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10058437-DS-2	10,058,437	21,570,649	DS	2	2131-09-04 00:00:00	2131-09-04 16:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall with headstrike Major Surgical or Invasive Procedure: None History of Present Illness: Neurosurgery Admission: ___ is a ___ female who presents to ___ on ___ with a mild TBI. Patient has a PMH of AFib on coumadin, CKD, alzheimers, dementia and presents s/p a witnessed fall this afternoon at her nursing facility. Patient was brought to OSH for evaluation. Upon arrival to OSH patient had a NCHCT done that showed an acute on chronic SDH with 0.8cm of midline shift. Patient was found to have an INR of 2.9 and she received KCentra and Vitamin K for reversal. Patient was transferred to ___ for further evaluation and neurosurgery was consulted. Upon examination in ED patient was alert and oriented to self (baseline), year and hospital with choices. She was ___ strength throughout and did not have pronator drift. Patient has dementia at baseline, unable to provide PMH so history obtained through ED report. Mechanism of trauma: Fall Past Medical History: Afib on Coumadin Alzheimer's Dementia CKD Nephrectomy with unilateral kidney Social History: ___ Family History: Unknown Physical Exam: ON ADMISSION: = = = = = = = = = = ================================================================ ___ Physical Exam: T:97.6 HR: 67 BP: 130/88 RR: 16 SPO2: 96% RA GCS at the scene: 14__ GCS upon Neurosurgery Evaluation: 14 Time of evaluation:2220 Airway: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [x]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: WD/WN, comfortable, NAD. Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place (hospital) with choices, and date (___) with choices. Language: Speech is fluent with good comprehension. If Intubated: [ ]Cough [ ]Gag [ ]Over breathing the vent Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Handedness Right DISCHARGE PHYSICAL EXAM: ======================== VS: 24 HR Data (last updated ___ @ 2327) Temp: 97.7 (Tm 98.5), BP: 127/77 (97-136/63-89), HR: 58 (58-91), RR: 18 (___), O2 sat: 96% (94-96), O2 delivery: Ra ___ 0830 T 98.4 BP 130/70 HR 62 RR 18 O2 96% RA HEENT: AT/NC, anicteric sclera and without injection, MMM CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes/rales/rhonchi, breathing comfortably on RA GI: abdomen soft, BS+, nondistended, nontender, no suprapubic tenderness EXTREMITIES: no cyanosis, clubbing, or edema SKIN: Warm and well perfused, no visible rash NEURO: A&Ox1 to self, moving all 4 extremities with purpose, face symmetric Pertinent Results: ADMISSION LABS =============== ___ 10:01PM BLOOD WBC-9.6 RBC-3.79* Hgb-11.7 Hct-36.3 MCV-96 MCH-30.9 MCHC-32.2 RDW-13.3 RDWSD-47.0* Plt ___ ___ 10:01PM BLOOD Neuts-79.6* Lymphs-11.5* Monos-7.4 Eos-0.4* Baso-0.7 Im ___ AbsNeut-7.64* AbsLymp-1.10* AbsMono-0.71 AbsEos-0.04 AbsBaso-0.07 ___ 10:01PM BLOOD ___ PTT-24.3* ___ ___ 10:01PM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-139 K-4.5 Cl-104 HCO3-20* AnGap-15 ___ 10:01PM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0 DISCHARGE LABS =============== ___ 05:45AM BLOOD WBC-9.5 RBC-3.38* Hgb-10.4* Hct-32.8* MCV-97 MCH-30.8 MCHC-31.7* RDW-14.3 RDWSD-50.4* Plt ___ ___ 05:45AM BLOOD Glucose-74 UreaN-21* Creat-1.2* Na-143 K-4.0 Cl-108 HCO3-22 AnGap-13 ___ 05:45AM BLOOD cTropnT-<0.01 ___ 10:33AM BLOOD cTropnT-<0.01 ___ 05:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0 OTHER PERTINENT LABS/MICRO ============================ ___ 08:11PM URINE Color-Straw Appear-CLEAR Sp ___ ___ 08:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0 Leuks-SM* ___ 08:11PM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE Epi-1 ___ 08:11PM URINE Mucous-RARE* ___ 8:11 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 08:00PM BLOOD Lactate-1.3 ___ 03:31PM URINE Color-Straw Appear-HAZY Sp ___ ___ 03:31PM URINE Blood-NEG Nitrite-NEG Protein-10* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-MOD* ___ 03:31PM URINE RBC-0 WBC-13* Bacteri-FEW* Yeast-NONE Epi-9 RenalEp-<1 ___ 03:31PM URINE Mucous-FEW* PERTINENT IMAGING ================== CT Head wo Contrast (___) IMPRESSION: - Acute on chronic left subdural hematoma interval slightly increased in size compared to the previous study with slightly worsening 9 mm midline shift to the right and subfalcial herniation. - Small right-sided subdural collection again seen, which contains a small dense component anterior to the frontal lobe also suggesting acute on chronic subdural hematoma. No significant mass effect related to the right subdural collection. EKG (___) Atrial fibrillation with rapid ventricular response, HR ___lock Abnormal ECG When compared with ECG of ___ 21:48, A fib has replaced sinus rhythm QTc 588 EKG (___) - QTc 602 with QRS duration 140ms EKG (___) - QTc 521 EKG (___) - QTc 497 CT Head wo Contrast (___) IMPRESSION: 1. Redemonstration of mixed density subdural hematoma overlying the left frontoparietal convexity measuring 2.3 cm in maximum thickness, not significantly changed in comparison to the prior study. There is associated mass effect with unchanged sulcal effacement and 8 mm of rightward midline shift and subfalcine herniation. 2. Small right-sided subdural hematoma overlying the right frontal convexity, not significantly changed in comparison to the prior study. 3. No evidence of acute large territory infarction or new hemorrhage. Brief Hospital Course: SUMMARY ============ ___ is a ___ year old female who presented to OSH s/p an unwitnessed fall at her nursing home. CTH at OSH significant for a left SDH and the patient was transferred for neurosurgical evaluation. Discussion was held with the patient's family and an MMA embolization was offered and the family declined intervention. Patient was then transferred to medicine where she remained stable, and was recommended to go to rehab by physical therapy. TRANSITIONAL ISSUES ==================== [] Pt will continue to hold any anticoagulation until follow up with Dr. ___ in 1 week with a repeat Head CT [] Follow-up chemistry on ___ to monitor electrolytes and kidney function [] Held several medications due to prolonged QTc - recommend rechecking EKG as outpatient and consider restarting appropriate meds [] Sertraline held due to prolonged QTc, consider alternative antidepressant [] Amiodarone held this admission due to prolonged QTc, although was still having RVR earlier in admission on Amio - consider adjusting regimen for atrial fibrillation [] ensure enlive 4x/day, encourage PO intake [] manage constipation ACUTE ISSUES ============== #Acute on Chronic SDH Unwitnessed fall at her nursing home. CTH at OSH significant for a left SDH and the patient was transferred for neurosurgical evaluation. Patient was taking Coumadin for history of Afib and INR at OSH was 2.9, Kcentra and vitamin K was given and INR on arrival to our ED was 1.2. Patient was admitted to the neurosurgery service and transferred to the ___ from the ED. Coumadin was held on admission. Patient remained what appeared to be at her neurological baseline. CTH in the AM on ___ revealed a slightly larger left SDH and a very small right frontal SDH. Discussion was held with the patient's family and an MMA embolization was offered and the family declined intervention. On ___, the patient's neurologic checks were liberalized and she was transferred to the floor. Given vomiting, had repeat CT Head ___ which was stable from prior. #Atrial Fibrillation, on coumadin CHADS-VASc = 3 for age and female gender. On warfarin, amiodarone, and metoprolol at home. This admission, patient was continued on metoprolol and had episodes of RVR as well as episodes of bradycardia. Metoprolol was adjusted to prior home dose and HRs remained stable. Amiodarone was held in the setting of prolonged QTc. Warfarin was held in setting of acute on chronic SDH, with plans to continue holding until 2 week follow-up NCHCT with neurosurgery. #Prolonged QTc Noted on initial ECGs. Likely secondary to multiple medications that can prolong the QTc. Several medications were stopped and repeat EKG with QTc<500. Later in hospital course, QTc was rechecked and was in 500s. Continued to hold home medications that can contribute to prolonged QTc at time of discharge. ___ Pt with Cr 1.3 during admission in setting of poor PO intake, improved with IVF. Also with orthostasis with SBP 100s lying down to ___ standing, as well as decreased UOP. s/p another 1L LR and no longer orthostatic with improved urine output. Cr on discharge was 1.2. #Asymptomatic Pyuria UA with 13 WBC and moderate leuks however patient was asymptomatic and without dysuria or suprapubic tenderness on exam. Had leukocytosis to 12 later in admission which resolved after IVF, possibly representing hemoconcentration. Overall not concerning for active infection. #Fall Unwitnessed fall at nursing home. Unclear what work up was performed at OSH. Here she has had episodes of RVR on telemetry. No murmurs on exam to suggest valvular pathology. NO infectious signs/symptoms. Orthostasis is possible, however BPs have been stable this admission. Likely etiology was mechanical fall as etiology. Evaluated by ___ and recommended to go to ___ rehab. #Heartburn #GERD On day of discharge, patient reported epigastric and left-sided chest pain as well as nausea and lightheadedness. Received tums and symptoms completely resolved. Also received aspirin x1 however low suspicion for cardiac etiology. EKG obtained and was stable from prior, no ST or T wave changes. Vitals were stable during the event. Trops <0.01 x2. Likely represented heartburn/reflux given rapid improvement with tums. Was given Maalox/Diphenhydramine/Lidocaine for symptoms. Had also been receiving home PPI daily during admission. #Vomiting #Constipation Pt with vomiting x2 later in admission, not taking much PO as a result. CT Head ___ stable from prior. Pt asymptomatic and denied abd pain, n/v at those times, no localizing symptoms. Suspect constipation a large driver. Increased bowel regimen. Pt did not have further episodes of vomiting and remained asymptomatic. #T2 and T4 compression fractures (diagnosed at OSH) Per family she suffered a fall about 4 weeks ago and was dx with a T2 and T4 compression fracture at that time. She was discharged from the ED without intervention and recommendation to follow up with her PCP who ordered ___ TLSO brace. She has no back pain or midline spinal tenderness and has been ambulating without any brace for 4 week now. Neurosurgery felt that she did not require a brace or any further intervention. It was felt that she may continue activity as tolerated. # Anion gap metabolic acidosis Progressively downtrended bicarb in the absence of clear etiology. No uremia, lactate wnl, UA without evidence of ketones. No significant diarrhea. Improving at the time of discharge. #Nutrition Concerns about poor PO intake from nursing staff and son. ___ by nutrition who recommended 4 Ensure Enlives per day. Pt was given thiamine 100mg daily as well as phosphorus repletion. CHRONIC ISSUES: =============== #CKD Cr remained wnl and stable this admission. #HLD Continued on home simvastatin 10mg qPM #Hypothyroidism Continued on home levothyroxine 50mcg daily #Alzheimers Continued on home memantine 5mg PO BID, ramelteon 8mg qPM prn. #Depression Held home sertraline in setting of prolonged QTc Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever 2. Amiodarone 200 mg PO EVERY OTHER DAY 3. Ferrous Sulfate 325 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Memantine 5 mg PO BID 6. Metoprolol Tartrate 12.5 mg PO BID 7. Pantoprazole 20 mg PO EVERY OTHER DAY 8. Sertraline 25 mg PO DAILY 9. Simvastatin 10 mg PO QPM 10. Warfarin 3 mg PO DAILY 11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 12. Gabapentin 200 mg PO QAM 13. Gabapentin 300 mg PO QHS 14. melatonin 3 mg oral QHS Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN heartburn 2. Polyethylene Glycol 17 g PO DAILY 3. Pantoprazole 20 mg PO Q24H 4. Acetaminophen 500 mg PO BID:PRN Pain - Mild/Fever 5. Ferrous Sulfate 325 mg PO BID 6. Gabapentin 200 mg PO QAM 7. Gabapentin 300 mg PO QHS 8. Levothyroxine Sodium 50 mcg PO DAILY 9. melatonin 3 mg oral QHS 10. Memantine 5 mg PO BID 11. Metoprolol Tartrate 12.5 mg PO BID 12. Simvastatin 10 mg PO QPM 13. HELD- Amiodarone 200 mg PO EVERY OTHER DAY This medication was held. Do not restart Amiodarone until you see your primary care doctor. 14. HELD- Sertraline 25 mg PO DAILY This medication was held. Do not restart Sertraline until you see your primary care doctor. 15. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This medication was held. Do not restart TraMADol until you see your doctor 16. HELD- Warfarin 3 mg PO DAILY This medication was held. Do not restart Warfarin until you see Dr. ___ in a few weeks. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Left acute on chronic SDH Small right acute SDH SECONDARY DIAGNOSIS: Prolonged QTc Atrial Fibrillation Anion gap metabolic acidosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You came into the hospital after a fall and were found to have new bleeding in your brain, as well as findings of old bleeding. You were monitored closely and you did not require surgical intervention. Some of your home medications were also adjusted. Please see the medication changes listed below for the complete list. It was a pleasure taking care of you! - Your ___ Medicine Team 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 may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___
