ___ O2 during the day,
and trach mask at 35% at night. This was started during past ICU
admission where he would tire out on the trach. Patient was also
overloaded on exam with a net positive fluid balance during most
of his stay and therefore was diuresed with lasix towards the
end of stay. He was continued on PO lasix on the floor and
maintained his saturations well on trach collar/trach mask 35%.
On the morning of ___, he was found to have tachypnea to the
30___ with increased sputum production. CXR showed worsened
pulmonary edema and he was given additional lasix, suctioned,
and given nebs with improvement ___ his respiratory status.
Sputum grew S. aureus resistant to levofloxacin. Placed on
bactrim but Cr bumped from 1 to 1.5 on ___ so switched to
doxycycline. Started cipro/linezolid on ___. The pt completed
a full course of abx. Diuresis was continued while ___ the MICU
and the patient was discharged on lasix 100mg PO BID. Daily
weights should be monitored and lytes checked ___ ___ days after
discharge.
#UTI: patient found to have evidence of a UTI; given his
hypotension and difficulty assessing symptoms, he was treated
empirically. Ucx returned negative. Foley changed, discontinued
CTX.
___: Cr bumped from 1 to 1.5 on ___ and again to 1.7 on
___. Most likely etiology is dehydration/Bactrim toxicity given
patient's extensive diuresis to improve his pulmonary status.
After IV successfully placed and patient given boluses, Cr
improved. Cr on discharge was 0.8.
#HSV outbreak: On ___, Mr. ___ was noted to have a
pustular rash on an erythematous base located on the bilateral
buttocks. He was started on a course of acyclovir (Day 1 =
___ and completed 10 days of treatment.
#Wound care: Patient has a deep ulcer located on his coccyx.
Wound recs: If the wound continues to become soiled frequently,
would use moistened ___ inch AMD( antimicrobial dressing )
packing strip for prevention of infection long term. change
daily and prn.
CHRONIC ISSUES:
# Systolic CHF with EF ___: Depressed EF of ___ seen on
Echo last admission which is down from previous 35%. Continued
metoprolol. Started Lisinopril 2.5mg po daily, was previously on
as outpatient. He was diuresed with po/IV lasix prn during his
hospital stay. Lisinopril was subsequently d/c'ed due to
hypotension. Outpatient providers should resume lisinopril when
BP tolerates. Pt should continue on lasix 100mg PO BID, with
daily weights and frequent electrolytes checked.
# HTN: Continued home metoprolol, with dose adjustment due to
hypotension.
# Bipolar: Continued home risperidone but dose changed to 2 mg
bid per psych recs as patient was refusing care and appearing
agitated frequently.
Transitional issues:
-Patient will need INR checks after discharge, and warfarin
adjustment PRN. He will be discharged on 7.5mg warfarin daily.
- Patient will need a follow up ultrasound on ___ or
___ to evaluate for removal of percutanous drain. ___
call ___ (#1) to schedule it. THe drain will be
evaluated for removal at that time.
-When BP tolerates, restart lisinopril at 2.5mg daily
-metoprolol dosing has been adjusted to 12.5mg QID.
-Pt should take lasix 100mg PO BID, with daily weights trended
and electrolytes checked ___ ___ days after discharge.
-Will need wound care. ___ wound recs: If the wound continues
to become soiled frequently, would use moistened ___ inch AMD(
antimicrobial dressing ) packing strip for prevention of
infection long term. change daily and prn.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Guaifenesin 10 mL PO Q6H:PRN cough
5. Metoprolol Tartrate 37.5 mg PO Q6H
6. RISperidone 2 mg PO HS
7. Rosuvastatin Calcium 10 mg PO HS
8. Senna 1 TAB PO BID:PRN constipation
9. TraZODone 25 mg PO HS
10. Warfarin 7.5 mg PO DAILY16
11. Lactulose 15 mL PO DAILY:PRN constipation
12. Morphine Sulfate ___ mg IV Q4H:PRN pain
13. Linezolid ___ mg IV Q12H
14. Lisinopril 2.5 mg PO DAILY
15. Furosemide 60 mg PO BID
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Ferrous Sulfate (Liquid) 300 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Guaifenesin 10 mL PO Q6H:PRN cough
5. Lactulose 15 mL PO DAILY:PRN constipation
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. RISperidone 2 mg PO BID
8. Senna 1 TAB PO BID:PRN constipation
9. Albuterol 0.083% Neb Soln 1 NEB IH Q2HR PRN sob/cough
10. Cepastat (Phenol) Lozenge 1 LOZ PO Q6H:PRN sore throat
11. Ipratropium Bromide Neb 1 NEB IH Q6H sob/cough
12. Mupirocin Ointment 2% 1 Appl TP BID
13. Ferrous Sulfate (Liquid) 300 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN breakthrough
pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 3 hours Disp #*20
Tablet Refills:*0
15. Warfarin 7.5 mg PO DAILY16
16. Metoprolol Tartrate 12.5 mg PO QID
17. Rosuvastatin Calcium 10 mg PO HS
18. Furosemide 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Active problems:
#Respiratory acidosis with metabolic alkalosis
#Pleural effusion
#Hypotension
# RUQ pain/acute cholecystitis
# Atrial Fibrillation
#MRSA pneumonia/RESPIRATORY STATUS
#UTI
___
#HSV outbreak
#Sacral wound
#CHEST PAIN
Chronic problems:
# Systolic CHF
# HTN
# Bipolar disorder
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after the tube draining your gallbladder became dislodged. We
replaced your tube and gave you some medication to reduce the
amount of fluid ___ your lungs. You were also found to have an
infection ___ your lungs and infection at the site of the tube
draining your gallbladder and at your feeding tube site. You
were started on antibiotics to treat these infections. ___
addition, we worked to make sure you had the appropriate dose of
medication to keep your heart rate normal without making your
blood pressure too low. You also needed to spend some time ___
the intensive care unit so that you could be ventilated
overnight to improve your breathing.
Please take your medications as directed and keep all your
follow-up appointments.
Followup Instructions:
___
|
10624280-DS-6 | 10,624,280 | 23,039,474 | DS | 6 | 2140-08-25 00:00:00 | 2140-08-27 17:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lithium / Heparin Analogues
Attending: ___.
Chief Complaint:
Worsening perianal wound
Failure to progress at rehab
Major Surgical or Invasive Procedure:
___ percutaneous cholesystostomy tube placement
___ replacement of percutaneous cholesystostomy tube
History of Present Illness:
Mr. ___ is a complicated ___ with a history of afib,
systolic CHF (EF 35%), CAD s/p CABG/AVR (___) presenting from
rehab for further evaluation of a worsening perineal wound, and
who is admitted for management of cholecystitis discovered on
imaging.
He's notably had a recent prolonged hospitalization at ___
___ from ___ through ___ due to pressor-dependent sepsis from
MSSA PNA that was complicated by respiratory failure requiring
intubation, acute on chronic CHF requiring diuresis, pleural
effusions, right hemidiaphragmatic paralysis, delirium, zoster,
difficulty extubating with eventual tracheostomy and
tracheostomy revision. Also required PEG placement. He was
discharged to rehab ___ and was referred to the ED due to
concern for worsening perineal wound- this wound was present
prior to discharge and had been treated with a 7d course of
cefepime as well as BID wet-to-dry dressings. He has notably had
a flexiseal in for 42 days. His wife requested evaluation at
___ rather than ___.
His WBC count appears to have been rising over the past few
days, with a peak of around 21 three days PTA. C dif had been
negative last week. Urine culture was negative. Blood cultures
negative. He was empirically started on vancomycin PO on ___,
it appears due to increased stool output. His warfarin had been
on hold due to elevated INR to 4.4 on ___.
Upon arrival to the ED, initial vitals were: 96.3 85 118/68 16
98% Vented with settings: Mode: PSV FiO2: 100 PEEP:5 PS: 15.
Labs were notable for leukocytosis (15), elevated lactate (2.4),
elevated INR (4.2) and elevated AST 106 and AP 219. Surgery was
consulted regarding his perineal wound but did not feel it was
acutely infected or in need of debridement. A CT abd/pelvis was
done for evaluation of abdominal pain and to search for
fistulizing disease of the perineum- it showed likely acute
cholecystitis. Surgery suggested percutaneous chole rather than
operative approach due to his many comorbidities and he was
subsequently admitted to MICU. He received cipro/flagyl prior to
transfer.
On arrival to the MICU, his vitals were stable. He is being
vented via trach and therefore history is limited to simple
questions. He's had abdominal pain intermittently over a
two-month period that has had no relation to his meals, though
is frequently accompanied by nausea. No history of gallstones.
He also notes severe buttock pain in the site of his perirectal
wound. He complains of shortness of breath which has been a
chronic problem. He otherwise denies headaches, sore throat,
dysuria, hemauturia, chest pain.
Past Medical History:
-MSSA PNA c/b respiratory failure and chronic ventilation at
___ ___
-CVA ___ with residual L hemiparesis
-DM2
-HTN
-OSA
-atrial fibrillation on coumadin
-heparin induced thrombocytopenia
-CKD, baseline Cr 1.2
-ASD vs PFO
-systolic heart failure with EF 35%
-CAD s/p CABG ___
-AVR ___ at time of CABG
-bipolar
Past Surgical History:
-trach ___ and replacement ___,
-PEG ___
-CABG, AVR (bioprosthetic) ___
-right hip replacement
Social History:
___
Family History:
Diabetes mellitus
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: HR105 BP123/84 RR29
GENERAL: trached, fatigued male, in no acute distress
HEENT: tracheostomy site is clean, intact
PULM: decreased breath sounds at the bases but otherwise clear
to auscultation
CARDS: irregularly irregular, variable S1 S2 no MRG
ABD: Gtube site with scant bleeding, mild TTP in the RUQ without
classic ___ sign. Abd otherwise soft, bowel sounds
tympanic. Bruising over the anterior belly.
GU: foley, mild scrotal edema
Rectal: a 4cm erosion that is approximately ___ deep is in the
___ area, though the skin borders are clean, intact.
abuts the flexiseal site.
EXT: PICC line in right arm, dressed today. DP and ___ pulses 2+
bilaterally. no peripheral edema.
DISCHARGE PHYSICAL EXAM:
T98.0, HR72-106 ___ (142/70) RR22-26 95-100% on
trach mask 50% O2 with frequent suctioning
Chole-tube drain: brown tea-colored liquid, 300ml output
General: Lying in bed, NAD, alert on trach collar
HEENT: EOMI, oropharynx clear
Lungs: Coarse rhonchi upper airways, bibasilar crackles.
CV: irreg irregular tachycardic
Abdomen: Obese, distended, tender around RUQ mostly, but tender
diffusely, drain site c/d/i
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Large rectal abscess with rectum protrusion
Pertinent Results:
ADMISSION LABS
___ 06:40PM BLOOD WBC-15.3* RBC-3.62* Hgb-10.8* Hct-33.1*
MCV-91 MCH-29.9 MCHC-32.7 RDW-14.8 Plt ___
___ 06:40PM BLOOD Neuts-80.9* Lymphs-10.2* Monos-7.3
Eos-1.3 Baso-0.3
___ 06:40PM BLOOD ___
___ 03:31AM BLOOD ___ PTT-43.8* ___
___ 06:40PM BLOOD Glucose-132* UreaN-65* Creat-1.3* Na-140
K-5.7* Cl-104 HCO3-22 AnGap-20
___ 06:40PM BLOOD ALT-38 AST-106* AlkPhos-219* TotBili-0.8
___ 03:31AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.4
Mg-2.9*
___ 03:37AM BLOOD ___ Temp-37.4 ___ Tidal V-450
PEEP-5 FiO2-50 pO2-34* pCO2-47* pH-7.34* calTCO2-26 Base XS-0
-ASSIST/CON Intubat-INTUBATED
___ 06:53PM BLOOD Lactate-2.4* K-4.9
___ 03:37AM BLOOD freeCa-1.17
Pertinent discharge labs:
___ 06:19AM BLOOD ___ RBC-2.85* Hgb-8.3* Hct-26.6*
MCV-93 MCH-29.1 MCHC-31.2 RDW-14.6 Plt ___
___ 06:19AM BLOOD Plt ___
___ 06:19AM BLOOD ___ PTT-37.8* ___
___ 06:19AM BLOOD Glucose-138* UreaN-36* Creat-1.1 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
___ 06:19AM BLOOD ALT-10 AST-22 AlkPhos-103 TotBili-0.3
___ CT ___:
IMPRESSION:
1. Findings concerning for acute cholecystitis.
2. No evidence of perineal abscess.
3. Bilateral pleural effusions with compressive lower lobe
atelectasis.
4. Atrophic left kidney with numerous bilateral renal
hypodensities, larger
of which likely represent simple cysts.
5. Small volume ascites.
6. PEG tube in place.
___ CXR:
FINDINGS: There is tracheostomy tube. There is median
sternotomy wires.
There are bilateral pleural effusions, right greater than left.
There is some prominence of pulmonary interstitial markings,
suggestive of fluid overload.
There is left retrocardiac opacity.
___ CXR
FINDINGS: Tracheostomy tube remains in place, and
cardiomediastinal contours are stable in appearance. Persistent
moderate right pleural effusion with adjacent right lower lobe
atelectasis and/or consolidation. Slight improvement in left
retrocardiac opacity and adjacent small left pleural effusion.
Otherwise, no relevant short interval changes.
___ CXR:
IMPRESSION:
1. Left PICC in the cavoatrial junction.
2. Otherwise, no significant change.
___ CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The lung volumes remain very low, the extent of
bilateral pleural effusions, right more than left, is unchanged.
Relatively extensive basal areas of atelectasis. Mild
cardiomegaly and signs of mild-to-moderate fluid overload. The
tracheostomy tube and the left PICC line are unchanged.
Unchanged alignment of the sternal wires.
___ RUQ US
IMPRESSION:
1. Fully distended gallbladder with stones and echogenic
material in the lumen adjacent to the drainage catheter tip.
The distended state of the gallbladder suggests the drain is not
working. A fluoroscopy exam is recommended to further assess
the drainage tube and re-position as needed..
2. Trace ascites and small right pleural effusion.
___ CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The tracheostomy tube is in unchanged position.
Unchanged alignment of the sternal wires, unchanged course of
the left-sided PICC line and unchanged position of the right
upper quadrant drain. Lung volumes remain very low, a
substantial right and a moderate left pleural effusion are seen.
The size of the cardiac silhouette continues to be enlarged and
signs suggestive of moderate pulmonary edema are still present.
Extensive atelectasis at both lung bases. Well ventilated areas
of the lung show no evidence for newly appeared parenchymal
opacities suggestive of pneumonia.
___ DUPLEX:
IMPRESSION:
No evidence of left upper extremity DVT
Brief Hospital Course:
Mr. ___ is a ___ with multiple problems recently
hospitalized for pneumonia complicated by respiratory failure
and tracheostomy/chronic vent who presented with cholecystitis,
admitted to MICU.
# ACUTE CHOLECYSTITIS: Conservative management indicated given
his multiple comorbidities. Started on Cipro/Flagyl. ___
consulted for decompression, agreed w/ need for procedure but
INR > 3.7, so pt given FFP x 4 on ___, with aim to decrease INR
below 1.5 per ___ recs. Patient required vitamin K x2 with
appropriate decrease in INR. He underwent placement of
___ perc chole tube on ___. Tolerated procedure well, but
on ___ had increasing pain, tube found to have little drainage.
Returned to ___ suite for repeat drain placement, new tube placed
w/ drainage of 300 cc of bilious fluid. LFTs have downtrended
towards normal and remain stable. Patient continues to complain
of RUQ pain, likely related to the tube. Surgery followed along
throughout hospital course and plan to keep perc tube in place
until followup with them in ___ weeks.
# CHRONIC PERINEAL WOUND: Roughly 3cm wide perineal wound
beginning just anterior to the anus which tracks anteriorly to
the scrotum and minimally posteriorly toward the rectum. Wound
was clean on arrival without signs of necrosis or cellulitis,
but was very severe. Etiology of wound unclear - reported to be
from trauma, vs. erosion from flexiseal and poor nutritional
status (although per nursing, flexiseal placed at OSH after
wound was noted); flexiseal was removed while in ICU. Surgery
consulted, no debridement warranted at the time. Wound care and
nutrition consulted, wet-to-dry dressings applied.
# Blood culture positive x2 for Corynebacterium diphtheria.
Infectious disease believed the culture to be contaminant, with
repeat cultures pending at time of transfer. WBC count
normalized and patient remained afebrile. Facility will
contacted if pending cultures return positive requiring
treatment.
# CHRONIC VENT DEPENDENCE/RESPIRATORY FAILURE: patient remained
vent dependent following his protracted ICU course at ___.
Baseline CXR obtained. Patient was tolerating trach mask with
50% FiO2 requiring frequent suctioning at the time of discharge.
He did not require ventilatory support.
# ATRIAL FIBRILLATION. Pt in Afib on arrival to ICU. CHADS2 was
4. Rate controlled on metoprolol, which was continued. Coumadin
held pending procedure, and because INR supratherapeutic at 3.7.
Pt had initially been on 10mg warfarin daily, though was slow to
become therapeutic at rehab and was increased to 12.5 daily. Pt
restarted on warfarin after final ___ procedure (day 1 = ___
bridged with fondaparinux (history of HIT). Pt had another
episode Afib w/RVR on ___, responded to 5mg IV Lopressor and
additional 25mg PO. Increased PO Lopressor to 37.5mg QID with
good rate control.
# DIABETES MELLITUS TYPE II: On ISS on admission, which was
discontinued due to low blood sugars. ___ reconsider restarting
if blood sugars running high.
# CONGESTIVE HEART FAILURE, CHRONIC : Pt satting well on arrival
to ICU without SOB. Lasix was initially held in the setting of
elevated lactate and acute infection, with close monitoring of
fluid status and restarted on date of transfer. Patient
continued on metoprolol as above, lisinopril had been
discontinued on arrival due to sepsis and was restarted on date
of transfer.
# CORONARY ARTERY DISEASE: Chest pain free on arrival. Continued
aspirin but decreased to 81mg in ICU. Was increased to home
dose on date of transfer.
TRANSITIONAL ISSUES:
-Patient will need trach exchanged for a smaller size (currently
size 8 cuff) to facilitate use of Passey-Muir valve which
patient has been using. This can be done by rehab or by
interventional pulm who will also perform outpatient bronch eval
in ___ weeks. Facility will be contacted with time and date of
pulmonology follow-up appointment.
-Continue to trial patient with Passey-Muir valve as tolerated.
Always deflate the cuff prior to placing the valve. Patient
requires ___ supervision from RN or RT while valve in place with
close O2 monitoring. Do not allow patient to sleep with valve in
place.
-Please keep strict NPO with all nutrition, hydration and
medication.
-Please continue tube feeding.
-Subtherapeutic INR @ time of transfer on ___ bridge
and warfarin-will require continued monitoring.
-Perc chole-tube in place with drainage to be left in place.
Output should be monitored along with liver enzymes and clinical
improvement while awaiting surgery re-evaluation of patient in
___ weeks. Patient should be continued on antibiotics (cipro,
Flagyl) until surgery appointment.
-Blood cultures pending at time of discharge with no growth to
date. Facility will be contacted if positive cultures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
not to exceed 4g daily
2. Albuterol Inhaler 4 PUFF IH Q4H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Bacitracin Ointment 1 Appl TP BID
6. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
7. Lactulose 15 mL PO DAILY
8. Metoprolol Tartrate 25 mg PO Q6H
hold for HR<50, SBP<100
9. Pantoprazole 40 mg IV Q24H
10. Vancomycin Oral Liquid ___ mg PO Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Tartrate 37.5 mg PO Q6H
6. RISperidone Oral Solution 2 mg PO HS
7. Warfarin 10 mg PO DAILY16
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
9. Fondaparinux 7.5 mg SC DAILY
10. Ipratropium Bromide Neb 1 NEB IH Q6H SOB
___. Morphine Sulfate ___ mg IV Q4H:PRN pain
12. Pantoprazole 40 mg PO Q12H
13. Bacitracin Ointment 1 Appl TP BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Lactulose 15 mL PO DAILY
16. RISperidone Oral Solution 1 mg PO QAM
17. Rosuvastatin Calcium 10 mg PO DAILY
18. TraZODone 25 mg PO HS
19. Ciprofloxacin HCl 500 mg PO Q12H
Please continue until surgical follow-up
20. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Please continue until surgical follow-up
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute cholecystitis
Atrial fibrillation with rapid ventricular response
Perirectal abscess
Secondary:
Trach dependence
Coronary artery disease
Congestive heart failure
Diabetes mellitus, type II
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission. You were initially admitted to the ICU and found to
have an infection in your gallbladder. You were started on
antibiotics and a drain was placed to remove the infection. The
drain will stay in place until you follow-up with the surgeons.
You will also continue antibiotics until you follow-up with the
surgeons.
Your rectal abscess was evaluated by the surgeons and our wound
care nurses. ___ will require regular monitoring at rehab but
does not need a surgical intervention at this time.
Followup Instructions:
___
|
10624313-DS-21 | 10,624,313 | 23,592,737 | DS | 21 | 2118-08-28 00:00:00 | 2118-08-28 20:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Bacitracin / Ace
Inhibitors / Penicillins
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Stroke Scale score was : 11
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 0
3. Visual fields: 1
4. Facial palsy: 0
5a. Motor arm, left: 1
5b. Motor arm, right: 1
6a. Motor leg, left: 1
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 2
10. Dysarthria: 0
11. Extinction and Neglect: 0
GCS Score at the Scene: 15
ICH volume by ABC/2 method: 24 cc
ICH Score:
Pre-ICH mRS ___ social history for description):
If ___ component:
___ score (clinical): n/a
REASON FOR CONSULTATION: ___
HPI:
Neurology Consult
Neurology Resident Consult Note
Reason for Consultation: IPH
HPI: The patient is a ___ year old woman with a PMH of dementia
(resides in ___ unit), Afib not on AC presents with IPH
History obtained per daughter by phone, as patient unable to
give
Patient resides at ___. She was found
after falling in the bathroom today, however it was not clear
what exactly it happened. The daughter states that she spoke
with ___ overnight however they were not able to
provide
much further detail on the exact course of the events. The
patient is not on any blood thinners. She presented to outside
hospital where CT scan was done and which showed left-sided IPH,
and she was transferred here for further management. Per ED
report, she reportedly fell backwards and hit her head with no
LOC.
Her daughter states that at baseline she is sometimes lucid and
can have a good conversation, but usually can have a decent
conversation with her though notes that she often sometimes
repeats herself but would be able to follow commands. She is
not
oriented at baseline. Based on my description of her current
state to the daughter, the daughter thinks that the patient is
not currently at baseline.