10058697-DS-19	10,058,697	23,920,871	DS	19	2126-07-09 00:00:00	2126-07-11 20:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R ankle pain Major Surgical or Invasive Procedure: ORIF R ankle History of Present Illness: ___ was walking today when she sustained a mechanical fall on ice, no HS or LOC. She reports immediate pain and inability to ambulate. She went with her daughter to the urgent care center in ___ and was transferred to ___ for further management. She denies numbness, tingling or weakness in the RLE and denies pain in other locations Past Medical History: - HTN - HL - s/p L wrist fracture - Osteopenia (previously on bisphosphanates, now off) Social History: ___ Family History: nc Physical Exam: AVSS G:NAD Dr:c/d/i RLE:NVID 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 ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for , which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to **** was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is ** in the ** extremity, and will be discharged on **** for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO QPM 2. Amlodipine 2.5 mg PO DAILY Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Acetaminophen 650 mg PO Q6H 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QHS Duration: 14 Days Start: Today - ___, First Dose: Next Routine Administration Time 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. OxycoDONE (Immediate Release) 2.5-7.5 mg PO Q3H:PRN pain 9. Senna 17.2 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R ankle fracture Discharge Condition: Improved. AO3. NWB RLE in splint. 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. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: - NWB RLE in splint Followup Instructions: ___
10058750-DS-12	10,058,750	28,356,091	DS	12	2149-11-16 00:00:00	2149-11-16 14:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Compazine / Gadolinium-Containing Contrast Media Attending: ___. Chief Complaint: Progressive, recurrent abdominal pain Major Surgical or Invasive Procedure: Celiac plexus block History of Present Illness: ___ with hx of GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C. diff, multiple episodes of recurrent pancreatitis, admitted ___ with recurrent abdominal pain presenting with recurrent abdominal pain reminiscent of prior episodes of pancreatitis. Pt describes onset of RUQ pain that radiates to his back starting on ___, progressive despite home medications. He endorses associated anorexia, denies F/C, chest pain, diarrhea, melena, hematochezia. Pain is the same as prior episodes; he notes that evaluation at Dr. ___ prior to presenting to the ED included an abdominal exam that escalated his pain (although is also appropriately understanding of the need for serial abdominal exams). Pt reports that when he left the hospital on ___, he was in ___ pain, RUQ and epigastrium, intermittently sharp and hard, throbbing pain. As it escalates from ___ to ___, it typically migrates from RUQ more towards the epigastrium. He does not add OTC medications during acute episodes. He uses hydrocodone/APAP at home, which is prescribed q6h prn but he only takes at night. He endorses nausea without emesis. He denies diarrhea, constipation. Denies headaches, SOB. He does get chest pain that is actually radiating epigastric pain, radiates up through R chest. He has been followed by pain service as outpatient, and is undergoing evaluation for celiac plexus block. As part of that evaluation, plan was for u/s guided injection into abdominal muscles on ___, to rule out abdominal wall pain. Pt was seen by Dr. ___ on ___. Based on Dr. ___ from that visit, potential etiologies for his chronic pain with intermittent flares include gallstones within remnant gallbladder, postcholecystectomy syndrome. Plan per Dr. ___ note is to review pt's case at Pancreaticobiliary multidisciplinary management conference on ___. In the ___ ED: VS 97.6, 62, 137/86, 99% RA Exam notable for: General: no acute distress HEENT: Normal oropharynx, no exudates/erythema Cardiac: RRR , no chest tenderness Pulmonary: Clear to auscultation bilaterally with good aeration, no crackles/wheezes Abdominal/GI: Right upper quadrant tenderness to palpation, soft, nondistended Renal: No CVA tenderness MSK: No deformities or signs of trauma, no focal deficits noted Neuro: Sensation intact upper and lower extremities, strength ___ upper and lower, no focal deficits noted, moving all extremities Labs notable for: WBC 6.9, Hb 14.8, Plt 243 Cr 1.0 LFTs WNL Lipase 45 INR 1.0 Imaging: RUQ u/s: 1. No evidence of biliary ductal stone or obstruction. 2. Mild pneumobilia, previously seen on prior CT dated ___. 3. Nonvisualization of the pancreas. Consults: none Received: Dilaudid 0.5 mg IV x2 Zofran 4 mg IV x2 IVF On arrival to the floor, pt reports ___ pain with nausea. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: Chronic GERD Tubular adenoma of colon ___ GERD ___ Pancreatitis ___ Cough Epidermoid cyst of the skin Cough Fatigue H/o difficulty sleeping Obestiy RLQ pain ============= SURGICAL HISTORY: ___: ERCP stent removal ERCP duct stent placement ___ CCY ___ ERCP to remove duct calculi ___ Elbow arthrosopy/surgery ___ reattached tendon Orthopedic surgery ___ - left elbow tendon repair, ulnar repair, ulnar nerve repair - 2 surgeries ___ Social History: ___ Family History: Mother with multiple sclerosis, paranoid schizophrenia, heart disease. His father has HTN. His paternal GF had ___ disease. ___ had heart disease and died at age ___. PGM had a malignant tumor breast and DM. She died at age ___. Physical Exam: GEN: alert and interactive, no acute distress HEENT: anicteric sclera, face mildly flushed. LUNGS: non labored breathing GI: soft, mild tenderness in epigastrium, normal active bowel sounds EXTREMITIES: no edema SKIN: no new rashes, skin warm NEURO: Alert and interactive, speech fluent PSYCH: normal mood and affect Pertinent Results: ___ 04:08PM BLOOD WBC-6.9 RBC-5.09 Hgb-14.8 Hct-44.5 MCV-87 MCH-29.1 MCHC-33.3 RDW-12.9 RDWSD-41.3 Plt ___ ___ 06:10AM BLOOD WBC-6.0 RBC-5.09 Hgb-14.7 Hct-44.2 MCV-87 MCH-28.9 MCHC-33.3 RDW-12.9 RDWSD-40.3 Plt ___ ___ 04:08PM BLOOD Plt ___ ___ 06:10AM BLOOD ___ ___ 03:11PM BLOOD UreaN-19 Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-21* AnGap-16 ___ 06:10AM BLOOD Glucose-83 UreaN-15 Creat-1.1 Na-145 K-4.0 Cl-107 HCO3-25 AnGap-13 ___ 03:11PM BLOOD ALT-21 AST-16 AlkPhos-120 Amylase-80 TotBili-0.3 ___ 06:10AM BLOOD ALT-19 AST-13 AlkPhos-104 TotBili-0.8 ___ 06:18AM BLOOD Triglyc-257* HDL-26* CHOL/HD-5.7 LDLcalc-71 ___ 06:18AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 Cholest-148 MRCP w/ secretin: 1. Findings suggestive of chronic pancreatitis with decreased normal intrinsic T1 hyperintensity of the pancreas, 3 mm dilated side branch in the pancreatic body, and decreased compliance of the pancreatic duct post secretin administration. 2. No findings to suggest main pancreatic duct stricturing or findings to suggest papillary stenosis/pancreatic duct orifice stenosis post secretin administration. 3. No evidence of acute pancreatitis, pancreatic necrosis or peripancreatic collection. 4. Pancreatic fluid is secreted into the second portion of the duodenum after secretin administration, with evaluation of passage of this fluid past the genu limited by pre-existing fluid within small bowel loops which overlap the duodenum. 5. Mild splenomegaly and trace bilateral pleural effusions. Brief Hospital Course: ___ with hx of GERD, choledocholithiasis s/p ERCP and CCY c/b bile leak requiring stent placement (subsequently removed), C. diff, multiple episodes of recurrent pancreatitis, presenting with acute on chronic pain in the setting of chronic pancreatitis # Acute on chronic RUQ/epigastric pain # Chronic pancreatitis # PTSD: Previous EUS and now MRCP with signs of chronic pancreatitis, though his symptoms are such that chronic pancreatitis would not make since as a sole etiology. Other possible contributions include postcholecystectomy pain syndrome and visceral hyperalgesia. A history of trauma is likely also impacting his current experience and his interpretation of pain. Opioid tolerance and hyperalgesia may also be playing a roll. - Weaned opioids to hydromorphone PO 2 mg q 4 hours as needed - ___ has been following with Dr. ___ - ___ to re-schedule his therapy intake - Genetic testing for chronic pancreatitis (Ambry Genetics) pending - Increased home amitriptyline to 25 mg qHS - Continue home tizanidine, topiramate, and zenpep The ___ was seen and examined on the day of discharge. The total time spent preparing discharge was >30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Pantoprazole 40 mg PO Q24H 3. Topiramate (Topamax) 50 mg PO DAILY 4. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN pain 5. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY 6. Tizanidine 2 mg PO QHS:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H RX hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours as needed Disp #42 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #30 Packet Refills:1 4. Senna 8.6 mg PO QHS RX sennosides 8.6 mg 1 tab by mouth once a day Disp #30 Tablet Refills:1 5. Amitriptyline 25 mg PO QHS RX amitriptyline 25 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:3 6. Pantoprazole 40 mg PO Q24H 7. Tizanidine 2 mg PO QHS:PRN pain 8. Topiramate (Topamax) 50 mg PO DAILY 9. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Chronic pancreatitis, postcholecystectomy pain syndrome, visceral hyperalgesia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were seen at ___ for abdominal pain. We performed a celiac plexus block and adjusted your medications to help with this. Followup Instructions: ___
10058856-DS-18	10,058,856	29,328,838	DS	18	2127-07-23 00:00:00	2127-07-23 15:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Duragesic / Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Penicillins / Flagyl Attending: ___ Chief Complaint: Left groin pain at incision site for 3 days Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p left common femoral endarterectomy ___ with Dr. ___ with complain of left groin pain at incision site for 3 days, found on OSH CT scan (currently unavailable) to have reported 2 cm collection superficial to CFA. The patient states she has had 3 days of left groin pain that is ___, causing her to go to her PCP ___. Her PCP obtained ___ CT scan which revealed the fluid collection. She came to ___ ED after learning the results. The scans are not currently available due to a tech issue. She reports taking her Plavix as prescribed (scheduled to stop next day after admission). She denies numbness or tingling in either lower extremity, extremities are WWP, and denies CP, SOB, HA, and all other symptoms. Past Medical History: HTN migraines, takes fioricet multiple times a day IBS OA ?seizure disorder GERD depression borderline personality d/o narcotic abuse had port-a-cath for "IVF" for "chronic ileus" per patient Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM ============================= Vitals: T 98.1 / BP 136/83 / HR 64 / RR 18 / O2sat 97%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: non-labored respirations on RA ABD: Soft, nondistended, focal mild TTP LLQ, no rebound or guarding, normoactive bowel sounds, no palpable masses. Left groin incision well healed Extremities: warm and well-perfused Neuro: A&OX3 DISCHARGE PHYSICAL EXAM ========================= VS: AF 100-140s/70s 50-60s 18 95-97% RA I/O: ___ GENERAL: NAD, resting comfortably, A&O to hospital, year, self HEENT: AT/NC HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: mildly tender in LLQ. +BS. EXTREMITIES: site of L femoral endarterectomy appears c/d/I without tenderness or erythema/ no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII grossly intact except baseline L sided facial droop, moving all extremities with purpose, DOWB intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ==================== ___ 12:15AM BLOOD WBC-21.7* RBC-4.74 Hgb-11.3 Hct-36.4 MCV-77* MCH-23.8* MCHC-31.0* RDW-16.6* RDWSD-45.6 Plt ___ ___ 12:15AM BLOOD Neuts-80.8* Lymphs-9.5* Monos-6.1 Eos-2.4 Baso-0.6 Im ___ AbsNeut-17.50* AbsLymp-2.07 AbsMono-1.33* AbsEos-0.52 AbsBaso-0.14* ___ 12:15AM BLOOD ___ PTT-27.2 ___ ___ 12:15AM BLOOD Glucose-80 UreaN-6 Creat-0.7 Na-138 K-3.2* Cl-98 HCO3-23 AnGap-17 ___ 05:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.5* DISCHARGE LABS =================== ___ 05:45AM BLOOD WBC-12.6* RBC-4.06 Hgb-9.6* Hct-31.2* MCV-77* MCH-23.6* MCHC-30.8* RDW-16.7* RDWSD-46.3 Plt ___ ___ 05:45AM BLOOD Glucose-101* UreaN-5* Creat-0.8 Na-136 K-4.2 Cl-101 HCO3-24 AnGap-11 ___ 05:45AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8 IMAGING =========== CT ABD/PELV ___. Limited examination without IV contrast. 2. No imaging findings to explain left lower quadrant pain. While there is mild thickening of the sigmoid colonic wall and equivocal adjacent fat stranding, this is a fairly similar appearance to the prior CT from ___, and likely related to muscular hypertrophy related to chronic diverticular disease. 3. Small amount of fat stranding in fluid density in the left groin region likely represent sequelae from prior intervention. Please correlate with any prior recent interventions to the left groin. 