Past Medical History:
PMHx:
VASCULAR DEMENTIA
ATRIAL FIBRILLATION
*S/P LEFT MASTECTOMY
ABNORMAL MAMMOGRAM
ATRIAL FIBRILLATION
BREAST CANCER
CYSTOCELE
VIRAL SYNDROME
G2P2
ECZEMATOUS DERMATITIS
SEBORRHEIC KERATOSIS
TINEA PEDIS
H/O BREAST CANCER
H/O SKIN CANCER
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Oriented to name. can only answer simple
questions correctly when asked, like her name. Otherwise unable
to provide appropriate answers to questions. Perseverative.
often
says i'm doing ok in response to any question. Language syntax
appears intact, but again are not correct responses. Unable to
follow any commands.Speehc was not dysarthric
-Cranial Nerves:
II, III, IV, VI: PERRL R 3 to 2mm and brisk. L pupil ovoid EOMI
without nystagmus. blinks less to threat on R side.
V: Facial sensation intact to light touch.
VII: No facial droop at rest
VIII: Hearing intact to conversaton
IX, X: unable to assess
XI: unable to assess
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
not able to assess confrontationally as not following commands.
Moves all extremities antigravity without any obvious asymmetry.
-Sensory: appears intact to light touch.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor on object reach
-Gait: deferred
Discharge Exam:
General: Awake, NAD
HEENT: Small left frontal scalp hematoma. Left posterior scalp
laceration with skin staples in place. No scleral icterus noted,
MMM, no lesions noted in oropharynx.
Neck: Supple
Pulmonary: Breathing comfortably
Cardiac: Intermittently irregular rhythm, regular rate
Abdomen: Soft, NT/ND
Extremities: No ___ edema
Neurologic: sleeping. arousable. sparse verbal output. does not
follow commands. Moves all extremities
Pertinent Results:
Head CT (___):
FINDINGS:
Approximately 3.9 x 5.8 cm left parieto-occipital hematoma
previously measured
approximately 3.8 x 5.7 cm when measured similarly. The degree
of surrounding
edema is not significantly changed since prior. Mass effect
with compression
of the occipital horn of the left lateral ventricle is similar
to prior. Left
parieto-occipital sulcal effacement is also similar to prior.
There is a
small amount of layering hemorrhage in the occipital horn of the
right lateral
ventricle, not seen on prior. There is no evidence of acute
territorial
infarction. The configuration of the ventricles and sulci is
otherwise not
significantly changed since prior.
Small left frontal scalp hematoma is again seen. There is no
evidence of
fracture. Skin staples are again seen overlying the left
frontoparietal
region. The visualized portion of the paranasal sinuses,
mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
There is
bilateral carotid siphon calcification.
IMPRESSION:
1. Small amount of layering hemorrhage in the occipital horn of
the right
lateral ventricle was not seen on prior and may be due to
redistribution.
2. No significant interval change in the 5.8 cm left
parieto-occipital
intraparenchymal hematoma.
Brief Hospital Course:
Ms. ___ is a ___ woman with vascular dementia, Afib not on
A/C, who presented from her assisted living facility (___
___ unit) after an unwitnessed fall with head strike without
LOC, found to have a large left parietal/occipital IPH likely
secondary to cerebral amyloid angiopathy. Patient underwent
serial head CTs which initially showed slight increase size of
hemorrhage and then stabilized.
Patient's blood pressure was initially controlled with
intermittent IV antihypertensives. Patient also underwent trauma
eval given fall which revealed left humeral neck fracture for
which sling was recommended. Otherwise her hospital course was
notable for intermittent fevers. Blood cultures showed no growth
date. Urine culture ultimately grew coagulase negative staph but
it was felt to be contaminant.
She was evaluated by Speech therapy who approved her for a
modified diet. On subsequent visits, patient declined to
participate with speech and swallow, physical therapy and
occupational therapy.
Patient's exam was notable for patient being alert but
withdrawn. She was oriented only to her name. She was notable to
follow any commands but patient was fluent. She was able to move
all extremities antigravity but became increasingly frustrated
with exam
Patient's family expressed that she would not want to live with
this type of disability. Palliative care was consulted. After
further discussions with her daughter and HCP regarding
patient's prognosis, likely inability to have meaningful
recovery, and patient's previous wishes indicating that she
would not wish for life sustaining measures including
resuscitation, intubation, artificial nutrition, IV antibiotics
in a debilitated state, patient's family decided to pursue
___ focused care and home hospice. Anti-hypertensives, and
IVF were stopped. Patient given tylenol as needed for
pain/fever. Morphine and haldol were ordered as needed but
patient didn't require any.
Patient was refusing home Seroquel and metoprolol so these were
stopped.
Patient was discharged to ___
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? () Yes - (x) No- patient
transitioned to CMO
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - (x) unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? () Yes - (x) No -- patient transitioned to CMO.
Discharged on home hospice
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 12.5 mg PO DAILY
2. QUEtiapine Fumarate 25 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PR Q4H:PRN pain/fever
2. Docusate Sodium 100 mg PO BID
3. Haloperidol 0.5-2 mg IV Q4H:PRN delirium
4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN Pain or respiratory
5. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left parietal occipital intraparenchymal hemorrhage
vascular dementia
atrial fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___ of Ms. ___,
You were hospitalized due to symptoms of confusion, difficulty
speaking and weakness resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where there is bleeding in the brain. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Because of Ms. ___ prognosis, likely inability to recover
and her previous wishes, comfort focused care and hospice was
arranged.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10624517-DS-28 | 10,624,517 | 29,826,516 | DS | 28 | 2180-04-17 00:00:00 | 2180-04-17 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / adhesive tape / lisinopril / Enalapril / amiodarone
Attending: ___
Chief Complaint:
atrial fibrillation with rapid ventricular response
Major Surgical or Invasive Procedure:
___ - Attempted but unsuccessful transesophageal
echocardiogram with cardioversion
History of Present Illness:
The patient is an ___ woman with a PMH significant for
non-cardiomyopathy (LVEF 25%), failed endomyocardial biopsy at
___ secondary to induction of complete heart block (which
resolved), anterior MI s/p BMS to LAD and moderate-to-severe MR
who was initially admitted to the ___ service on
___ for chest pain found to be in new-onset atrial
fibrillation with rapid ventricular rate.
.
On the day of admission, the patient noted substernal chest
discomfort, described as a dull,non-radiating and not associated
with any dyspnea, N/V, lightheadedness, or palpitations. Patient
also denied any DOE, PND, orthopnea, ankle edema, syncope or
pre-syncope prior to admission. She denies any recent fevers or
chills; no cough or dysuria.
.
In the ___, patient was noted to be in atrial fibrillation with
RVR, rate in the 140s with a BP of 116/92. Of note, Labs on
admission were notable for a Troponin of 0.17, potassium of 3.1
and magensium of 1.7. She received IV Diltiazem, was started on
Heparin gtt, and was admitted for planned cardioversion. She
then spontaneously converted to sinus rhythm, and was started on
warfarin for anticoagulation. Hoewever, she converted back into
A.fib and was then started on Amiodarone on ___. LFTs
revealed a mild transaminitis.
.
Upon admission to the Medicine floor, her course has been
notable for elevated cardiac enzymes and presumed acute systolic
CHF exacerbation with worsening hyponatremia (to nadir of 117),
___ (peak 1.9 from baseline 0.7-0.9), transaminitis (which
worsened with AST in the 6000s and ALT in the 3000 range;
Hepatology attributing this to congestive hepatopathy vs.
Amiodarone toxicity), and an Enterococcal UTI (sensitive to
Ampicillin, 7-day course planned). Cardiac enzymes were cycled
with a peak Troponin of 0.22, CK-MB 10. MB index was 3.2. She
was diuresed with Torsemide and Metolazone and was continued on
Metoprolol for rate control. The patient also had some issues
with bloody stools which was attributed to hemorrhoidal
bleeding; she received 2 units of FFP for an INR of 4.7 at that
time. The patient was noted to again spontaneoulsy convert to
NSR overnight on ___. In the AM of ___, she acutely became
hypotension to the 60-70 mmHg systolic range, with HR of 40-50s.
They attributed this to over-duresis, for which she received
aggressive IVF resuscitation (3L IVF). She also received
Atropine x 1 without effect. An emergent central venous catheter
and EJ were placed on the Cardiology floor with a Dopamine gtt
started peripherally. She was transferred to the MICU on ___
for further management.
.
On arrival to the MICU, patient was awake on a NRB and answering
questions. She was continued on the Dopamine infusion, and
started on Vasopressin with initial improvement in her SBP to
110-120s and HR of 60 bpm. Antibiotics were broadened to
Vancomycin and Cefepmine IV. CVP was roughly 20, and aggressive
IVF administration ceased. Bedside 2D-Echo did not reveal a
pericardial effusion. In the setting of worsening mental status
status and poor perfusion she was switched to Dobutamine,
Levophed, and Vasopression gtts. A femoral A-line was placed,
after sveral attempts at a radial A-line were unsuccessful.
Patient was intubated in the setting of increased work of
breathing.
.
In the MICU, she was weaned off of Levophed gtt, started on 3
amps of sodium bicarbonate and Lasix IV was initiated for
diuresis. She was extubated on ___ without issues. She was
started on a Diltiazem gtt for A.fib with rapid ventricular
response with adequate rate control. The patient was transferred
to the CCU for further management.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or pre-syncope.
Past Medical History:
CARDIAC HISTORY: Hypertension
* CABG: None
* PCI: s/p BMS to proximal LAD (___)
* PACING/ICD: None
.
PAST MEDICAL & SURGICAL HISTORY:
1. Coronary artery disease (NSTEMI in ___ with cardiac
catheterization and BMS x 1 to the proximal LAD)
2. Dilated cardiomyopathy (left ventricular cavity is mildly
dilated with moderate to severe regional systolic dysfunction;
with basal inferior and inferolateral walls contract best; LVEF
= 25%) on ___
3. Mitral regurgitation (2+) on ___ 2D-Echo
4. Tricuspid regurgitation (2+) on ___ 2D-Echo
5. Arthritis
6. Left breast cancer (s/p mastectomy, node dissection,
radiation, ___
7. History of gastritis (with GI bleeding)
8. Macular degeneration
9. Persumed syndrome of inappropriate ADH (SIADH); received
Tolvaptan
Social History:
___
Family History:
Mother died of ? stomach cancer in her ___. Father died of
natural causes in his ___. 9 siblings, all deceased, no medical
problems. Denies family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
.
PHYSICAL EXAM:
VITALS: 95.2 119/71 132(irregular) 26 97%6L NC
GENERAL: Caucasian female, speaks in ___ word sentences
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No xanthalesma.
NECK: JVP slightly elevated, prominent V waves
___: PMI located in the ___ intercostal space, mid-clavicular
line. Irregular rhythm, increased rate, II/IV systolic murmur
LLSB
RESP: Respirations labored w/ accessory muscle use, decreased
breath sounds at bases.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Abdominal aorta
not enlarged to palpation, no bruit.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: sacral edema
NEURO: CN II-XII intact throughout. patient refuses to answer
questions about orientation, strength ___ bilaterally, sensation
grossly intact.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
DISCHARGE EXAM:
unchanged from admission
Pertinent Results:
Admission Labs:
___ 09:05AM BLOOD WBC-8.6 RBC-4.02* Hgb-13.5 Hct-40.0
MCV-100* MCH-33.7* MCHC-33.8 RDW-14.0 Plt ___
___ 09:05AM BLOOD Neuts-84.5* Lymphs-7.8* Monos-7.0 Eos-0.6
Baso-0.1
___ 09:05AM BLOOD ___ PTT-25.2 ___
___ 09:05AM BLOOD Glucose-112* UreaN-15 Creat-0.7 Na-136
K-3.1* Cl-96 HCO3-27 AnGap-16
___ 09:05AM BLOOD CK(CPK)-317*
___ 09:05AM BLOOD CK-MB-10 MB Indx-3.2
___ 09:05AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.7
___ 09:10AM BLOOD VitB12-901* Folate-GREATER TH
___ 05:00PM BLOOD TSH-2.3
.
IMAGING:
.
CARDIAC CATH (___) - Severe one vessel coronary artery
disease: see above comments Mild systemic arterial hypertension.
Successful direct stenting of the proximal LAD with a VISION
3.0x12 mm bare-metal stent (BMS) deployed at 18 atm with
improved TIMI flow post stent deployment. (see PTCA comments) R
___ femoral artery sheath sutured into position post procedure
ASA indefinitely; plavix (clopidogrel) 75 mg daily for at least
one month for bare-metal stent placement. Importance of plavix
emphasized to patient.
.
___ LIVER OR GALLBLADDER US - Prominent hepatic veins
along with exaggerated phasicity of portal vein waveforms. These
findings are consistent with hepatic congestion most probably
secondary to right heart failure. Trace amount of ascites.
Bilateral pleural effusions.
.
___ TTE - The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 20 %). The left ventricular
mechanical activation sequence is dyssynchronous. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric, posteriorly directed jet of
moderate (2+) 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 moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are similar.
.
___ TEE - No spontaneous echo contrast or thrombus is seen
in the body of the left atrium/left atrial appendage or the body
of the right atrium/right atrial appendage. Overall left
ventricular systolic function is depressed. The mitral valve
leaflets are mildly thickened and mitral regurgitation is
present. There is no pericardial effusion. No SEC of thrombus
seen. depressed left ventricular systolic function.
.
___ CXR - Endotracheal tube and right internal jugular
central line unchanged in position. Nasogastric tube is seen
coursing below the diaphragm with the tip not identify.
Persistent layering bilateral pleural effusions. However, there
is improving pulmonary edema compared to the prior study.
Overall stable cardiac and mediastinal contours given
differences in patient positioning. No
pneumothorax.
.
MICROBIOLOGY DATA:
___ Urine culture - Enterococcus (sensitive to Vancomycin)
___ Blood culture - no growth
___ MRSA screen - negative
___ Urine culture - negative
___ Sputum culture - contaminated specimen
.
DISCHARGE LABS:
___ 08:10 WBC 9.5 RBC 3.53* Hgb 11.6* Hct 35.5* MCV 101*
MCH 32.8* MCHC 32.6 RDW 14.1 Plts 306 INR 2.2
___ 08:10 glc 94 urea 32* Cr 0.8 Na 137 K 3.3 Cl 95*
HCO3 33*
Brief Hospital Course:
___ with a medical history of dilated cardiomyopathy (LVEF 25%)
NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD,
and moderate-to-severe mitral regurgitation who was initially
admitted for chest pain and dyspnea found to be in new-onset
atrial fibrillation with rapid ventricular rate with hospital
course complicated by decompensated congestive heart failure,
pneumonia, and shock liver versus congestive hepatopathy.
.
ACUTE CARE
# ATRIAL FIBRILLATION - The patient presented on ___ with
new-onset atrial fibrillation, which was likely due to
chronically dilated atria from worsening mitral regurgitation.
She spontaneously converted during her early hospital course but
then went back into atrial fibrillation during her medical ICU
course. She was suboptimally rate controlled on PO Diltiazem, so
was started on a diltiazem drip and digoxin. In the setting of
her poorly controlled tachyarrythmia she developed decompensated
heart failure requiring intubation early in her hospital course.
On ___, TEE/cardioversion was attempted and was unsuccessful
at restoring sinus rhythm. We felt that given her symptomatic
heart failure, intraventricular conduction delay, and low
ejection fraction that she would benefit from cardiac
resynchronization therapy. There was an attempt to place a
BiVentricular pacemaker (CRT) but the CS lead was unable to be
placed so just a permanent pacemaker (PPM) was placed. She
requires one more day of cephalexin for this. She has been rate
controlled with ventricular rates in the ___ on current
doses of digoxin and metoprolol. The plan is to start amiodarone
in the future once her liver function tests normalize. Her
CHADS-2 score is 3 (age, hypertension, heart failure) and she
was maintained on Coumadin for anticoagulation with goal INR of
___. Her INR was 2.2 at discharge, up from 1.2 the day prior. We
would recommend rechecking an INR on ___. If amiodarone is
started in the future, she will require close monitoring of INR.
.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE - The patient has a
history of
systolic heart failure, likely ischemic from past myocardial
infarction, who presented with sacral edema, elevated JVP,
decreased breath sounds and imaging findings (pleural effusion)
consistent with decompensated biventricular heart failure. The
etiology is likely due to uncontrolled atrial fibrillation and
volume resuscitation patient received early in her hospital
course. A 2D-Echo this admission showed a left ventricular
cavity that was moderately dilated and severe global left
ventricular hypokinesis (LVEF = 20%). The left ventricular
mechanical activation sequence was clearly dyssynchronous. She
was diuresed with a lasix drip and metolazone and then
re-started on her home torsemide at 40mg daily, slightly lower
than her home dose of 60mg daily. We resumed her home losartan
25mg daily, increased her metoprolol to 200mg daily (for rate
control), and started her digoxin 0.125 daily and spirolactone
12.5mg daily. She was felt to be euvolemic at discharge.
.
# CORONARY ARTERY DISEASE - The patient has a history of NSTEMI
and was status-post bare-metal stenting to the LAD in ___. She
was without evidence of active ischemia this admission, with a
reassuring EKG. We continued Aspirin 81 mg PO daily.
.
# PNEUMONIA - The patient presented with shortness of breath
with a possible retro-cardiac opacity on chest imaging; athough
she remained afebrile without leukocytosis. She was started on
levaquin for this and completd a five day course. She did have
an incidental Enterococcal UTI while being treated in the
medical ICU and this was treated with IV Vancomycin. A clearance
urine culture was negative for any growth on ___.
.
# TRANSAMINITIS - The patient presented with a transaminitis in
the thousands likely due to either congestive hepatopathy from
decompensated failure or shock liver from hypotension, on
admission. She had RUQ U/S on ___ that showed hepatic
congestion most likely due to right sided heart failure. Her
transaminitis continues to improve and when last checked on ___
her ALT was 220s and AST was 60.
.
# MECHANICAL FALL: The patient had an unwitnessed fall during
the night of ___. She denied syncopal or pre-syncopal sx,
endorsing a mechanical etiology. She did hit her head. She was
found on the floor by the RN. Her neuro exam was intact and
unchanged. She had a head CT with preliminary read negative for
bleed.
.
TRANSITION OF CARE:
.
#VOLUME STATUS: Her home torsemide was started at 40mg daily
rather than 60mg daily in setting of poor po intake and she
develops symptoms concerning for volume overload.
.
# ANXIETY - We continued her home dosing of Diazepam 2 mg TID
PRN anxiety.
.
# NUTRITION - She was followed by speach and swallow during her
hospital course. Early on she failed and thin liquids were
avoided. later this was advanced and at discharge she was
tolerating thin liquids adn moist, soft solids with meds crushed
in puree. PO intake has not been very good while hospitalized.
.
TRANSITION OF CARE ISSUES:
ISSUES TO ADDRESS AT FOLLOW UP:
1. Coumadin monitoring with INR
2. Wound care for L chest site of pacemaker incision
3. Nutrition -- patient has a very poor appetite.
4. Titration of torsemide dose.
5. Follow LFTs
CODE STATUS: FULL CODE
COMMUNICATION: ___ (nephew) ___ is HCP
PENDING STUDIES: Head CT final read pending
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Clotrimazole-betamethasone 1%-0.05 % cream BID PRN rash
2. Diazepam 2 mg PO QID
3. Losartan 25 mg PO daily
4. Metoprolol succinate 100 mg PO daily
5. Omeprazole 20 mg PO daily
6. Potassium chloride 20 mEq PO daily
7. Torsemide 60 mg PO daily
8. Acetaminophen 500 mg PO QID PRN pain
9. Aspirin 81 mg PO daily
Discharge Medications:
1. diazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
2. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Disp:*30 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for fever or pain.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. potassium chloride 20 mEq Packet Sig: One (1) PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO once a day.
12. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injevtion Injection TID (3 times a day): please stop one INR is
therapeutic.
14. methyl salicylate-menthol Ointment Sig: One (1) Appl
Topical PRN (as needed) as needed for shoulder pain.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal BID (2
times a day) as needed for hemmorhoid discomfort.
19. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
A-Fib with RVR
Secondary Diagnosis:
sCHF
HTN
Mitral Regurgitation
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 caring for you at the ___
___. You were admitted for your atrial fibrillation
that was beating very fast. We gave you medicines to lower the
heart rate and medicine to get rid of extra fluid. An attempt
was made to place a biventricular pacemaker to help coordinate
your heart rhythm but Dr. ___ was unable to place the
third lead. You still have a pacemaker to prevent your heart
rate from becoming too slow from the medicines. You cannot lift
more than 5 pounds You have been started on warfarin (coumadin)
to prevent a stroke from the atrial fibrillation. Your
medications were adjusted to help your heart work as best it
can.
Please note the following changes to your medications:
1. STARTED Coumadin 2mg by mouth once a day to prevent a stroke
2. STARTED senna, colace and miralax to prevent constipation
3. STARTED Digoxin to slow your heart rate and help your heart
pump better
4. STARTED Spironolactone to help your heart pump better
5. STARTED multivitamin to help your nutrition
6. STARTED ___ gay for shoulder pain
7. STARTED Hydrocortisone cream for your hemmorrhoids.
8. STARTED heparin shots to prevent blood clots
9. DECREASED Torsemide to 40 mg daily
10. INCREASED metoprolol to 100 mg twice daily to slow your
heart rate
11. DECREASED Valium to twice daily
Coumadin is a blood thinner. You will need to have your blood
checked often at your primary care doctor's office until your
primary care doctor determines the appropriate dose of coumadin
for you. After that, you will continue to need regular blood
checks.
Weigh yourself every morning, call ___ NP if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
___
|
10624517-DS-29 | 10,624,517 | 23,915,035 | DS | 29 | 2180-07-05 00:00:00 | 2180-07-05 17:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / adhesive tape / lisinopril / Enalapril / amiodarone
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
___ y/o female w/ PMHx dilated cardiomyopathy (LVEF 25%) NYHA
Stage II , coronary artery disease s/p BMS to proximal-LAD,
moderate-to-severe mitral regurgitation, atrial fibrillation on
coumadin s/p PPM placement who presents s/p fall. Patient had
very complicated hospitalization from ___ during which
she was initially admitted to ___ for A fib w/ RVR. Her
hospital course was c/b shock liver vs amiodarone toxicity with
LFTs rising to 6000s, enterococcal UTI, MICU transfer for
hypotension of unclear etiology. She was intubated due to
respiratory failure likely ___ fluid overload, was diuresed,
extubated, then transferred to CCU in setting of a fib with RVR.