4. Persistent dilation of the right renal collecting system. LLE U/S A2.4 x 1.2 x 0.8 cm irregular fluid collection with internal debris could represent abscess versus hematoma. Surrounding soft tissue edema favors abscess. Comparison can be made if prior imaging becomes available. Brief Hospital Course: ___ s/p left common femoral endarterectomy ___, who's presenting with 3 days of pain, found to likely have small hematoma at site of recent endarterectomy with leukocytosis to 21 initially concerning for abscess, but found to have possible diverticulitis on CT scan, which improved with antibiotics. # Diverticulitis # Leukocytosis Patient with elevated WBC and LLQ abdominal pain, initially thought ___ abscess at L femoral site per vascular surgery. However CT scan unremarkable for infection at site, but did reveal sigmoid thickening initially concerning for diverticulitis on preliminary read, but then later final read thought this was less likely. UA/cx NGTD, BCx NGTD, CXR unremarkable, no other signs of infection elsewhere. Patient was initially treated with vanco/cipro/flagyl (note that per chart she has a Flagyl allergy but pt denies this and she tolerated flagyl well) which was narrowed to cipro/flagyl only, with improvement in leukocytosis and abdominal pain. She will complete 7 day course of abx (last day ___. Patient was continued on bowel regimen and pain controlled with oxycodone initially 10mg q4h downtitrated to 5mg q4h on discharge. Tolerating solid PO diet on discharge. She should have a colonoscopy ___ weeks after discharge #Peripheral vascular disease s/p left common femoral endarterectomy ___ Patient continued on Plavix and statin. Normally, would transition to ASA 81mg 30 days after vascular procedure; however, patient with aspirin allergy. Recommend continuing Plavix until follow up with vascular in 1 month after discharge. #Abdominal Pain Continued home dicyclomine and Zofran. Treated diverticulitis as above. # HTN Continued home lisinopril and propranolol # history psych disorders Continued home perphenazine 4mg and fluoxetine 40mg # GERD Continued home pantoprazole # Disposition/inability to care for self As per social history, patient had been living with a roommate who was also not very good at self-care but together the two of them compensated for each other. Per her sister and her case manager, since the roommate died the patient has had poor self care due to chronic cognitive weakness, namely not eating, not being able to do ADLs, and at one point getting lost outside in the winter. Was seen by ___ who found she had impaired orientation, memory, safety awareness. Sister had been working on a bed at a facility, and patient was amenable to go there on discharge, so HCP did not need to be invoked. For billing purposes only: >30 minutes spent on patient care and coordination. TRANSITIONAL ISSUES ========================= []Continue ciprofloxacin and flagyl to complete 7 day course of abx (last day ___. []Recommend colonoscopy ___ weeks after discharge []Please titrate off oxycodone as was only started for abdominal pain on admission []Recommend allergy appt as outpatient as has multiple unknown allergies including penicillin, sulfas []Pt with aspirin allergy. She will continue on Plavix until follow up with vascular surgery. She should have duplex of her LLE and follow up with Dr. ___ 1 month after discharge. Please call ___ to receive this followup appointment as it is currently pending. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. DICYCLOMine 20 mg PO BID 4. FLUoxetine 20 mg PO DAILY 5. Gabapentin 200 mg PO TID 6. Lisinopril 20 mg PO DAILY 7. Ondansetron Dose is Unknown PO Frequency is Unknown 8. Pantoprazole 40 mg PO Q24H 9. Perphenazine 4 mg PO ONCE 10. Propranolol LA 60 mg PO DAILY 11. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 12. Cyanocobalamin 500 mcg PO DAILY 13. Centrum Silver Men (multivit-min-FA-lycopen-lutein) 0.4 mg-300 mcg-250 mcg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO Q8H 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #15 Capsule Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 17.2 mg PO HS 6. Acetaminophen 1000 mg PO TID 7. Ondansetron ODT 4 mg PO Q8H:PRN nausea 8. Atorvastatin 80 mg PO QPM 9. Centrum Silver Men (multivit-min-FA-lycopen-lutein) 0.4 mg-300 mcg-250 mcg oral DAILY 10. Clopidogrel 75 mg PO DAILY 11. Cyanocobalamin 500 mcg PO DAILY 12. DICYCLOMine 20 mg PO BID 13. FLUoxetine 40 mg PO DAILY 14. Gabapentin 500 mg PO TID 15. Lisinopril 20 mg PO DAILY 16. Pantoprazole 40 mg PO Q24H 17. Perphenazine 4 mg PO DAILY 18. Propranolol LA 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Diverticulitis SECONDARY: Hypertension Psychiatric Disorders Peripheral vascular disease s/p Left common femoral endarterectomy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you. Why you were admitted? - You were admitted because you were having abdominal pain. What we did for you? - You were found to have an infection in your bowel can diverticulitis. You were treated with antibiotics with improvement. - The occupational therapist recommended that you go to rehab What should you do when you leave the hospital? - Please continue taking all your medications - Please continue taking your antibiotics (ciprofloxacin & metronidazole) to complete a 7 day course (last day ___. - Please attend your follow up appointments. - You should receive a call from the vascular surgery clinic regarding an appointment with Dr. ___ to be scheduled in 1 month after discharge. If you do not hear back within 3 days please call ___. We wish you the best, Your ___ team Followup Instructions: ___
10058974-DS-15	10,058,974	26,763,452	DS	15	2189-08-15 00:00:00	2189-08-16 16:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: AMS Major Surgical or Invasive Procedure: Nephrostomy tube History of Present Illness: ___ yo male with history of ___ disease, dementia, CAD, and CHF with EF 25% who presented for altered mental status. He was last at his baseline yesterday at 10am. Last night, his careworkers reported that he was refusing medications and hallucinating. Over the past few days he has had his eyes closed more and has had a decreased appetite. Last night, he was diaphoretic and uncovering himself in bed. He was very restless and pointing to his abdomen. This morning, patient remained altered and had one episode of emesis. His finger sticks were also higher than they were normall, elevated at 280 from 100. At baseline, pt speaks few words in ___ and is bed-bound, but is responsive and recognizes familiar faces. In the ED, initial vitals were: HR85, BP 132/89, RR 16, 02 97% RA, rectal temp 101.2. He was responsive only to pain. -UA was grossly positive -He was given ceftriaxone -He was tachy with abd pain? CT abdomen performed and revealed 8-mm obstructing right mid ureteric stone with upstream hydronephroureter. -Urology deferred to ___ to put in perc neph tube tonight -Initial lactate 4.1 w/ markedly abnl UA suggestive of infection. Pt received rectal tylenol, 2L NS. Pt also given Zofran for nausea after several episodes of gagging. -CXR nonacute. CT head negative for intracranial hemorrhage. -access 2PIV Most recent vitals prior to transfer: He went to ___ for perc neph tube placement where he was on pressors during the procedure. An ___ catheter was placed on the right side draining to vac. On arrival to the MICU, he will not respond to voice or noxious stimuli. Family reports this is at his baseline at times. Review of systems: Unable to report. Past Medical History: 1. ___ Disease, severe, with dementia 2. CAD s/p STEMI ___ with PCI/stenting of LAD 3. CHF with EF 25% in ___ 4. Hypertension 5. Hyperlipidemia 6. DM on glypizide 7. Chronic bilateral shoulder pain 8. Appendectomy 9. DVT on chronic LMWH Social History: ___ Family History: non-contributory to current presentation Physical Exam: Admission exam: VITALS: Tm 100.6 Tc 99.8 HR 72 BP 141/39 RR 17 SpO2 95/RA GENERAL: awake and alert, makes eye contact, appears comfortable HEENT: PERRL, EOMI, dry MMM NECK: no carotid bruits, JVP not elevated LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly BACK: No CVA tenderness appreciated, nephrostomy drain in place on right GU: Foley in place EXTREMITIES: Trace ___ edema, 1+ DP pulses bilat NEUROLOGIC: A&Ox0, tries to communicate, follows simple commands by miming, moving all extremities, unable to cooperate with full neuro exam. Fasked face with ridigity in upper extremities. Discharge Exam: VITALS: T 98, HR 54 BP 130/60 RR 20 SpO2 97% RA GENERAL: asleep, but easily arousable HEENT: PERRL, EOMI, moist MMM NECK: no carotid bruits, JVP not elevated LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly BACK: No CVA tenderness appreciated, nephrostomy drain in place on right GU: Condom catheter in place. EXTREMITIES: No ___ edema NEUROLOGIC: Sleeping, and slightly snoring Pertinent Results: Admission labs: ___ 01:45PM BLOOD WBC-7.2 RBC-4.00* Hgb-11.1* Hct-35.0* MCV-88 MCH-27.6 MCHC-31.6 RDW-14.3 Plt ___ ___ 01:45PM BLOOD Neuts-95.6* Lymphs-3.2* Monos-0.9* Eos-0.3 Baso-0.1 ___ 01:45PM BLOOD ___ PTT-32.0 ___ ___ 01:45PM BLOOD Glucose-256* UreaN-32* Creat-1.4* Na-139 K-4.3 Cl-104 HCO3-24 AnGap-15 ___ 01:45PM BLOOD ALT-17 AST-15 AlkPhos-45 TotBili-0.8 ___ 01:45PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.4* Mg-1.8 LACTATE TREND: ___ 02:00PM BLOOD Lactate-4.1* ___ 05:17PM BLOOD Lactate-3.5* ___ 04:38AM BLOOD Lactate-1.9 DISCHARGE LABS: ___ 06:40AM BLOOD WBC-6.7 RBC-3.74* Hgb-10.4* Hct-31.9* MCV-85 MCH-27.7 MCHC-32.5 RDW-14.2 Plt ___ ___ 06:40AM BLOOD Glucose-185* UreaN-18 Creat-0.6 Na-140 K-4.0 Cl-104 HCO3-28 AnGap-12 ___ 06:40AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.7 Microbiology: ___ 1:45 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: PROTEUS MIRABILIS. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R ___ 2:10 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Imaging: # CHEST (PORTABLE AP) Study Date of ___ FINDINGS: Single AP upright radiograph of the chest was obtained. The lungs are slightly lower in volume but clear. There is no pleural effusion or pneumothorax. Heart is top normal in size with normal cardiomediastinal contours. # CT HEAD W/O CONTRAST Study Date of ___ FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift of normally midline structures. The gray-white matter differentiation is preserved. There is extensive periventricular and subcortical white matter hypoattenuation, compatible with a small vessel ischemic disease. Ventricles and sulci are prominent, compatible with age-related involution. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. Vascular calcifications are seen in the cavernous carotid arteries. The middle ear structures are symmetric. Soft tissue density in bilateral external auditory canals likely represents cerumen. Globes are intact with bilateral lens replacement. IMPRESSION: 1. No acute intracranial process. 2. Extensive age-related involution and small vessel ischemic disease. 3. If there is persistent clinical concern for ischemia, consider MRI if not contraindicated. # CT ABD & PELVIS WITH CONTRAST Study Date of ___ CT ABDOMEN: There is trace bibasilar dependent atelectasis. The heart is normal in size without pericardial effusion. Multivessel coronary arterial calcifications are noted, with concurrent aortic valve calcification. The liver demonstrates no focal lesion. The gallbladder, spleen, and adrenal glands appear unremarkable. The pancreas is diffusely atrophic and demonstrates a 9-mm cyst in the head. There is no pancreatic ductal dilatation. The nephrograms are symmetric. There is moderate right hydronephroureter upstream of an 8-mm mid ureteric stone (2, 51). There is also a suggestion of urothelial hyperenhancement upstream of the stone, suggestive of pyelitis. There is no left-sided renal obstruction. No additional stone is seen. Moderate stranding and free fluid is seen around the right kidney. Small and large bowel loops are normal in caliber. Trace free fluid is seen subjacent to the cecal tip. There is no intra-abdominal lymphadenopathy. Great vessels are patent. Moderate atherosclerotic disease is present throughout the descending aorta extending into branching vessels. There are bilateral renal cysts, some of which too small to fully characterize. CT PELVIS: The bladder is partially distended, but demonstrates urothelial hyperemia and mural thickening, likely reflecting presence of cystitis. There is nondependent air and a Foley catheter in place, possibly related to recent instrumentation. The prostate gland appears enlarged to 5.9 cm. There is significant fecal impaction within the rectum. No inguinal or pelvic sidewall adenopathy. No focal concerning lesion. Multilevel lower thoracic spondylosis is present. IMPRESSION: 1. 8-mm right mid ureteric obstructing stone with moderate upstream hydronephroureter, as well as urothelial hyperenhancement suggestive of pyelitis. Consider percutaneous nephrostomy placement. 2. Bladder thickening and urothelial hyperenhancement suggestive of concurrent cystitis. 3. Bilateral renal cysts. 4. 9-mm pancreatic head cyst, statistically most likely to represent side branch IPMN, which could be followed by MRCP. # PORTABLE ABDOMEN Study Date of ___ FINDINGS: There is an 8-mm main ureteral stone seen on the right which appears to be similar in location as seen on the CT exam. Right percutaneous nephrostomy tube catheter is in place. There is a nonspecific bowel gas pattern with air in both the colon and small bowel. There is no evidence of obstruction, ileus, or large amount of free air. There are degenerative changes in the lower lumbar spine. IMPRESSION: 8-mm right mid ureteral stone in similar position as prior CT. Brief Hospital Course: ___ yo male with history of ___ disease, dementia, CAD, and CHF with EF 25% who presented for altered mental status found to have a UTI and an obstructing right mid ureteric stone with upstream hydronephroureter. His mental status improved with ceftriaxone treatment. ACTIVE ISSUES: # Urosepsis: Patient presented with fever, hypotension, and left shift with positive UA as the source. Pt was found to have a UTI with upstream hydronephroureter and acute kidney injury secondary to obstructing right mid ureteral stone. Patient underwent urgent decompression of the right collecting system with percutaneous nephrostomy tube in ___. He was transiently hypotensive during the procedure requiring pressors, which the patient was quickly weaned from. He was initially placed on ceftriaxone, but then broadened to cefepime when blood cultures returned positive for gram negative bacteremia. However, he was narrowed back to ceftriaxone once speciation and sensitivities returned. His lactate was elevated on presentation, which normalized with IVFs. Anti-hypertensives were held on admission. Mental status improved after two days of antibiotics and blood cultures were negative for 48 hours before he was discharged. Antibiotics will be continued for a total of 2 weeks, until ___. Patient has a MIDLINE for antibiotic administration in his rehab facility. # ___: Pt's creatinine noted to be doubled compared to patient's baseline on admission, likely secondary to obstruction from nephrolithiasis and