Given her severe CM, a BiV ICD was attempted to be placed but
coronary sinus lead could not be placed so a PPM was left. Since
her discharge, she went to rehab and then was sent home. Story
today is a bit unclear given what patient reports and notes from
PCP however patient states she was seen in her PCPs office early
today and was told things were going well apart from increased
lower extremity edema with a blister on her left foot. Her PCP
increased her dose of lasix at that time. She went home and had
a mechanical fall after her slipper got caught on the ground -
she had head trauma as well as left ribs, knee, and elbow. She
called a friend who then called EMS to take her to the ___.
(Call-in on ___ states patient was seen at PCPs after fall
and was sent to ___ from PCPs office)
.
In the ___, initial VS: 5 97.6 86 109/55 16 93% ra. She had CT
Head that showed no acute process, CT Chest that showed severe
cardiomegaly with bilateral pleural effusions, plain films of
the knee and elbow that were negative. Labs showed potassium of
3.2, INR of 2.1. She was given KCl 40meq, tylenol and tramadol
for pain. On transfer, vitals were: Temp: 97.2, Pulse: 73, RR:
20, O2Sat: 98, O2Flow: RA, Pain: 3.
.
Currently, she complains of pain in her left shoulder/ribs where
she fell. Denied any chest pain, palpitations, dizziness, light
headedness prior to fall.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
.
Past Medical History:
1. Coronary artery disease (NSTEMI in ___ with cardiac
catheterization and BMS x 1 to the proximal LAD)
2. Dilated cardiomyopathy (left ventricular cavity is mildly
dilated with moderate to severe regional systolic dysfunction;
with basal inferior and inferolateral walls contract best; LVEF
= 25%) on ___
3. Mitral regurgitation (2+) on ___ 2D-Echo
4. Tricuspid regurgitation (2+) on ___ 2D-Echo
5. Arthritis
6. Left breast cancer (s/p mastectomy, node dissection,
radiation, ___
7. History of gastritis (with GI bleeding)
8. Macular degeneration
9. Persumed syndrome of inappropriate ADH (SIADH); received
Tolvaptan
Social History:
___
Family History:
Mother died of ? stomach cancer in her ___. Father died of
natural causes in his ___. 9 siblings, all deceased, no medical
problems. Denies family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
admission exam
VS - 95.9 123/82 60 20 95%RA
GENERAL - Alert, interactive, NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD,
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - bibasilar crackles
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ lower extremity edema, pulses dopplerable
bilaterally. Dusky areas on heel and balls of feet bilaterally
including toes, Cap refill < 2 seconds, DP pulses dopplerable
bilaterally.
TTP over left upper chest/shoulder, left elbow
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact,
discharge exam
Afebrile, HR ___, BP ___ to 100s
GENERAL - Alert, interactive, NAD, frail appearing
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD,
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - bibasilar crackles
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, thin legs, no edema, left dorsal foot blister
with bandage
Pertinent Results:
admission labs:
___ 12:58PM BLOOD WBC-5.4 RBC-3.67* Hgb-11.8* Hct-37.1
MCV-101*# MCH-32.2* MCHC-31.9 RDW-14.1 Plt ___
___ 11:45PM BLOOD ___ PTT-36.2 ___
___ 12:58PM BLOOD UreaN-18 Creat-0.7 Na-133 K-3.2* Cl-93*
HCO3-23 AnGap-20
___ 12:58PM BLOOD Glucose-78
___ 12:58PM BLOOD ALT-26 AST-45* CK(CPK)-207* AlkPhos-105
TotBili-1.3
___ 12:58PM BLOOD CK-MB-4 cTropnT-0.02*
___ 07:05AM BLOOD CK-MB-4 cTropnT-0.02*
___ 07:05AM BLOOD Albumin-3.4* Calcium-8.4 Phos-3.4 Mg-1.7
___ 07:05AM BLOOD VitB12-734
___ 12:58PM BLOOD TSH-4.0
___ 12:58PM BLOOD Free T4-1.5
.
studies
admission ECG:
Sequential atrial and ventricular pacing. Pacing from the right
ventricle
only.
.
CT head without contrast: No evidence of acute intracranial
process.
.
Knee AP, lateral, oblique: No acute fracture
.
Elbow AP, lateral, oblique: Soft tissue swelling without
visualized acute fracture.
.
Chest/Rib films: No acute cardiopulmonary process. No visualized
rib fracture.
Persistent moderate-sized bilateral pleural effusions.
.
CT chest: Moderate simple bilateral pleural effusions, slightly
increased
from the prior examination. No evidence of hemothorax or
fracture. Severe
cardiomegaly.
.
KUB: 1. Nonspecific bowel gas pattern without evidence of bowel
obstruction or free air.
C. CATH: 1. Decrease PVR in the absence of a drop in mean
pulmonary pressure.
ECHO: The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= ___. There is considerable beat-to-beat
variability of the left ventricular ejection fraction due to an
irregular rhythm/premature beats. Left ventricular dysnchrony is
present. Doppler parameters are indeterminate for left
ventricular diastolic function. The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is a small pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the estimated pulmonary artery pressures are lower (although may
be underestimated). The degrees of mitral and tricuspid
regurgitation are probably similar.
Brief Hospital Course:
___ with a medical history of dilated cardiomyopathy (LVEF 25%)
NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD,
and moderate-to-severe mitral regurgitation who presents s/p
fall with increased lower extremity edema.
ACUTE ISSUES:
# Acute on chronic systolic CHF - Patient reports increasing
lower extemity swelling. This was likely secondary to recent
medication changes to her diuretic regimen. (Patient reports she
was off of them for some time and recently restarted a few weeks
prior to presentation at a lower dose than previously on).
Patient denied orthopnea, PND, SOB, or DOE. CXR showed bilateral
pleural effusions, but she was satting well on room air. Patient
was initially diuresed with boluses of IV lasix. However, the
following morning, patient was noted to have an anion gap
metabolic acidosis due to elevated lactate from decreased
perfusion to extremities thought to be secondary to poor forward
flow. Diuretics were held and lactates were trended. Cardiology
was consulted, and the patient was subsequently transferred to
the cardiology service for further management. She was placed on
a lasix drip and diuresed over 10L of fluid. Her lactate trended
down and was thought to be ___ hepatic congestion in the setting
of right heart failure, which was suspected due to her lack of
SOB despite clear volume overload. A right heart cath was
performed which showed pulmonary hypertension, supporting a
diagnosis of right heart failure, and she was given a trial of
sildenafil and her vomue overload dramitically improved while on
the lasix drip. She was transitioned to po torsemide 10 mg
daily for maintenance and her electrolytes remained stable so
she was discharged. She was continued on aspirin, metoprolol,
and losartan in house and on discharge. She was not on a statin
and it is unclear why this had not been restarted. A note from
Dr. ___ ___ stated he planned to restart this
medication in the future pending lipid panel. Lipds from ___
showed tchol 214 and calculated LDL elevated at 150. However,
her LFTs are also elevated (thought to be from hepatic
congestion from CHF) therefore statin was not restarted this
admission. This should be readdressed at her outpatient follow
up with Dr. ___ on ___.
# s/p fall - Patient reports that she tripped and fell on the
day of presentation. There was no evidence of fracture on knee,
rib, and elbow films. Head CT was negative for an acute process.
Patient denied LOC, chest pain, or palpitations. She had 2 sets
of troponins which were stable with negative CKMB making cardiac
cause unlikely. There was no evidence of bowel or bladder
incontinence and no neurologic deficits on exam or imaging to
suggest acute neurologic process. Patient was evaluated by
physical therapy who thought patient was safe to go home. She
continues to complain of some rib pain that is controlled with
tylenol.
# lactic acidosis: thought to be ___ hepatic congestion causing
impaired lactic acid metabolism in the setting of right heart
failure. Trended down with diuresis.
# cyanotic extremities: pt was noted to have cyanotic, cold
fingers and toes shortly after admission in the setting of an
elevated lactate. There was concern for cardiogenic shock, but
her pressures and heart rate had been normal at the time the
symptoms were noted. After being transferred to the cardiology
service, vascular surgery was consulted but did not feel this
was an acute vascular presentation. They recommended serial
pulse exams and those were all normal. The purple appearance
seemed to come and go and on occasion her fingers looked white,
so question of ___ was considered and rheumatology was
consulted, but they did not feel this was ___. Pt's
symptoms improved rapidly with diuresis, so phenomenon was
ultimately thought to be ___ severe volume overload, leading to
poor perfusion with underlying small or atherosclerotic vessels
of the digits.
CHRONIC ISSUES:
# Atrial fibrillation - s/p PPM placement. Patient was continued
on digoxin and coumadin, with temporary reversal of coumadin for
cardiac cath. It was subsequently restarted without bridging.
She became transiently supratherapeutic so her coumadin dose was
held on ___ and her ___ dose was decreased in half to 1
mg a day. She will need to have her INR checked until stable on
dose with INR goal ___.
# CAD s/p stenting - Stable, continued aspirin, metoprolol,
losartan. Patient was not on a statin, and this should be
readdressed as an outpatient.
# Hypertension - stable, continued home meds
# Anxiety - Continued diazepam
Transitional Issues:
# follow daily weights and titrate Torsemide po as needed to
maintain euvolemia
# check INR on ___ and adjust coumadin dose as needed
# Follow up with cardiology
Medications on Admission:
DIAZEPAM - 2 mg Tablet - 1 (One) Tablet(s) by mouth four times a
day
DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth daily
IODOSORB GEL - - apply topically every 3 days
LOSARTAN - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth
daily
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr -
one
Tablet(s) by mouth once a day
WARFARIN - 2 mg Tablet - ___ Tablet(s) by mouth daily or as
directed
ACETAMINOPHEN - (OTC) - 500 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed
ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other
Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s)
by
mouth once a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. diazepam 2 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for anxiety.
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Iodosorb Topical
4. losartan 25 mg Tablet Sig: ___ Tablet PO DAILY (Daily).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
15. torsemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
acute right heart failure
pulmonary hypertension
Secondary Diagnoses:
chronic systolic heart failure
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___, it was a pleasure taking part in your care.
You came to the hospital because you fell. There was no evidence
of a fracture from your fall but you had significant swelling in
your legs and numbness. You were transferred to the cardiology
service where you were placed on a lasix drip to reduce the
fluid that had built up in your legs. You have fluid build up
due to heart failure. A cardiac catheterization was done to
evaluate the function of your heart and confirmed that you have
pulmonary hypertension, which has worsened your heart failure.
You were given a trial of sildenafil to see if it would improve
your pulmonary hypertension and it did. You were discharged
after removing several liters of fluid and you felt better.
Your new medication list is attached. Please note we have made
some changes. These include:
**START Torsemide 10 mg a day for systolic heart failure
**START Sildenefil 20 mg three times a day for pulmonary
hypertension
**DECREASE Warfarin to 1 mg a day. You will need to have your
INR checked until you are therapuetic on your dose.
Please follow up with Dr. ___ in cardiology (see below). You
should also have your rehab facility help make a follow up
appointment with your primary care doctor ___ you are ready to
be discherged back home.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10624544-DS-15 | 10,624,544 | 27,763,100 | DS | 15 | 2159-01-24 00:00:00 | 2159-03-09 19:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
s/p bicycle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who was a helmeted bicyclist
hit a bump on the road and fell off bike sliding underneath the
car unconscious at the scene and then combative now awake alert
without significant complaints. Timing: Sudden Onset. Duration:
Minutes. Context/Circumstances: No known past medical history.
Associated Signs/Symptoms: Notes left-sided chest pain
Past Medical History:
gout
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Constitutional: Comfortable
HEENT: Abrasions and superficial laceration to nasal bridge
and forehead
Neck no focal tenderness
Chest: Clear to auscultation left-sided chest wall
tenderness no flail
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: Abrasion to back nontender
Skin: Warm and dry
Neuro: Speech fluent no gross motor or sensory deficits
Psych: Normal mentation
Discharge Physical Exam:
VS: T: 98.1 PO BP: 154/72 R Sitting HR: 62 RR: 17 O2: 94% Ra
GEN: A+Ox3
HEENT: nasal abrasion, forehead abrasion
Chest: symmetric chest rise
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT SINUS/MANDIBLE/MAXIL:
1. Equivocal subtle irregularity at the distal tip of the nasal
spine of the maxilla could represent a fracture of indeterminate
age. No acute fracture seen elsewhere in the face.
___: CT Head:
1. Subarachnoid hemorrhage delineating the sulci in left
parietal lobe.
2. Right frontal parafalcine density probably reflects extension
of
subarachnoid hemorrhage.
3. Probable small left frontoparietal contusion.
4. No mass effect.
5. No acute fractures.
___: CT Torso:
1. Posttraumatic hemorrhagic cyst in lower pole of left kidney
associated with a perirenal hematoma. Ill-defined high-density
within the hematoma could reflect cortical enhancement, however,
a focus of active extravasation cannot
be excluded.
2. Small left anterior pneumothorax.
3. Minimally displaced fractures of lateral aspect of ___ and
4th ribs on the left.
4. Slightly displaced fracture of the distal left clavicle.
5. Probably chronic right clavicular fracture.
___: CT C-spine:
No acute fracture or traumatic malalignment of the cervical
spine.
Acute left clavicular fracture seen on scout image. Likely old
mid right
clavicular fracture.
___: CT Head:
No significant change in left temporoparietal subarachnoid
hemorrhage. No new hemorrhage.
___: CXR (PA & LAT):
Lungs are low volume with bibasilar atelectasis. There is a
displaced
fracture involving the left clavicle and second and the 4 ribs
on the left. Old healed right clavicular fracture. Bibasilar
atelectasis. Heart size is normal. No pneumothorax is seen.
LABS:
___ 10:56PM WBC-13.8* RBC-4.89 HGB-15.1 HCT-44.9 MCV-92
MCH-30.9 MCHC-33.6 RDW-13.5 RDWSD-45.6
___ 10:56PM PLT COUNT-185
___ 10:56PM ___ PTT-25.0 ___
___ 06:07PM WBC-18.6* RBC-5.11 HGB-15.4 HCT-47.7 MCV-93
MCH-30.1 MCHC-32.3 RDW-13.5 RDWSD-46.4*
___ 06:07PM PLT COUNT-187
___ 04:52PM LACTATE-1.5
___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:00PM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:00PM URINE MUCOUS-RARE*
___ 01:42PM PO2-53* PCO2-44 PH-7.39 TOTAL CO2-28 BASE
XS-0 COMMENTS-GREEN TOP
___ 01:30PM UREA N-18 CREAT-1.0
___ 01:30PM LIPASE-35
___ 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:30PM WBC-7.5 RBC-4.80 HGB-14.7 HCT-44.1 MCV-92
MCH-30.6 MCHC-33.3 RDW-13.4 RDWSD-45.4
___ 01:30PM PLT COUNT-178
Brief Hospital Course:
Mr. ___ is a ___ y/o M with unknown pmh who presented to ___
s/p bicycle crash. He presented to ___ ED for trauma
evaluation. In the ED, FAST was negative. On physical exam,
there were abrasions and ecchymoses to face, left shoulder,
right thigh, and he was tender down left chest wall. CT head was
notable for SAH. CT chest revealed rib fractures, a small left
apical pneumothorax, and an acute left clavicle fracture. There
was also concern for possible blush of the left kidney. ___ was
consulted and ___ felt the patient was stable and did not require
___ intervention. The patient was hemodynamically stable and was
admitted to the Trauma Surgery service to trend CBC, pain
control, respiratory and neurologic monitoring. CBC remained
stable. The Neurosurgery service was consulted and recommended
an interval head CT which was stable. No keppra was needed, the
patient was started on ___ and plan was to ___ in the
outpatient concussion clinic as needed.
Orthopedic Surgery was curbsided regarding the patient's left
clavicle fracture and it was recommended that he wear a sling,
remain non-weight bearing on the LUE and he may perform range of
motion as tolerated. Physical Therapy and Occupational Therapy
worked with the patient and he was ultimately cleared for
discharge home with outpatient OT.
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
___ instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Allopurinol
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
2. Lidocaine 5% Patch 1 PTCH TD QAM
apply for 12 hours and then remove and leave off for 12 hours
RX *lidocaine 5 % Apply patch to area of rib pain QAM Disp #*7
Patch Refills:*1
3. Senna 8.6 mg PO BID:PRN Constipation - Second Line
4. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
Wean as tolerated.
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Allopurinol ___ mg PO DAILY
7.Outpatient Physical Therapy
Dx: subarachnoid hemorrhage, left clavicle fracture, left rib
fractures
Px: good
Duration: 13 (thirteen) months
Discharge Disposition:
Home
Discharge Diagnosis:
- Subarachnoid hemorrhage
- Left parietal contusion
- Hemorrhagic left renal cyst
- Small left anterior pneumothorax
- Nondisplaced left 4 & 5 rib fractures
- Left clavicle fracture
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 ___
(___) after a bicycle crash. You were found to have a mild
traumatic brain injury, a left clavicle fracture, left-sided rib
fractures, a small traumatic puncture to your left lung, and a
stable traumatic bleed from the left kidney. You were admitted
to the Trauma Surgery service for care. The Neurosurgery
service evaluated your traumatic brain injury and recommended a
repeat head CT scan which was stable. No intervention was
necessary and you may ___ in the traumatic brain
injury/concussion clinic as needed. Your rib fractures will
heal on their own. You had a repeat chest x-ray of your lungs
which showed that the puncture of your left lung has resolved.
For your left clavicle fracture, the Occupational and Physical
Therapists have worked with you and it is recommended you wear a
sling for comfort and ___ with outpatient physical
therapy. It is recommended that you ___ in the Orthopedic
Surgery clinic to evaluate your clavicle fracture in
approximately two (2) weeks. Your traumatic left kidney injury
will resolve on its own and your blood counts have remained
stable.
You are now ready to be discharged home to continue your
recovery. Please note the following discharge instructions:
Rib Fractures:
* Your injury caused left-sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( 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).
Instructions for Traumatic Brain Injury:
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
Instructions for Left Clavicle Fracture:
Left upper extremity: Non weight bearing
Sling: Wear for comfort
Range of motion to the left arm as tolerated
General 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 ___ with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10624765-DS-21 | 10,624,765 | 24,865,554 | DS | 21 | 2199-08-24 00:00:00 | 2199-08-24 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Theophylline / nitroglycerin / Morphine / Codeine / Metal
___ Top Applicator
Attending: ___.
Chief Complaint:
wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ Severe Asthma, GERD, OSA on CPAP and HTN who presents
with acute onset of worsening SOB thought to be ___ asthma
exacerbation who has failed outpatient treatment with oral
prednisone 40mg. Patient also received levofloxacin 500mg PO
q24 x 7 days. Has had productive cough of white sputum. States
that she has had worsening dyspnea, cough, and chest tightness x
1 month. Minimal improvement with above stated interventions.
Night prior to admission had an episode of emesis and nausea, at
which time her asthma became acutely worse. Denies chest pain
other than tightness. When patient was seen in clinic by Dr.
___ peak flow of 150.
Patient had 1 day of nb/nb vomiting. Symtpoms have resolved.
Does not note any sick contacts. No new types of food.
In the ED, initial vs were: 98.9 88 130/72 22 98% ra . Labs were
remarkable for pH 7.45 pCO2 38 pO2 68. Patient was given
MethylPREDNISolone Sodium Succ 125mg, Duonebs. Vitals on
Transfer:97.9 77 119/63 21 98%
On the floor, vs were: 98.6 146/83 84 21 100RA. Patient was
comfortable at time of interview.
Past Medical History:
-Severe Asthma: never intubated
-Allergies
-GERD
-Obstructive sleep apnea, on home CPAP via face mask
-Hypertension
-Osteoporosis
-Osteoarthritis
Social History:
___
Family History:
Mother- died ___ yo of cerebral aneurysm; PMH- HBP
Father- died ___ yo of MI
5 Brothers- 1 died of MI, 2 died in accidents, 1 died of MI, 1
brother w/ CAD
8 Sisters- 1 died liver disease (h/o EtOH abuse), 6 alive &
well, 1 w/ BA
Physical Exam:
ADMISSION EXAM:
Vitals: 98.6 146/83 84 21 100RA
Peak Flow: 175
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased air movement, prominent expiratory wheezes and
squeaks, no rhonchi appreciated.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: mildly cold, 2+ pulses, no clubbing, cyanosis or edema
DISCHARGE EXAM:
VS: T97.7F, BP 116/60 (SBP ___, HR 80 (___), RR 20,
100%RA
GEN: NAD, A&Ox3, speakingin long sentences
HEENT: MMM, OP clear
CV: RRR, no murmur
LUNGS: No accessory muscle use. Diffuse expiratory wheezes
Abd: Soft, obese, ___
Extr: Warm. No edema
Pertinent Results:
ADMISSION:
___ 07:30AM BLOOD ___
___ Plt ___
___ 07:30AM BLOOD ___
___
___ 07:30AM BLOOD ___
___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD cTropnT-<0.01
___ 07:43AM BLOOD ___
___ Base ___ TOP
DISCHARGE:
___ 08:10AM BLOOD ___
___ Plt ___
___ 08:10AM BLOOD ___
___
___ 08:10AM BLOOD ___
MICRO:
___ 3:40 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS
ANDCLUSTERS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
___ 10:40 am URINE **FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM POSITIVE BACTERIA. ___ ORGANISMS/ML..
___ STOOL C. difficile DNA amplification ___
NEGATIVE
___ Blood Culture, ___ AT DISCHARGE
IMAGING:
CXR: No acute cardiopulmonary process
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of severe
asthma, OSA, GERD, and HTN who presents with shortness of breath
___ asthma exacerbation, refractory to outpatient management.
.
#Asthma Exacerbation: Seen in clinic during exacerbation with
peak flow 150 and several days of SOB and wheezing. Was given
prednisone, levofloxacin as an outpatient, completed a week of
these but given persistent symtpoms she was admitted for closer
monitoring. She received 125mg IV solumedrol in the ED and CXR
was unremarkable. BNP was negative. No documented hypoxia
throughout her course. Continued advair, tiotropium,
zafirleukast and received standing albuterol nebs. Wheezing and
dyspnea on exertion improved, peak flow returned to baseline of
about 200 and patient was noted to have stable O2 saturation on
ambulation. She was discharged to finish high dose steroid burst
on ___. It was not felt that a longer course
of taper would benefit her at this time, given no notable change
over 1.5 weeks on high dose steroids. She will follow up with
her PCP and allergy clinic next week, and with pulmonology next
month.
.