prerenal state secondary to poor PO intake and febrile illness. His creatinine trended down with resolution of obstruction and IVF. His serum creatinine improved with IVFs and correction of obstruction and are now to his baseline of 0.8. # Altered mental status: This was attributed to fevers, UTI, and dehydration from febrile illness. Family reports he is now back to his baseline. CHRONIC ISSUES: # Normocytic anemia: Likely secondary to anemia of chronic disease. Pt was guaiac negative in ED. His HCT remained stable in ICU and on medical unit. # DVT: Pt was on sub therapeutic dosing of Lovenox on admission. This was increased to 1.5 mg/kg/day prior to discharge. # CHF: last EF reported 25%. Pt was hypovolemic on admission and was fluid resuscitated. He appeared euvolemic on discharge and was satting well on room air. # CAD/HTN: Pt was continued on his aspirin. His lisinopril and metoprolol were initially held for hypotension but these were resumed without problem on the medical unit. # HL: Continued atorvastatin. # ___: Continued carbidopa-levodopa. Initially his home Seroquel was held given AMS, but then tolerated it well once mental status improved. # DM: Pt's glipizide was held while in house, but resumed on discharge. # Constipation: Continued MiraLax. Also added Colace, senna and bisacodyl. # Urinary Retention: Patient required Foley placement. Started on Flomax. #Transitional issues: Pt will be discharge to rehab for IV antibiotic treatment. He will need to follow up with urology on ___ for continued treatment planning of his obstructing kidney stone. They will also determine whether his Foley can be discontinued at that time. Medications on Admission: 1. Atorvastatin 80 mg PO DAILY 2. Carbidopa-Levodopa (___) 0.5 TAB PO TID 3. GlipiZIDE 10 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Quetiapine Fumarate 12.5 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY 9. Enoxaparin Sodium 60 mg SC DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Carbidopa-Levodopa (___) 0.5 TAB PO TID 4. Polyethylene Glycol 17 g PO DAILY 5. GlipiZIDE 10 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Enoxaparin Sodium 100 mg SC DAILY 9. Quetiapine Fumarate 12.5 mg PO BID Hold for sedation or RR<10. 10. CeftriaXONE 1 gm IV Q24H 11. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 13. Senna 1 TAB PO BID:PRN constipation 14. Outpatient Lab Work Please have labs checked at your urology appointment on ___: CBC, Chem 10, AST, ALT, alk phos, total bili Have results faxed to Dr. ___: ___ Fax: ___ ICD 9:___ 15. IV care Please discontinue MIDLINE once antibiotic course is complete. 16. Tamsulosin 0.4 mg PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Urosepsis right obstructing kidney stone Urinary retention SECONDARY: Diabetes hypertension coronary artery disease ___ Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you. You were admitted to the hospital for altered mental status and were found to have a urinary tract infection that had spread to your blood stream, likely a result of blockage of your right urinary tract from a kidney stone in your right kidney. You were treated with intravenous antibiotics which you must continue taking to make sure that infection resolves. You have an appointment scheduled with urology on ___ for follow up of your kidney stone. Please make the following changes to your medications: # START ceftriaxone 1 gram every 24 hours, last dose ___ # START Flomax 0.4mg QHS for urinary retention Continue all other medications as prescribed. Followup Instructions: ___
10059917-DS-6	10,059,917	24,017,710	DS	6	2160-07-07 00:00:00	2160-07-19 13:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Erythromycin Base / Keflex Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old female who presents as transfer from OSH with rib fractures. Patient stated that she arrived home last night and was "hurrying to the bathroom" secondary to having taken a laxative and having diarrhea. She then thinks she turned quickly and struck her chest on the counter. She denies head strike or LOC. She denies any fall or syncope. She had chest pain throughout the night and spent the night sitting in a recliner after which she called her family in AM and was brought to ___. There she was found to have multiple left rib fractures (___). Ms. ___ endorses mild pain to the left chest radiating to the back with inspiration. She denies SOB or other constitutional symptoms. She denies HA or other pain besides her left flank with deep inspiration. She has a mild cough with deep inspiration. Of note, patient had a slip and fall in ___ also with multiple left sided rib fractures and evidence of additional old rib fractures on CT scan. She lives at home alone and ambulates independently at baseline. She has a history of osteopenia. Past Medical History: Past Medical History: - Osteopenia - Hypertension - Hyperlipidemia - GERD - Chronic LBP - Depression - Anxiety - Urge incontinence - Allergic rhinitis Past Surgical History: - ___, Hysterectomy for fibroids. - ___, Breast reduction - Tonsillectomy. Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: VS: 98.5 72 192/78 17 98% RA Gen: WA, NAD CV: RRR Pulm: comfortable on RA, some pain with deep inspiration which also elicits cough, normal WOB. TTP of left lateral chest wall Abd: soft, NT/ND Ext: WWP, small skin avulsion over left anterior forearm. Discharge Physical Exam: VS: T: 97.3 BP: 167/74 HR: 60 RR: 17 O2: 98% Ra GEN: A+Ox3, NAD HEENT: normocephalic, atraumatic CV: RRR PULM: CTA b/l CHEST: tender to palpation over left posterior chest wall c/w rib fracture pain. Symmetric expansion, no lesions ABD: soft, non-distended, non-tender to palpation EXT: LUE abrasion, b/l scattered old abrasions Pertinent Results: IMAGING: ___: CT Head: No acute intracranial abnormality. ___: CT C-spine: 1. No acute fracture or traumatic malalignment. 2. Moderate to severe cervical spondylosis. LABS: ___ 03:10PM GLUCOSE-173* UREA N-24* CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 ___ 03:10PM WBC-8.6 RBC-3.61* HGB-11.2 HCT-34.9 MCV-97 MCH-31.0 MCHC-32.1 RDW-14.4 RDWSD-51.2* ___ 03:10PM NEUTS-70.6 LYMPHS-18.0* MONOS-9.0 EOS-1.1 BASOS-1.1* IM ___ AbsNeut-6.04 AbsLymp-1.54 AbsMono-0.77 AbsEos-0.09 AbsBaso-0.09* ___ 03:10PM PLT COUNT-220 ___ 03:10PM ___ PTT-25.5 ___ Brief Hospital Course: Ms. ___ is a ___ year-old female who presented to ___ as a transfer from ___ with left-sided ___ rib fractures after she struck her chest on a counter. The patient was admitted to the Acute Care Surgery Trauma service for pulmonary toilet and pain control. Pain was managed with tramadol and acetaminophen. 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 worked with Physical Therapy and it was recommended she be discharged to rehab to continue her recovery. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, out of bed with asssist, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMLODIPINE - 5mg daily ATORVASTATIN - atorvastatin 20 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) DIAZEPAM [VALIUM] - Valium 2 mg tablet. 1 Tablet(s) by mouth daily as needed - (Prescribed by Other Provider) (Not Taking as Prescribed) DOXAZOSIN - doxazosin 1 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) DULOXETINE [CYMBALTA] - Cymbalta 30 mg capsule,delayed release. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Dosage uncertain - (Prescribed by Other Provider) ESCITALOPRAM OXALATE [LEXAPRO] - Lexapro 5 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed) ESTRADIOL - estradiol 0.5 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) EZETIMIBE [ZETIA] - Zetia 10 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) (Not Taking as Prescribed) FLUTICASONE-SALMETEROL [ADVAIR HFA] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) LISINOPRIL - lisinopril 20 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) NEBIVOLOL [BYSTOLIC] - Dosage uncertain - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - Dosage uncertain - (Prescribed by Other Provider) ASCORBIC ACID (VITAMIN C) [VITAMIN C] - Dosage uncertain - (Prescribed by Other Provider; OTC) (Not Taking as Prescribed) ASPIRIN - aspirin 81 mg tablet,delayed release. Tablet(s) by mouth daily - (Prescribed by Other Provider) CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - Dosage uncertain - (Prescribed by Other Provider) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain - (Prescribed by Other Provider) DIPHENHYDRAMINE HCL [BENADRYL] - Benadryl 25 mg capsule. 1 Capsule(s) by mouth daily @ hs - (Prescribed by Other Provider) (Not Taking as Prescribed) DOCUSATE SODIUM [COLACE] - Dosage uncertain - (Prescribed by Other Provider) L. GASSERI-B. BIFIDUM-B LONGUM ___ COLON HEALTH] - Dosage uncertain - (Prescribed by Other Provider) MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Centrum Silver tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider; ___) (Not Taking as Prescribed) OMEPRAZOLE [PRILOSEC] - Prilosec 20 mg capsule,delayed release. 1 Capsule(s) by mouth daily - (Prescribed by Other Provider; ___) POLYETHYLENE GLYCOL 3350 [MIRALAX] - Dosage uncertain - (Prescribed by Other Provider) PSYLLIUM HUSK [METAMUCIL] - Metamucil 0.52 gram capsule. 6 Capsule(s) by mouth daily - (Prescribed by Other Provider; ___) (Not Taking as Prescribed) SENNOSIDES [SENNA] - Dosage uncertain - (Prescribed by Other Provider) SODIUM CHLORIDE [NASAL] - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) VITAMINS A,C,E-ZINC-COPPER [PRESERVISION AREDS] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Docusate Sodium 100 mg PO BID Hold for loose stool 3. TraMADol 25 mg PO Q4H:PRN pain Wean as tolerated RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO 3X/WEEK (___) 6. Atorvastatin 20 mg PO DAILY 7. Doxazosin 1 mg PO BID 8. DULoxetine 30 mg PO DAILY 9. Estradiol 0.5 mg PO DAILY 10. Lisinopril 20 mg PO DAILY 11. nebivolol 2.5 mg oral DAILY 12. Omeprazole 40 mg PO QHS 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Left ___ rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with left-sided rib fractures after striking your chest on the counter. You received medication for pain management and your breathing was monitored. You were evaluated by the physical therapist who recommends that you be discharged to rehab to regain your strength. You are now ready to be discharged from the hospital. Please note the following instructions regarding your rib fractures: Your injury caused multiple left-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 10 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Followup Instructions: ___
10059952-DS-20	10,059,952	26,572,318	DS	20	2121-02-08 00:00:00	2121-02-08 16:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Crestor Attending: ___. Chief Complaint: Dizziness, s/p ICD shock Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old male CAD status post CABG and prior PCI x5 (most recently PCI was reportedly in ___ a couple years ago), ischemic cardiomyopathy (LVEF reportedly 40-45%), history of Vfib arrest, VT s/p ICD in ___ (___, see below for information on settings), on mexilitine due to thyroid issues while on amio, h/o thyroid storm hypertension, hyperlipidemia, atrial fibrillation on apixaban, insulin-dependent diabetes mellitus, and GERD who awoke lightheaded at 4AM, and sat for ___ min, and his defibrillator fired x3. Reportedly had CP prior to firing (but patient currently notes he didn't have CP, just felt 'unwell'. Upon arrival to ___ reportedly in ___ given Amiodarone, shocked 100 joules. Changed from reported VT to narrow complex AF 125. no sob. En route w/ EMS, recurrent shock converted from AF --> Sinus Rhythm. Patient was discussed with his outpatient general cardiologist while at ___, Dr. ___ recommended the patient be transferred to ___ to see electrophysiology. he did not recommend further antiarrhythmic medications at this time. In the ED, - Initial vitals were: 96 98 147/82 20 100% RA - Exam notable for: Gen: Comfortable, No Acute Distress HEENT: NC/AT. EOMI. Neck: No swelling. Trachea is midline. No JVD Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Soft, NT, ND. Bowel sounds present Ext: No edema, cyanosis, or clubbing. Skin: No rashes. No skin breakdown Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. Heme: No petechia. No ecchymosis. - Labs notable for: Chem7: 140/4.8 / 102/20 / ___ < 158 Trop < 0.01 Lactate 2.4 Ca 9.5, Mg 2.1, P 2.5 LFTs WNL CBC WNL INR: 1.2 - Studies notable for: CXR: No acute cardiopulmonary abnormality. EKG: Sinus at 89. Normal axis. Slightly widened QRS at 131. Lateral TWI, similar to prior. - Vitals on transfer: 97.4 84 125/74 12 97% RA Of note, patient had myelogram earlier this month at outside facility, had aspirin and apixaban held for several days On arrival to the CCU, patient feels better. he notes feeling lightheaded quite often, but felt dizzy as though the room was spinning earlier today. No CP, SOB, abd pain. +constipated, no dysuria. Notes he usually wears CPAP but was off it during much of the night. ROS: Otherwise negative Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - + CABG; coronary anatomy unknown - + PERCUTANEOUS CORONARY INTERVENTIONS x4; coronary anatomy unknown; most recently PCI x3 approximately 8 months ago - PACING/ICD: None - Atrial fibrillation on warfarin - Ischemic cardiomyopathy (LVEF 40-45%) 3. OTHER PAST MEDICAL HISTORY: GERD Peripheral neuropathy Chronic serous otitis media Lumbar spinal stenosis status post laminectomy in ___ LFT abdnormalities Squamous cell carcinoma of the skin Status post tonsillectomy Social History: ___ Family History: Mother with "heart disease," died at ___ years old. Brother, ___ years old, with "heart disease." No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: 76 132/75 94% RA GENERAL: Well developed, well nourished in NAD. Oriented x3. Slightly masked facies HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. No LAD, unable to appreciate elevation of JVP CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, some mild tenderness in the lower quadrants but otherwise without tenderness. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: Strength upper and lower in tact proximally. CNII-XII grossly intact. DISCHARGE PHYSICAL EXAM ========================= VS: 24 HR Data (last updated ___ @ 553) Temp: 97.8 (Tm 97.8), BP: 153/70 (136-153/58-71), HR: 50, RR: 18 (___), O2 sat: 95% (95-96), O2 delivery: RA, Wt: 198.41 lb/90 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. Slightly masked facies HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. No LAD, unable to appreciate elevation of JVP CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. ABDOMEN: Soft, some mild tenderness in the lower quadrants but otherwise without tenderness. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: Strength upper and lower in tact proximally. CNII-XII grossly intact. Pertinent Results: ADMISSION LABS ================= ___ 08:05AM BLOOD WBC-8.0 RBC-4.53* Hgb-14.7 Hct-43.0 MCV-95 MCH-32.5* MCHC-34.2 RDW-12.4 RDWSD-43.0 Plt ___ ___ 08:05AM BLOOD Neuts-73.0* Lymphs-14.9* Monos-10.5 Eos-0.6* Baso-0.4 Im ___ AbsNeut-5.84 AbsLymp-1.19* AbsMono-0.84* AbsEos-0.05 AbsBaso-0.03 ___ 08:05AM BLOOD ___ PTT-34.7 ___ ___ 08:05AM BLOOD Glucose-158* UreaN-13 Creat-1.0 Na-140 K-4.8 Cl-102 HCO3-20* AnGap-18 ___ 08:05AM BLOOD ALT-<5 AST-31 AlkPhos-63 TotBili-0.5 ___ 08:05AM BLOOD Albumin-4.3 Calcium-9.5 Phos-2.5* Mg-2.1 ___ 08:05AM BLOOD TSH-3.4 ___ 08:05AM BLOOD T4-8.3 ___ 08:10AM BLOOD Lactate-2.4* Pertinent Labs ================= Imaging ================= ___ TTE The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a moderately increased/dilated cavity. There is mild to moderate regional left ventricular systolic dysfunction with near-akinesis of the basal and mid inferolateral and hypokinesis of the inferior walls (see schematic). The visually estimated left ventricular ejection fraction is 35-40%. 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 valve leaflets (3) are moderately 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. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle. Mild to moderate regional systolic dysfunction consistent with coronary artery disease. Aortic sclerosis without frank stenosis, although leaflets do not appear to be opening normally (reduced ejection fraction). Mild mitral and tricuspid regurgitation. Brief Hospital Course: SUMMARY: ===================== ___ year old male CAD status post CABG and prior PCI x5 (most recently PCI was reportedly in ___ a couple years ago), ischemic cardiomyopathy (LVEF reportedly 40-45%), history of Vfib arrest, VT s/p ICD in ___, on mexilitine due to thyroid issues while on amio, h/o thyroid storm hypertension, hyperlipidemia, atrial fibrillation on apixaban, insulin-dependent diabetes mellitus, and GERD who is presenting with several episodes of tachycardia, with possible VT vs. afib with rapid rates. ACUTE ISSUES: ============= #Tachycardia #history of VT/Vfib #history of afib Patient with several episodes of tachycardia, with morphologies appearing c/w either VT or afib with RVR and aberrancy when interrogating pacer. Discussing with EP which it may be or if both. Currently stable and in sinus. No recent HF exacerbations and looks euvolemic on exam. No recent illnesses. Amiodarone is not an option given his history of thyroid storm and mexiletine controls his VT but not A fib. After consultation with EP and collaboration with pt's outpatient EP, decision was made for an ablation to be completed after this hospitalization. Medication regimen included mexiletine, metoprolol 100mg bid and home aspirin,statin. Pacemaker settings were changed to the following: VT1 (monitor) increased from 120 -> 141; VT2 therapy zone increased to 180 (from 142) and initial shock increased from 5J to 30J. #CAD s/p CABG/multiple PCIs: Continued home aspirin, statin, beta blocker CHRONIC ISSUES: =============== # Insulin-dependent diabetes mellitus: Held metformin on admission. Restarted on discharge along with home insulin regimen. # Hyperlipidemia: Continued home Lipitor # GERD: Continued home famotidine # Chronic low back pain: Continued gabapentin #Sleep apnea: Continued CPAP Transitional Issues: - Will need close follow up (within ___ weeks) with his cardiologist: ___. MD for further management of tachyarrythmia (Dr. ___ will call the patient for an appointment for ablation) - Patient on Mexilitene: Would get LFTs every six months to follow liver function - Metoprolol tartrate increased to 100mg PO BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 40 mg PO QHS 2. Gabapentin 300 mg PO DAILY pain 3. Losartan Potassium 25 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Apixaban 5 mg PO BID 7. Atorvastatin 40 mg PO QHS 8. Carbidopa-Levodopa (___) 1 TAB PO TID 9. canagliflozin 300 mg oral QHS 10. Levothyroxine Sodium 75 mcg PO DAILY 11. Metoprolol Tartrate 75 mg PO BID 12. Mexiletine 150 mg PO Q8H 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Oxybutynin 5 mg PO QHS 15. rivastigmine tartrate 3 mg oral BID 16. Tresiba FlexTouch U-100 (insulin degludec) 40 u subcutaneous DAILY 17. FoLIC Acid 0.4 mg PO DAILY 18. coenzyme Q10 100 mg oral DAILY Discharge Medications: 1. Metoprolol Tartrate 100 mg PO BID RX metoprolol tartrate 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QHS 5. canagliflozin 300 mg oral QHS 6. Carbidopa-Levodopa (___) 1 TAB PO TID 7. coenzyme Q10 100 mg oral DAILY 8. Famotidine 40 mg PO QHS 9. FoLIC Acid 0.4 mg PO DAILY 10. Gabapentin 300 mg PO DAILY pain 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Losartan Potassium 25 mg PO DAILY 13. MetFORMIN (Glucophage) 500 mg PO BID 14. Mexiletine 150 mg PO Q8H 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Oxybutynin 5 mg PO QHS 17. rivastigmine tartrate 3 mg oral BID 18. Tresiba FlexTouch U-100 (insulin degludec) 40 u subcutaneous DAILY Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia Atrial Fibrillation with rapid ventricular response Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while you were admitted at ___. Below is some information regarding your hospitalization. Why was I admitted to the hospital? -Your heart was beating at an abnormally fast rate and in a potentially dangerous rhythm. This required close monitoring in the cardiac intensive care unit. What happened while I was in the hospital? -We monitored your heart rate and rhythm very closely to ensure that it was not beating in a dangerous rhythm. -We adjusted your medications to reduce the risk of your heart beating too quickly. -We adjusted your pacemaker to help keep your heart in a safe rhythm. -We worked close with our team of electrophysiologists (heart rhythm specialists) to develop a treatment plan for your heart. You will need a procedure called an ablation which can be performed by your outpatient electrophysiologist Dr. ___. What should I do when I go home? -See your primary care doctor in ___ weeks. -Take all of your medications as prescribed -Seek emergency medical care if notice that your heart is beating at a rapid rate. Followup Instructions: ___
10060142-DS-11	10,060,142	28,331,272	DS	11	2156-01-21 00:00:00	2156-01-27 22:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / vancomycin Attending: ___ Chief Complaint: Pancreatitis with pancreatic pseudocyst Major Surgical or Invasive Procedure: ___: Endoscopic placement of nasojejunal tube for enteral feeding ___: Endoscopic repositioning of displaced/obstructed nasojejunal tube for enteral feeding History of Present Illness: Mr ___ is a ___ with h/o Hiatal Hernia, ___ esophagus, Esophageal ulcer, anxiety and L4-L5 radiculitis as well as severe biliary pancreatitis in ___ c/b pancreatic necrosis and large pseudocyst s/p endoscopic cystogastrostomy and elective ccy ___ who presents from ___ for recurrent pancreatitis and enlarging pseudocyst. His necrotizing pancreatitis in ___ was initially treated with bowel rest and NJ feedings. He was then readmitted on ___ for a pancreatic pseudocyst with successful EUS guided cystogastrostomy with placement of 3 double pigtail stents and elective ccy. He was then readmitted to ___ in ___ where CT showed rim enhancing, 2-cm pancreatic cyst. Following this he was admitted to ___ ___ for elective ERCP for stent removal, however stents were not seen. He was monitored for pain control and discharged ___ with outpatient f/u. Patient now presents with acute onset of pain starting at 11am when patient awoke on ___. He describes diffuse upper abdominal pain worse in LUQ that is constant with occasional spasms of pain. Pain does not radiate to back, is sharp in nature and at peak was ___ in severity. (Patient reports h/o chronic pancreatitis w/ baseline level of pain ___, dull, constant, present most days). He reports associated nausea, but no vomiting. Reports normal BM ___ and denies constipation, diarrhea, melana, hematochezia, acholic stools. He denies fever, but reports slight chills. Denies relation of pain onset with meal, denies any alcohol use. Patient is on hydromorphone at home, which he reports had not used since 3 days prior to presentation and did not take any meds at home. He called his GI doctor who instructed him to present to local ER. At ___ ___ VS were T 98 HR 79 RR 18 BP 131/80 O2 99RA. Patient's Temp rose to 100.8 (for which he received 1g IV Tylenol at 9pm.) His exam was notable for diffuse abdominal tenderness. Labs notable for WBC 11, lipase 325; blood cultures drawn. CT scan showed enlarging pseudocyst. Patient transferred to ___ for further management. At ___, he received cipro and flagyl, 3mg IV dilaudid and 1750mg vanco was infusing on arrival to ___ ED. On arrival to the ED here, VS: ___ 80 123/77 16 100%. Patient noted to have erythematous, pruritic rash on neck and trunk. Patient denies any associated throat pruritus, oral mucosal swelling, shortness of breath. This was thought ___ Vancomycin, which was discontinued. He received 50mg IV Benadryl with resolution of symptoms. Labs were remarkable for lipase 772, normal LFTS, normal WBC. Patient was seen by surgery in ED who felt no surgical intervention needed per ED dashboard documentation. Patient admitted to medicine for management of pancreatitis. On the floor patient reports still having some abdominal pain, although improved with hydromorphone in ED. No nausea, chills. Review of sytems: (+) Per HPI (-) Denies headache, cough, shortness of breath. Denies chest pain or tightness, palpitations. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: -Necrotizing biliary pancreatitis ___ -s/p endoscopic cystogastrostomy and elective ccy ___ -Hiatal Hernia -___ esophagus -Esophageal ulcer -anxiety -pinched nerve L4-L5 (followed by neurologist Dr ___ Social History: ___ Family History: Mother died of metastatic lung cancer in ___. Father had CVA and MI at age ___, doing well. No family history of pancreatic malignancy. Brother is healthy. Physical Exam: Admission Physical Vitals- T 98.1 BP 131/76 HR 78 RR 16 O2 100ra PAIN ___ General- Alert, orientedx3, in no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs, gallops Abdomen- non-distended, +BS x 4, + voluntary guarding with diffuse TTP most prominent in LUQ, no rebound GU- no foley Ext- warm, well perfused, 2+ pulses Skin- small, benign appearing excoriations on ___ bilaterally (mosquito bites per patient) Neuro- CNs2-12 intact, motor function grossly normal Discharge Physical Vitals- T 98.1 BP 120/70 HR 68 RR 16 O2 100ra PAIN ___ General- Alert, orientedx3, in no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear, NJ tube well anchored Neck- supple, JVP not elevated Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs, gallops Abdomen- soft, non-distended, +BS x 4, tenderness to palpation most prominent in LLQ, no rebound GU- no foley Ext- warm, well perfused, 2+ pulses Skin- small, benign appearing excoriations on ___ bilaterally (mosquito bites per patient) Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: Admission Labs ___ 04:10AM BLOOD WBC-8.8 RBC-4.29* Hgb-10.8* Hct-32.7* MCV-76* MCH-25.3* MCHC-33.1 RDW-13.3 Plt ___ ___ 04:10AM BLOOD Neuts-67.3 ___ Monos-5.3 Eos-2.3 Baso-0.5 ___ 04:10AM BLOOD Glucose-94 UreaN-8 Creat-0.9 Na-138 K-4.1 Cl-102 HCO3-24 AnGap-16 ___ 04:10AM BLOOD ALT-25 AST-28 AlkPhos-70 TotBili-0.5 ___ 04:10AM BLOOD Lipase-772* ___ 04:10AM BLOOD Albumin-3.7 Calcium-8.6 Iron-23* ___ 04:10AM BLOOD calTIBC-361 Ferritn-13* TRF-278 ___ 04:20AM BLOOD Lactate-1.1 Iron Studies ___ 04:10AM BLOOD Albumin-3.7 Calcium-8.6 Iron-23* ___ 04:10AM BLOOD calTIBC-361 Ferritn-13* TRF-278 Discharge Labs ___ 08:15AM BLOOD WBC-6.6 RBC-3.95* Hgb-9.7* Hct-29.7* MCV-75* MCH-24.6* MCHC-32.8 RDW-13.0 Plt ___ ___ 08:15AM BLOOD Plt ___ ___ 07:45AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-140 K-3.8 Cl-100 HCO3-31 AnGap-13 ___ 08:15AM BLOOD Mg-2.1 ___ 07:45AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.7 ___ 04:10AM BLOOD calTIBC-361 Ferritn-13* TRF-278 Reports ___* CT scan for ___ ___ (OMR records) 2 cm rim enhancing cyst with stent in tail of pancreas. No comment on rest of pancreas. EGD ___ Impression: There is peripancreatic and perigastric stranding and hypodensity. There is a cyst in the pancreas which has increased in size since the prior study. These findings are suggestive of acute pancreatitis. No discrete adrenal collection is identified in the peripancreatic tissue. ___ Imaging* ___: Portable CXR: 1. Nasogastric tube is seen coursing below the diaphragm with the tip likely within the jejunum. Lungs are well inflated without evidence of focal airspace consolidation. No pleural effusions or pulmonary edema. No pneumothorax. Overall cardiac and mediastinal contours are within normal limits. EGD ___ Nasojejunal tube was identified under fluoroscopy in the proximal jejunum. The kink seen on previous abdominal imaging was identified. Subsequently, the tube was retracted until the kink was removed. The NJ tube was then pushed forward to ensure placement past the ligament of Treitz. At the end of procedure, the tube was flushing easily with both air and water. Brief Hospital Course: Mr ___ is a ___ with h/o Hiatal Hernia, ___ esophagus, Esophageal ulcer, anxiety and L4-L5 radiculitis as well as severe biliary pancreatitis in ___ c/b pancreatic necrosis and large pseudocyst s/p endoscopic cystogastrostomy and elective ccy ___ who presents from ___ for recurrent pancreatitis and enlarging pseudocyst. # Pancreatitis: Patient with h/o necrotizing pancreatitis s/p endoscopic cystogastrostomy for drainage of pseudocyst with inability to visualize previously placed stents on recent EGD as well as concern for pancraetic duct stricture. Patient with CT at OSH c/f acute pancreatitis and enlarging pseudocyst (2cm in ___, now 2.6 x 1.9cm) with associated rising lipase and possible infection given fever and elevated WBC at OSH. Patient started on cipro/flagyl on admission. Nasojejunal tube placed via endoscopy on ___ for enteral feeding post-pancreatic duct. NJ tube feeding started ___ however, NJ tube stopped flushing requiring repositioning by EGD on ___ controlled with hydromorphone PCA beginning ___, transitioned to PO Hydromorphone on the ___. # Anemia: Microcytic anemia w/ Hct 29.9 on admission, stable from prior values. Iron studies notable for significant iron deficiency and patient with known history of esophageal ulcer. Further evaluation deferred to outpatient setting. # ___ esophagus: Continued on PPI (IV while NPO) while inpatient. # Anxiety: Continued on home alprazolam while inpatient. # CODE: Full (confirmed) # CONTACT: ___, niece/HCP: ___ -- ___ Issues: -Patient has no PCP. New appointment made for new PCP (___) at ___ next week. PCP to manage ___ and start narcotic contract. -discharged with dilaudid po 8mg q6h:PRN for one week (until appointment with PCP ___ ___ -will follow up with pain clinic -bowel rest and ___ for 3 weeks with follow up repeat imaging with surgery for consideration of possible surgery -cipro and flagyl antibiotics for 1 more week -has iron deficiency anemia, please start on po iron supplement after resolution of pancreatitis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 1 mg PO TID 2. Pantoprazole 40 mg PO Q12H 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 4. Multivitamins 1 TAB PO DAILY 5. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. ALPRAZolam 1 mg PO TID 2. ___ Tubefeeding: Replete w/fiber or Promote w/fiber Full strength; Starting rate: 50 ml/hr; Advance rate by 10 ml q4h Goal rate: 75 ml/hr Flush w/ 100 ml water q6h 3. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet,delayed release (___) by mouth every 12 hours Disp #60 Tablet Refills:1 4. Ciprofloxacin HCl 500 mg PO Q12H please take for one more week RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every 12 hours Disp #14 Tablet Refills:0 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Please take for one more week RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8 hours Disp #21 Tablet Refills:0 6. Multivitamins 1 TAB PO DAILY RX multivitamin [Daily Multiple] 1 tablet(s) by mouth daily Disp #30 Capsule Refills:1 7. Docusate Sodium 200 mg PO BID RX docusate sodium [Colace] 100 mg 2 capsule(s) by mouth every 12 hours Disp #60 Capsule Refills:0 8. HYDROmorphone (Dilaudid) 8 mg PO Q6H:PRN Pain Duration: 1 Week RX hydromorphone [Dilaudid] 8 mg 1 tablet(s) by mouth every 6 hours as needed for pain Disp #28 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: 1. Acute Pancreatitis 2. Pancreatic Pseudocyst Secondary: 1.Pancreatic duct ectasia 2.Iron deficiency anemia 3. Anxiety disorder NOS 4. L4-5 Radiculopathy 5. ___ esophagus 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 ___ with worsening abdominal pain and found to have recurrent acute pancreatitis with enlarging pancreatic pseudocyst. A nasojejunal feeding tube was placed endoscopically and you were started on tube feedings. Your pain was initially controlled with a PCA and you were transitioned to oral hydromorphone prior to discharge. You will need to continue on tube feeds for at least 3 weeks and then follow-up with Dr. ___ to discuss the need for surgery to treat your cyst and prevent recurrence of your pancreatitis. You can drink ONLY clear liquids. It is VERY IMPORTANT that you establish care with a new primary care physician. An appointment has been made for you for ___ with Dr. ___ at ___. Dr. ___ will be the doctor to manage your ___ and pain medications. You should also make an appointment to see your neurologist as soon as possible for refill of your other medications. It was a pleasure taking care of you! Your ___ Team Followup Instructions: ___
10060142-DS-13	10,060,142	28,026,353	DS	13	2156-05-28 00:00:00	2156-05-29 17:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / vancomycin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Upper EUS with 4 stents placed in cystogastrostomy (___) History of Present Illness: ___ yo M w/PMH of necrotizing pancreatitis c/b pseduocysts s/p cystogastrostomy presenting with abd pain x 3 d, starting on the ___ prior to admission. On ___ and ___ he was unable to eat because of the pain and spent most of his time in bed. The patient states that his sx's are c/w his pancreatitis flares. He was last admitted for pancreatitis in ___. He reports nausea, but no vomiting. He has been unable to tolerate PO due to pain. No fevers, chills, diarrhea or constipation. He also reports that he stopped taking his 8mg PO Dilaudid Q6H about 1 month ago. Up until last month he was receiving enteral feeding through a post pancreatic duct NG tube. The patient says the tube became dislodged at home, so he removed it entirely. He presented to ___ by EMS where he was found to have a mildly elevated lipase and LFTs. CXR showed a small left pleural effusion. He was given 4 mg IV Dilaudid and 3 mg IV Ativan and transferred to ___. OSH data: CXR: small left pleural effusion CBC: WBC 7.0, Hct 37.2, Plt 357 Chem 10: Ca 8.0, Na 135, K 3.8, Cl 102, HCO3 25, BUN 8, Cr 0.84 ALT 90, AST 59, AP 76, Albumin 3, T bili 0.7, Lipase 68 Unremarkable UA . In the ___ ED intial vitals were: 99, 90, 128/90, 18, 99% RA - Labs were significant for WBC 6.4, H/H 10.7/34.5, plt 313, ALT 84, AST 63, alkp 73, lipase 166, Tbili 0.3, alb 3.3, lactate 1, Na 140, K 3.8, Cl 106, HCO3 25, BUN 11 Cr 0.8 and glucose 91 - Patient was given lorazepam, hydromorphone 1 mg IV x2 Of note the patient attempted to acquire IV flushes and gauze in the emergency department. Nursing staff responded and confiscated the items. Vitals prior to transfer were: 78, 122/81, 18, 99% RA On the floor the patient reports ___ abdominal pain. He denies nausea and vomiting. No reports of fever. Past Medical History: -Necrotizing biliary pancreatitis c/b pseudocyst (___) -Chronic pancreatitis -Hiatal hernia -___ esophagus -Esophageal ulcer -Anxiety -pinched nerve L4-L5 (followed by neurologist Dr ___ . PAST SURGICAL HISTORY: S/p endoscopic cystogastrostomy S/p elective cholecystectomy (___) S/p endoscopic placement of nasojejunal tube for enteral feeding (___) . Social History: ___ Family History: Mother died of metastatic lung cancer in ___. Father with prior CVA's and MI's, doing well. No family history of pancreatic malignancy. Brother is healthy. Physical Exam: On admission: Vitals- 98 121/83 60 18 96% RA General- well appearing gentleman in NAD HEENT- PERRL, OP w/o lesions, nose clear Neck- supple, no LAD Lungs- CTA b/l CV- RRR, S1/S2 normal, no MRG Abdomen- +BS, S/ND, no tenderness on right, moderate tenderness to palpation on left esp in LLQ, no rebound/guarding Ext- WWP, no CCE Neuro- CNII-XII intact, ___ upper and lower extremity strength . On discharge: Vitals- 98.4 109/62 85 16 98%RA General- well appearing gentleman in NAD, alert and oriented HEENT- mildly dry MM, OP clear Lungs- CTA b/l CV- RRR, S1/S2 normal, no MRG Abdomen- +BS, S/ND, no tenderness on right, moderate tenderness to palpation on left, no rebound/guarding Ext- WWP, no CCE Pertinent Results: ==================== Labs: ==================== ___ 11:45PM BLOOD WBC-6.4# RBC-4.61# Hgb-10.7* Hct-34.5# MCV-75 MCH-23.1* MCHC-30.9* RDW-15.2 Plt ___ ___ 07:30AM BLOOD WBC-6.3 RBC-4.20* Hgb-9.8* Hct-31.8* MCV-76* MCH-23.4* MCHC-30.9* RDW-14.8 Plt ___ ___ 11:45PM BLOOD Neuts-58.9 ___ Monos-7.1 Eos-1.5 Baso-0.9 ___ 11:45PM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-140 K-3.8 Cl-106 HCO3-25 AnGap-13 ___ 07:30AM BLOOD Glucose-89 UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-103 HCO3-34* AnGap-9 ___ 11:45PM BLOOD ALT-84* AST-63* AlkPhos-73 TotBili-0.3 ___ 11:45PM BLOOD Lipase-166* ___ 11:45PM BLOOD Albumin-3.3* ___ 07:40AM BLOOD Calcium-8.4 Phos-4.0# Mg-2.1 ___ 07:30AM BLOOD Calcium-8.1* Phos-4.5 Mg-2.0 ___ 11:50PM BLOOD Lactate-1.0 ==================== Imaging/Procedures: ==================== CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2:07 AM . FINDINGS: The bases of the lungs are clear. There is mild dependent atelectasis. The liver is normal without evidence of focal lesions or intrahepatic biliary ductal dilatation. The spleen is homogeneous and normal in size. The portal vein is patent. The patient is status post cholecystectomy. The adrenal glands bilaterally are normal. The left kidney demonstrates a hypodense lesion, too small to characterize by CT but likely secondary to a simple renal cyst. The kidneys are otherwise unremarkable. There has been an interval increase of the hypodense collection in the body/tail of the pancreas, now measuring 9.6 cm x 9.5 cm x 9.7 cm compared to the prior exam, at which time this measured 5.1 cm x 5.9 cm x 5.9 cm. This is consistent with known pancreatic pseudocyst. The surrounding pancreatic tissue otherwise enhances homog eneously without any signs of necrosis. Minimal fat stranding is seen along the anterior pancreas. . The stomach, duodenum and small bowel are normal without evidence of wall thickening or obstruction. The colon is stool filled. There is no retroperitoneal or mesenteric lymphadenopathy. . CT PELVIS: The urinary bladder and prostate, seminal vesicles are unremarkable. There is no pelvic free fluid. No pelvic wall or inguinal lymphadenopathy is identified. . OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are identified. . IMPRESSION: Interval increase of the pancreatic pseudocyst in the body/tail of the pancreas, now measuring up to 9.6 cm. No other complications from pancreatitis; however, there is mild stranding at the head of the pancreas. . Upper EUS Report ___: A bulge from the pseduocyst was seen in the body of the stomach EUS was performed using a linear echoendoscope at ___ MHz frequency An 8.3 x 8.6 cm cystic fluid collection was identified from the stomach. The lesion was hypoechoic and homogenous with defined walls. No debris was noted within the cyst. FNA was performed. Color doppler was used to determine an avascular path for needle aspiration. A 19-gauge needle with a stylet was used to perform the puncture. Ten cc of clear fluid was aspirated and sent for cytology, CEA and amylase. A wire was passed through the 19-G needle into the pancreatic fluid collection/cavity. A 10mm Hurricane balloon was used to dilated the opening of the cystogastrostomy. Then a CRE balloon was used to dilated the opening of the cystogastrostomy to 15mm. Four double pig tail stents were placed across the cystogastrostomy under endoscopic, EUS and fluoroscopic guidance. Overall successful cystogastrostomy. . Cyst Fluid: ___ 06:31PM OTHER BODY FLUID ___ Misc-CEA = 1.7 . ___ Cytology CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: FINE NEEDLE ASPIRATION DIAGNOSIS: FINE NEEDLE ASPIRATION, PSEUDOCYST FLUID: No definite epithelial cells seen; scattered degenerated macrophages only. Brief Hospital Course: ___ w/ hx necrotizing pancreatitis complicated by pseudocyts s/p endoscopic cystgastrostomy ___ and lap ccy ___, p/w abd pain elevated lipase to 166 and CT scan showing enlarging pseudocyst. S/p EUS ___ with 4 stents placed in cystgastrostomy. . #CHRONIC PANCREATITIS/PANCREATIC PSEUDOCYST: Pt with history of chronic pancreatitis presumed to be secondary to gallstone pancreatitis. The patient is s/p endoscopic cystogastrostomy and elective cholecystectomy. Based on abdominal imaging his pseduocyst is enlarging 6->9.8. The patient's labs were consistent with ongoing pancreatic inflammation. He has no signs of pseudocyst infection such as leukocytosis or fever. Surgery recommended medical management. Pt was treated with IV fluids and pain control with dilaudid. S/p EUS ___ with 4 stents placed in cystogastrostomy. Tolerated a low fat diet prior to discharge. Will be treated with 1 week course of ciprofloxacin, to be completed ___. Pt to follow up with GI after repeat CT scan in ___ months. Stents to be removed in ___ year. . #PLEURAL EFFUSION: Small left pleural effusion on CXR at outside hospitla. Most likely secondary to recurrent pancreatitis. Small volume unamenable to thoracentesis. Should have CXR followed as outpt. . ___: Continued on home pantoprazole. . #ANXIETY: Continued on home alprazolam 2mg BID. Pt reports he has failed multiple other agents in past including SSRI. . Transitional issues: -Will complete 1 week course of ciprofloxacin (end date ___ -Repeat abdominal CT scan in ___ months -Cystgastrostomy stent removal in ___ year -Pt with small pleural effusion likely due to pancreatitis. Should have CXR followed as outpt. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 2 mg PO BID:PRN anxiety 2. Pantoprazole 40 mg PO Q12H 3. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. ALPRAZolam 2 mg PO BID:PRN anxiety 2. Pantoprazole 40 mg PO Q12H 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice daily Disp #12 Tablet Refills:0 4. Multivitamins 1 TAB PO DAILY 5. HYDROmorphone (Dilaudid) 8 mg PO Q6H:PRN pain RX hydromorphone 8 mg 1 tablet(s) by mouth every 6 hours Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Chronic pancreatitis with pancreatic pseudocyst Pleural effusion, likely due to pancreatitis ___ esophagus 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 to care for you. You were hospitalized due to worsening abdominal pain. A CT scan of your abdomen showed that the pancreatic pseudocyst had increased in size. You were treated with IV fluids and medications for pain and nausea. Upper EUS (endoscopic ultrasound) was performed, with placement of stents across the cystogastrostomy (connection between the stomach and pseudocyts) to help the pseudocyts drain. You will be on antibiotics for 1 week total. Please take your medications as prescribed and attend your follow up appointments. Followup Instructions: ___