#Nausea/Vomiting/Diarrhea: Likely medication side effect,
possibly due to high dose steroids, as started about when
started prednisone as outpatient. She maintained ability to
tolerate PO, labs did not show evidence of volume depletion. No
blood in emesis or stool. Stool for sent for c.diff given recent
levofloxacin exposure and risk factor of PPI use, which was
negative.
#HTN: Continued felodipine, hydrochlorothiazide. Lisinopril was
not realized to be a home med until PACT team did medication
reconciliation with patient. This was not restarted as systolic
blood pressures were ___ at time of discharge. Patient was
instructed to discuss with her PCP prior to restarting
lisinopril.
#GERD: continued home ranitidine and PPI
Transitional Issues:
- Will follow up in Allergy Clinic and with PCP
- ___ continued to ___, not tapered given
course <3wks
- Lisinopril held at discharge for SBPs ___, to be
restarted by PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. azelastine *NF* 137 mcg NU bid
3. ciclopirox *NF* 0.77 % Topical bid
4. cromolyn *NF* 4 % ___ eye inflammation
5. diclofenac sodium *NF* 1 % Topical ___ pain
6. esomeprazole magnesium *NF* 40 mg Oral qd
7. Felodipine 2.5 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. ___ Diskus (500/50) 1 INH IH BID
10. Hydrochlorothiazide 25 mg PO DAILY
11. ___ *NF* 0.5 ___ mg(2.5 mg base)/3 mL
Inhalation ___
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Lorazepam 0.5 mg PO HS:PRN insomnia
14. Mupirocin Cream 2% 1 Appl TP BID
15. PredniSONE 40 mg PO DAILY
16. Simvastatin 10 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. ___ *NF* ___ mg Oral bid ___
19. traZODONE 50 mg PO HS:PRN insomnia
20. zafirlukast *NF* 20 mg Oral bid
21. Cetirizine *NF* 10 mg Oral qd
22. Docusate Sodium 100 mg PO BID
23. echinacea *NF* 500 mg Oral tid
24. Guaifenesin ER 600 mg PO Q12H
25. Multivitamins 1 TAB PO DAILY
26. Senna 1 TAB PO BID:PRN constipation
27. Qvar *NF* (beclomethasone dipropionate) 80 mcg/actuation
Inhalation ___ puffs
in addition to advair during asthma flares
28. Ranitidine 150 mg PO BID
29. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Cetirizine *NF* 10 mg Oral qd
2. Docusate Sodium 100 mg PO BID
3. Felodipine 2.5 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. ___ Diskus (500/50) 1 INH IH BID
6. Guaifenesin ER 600 mg PO Q12H
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lorazepam 0.5 mg PO HS:PRN insomnia
9. Multivitamins 1 TAB PO DAILY
10. Mupirocin Cream 2% 1 Appl TP BID
11. Senna 1 TAB PO BID:PRN constipation
12. Simvastatin 10 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. traZODONE 50 mg PO HS:PRN insomnia
15. zafirlukast *NF* 20 mg Oral bid
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
17. azelastine *NF* 137 mcg NU bid
18. ciclopirox *NF* 0.77 % Topical bid
19. cromolyn *NF* 4 % ___ eye inflammation
20. diclofenac sodium *NF* 1 % Topical ___ pain
21. echinacea *NF* 500 mg Oral tid
22. Esomeprazole Magnesium *NF* 40 mg ORAL QD
23. ___ *NF* 0.5 ___ mg(2.5 mg base)/3 mL
Inhalation ___
24. Qvar *NF* (beclomethasone dipropionate) 80 mcg/actuation
Inhalation ___ puffs
25. Ranitidine 150 mg PO BID
26. ___ *NF* ___ mg Oral bid ___
27. Lidocaine 5% Patch 1 PTCH TD DAILY
28. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: asthma
Secondary: hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were admitted for an asthma exacerbation which was treated
with nebulizer treatments and prednisone. ___ also had nausea,
vomiting, and diarrhea, most likely from stomach upset from
medications or a mild viral illness. A test of your stool was
negative for an infection called Clostridium difficile diarrhea
which can occur after taking antibiotics. ___ were able to
tolerate food and drink very well.
Please be sure to follow up at the appointments listed below.
Please wait until your PCP takes your blood pressure before
restarting lisinopril. ___ will finish taking prednisone after
___. If ___ continue to have symtpoms, your
PCP can decided if ___ need more steriods
Followup Instructions:
___
|
10624765-DS-22 | 10,624,765 | 24,485,659 | DS | 22 | 2201-08-30 00:00:00 | 2201-09-01 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Theophylline / nitroglycerin / Morphine / Codeine / Metal
Can-Brush Top Applicator / Augmentin
Attending: ___.
Chief Complaint:
Chest pain, diaphoresis
Major Surgical or Invasive Procedure:
Cardiac cath ___, DES to LCX
History of Present Illness:
___ female the past medical history of hypertension,
hyperlipidemia, severe asthma and allergic rhinitis and
conjunctivitis who is presenting from allergy clinic with one
hour of head, neck and chest burning following by chest
discomfort.
She was at ___ for a routine appointment for
scheduled omalizumab injection when she developed facial, neck
and precordial tingling and burning. She denies any swelling in
the mouth, no respiratory distress. As the facial and neck pain
improved she felt ___ precordial discomfort that she
characterizes as pinching and pressure. She denies abdominal
pain, nausea vomiting or diaphoresis this time.
Her ED Course is significant for:
-Initial vitals of: 98.0 28 143/90 16 100% RA
-EKG: SR 88, no ST changes, tall Tw in V2-V3 unchanged from b/l
EKG
-Labs were notable for: initial Tnt <0.01, then TnT: 0.24
Patient was given: Aspirin, SL nitro, Heparin IV then
nitroglycerin gtt with improvement of chest discomfort to ___
-Vitals on transfer: 87 182/72 16 97% RA
On the floor her vitals were 98.2 118/71 87 18 96%RA. She still
complained of ___ chest discomfort, denied dyspnea or
palpitations. Complained of ___ global headache since
nitroglycerin gtt started.
Of note, had episode of mild precordial discomfort last ___
while taking a shower that was associated with diaphoresis and
nausea.
ROS: On review of systems, she denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of c dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-Severe Asthma: never intubated
-Allergies
-GERD
-Obstructive sleep apnea, on home CPAP via face mask
-Hypertension
-Osteoporosis
-Osteoarthritis
Social History:
___
Family History:
Mother- died ___ yo of cerebral aneurysm; PMH- HBP
Father- died ___ yo of MI
5 Brothers- 1 died of MI, 2 died in accidents, 1 died of MI, 1
brother w/ CAD
8 Sisters- 1 died liver disease (h/o EtOH abuse), 6 alive &
well, 1 w/ BA
Physical Exam:
GENERAL: Elderly female resting in bed, appears tired.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Oropharynx
clear.
NECK: Supple, no JVD
CARDIAC: Grade ___ systolic murmur loudest at base.
PULM: b/l end expiratory wheezing, but no crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No hematoma of right groin or right radial, but
right groin tender to palpation. ROM and sensation and sensation
intact.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 10:10AM BLOOD WBC-9.7 RBC-3.76* Hgb-11.9* Hct-34.3*
MCV-91 MCH-31.5 MCHC-34.6 RDW-15.3 Plt ___
___ 10:10AM BLOOD Glucose-95 UreaN-9 Creat-0.5 Na-141 K-4.0
Cl-104 HCO3-26 AnGap-15
___ 10:25AM BLOOD cTropnT-<0.01
___ 03:50PM BLOOD cTropnT-0.24*
___ 10:20PM BLOOD cTropnT-0.28*
___ 02:04AM BLOOD cTropnT-0.25*
___ 12:45PM BLOOD CK-MB-1 cTropnT-0.15*
Brief Hospital Course:
# NSTEMI: ___ with PMhx HTN, HLD, and severe asthma who was
admitted for chest pain associated with diaphoresis. Her EKG was
negative for ST changes, but her troponin peaked at 0.28. Thus
she was given IV heparin and full dose ASA for NSTEMI.
Pt underwent cardiac cath ___ which revealed a 90% stenosis
of the LCX for which a DES was placed.
She was started on ticagrelor 90mg BID which should be continued
for one year. She should also continue ASA 81mg daily. Her
simvastatin was changed to high dose atorvastatin. We attempted
beta blocker as inpatient, but her hx of severe asthma and
residual CP, we ultimately d/c beta blocker as it may be
exacerbating her asthma symptoms. We were unable to start
ace-inhibitor ___ due to low blood pressures. This should be
considered as an outpatient.
# non-cardiac CP: She complained of residual chest pain
post-cath. However, numerous EKGs consistently negative for
ischemic changes, and her serial troponin and CK-MB continued to
trend downwards appropriately post-cath. A repeat echo obtained
during episode of pain which showed LVEF > 55% without wall
motion abnormalities. Her CP did not relief with SL nitro. Her
CP was intermittently reproducible upon palpation. Thus we
believe her chest pain is non-cardiac and she was recommended
tylenol for MSK chest pain. She also complained of sinus
congestion and sore throat suggestive of viral illness or
allergies which may contribute to chest discomfort.
# BP: Her HCTZ dosage was decreased due to soft systolic BPs 110
and complaint of dizziness. This should be adjusted accordingly
as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis
2. Lactulose 15 mL PO Q8H:PRN constipation
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. azelastine 2 puffs nasal bid
5. olopatadine 1 drop ophthalmic bid
6. Pregabalin 75 mg PO BID
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
asthma
8. Tiotropium Bromide 2 CAP IH DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
11. Lorazepam 0.5 mg PO QHS:PRN insomnia
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO PRN 3d w/o BM
15. Beclomethasone Dipro. AQ (Nasal) 1 spray Other DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Felodipine 5 mg PO DAILY
18. Simvastatin 10 mg PO QPM
19. Montelukast 10 mg PO DAILY
20. cromolyn 1 drop ophthalmic q4h:prn eye itch
21. beclomethasone dipropionate ___ puffs inhalation QID:prn
flares
22. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
23. Omeprazole 20 mg PO BID
24. TraMADOL (Ultram) 50 mg PO TID:PRN pain
25. omalizumab 375 mg subcutaneous q2weeks
26. Cetirizine 10 mg PO DAILY
27. Aspirin 81 mg PO DAILY
28. albuterol sulfate 2 puffs inhalation QID:prn sob
29. Hydrochlorothiazide 25 mg PO DAILY
30. TraZODone 50-100 mg PO QHS:PRN bedtime insomnia
31. Nortriptyline 25 mg PO QHS
Discharge Medications:
1. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*3
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Felodipine 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*3
9. Lactulose 15 mL PO Q8H:PRN constipation
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Lorazepam 0.5 mg PO QHS:PRN insomnia
12. Montelukast 10 mg PO DAILY
13. Nortriptyline 25 mg PO QHS
14. Omeprazole 20 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY
16. Pregabalin 75 mg PO BID
17. Senna 8.6 mg PO PRN 3d w/o BM
18. Tiotropium Bromide 2 CAP IH DAILY
19. TraZODone 50-100 mg PO QHS:PRN bedtime insomnia
20. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once nightly Disp
#*30 Tablet Refills:*3
21. albuterol sulfate 2 puffs INHALATION QID:PRN sob
22. azelastine 2 puffs nasal bid
23. Beclomethasone Dipro. AQ (Nasal) 1 spray Other DAILY
24. beclomethasone dipropionate ___ puffs inhalation QID:prn
flares
25. cromolyn 1 drop ophthalmic q4h:prn eye itch
26. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis
27. Fluticasone Propionate NASAL 2 SPRY NU DAILY
28. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
29. olopatadine 1 drop ophthalmic bid
30. omalizumab 375 mg subcutaneous q2weeks
31. TraMADOL (Ultram) 50 mg PO TID:PRN pain
32. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
asthma
33. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN arthritis
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI s/p PCI to LCX
Residual MSK chest pain
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. You were admitted to our
hospital for chest pain. We were concerned as your blood work
revealed an elevated troponin, which is a marker for heart
tissue damage (heart attack). Thus you underwent cardiac
catherization where they found a diseased vessel with 90%
occlusion. A cardiac stent was placed in the vessel to allow
increased blood flow to your heart tissue. You were started on a
new medication called ticagrelor which will prevent blockage of
the stent. You should take this medication everyday as directed
for one year. Your cholesterol medication (atorvastatin) was
also increased for heart protection.