10060142-DS-14	10,060,142	22,361,714	DS	14	2156-07-02 00:00:00	2156-07-06 20:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / vancomycin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ year old gentleman with a history of gallstone pancreatitis in ___ complicated by pancreatic necrosis and pseudocysts. He underwent cystgastrostomy and necrosectomy by GI in ___ and subsequent laparoscopic cholecystectomy in ___. In ___, he had reaccumulation of his pancreatic pseudocyst and underwent a repeat upper endoscopy with placement of stents across the cystgastrostomy. He has had ongoing abdominal pain and is seen by chronic pain. Past Medical History: -Necrotizing biliary pancreatitis c/b pseudocyst (___) -Chronic pancreatitis -Hiatal hernia -___ esophagus -Esophageal ulcer -Anxiety -pinched nerve L4-L5 (followed by neurologist Dr ___ . PAST SURGICAL HISTORY: S/p endoscopic cystogastrostomy S/p elective cholecystectomy (___) S/p endoscopic placement of nasojejunal tube for enteral feeding (___) . Social History: ___ Family History: Mother died of metastatic lung cancer in ___. Father with prior CVA's and MI's, doing well. No family history of pancreatic malignancy. Brother is healthy. Physical Exam: Physical exam: Upn admission ___ Vitals: 98.7 64 106/68 18 98% RA Gen: NAD, A&Ox3 CV: RRR, S1S2, no m/r/g Pulm: CTAB Abd: mildly distended, TTP in LLQ/LUQ/RUQ with tympany in those areas, no rebound, no guarding, small umbilical hernia that is easily reducible but mildly TTP ___: WWP Physical exam: Upon discharge ___ Vitals: 98.6 64 108/70 18 98% RA 82 Gen: NAD, A&Ox3 CV: RRR, S1S2, no m/r/g Pulm: CTAB Abd: non distended, mildly TTP in LLQ/LUQ/RUQ with tympany in those areas, no rebound, no guarding, small umbilical hernia that is easily reducible but mildly TTP ___: no edema; positive pedal pulses bilaterally; no discoloration Pertinent Results: ___ 12:20PM URINE HOURS-RANDOM ___ 12:20PM URINE UHOLD-HOLD ___ 12:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 12:20PM URINE RBC-4* WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 12:20PM URINE MUCOUS-OCC ___ 08:49AM LACTATE-1.2 ___ 08:30AM GLUCOSE-95 UREA N-11 CREAT-1.0 SODIUM-142 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-27 ANION GAP-14 ___ 08:30AM estGFR-Using this ___ 08:30AM ALT(SGPT)-85* AST(SGOT)-80* ALK PHOS-101 TOT BILI-0.5 ___ 08:30AM LIPASE-30 ___ 08:30AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.1 ___ 08:30AM WBC-6.6 RBC-4.71 HGB-11.0* HCT-36.4* MCV-77* MCH-23.4* MCHC-30.3* RDW-15.1 ___ 08:30AM NEUTS-63.5 ___ MONOS-6.1 EOS-2.4 BASOS-0.4 ___ 08:30AM PLT COUNT-388 CT ABD & PELVIS WITH CONTRAST Study Date of ___ IMPRESSION: The findings correspond to early small bowel obstruction. The oral contrast did not reach the point of obstruction therefore making identification of the transition point difficult. If exact delineation of the transition point is needed, the patient can be rescanned. ABDOMEN (SUPINE & ERECT) Study Date of ___ IMPRESSION: Oral contrast material now present within the colon. No dilated loops of small bowel visualized Brief Hospital Course: Mr. ___ has had ongoing abdominal pain and is seen by chronic pain. He came to the hospital on ___ with abdominal pain. He had gone to an outside hospital the day before for your abdominal pain and there had a cat scan of the abdomen which showed dilated loops of small bowel concerning for small bowel obstruction. He complained of having some emesis the day prior to your outside hospital visit however you no longer had nausea or vomiting upon admission to the ___ Service at ___. At ___ an imaging of the abdomen was performed which demonstrated partial bowel obstruction. Mr ___ put on an NPO diet and transferred to the floor where your pain was managed and you were monitored closely. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. The wound dressings were changed daily. Endocrine: The patient's blood sugar was monitored throughout his stay. The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. 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 received discharge teaching and was instructed and to follow up with your primary regarding your pancreatitis and chronic pain. Medications on Admission: 1. ALPRAZolam 1 mg PO TID 3. HYDROmorphone (Dilaudid) 8 mg PO Q6H:PRN pain 4. Pantoprazole 40 mg PO BID Discharge Medications: 1. ALPRAZolam 1 mg PO TID 2. Docusate Sodium 100 mg PO BID constipation do not take this if you are having loose stools 3. HYDROmorphone (Dilaudid) 8 mg PO Q6H:PRN pain 4. Pantoprazole 40 mg PO BID Discharge Disposition: Home Discharge Diagnosis: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital on ___ with abdominal pain. You had gone to an outside hospital the day before for your abdominal pain and there you had a cat scan of the abdomen which showed dilated loops of small bowel concerning for small bowel obstruction. You complained of having some emesis the day prior to your outside hospital visit however you no longer had nausea or vomiting upon your admission at ___. At ___ an imaging of the abdomen was performed which demonstrated partial bowel obstruction. You were put on an NPO diet and transferred to the floor where your pain was managed and you were monitored closely. Your pain improved and you were transitioned to a regular diet which you tolerated. You are now doing well and are ready to be discharged. Please adhere to the instructions below. Be sure to follow up with your primary regarding your pancreatitis and chronic pain. 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: ___
10060142-DS-15	10,060,142	22,559,711	DS	15	2157-09-16 00:00:00	2157-09-17 10:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / vancomycin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: ___ yo M with history of necrotizing pancreatitis in ___ with pseudocyst formation requiring cystgastrostomy drainage who has been largely symptom free for the past year who presents with abdominal pain. Pt w/ chronic ___ pain but able to tolerate regular diet over the past year. A week ago, he had escalating abdominal pain and was admitted to ___. Lipase at that time was in the 70's per pt. CT abdomen showed a cyst in the tail of the pancreas of 2cm. Pt conservatively managed with improvement in his symptoms and discharged home on ___. Pt ate fatty meals on day of discharge (KFC) and his usual meals the day after. On ___ night, pt developed severe pain. This persisted on ___ and accompanied by frequent vomiting and inability to keep fluids down. Pt went to work on ___ morning and his co-workers brought him to the ___ for evaluation. Workup there revealed lipase elevation to 240 ___bdomen showing peripancreatic stranding and interval change in peripancreatic cyst to 2.2 cm from 2.0 cm. Pt transferred to ___ for further management. On arrival here, pt reports epigastric pain radiating to the back. Nausea improved with Zofran given in the ER. Denies fevers or chills. ROS: negative except as above Past Medical History: -Necrotizing gallstone pancreatitis c/b pseudocyst (___), s/p cystgastrostomy placement -Chronic pancreatitis due to EtOH -Hiatal hernia -___ esophagus -Esophageal ulcer -Anxiety -pinched nerve L4-L5 (followed by neurologist Dr ___ . PAST SURGICAL HISTORY: S/p endoscopic cystogastrostomy S/p elective cholecystectomy (___) . Social History: ___ Family History: Mother died of metastatic lung cancer in ___. Father with prior CVA's and MI's, doing well. No family history of pancreatic malignancy. Brother is healthy. Physical Exam: Admission: Vitals: 98 135/52 67 18 94%RA Gen: NAD HEENT: NCAT, no scleral icterus CV: rrr, no r/m/g Pulm: clear bl Abd: soft, tender in mid abdomen, umbilical hernia Ext: no edema Neuro: alert and oriented x3 Discharge: General: no distress, lying in bed, pale Vitals: 97.7, 120/74, 50, 16, 100% RA Pain ___ HEENT: MMM Abd: tender in epigastric and periumbilical area, improved, no r/r/g Ext: wwp, no edema Neuro: alert, oriented, no focal deficits with normal discussion Pertinent Results: Admission labs: ___ 11:15PM BLOOD WBC-13.7# RBC-4.61 Hgb-9.7 Hct-31.7* MCV-69# MCH-21.1 MCHC-30.7* RDW-16.2* Plt ___ ___ 11:15PM BLOOD Glucose-83 UreaN-16 Creat-0.9 Na-138 K-3.6 Cl-107 HCO3-25 AnGap-10 ___ 11:15PM BLOOD ALT-39 AST-30 AlkPhos-65 TotBili-0.5 Interval and discharge labs: ___ 07:51AM BLOOD WBC-5.9# RBC-4.45* Hgb-9.0* Hct-29.8* MCV-67* MCH-20.3* MCHC-30.3* RDW-16.4* Plt ___ ___ 01:35PM BLOOD Glucose-88 UreaN-8 Creat-0.8 Na-143 K-4.6 Cl-107 HCO3-28 AnGap-13 ___ 12:07AM BLOOD AlkPhos-56 TotBili-0.4 ___ 12:07AM BLOOD Calcium-8.5 Iron-20* ___ 12:07AM BLOOD calTIBC-367 Ferritn-22* TRF-282 ___ 11:15PM BLOOD tTG-IgA-5 ___ 12:04AM BLOOD Lactate-0.7 Imaging: MRCP: 1. Sequela of acute pancreatitis, with absent pancreatic parenchyma the entire body of the pancreas, and with disconnected pancreatic duct and approximately 3.5 cm gap. 2. Connection between the distal pancreatic duct and the gastric lumen. 3. 2.2 cm pseudocyst adjacent anteriorly to the pancreatic tail, separate from the duct. 4. Splenomegaly. 5. Subcentimeter cortical renal cysts. Pending: Gastric biopsy Brief Hospital Course: ___ with history of necrotizing gallstone pancreatitis, history of opioid dependence, presents with abdominal pain secondary to pancreatitis. # Acute pancreatitis: He presented from OSH with acute pancreatitis. He was managed with bowel rest, IVF, analgesia. GI was consulted. MRCP was done. Eventually he improved and his diet was advanced to regular low fat diet. He was given a short course of dilaudid as an outpatient. He will follow up with his PCP and GI. # Anemia, iron deficiency: The cause of the iron loss is not clear. He was guaiac negative and EGD and colonoscopy did not show evidence of bleed. GI will consider capsule study which they can arrange at follow up. He was started on ferrous sulfate 325mg TID with ascorbic acid ___ with AM and ___ doses to improve absorption. His PPI (indicated for ___ esophagus, dosing per outpatient regimen) may inhibit some iron absorption. If he fails oral repletion, he may need IV iron infusion. He was started on colace and senna to prevent constipation. # Opioid dependence: He has some chronic pain. He has used heroin in past but has been clean for 14 months (per his report). We discussed this and prescribed a limited number of narcotics. He was in agreement with this approach and was very reasonable. # ___ esophagus: On protonix. Biopsy pending. He will need to follow up with GI for further evaluation and management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 80 mg PO QHS 2. ALPRAZolam 2 mg PO BID:PRN anxiety Discharge Medications: 1. ALPRAZolam 2 mg PO BID:PRN anxiety 2. Pantoprazole 80 mg PO QHS 3. Ascorbic Acid ___ mg PO BID RX ascorbic acid ___ mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Ferrous Sulfate 325 mg PO TID RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX hydromorphone 4 mg 1 tablet(s) by mouth every 4 hours Disp #18 Tablet Refills:0 7. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 8. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute pancreatitis Iron deficiency anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain likely from your pancreatitis. You had an MRCP to evaluation this. The final results are pending, but the preliminary results are similar to your prior imaging studies. In addition, you were found to have anemia and iron deficiency. You had an EGD and colonoscopy without finding evidence of bleeding. You can consider a capsule study to evaluation for bleed. Please discuss this with your outpatient physician. You were started on iron supplementation and ascorbic acid (to help your body absorb the iron). In addition, you were started on stool softenters to prevent constipation. You were able to eat and drink prior to discharge. You were discharged with a few days of dilaudid to help with the pain. If you have further pain, or are not able to tolerate food or drink, you should contact your physician ___. Followup Instructions: ___