You had residual chest pain after the procedure. We repeated
various tests including EKG, blood work, and echocardiogram
(heart ultrasound) which were all unremarkable. Your chest pain
worsens when we press on your left chest, which suggest your
pain is NOT coming from the heart, but instead is
musculoskeletal in nature. You were given tylenol and lidoderm
patch for pain.
Please follow-up with your PCP and cardiologist. Appts will be
arranged for you.
Followup Instructions:
___
|
10624765-DS-23 | 10,624,765 | 27,361,254 | DS | 23 | 2202-09-05 00:00:00 | 2202-09-06 11:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Theophylline / nitroglycerin / Morphine / Codeine / Metal
Can-Brush Top Applicator / Augmentin / trazodone / tramadol
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female with history of asthma, CAD
and chronic sinusitis who presents to ED with fever, productive
cough, pleuritic chest pain, and headache. Pt was in her usual
state of health until ___ during the day when she started
feeling sick. She reports increased nasal congestion and sinus
pressure. She also reports productive cough with left sided
chest pain and back pain that is c/w the discomfort she gets
when she has asthma attacks. Symptoms are associated with sore
throat. She also developed a headache over the last day which is
getting worse over time. She reports it as bifrontal pressure
that is c/w previous episodes of sinusitis. She denies increased
neck soreness or stiffness. She endorses f/c/ns. Denies CP with
exertion. Denies edema. No hemoptysis. No n/v/d/abd pain. No
sick contacts.
In the ED, initial vitals were: 102.5 95 140/72 20 99% RA
Exam was significant for lungs w/o signs of focal consolidation
with sparse wheezes.
Labs were significant for a normal white count, negative
troponins, a lactate of 1.
A CXR showed no signs of pneumonia.
The patient underwent an infectious workup, and was found to
have the flu. She was started on Tamiflu and given nebulizer
treatments for symptomatic relief. She was placed in observation
overnight in the ED, but as she remained symptomatic the
following day she was admitted.
On re-evaluation, pt not improved; still wheezing w/ influenza,
lives alone, husband out of country; will require admission for
ocntinued treatment.
On the floor, patient is in no acute distress, calm and
pleasant.
Past Medical History:
-Severe Asthma: never intubated
-Allergies
-GERD
-Obstructive sleep apnea, on home CPAP via face mask
-Hypertension
-Osteoporosis
-Osteoarthritis
-NSTEMI s/p DES to LCx
-hyperlipidemia
-recurrent sinusitis
Social History:
___
Family History:
Mother- died ___ yo of cerebral aneurysm; PMH- HBP
Father- died ___ yo of MI
5 Brothers- 1 died of MI, 2 died in accidents, 1 died of MI, 1
brother w/ CAD
8 Sisters- 1 died liver disease (h/o EtOH abuse), 6 alive &
well, 1 w/ BA
Physical Exam:
====================
EXAM ON ADMISSION
====================
Vital Signs: 97.7, 75, 124/67, 18, 100%RA
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Lungs with minimal air movement, with diffuse wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact
====================
EXAM ON DISCHARGE
====================
Vital Signs: 98.1, 98, 135/84, 18, 100%RA
General: Alert, oriented, no acute distress, speaking in full
sentences
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse wheezes bilaterally
Abdomen: Soft, non-tender, non-distended
Pertinent Results:
========================
LABS ON ADMISSION
========================
___ 08:00PM BLOOD WBC-7.0 RBC-3.65* Hgb-11.3 Hct-34.2
MCV-94 MCH-31.0 MCHC-33.0 RDW-15.5 RDWSD-53.1* Plt ___
___ 08:00PM BLOOD Neuts-74.0* Lymphs-8.1* Monos-12.5
Eos-4.3 Baso-0.7 Im ___ AbsNeut-5.14 AbsLymp-0.56*
AbsMono-0.87* AbsEos-0.30 AbsBaso-0.05
___ 07:45PM BLOOD Glucose-107* UreaN-8 Creat-0.5 Na-135
K-5.4* Cl-104 HCO3-22 AnGap-14
___ 07:45PM BLOOD Calcium-9.5 Phos-2.9 Mg-2.0
___ 07:45PM BLOOD cTropnT-<0.01
___ 07:45PM BLOOD Lactate-1.0 K-3.6
========================
LABS ON DISCHARGE
========================
___ 06:37AM BLOOD WBC-5.0 RBC-3.65* Hgb-11.1* Hct-34.2
MCV-94 MCH-30.4 MCHC-32.5 RDW-15.6* RDWSD-53.9* Plt ___
___ 06:37AM BLOOD Glucose-86 UreaN-11 Creat-0.4 Na-144
K-3.6 Cl-108 HCO3-25 AnGap-15
___ 06:37AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.9
========================
MICROBIOLOGY
========================
___ Blood cultures x2 - no growth
___ Urine culture - mixed bacterial flora
========================
IMAGING/STUDIES
========================
___ CXR - The cardiomediastinal and hilar contours are stable.
There is no pleural effusion or pneumothorax. Lungs are
well-expanded and clear without focal consolidation concerning
for pneumonia.
Brief Hospital Course:
Ms ___ is a ___ w/ a PMH of asthma, CAD, htn, presenting with
dyspnea and fever, found to have influenza.
# Dyspnea, secondary to Influenza, complicated by asthma
exacerbation -
Ms. ___ presented to the ED with complaints of dyspnea and
fever. In the ED, labs were significant for a normal white
count, negative troponins, a lactate of 1. A CXR showed no signs
of pneumonia, and a u/a showed no signs of infection. Further
testing showed the patient was positive for the flu. She was
started on Tamiflu and given nebulizer treatments for
symptomatic relief. She was also started on a prednisone burst
and azithromycin for an asthma exacerbation. She remained at
99-100% on room air during her hospitalization. Rehab was
recommended by ___ given her poor functional status, but patient
declined, and so she was discharged home with ___.
# Dizziness - patient states she feels weak when walking to
bathroom. No focal neurologic deficits were found. Given the
timing, it was felt that this was most likely related to the flu
and poor conditioning. As above, a short rehab course was
recommended, but patient declined, and will have home ___.
# Hypertension - Continued home felodipine 2.5 mg PO daily and
Hydrochlorothiazide 12.5 mg PO daily.
# History of CAD, s/p NSTEMI with DES placed to LCx - Trops
negative on admission. Continued home Atorvastatin 80 mg PO QPM,
Clopidogrel 75 mg PO daily, and Aspirin 81 mg PO daily. The
patient reported that she has been taking omeprazole at home for
GERD. This has a known interaction with Plavix, and they should
not be taken together. She was instructed to switch to
pantoprazole or lansoprazole.
# Restless leg syndrome - Continued home Pramipexole 0.125 mg PO
QHS.
# GERD - As above, instructed patient to switch from omeprazole
to pantoprazole or lansoprazole to avoid interaction with
Plavix.
# Allergies - Continued home allergy medications.
# Chronic pain - Continued home Hydrocodone-Acetaminophen
===============================
TRANSITIONAL ISSUES
===============================
- The patient will complete a 5 day course of prednisone 60mg
daily, Tamiflu, and azithromycin.
- The patient's omeprazole was changed to pantoprazole as
omeprazole interacts with the patient's Plavix.
- Patient was discharged home with home ___.
# CODE: daughter ___ (phone ___ and
___ (cell)
# CONTACT: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 75 mg PO BID
2. Mirtazapine 15 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO DAILY:PRN constipation
5. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
8. Felodipine 2.5 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Montelukast 10 mg PO DAILY
11. Pramipexole 0.125 mg PO QHS
12. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO BID PRN Pain
13. Naproxen 375 mg PO Q12H:PRN pain
14. Clopidogrel 75 mg PO DAILY
15. Omeprazole 20 mg PO BID
16. Aspirin 81 mg PO DAILY
17. Cetirizine 10 mg PO DAILY
18. Hydrochlorothiazide 12.5 mg PO DAILY
19. Nortriptyline 25 mg PO QHS
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID:PRN shortness of breath
22. azelastine 137 mcg (0.1 %) nasal BID
23. Beclomethasone Dipro. AQ (Nasal) 80 mcg Other DAILY
24. Budesonide Nasal Inhaler 0.5 mg Other DAILY
25. cromolyn 4 % ophthalmic QID
26. diclofenac sodium 1 % topical QID:PRN pain
27. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN shortness of
breath
28. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
29. olopatadine 0.1 % ophthalmic BID
30. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
31. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Cetirizine 10 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Felodipine 2.5 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO BID PRN Pain
11. Mirtazapine 15 mg PO QHS
12. Montelukast 10 mg PO DAILY
13. Pramipexole 0.125 mg PO QHS
14. Pregabalin 75 mg PO BID
15. Senna 8.6 mg PO DAILY:PRN constipation
16. OSELTAMivir 75 mg PO Q12H Duration: 5 Days
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice
daily Disp #*3 Capsule Refills:*0
17. PredniSONE 60 mg PO DAILY
This should be completed on ___
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
18. Azithromycin 250 mg PO Q24H
The last dose of this medication should be taken on ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
20. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID:PRN shortness of breath
21. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
22. olopatadine 0.1 % ophthalmic BID
23. Nortriptyline 25 mg PO QHS
24. azelastine 137 mcg (0.1 %) nasal BID
25. Beclomethasone Dipro. AQ (Nasal) 80 mcg Other DAILY
26. Budesonide Nasal Inhaler 0.5 mg Other DAILY
27. cromolyn 4 % ophthalmic QID
28. diclofenac sodium 1 % TOPICAL QID:PRN pain
29. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QID
30. Fluticasone Propionate NASAL 2 SPRY NU DAILY
31. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN shortness of
breath
32. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
33. Naproxen 375 mg PO Q12H:PRN pain
34. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
35. rolling walker
Please provide rolling walker.
Diagnosis: Influenza due to unidentified influenza virus with
other respiratory manifestations
ICD 10: ___
Prognosis: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
- influenza
- asthma exacerbation
Secondary Diagnoses
- Hypertension
- Coronary artery disease, s/p NSTEMI
- Restless leg syndrome
- GERD
- Allergies
- Shoulder pain
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 to be a part of you care team at ___
___. You were admitted to the hospital
because you were having trouble breathing and were found to have
the flu, which triggered your asthma. We treated the flu with an
antiviral, and treated your asthma with nebulizer treatments,
steroids, and azithromycin.
We have made a few changes to your medications - please see
below for more details. We have also arranged an appointment
with your primary care doctor - please see below.
Again, it was a pleasure to meet you, and we hope you feel
better!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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