10060142-DS-8	10,060,142	25,882,608	DS	8	2155-08-09 00:00:00	2155-08-10 12:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___: EUS guided cytogastrostomy w. placement of 3 double pig tail stents across cystogastrostomy History of Present Illness: ___ is a ___ year old gentleman well known to the ___ service. He was recently admitted ___ for necrotizing pancreatitis presumed to be secondary to gallstones. He was treated conservatively with antibiotics, postpyloric tube feeds, and plan for interval cholecystectomy once his pancreatitis had resolved. He has largely been lost to follow up and has missed numerous appointments. . He comes to the ED because of new abdominal pain that began at approximately 2 am today, waking him from sleep. He describes it as sudden, sharp, an 8 out of 10 on pain scale, and radiating to the back. Lying back exacerbates the pain. He has not found any alleviating factors. He otherwise denies nausea and emesis, but had an episode of chills earlier today. Approximately 1 week ago he had a bout of nausea and emesis which caused him to displace his dobhoff and subsequently pull it out. Since then he has been tolerating a PO diet without difficulty. Past Medical History: Hiatal Hernia ___ esophagus Esophageal ulcer anxiety Back pain Social History: ___ Family History: Mother passed of metastatic lung cancer. Father alive, had CVA and MI. No history of pancreatic malignancy Physical Exam: Vitals: 98.3 82 111/61 16 98%ra Gen: well appearing, no apparent distress Abd: soft, nontender, nondistended Cardio: regular rate and rhythm Pulm: nonlabored breathing, clear to ascultation Ext: nonedematous, noncyanotic Pertinent Results: ___ 04:47AM BLOOD WBC-11.0 RBC-4.14* Hgb-10.5* Hct-33.8* MCV-82 MCH-25.2* MCHC-31.0 RDW-14.2 Plt ___ ___ 04:47AM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-136 K-4.1 Cl-100 HCO3-28 AnGap-12 ___ 04:47AM BLOOD ALT-8 AST-19 AlkPhos-59 Amylase-275* TotBili-0.4 ___ 04:47AM BLOOD Calcium-8.0* Phos-4.4 Mg-1.8 CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1. Two pancreatic pseudocysts, the larger measuring up to 11 cm. No other complications from pancreatitis, specifically no necrosis. 2. Resolution of previously seen left pleural effusion and focal consolidation seen on the previous chest radiograph. US ABD LIMIT, SINGLE ORGAN Study Date of ___ 6.7 x 6.3 x 9.4 cm pseudocyst in the body/tail of the pancreas contains primarily anechoic fluid with a small amount of debris in the posterior aspect. Cytology Report PANCREATIC Procedure Date of ___ REPORT APPROVED DATE: ___ SPECIMEN RECEIVED: ___ ___ PANCREATIC SPECIMEN DESCRIPTION: Received in cytolyt. Prepared 1 ThinPrep slide. CLINICAL DATA: Upper EUS. ___ yo male, Recent episode of acute necrotizing pancreatitis, readmitted with ___ pain. CT shows one large 11 x 10 x 7 cm pseudocyst, in the body/tail and a second smaller one in the head. REPORT TO: ___. ___ ___: FNA, Pancreatic cyst: Acellular fluid. No epithelial cells present. DIAGNOSED BY: ___, CT(___) ___, M.D. Brief Hospital Course: The patient was admitted to the Hepatopancreaticobiliary Surgery Service for management of his abdominal pain secondary to his known pancreatic pseudocysts. The patient was sent for endoscopic ultrasound guided cyst-gastrostomy. The patient tolerated the procedure well. His abdominal pain did improve after the procedure but he was still requiring narcotic pain medications. He was written for a script of 35 2mg Dilaudid pills. He was also written for a course of Cipro and Flagyl to complete as an outpatient. GI was following him and will see him in clinic to schedule removal of the pigtail catheters that were placed between the pseudocyst and the stomach for drainage. At the time of discharge, the patient was tolerating a regular low fat diet, his pain was under control, and he was functioning independently. He understood the plan of care and the instructions for follow up. He understood the recommendation to consume a low fat diet. Medications on Admission: Protonix 40', ativan 1'' Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth q12hrs Disp #6 Tablet Refills:0 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hrs Disp #9 Tablet Refills:0 4. Pantoprazole 40 mg PO Q12H 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs prn Disp #35 Tablet Refills:0 6. Docusate Sodium 100 mg PO BID:PRN constipation RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth bid prn Disp #60 Capsule Refills:2 7. Senna 1 TAB PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth BID prn Disp #60 Tablet Refills:2 Discharge Disposition: Home Discharge Diagnosis: pancreatic pseudocyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen and evaluated by the Hepatopancreaticobiliary Surgery Service at the ___ for your abdominal pain. We sent you for imaging and determined the cause of your pain was a large pseudocyst at your pancreas. You had a procedure performed to allow the pseudocyst to drain into your stomach. You have recovered well after this procedure and are now safe to go home and continue your recovery there. . You will need to continue taking antibiotics for a total of 7 days after your procedure. Please take these as directed. You will need to call the GI office and schedule a follow up appointment with them and they will schedule a time to remove the tubes inside your stomach. You will need to observe a LOW FAT DIET while at home. . 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. 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: ___
10060703-DS-7	10,060,703	28,678,452	DS	7	2160-09-10 00:00:00	2160-09-10 20:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: polytrauma s/p MVC Major Surgical or Invasive Procedure: lip laceration sutured History of Present Illness: ___ unrestrained driver s/p MVC vs pole with facial fractures and a lip laceration. Per report, she had rapid extrication due to being unconscious at the scene. She was evaluated at ___ ___ where CT scans of her head, neck, and torso reportedly revealed nasal and left orbital fractures, no intracranial bleed, no spine fractures, left fifth rib fracture, no abdominal pathology, and right patellar fracture. She was transferred to ___ for further evaluation and plastic surgery was consulted for management of her facial fractures and lip laceration. Tox screen at the OSH reportedly revealed EtOH and cocaine. Past Medical History: depression back pain left knee pain Social History: etoh cocaine former cab driver Physical Exam: gen: ambulating with walker and right knee immobilizer, NAD head/ ENT: Vision grossly intact, EOMI, facial sensation intact, facial movements symmetric. Left periorbital ecchymosis, positive tenderness, small abrasion over left cheek and nose. No palpable bony step offs, crepitus, or instability. No obvious nasal deformity or ecchymoses, no crepitus. Small anterior inferior laceration of right nasal septum, no cartilage exposed, no septal hematoma. No oropharyngeal trauma. No loose teeth. cards: RRR, +S1 S2 lungs: CTAB abd: s/nt/nd extremities: right ___ in knee immobilizer, no edema Pertinent Results: ___ 10:03AM NEUTS-88.4* LYMPHS-7.0* MONOS-3.8 EOS-0.6 BASOS-0.2 ___ 10:03AM GLUCOSE-116* UREA N-11 CREAT-0.6 SODIUM-139 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12 ___ 10:03AM WBC-14.9* RBC-4.28 HGB-12.9 HCT-38.6 MCV-90 MCH-30.2 MCHC-33.5 RDW-12.7 Brief Hospital Course: Pt was hospitalized after polytrauma MVC with +LOC, +cocaine and etoh tests per OSH. Imaging in hospital remarkable for nondisplaced distal right patellar fracture, left orbital fracture, left nasal septum fracture, left maxillary fracture, and right ___ and 5th rib fractures. Orthopedic surgery did not recommend surgery during hospitalization for patella fracture- placed pt in knee immobilizer, WBAT, and ___ clinic follow up. Plastic surgery recommended Augmentin x 5 days and sinus precautions. Lip laceration was sutured in the ED. Ophthalmology was consulted for orbital fracture and recommended artificial tears and erythromycin ointment and no surgical intervention. Pt was evaluated by physical therapy and social work as well. At time of discharge she was clinically sober and ambulating with walker. Pt instructed to follow up with ortho, ophtho, and plastics. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 1 mg PO TID 2. Ferrous Sulfate Dose is Unknown PO TID 3. Tizanidine 4 mg PO QHS:PRN pain 4. Hydrocodone-Acetaminophen (5mg-500mg) Dose is Unknown PO Frequency is Unknown prn back pain 5. Adderall (dextroamphetamine-amphetamine) 20 mg oral BID 6. Gabapentin 600 mg PO HS 7. Albuterol Inhaler 2 PUFF IH 2 PUFFS Q6H PRN shortness of breath Discharge Medications: 1. Adderall (dextroamphetamine-amphetamine) 20 mg oral BID 2. ClonazePAM 1 mg PO TID 3. Gabapentin 600 mg PO HS 4. Tizanidine 4 mg PO QHS:PRN pain 5. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 5 Days Please continue taking until ___ RX amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth three times a day Disp #11 Tablet Refills:0 6. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes, eye irritation 7. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID RX erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch in left eye twice a day Disp #1 Tube Refills:0 8. Albuterol Inhaler 2 PUFF IH 2 PUFFS Q6H PRN shortness of breath 9. Ferrous Sulfate 325 mg PO TID please verify your dose with your doctor 10. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN prn back pain please verify dose with your doctor Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -nondisplaced distal right patellar fracture -left orbital fracture -left nasal septum fracture -left maxillary fracture -right ___ and 5th rib fractures Discharge Condition: Pt ambulating with walker, right knee immobilizer on. AAO x 3, clinically sober. Hemodynamically stable. Discharge Instructions: You were hospitalized after a car accident in which you were driving without your seatbelt and crashed into a pole. Cocaine and alcohol were found in your blood. In the hospital, you had xrays and CT scans which showed that you had a knee fracture, orbital fracture, nasal septum fracture, maxillary fracture, and rib fractures. You were seen by ophthalmology, orthopedics, and plastic surgery for your various injuries. You were also seen by physical therapy and social work. It is important that you stop using cocaine and decrease/ stop your alcohol use. Ortho: -please continue to wear your knee immobilizer and bear weight as tolerated. Keep your knee in extension. Wear your brace until you follow up with ortho in 2 weeks. Ophthalmology: -Please use erythromycin ointment twice a day in your left eye for ___ days and preservative-free artificial tears every ___ hrs as needed for dryness/ irritation in both eyes -you can use cool compresses to your left eye to help improve with swelling/ pain Plastics: -You received absorbable sutures in your lip for a laceration, which will dissolve on their own. You also had sutures placed above your lip, which were removed by plastic surgery. Please call your doctor if you have any fevers, pus, swelling, or increased pain in those areas that could be concerning for infection. -Plastic surgery decided that they did not need to operate for your facial fractures at this time. Followup Instructions: ___
10060733-DS-12	10,060,733	24,753,883	DS	12	2120-02-29 00:00:00	2120-02-29 16:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Painless Jaundice Major Surgical or Invasive Procedure: ___ -- ERCP History of Present Illness: Mr. ___ is a ___ with h/o diabetes, HLD, HTN, bladder and prostate cancer s/p prostatectomy and cystectomy in ___ with urostomy, who developed painless jaundice over one week. He was found to have elevated LFTs and D-bili at ___ without obvious source of obstruction and was transferred to ___. Patient presented to his primary care physician for asymptomatic jaundice approx. 1 week ago. An abdominal CT was obtained and showed a gallbladder that was mildly distended without bile duct dilation in the liver and lymphadenopathy within the retroperitoneum concerning for recurrent bladder cancer below the diaphragm. A Chest CT was normal. Jaundice persisted and he had repeat labs drawn 3 days ago, notable for CO2 of 14, bilirubin of 9.8, direct bilirubin of 6.3, alk phos of 1100, AST 145, ALT 261. He represented to ___ yesterday with persistant lab abnormalities and a RUQUS showed extra and intra hepatic duct dilation without obvious source of obstruction. He was transferred to ___ for further eval. He denies abdominal pain, fever, diarrhea, nausea, vomiting, decrease in appetite, pruritus. Reports he has been losing weight and nausea. Denies any history of jaundice or liver disease previously. In the ED, initial VS were: 97.1 82 111/70 16 99% RA Labs showed: T bili 10.9, D bili 9.0, ALT 238 AP 1346, AST 187, Cr 1.9 Received: ___ 00:59 PO/NG Cephalexin 500 mg ___ 00:59 PO/NG Ciprofloxacin HCl 500 mg Transfer VS were: 98.0 88 113/60 16 99% RA On arrival to the floor, patient reports continuing to have completely asymptomatic jaundice. No pain or fevers. He does note he was diagnosed with a UTI several days and started on cephalexin and ciprofloxacin on the ___ and ___. No other acute complaints. Past Medical History: Bladder cancer s/p Cystectomy in ___ with urostomy - Follows with Dr. ___ in ___ on ___ T2DM, diet controlled HLD HTN Prostate cancer s/p Prostatectomy in ___ Social History: ___ Family History: Mother - lung ___ Father - DM, cardiac problems Physical Exam: ADMISSION EXAM ====================== VS: 97.4 116/77 81 18 98 Ra GENERAL: Adult male in NAD HEENT: AT/NC, MMM, jaundiced 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, urostomy in place without discharge or drainage DISCHARGE EXAM ======================= Vitals: 97.7, HR 85, 128/85, RR 18, 99% RA General: Alert, oriented, no acute distress, pleasant HEENT: Sclerae icteric, Oropharynx jaundiced Neck: suppl Lungs: CTAB CV: RRR Abdomen: soft, nontender, nondistended Ext: warm, no edema Neuro: answers questions appropriately Skin: mild jaundice Pertinent Results: LABS ON ADMISSION ========================== ___ 11:42PM BLOOD WBC-5.1 RBC-4.70 Hgb-12.5* Hct-37.0* MCV-79* MCH-26.6 MCHC-33.8 RDW-18.6* RDWSD-52.3* Plt ___ ___ 11:42PM BLOOD Neuts-64.6 Lymphs-15.4* Monos-8.9 Eos-8.9* Baso-1.2* Im ___ AbsNeut-3.27 AbsLymp-0.78* AbsMono-0.45 AbsEos-0.45 AbsBaso-0.06 ___ 11:42PM BLOOD Glucose-168* UreaN-27* Creat-1.9* Na-133 K-3.6 Cl-100 HCO3-16* AnGap-17* ___ 11:42PM BLOOD ALT-238* AST-187* AlkPhos-1346* TotBili-10.9* DirBili-9.0* IndBili-1.9 ___ 11:42PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.1 Mg-2.3 ___ 09:30AM BLOOD %HbA1c-6.4* eAG-137* ___ 09:30AM BLOOD calTIBC-289 Ferritn-360 TRF-222 OTHER LABS ========================== ___ 06:00AM BLOOD CEA-11.8* (NORMAL ___ DISCHARGE LABS ========================== ___ 06:00AM BLOOD WBC-5.6 RBC-4.15* Hgb-10.9* Hct-32.8* MCV-79* MCH-26.3 MCHC-33.2 RDW-19.1* RDWSD-54.2* Plt ___ ___ 06:00AM BLOOD Glucose-175* UreaN-31* Creat-2.0* Na-136 K-3.8 Cl-106 HCO3-16* AnGap-14 ___ 06:00AM BLOOD ALT-157* AST-81* AlkPhos-1012* TotBili-4.3* DirBili-2.8* IndBili-1.5 ___ 06:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1 REPORTS ========================== RUQUS at ___ Right upper quadrant ultrasound showed moderate intrahepatic and extrahepatic biliary ductal dilation with cause not identified. Further evaluation with CT or MRI/MRCP recommended. Distended gallbladder containing small amount of sludge. No definite sonographic evidence of acute cholecystitis MRCP ___. 3.0 x 2.6 cm ill-defined mass-like region of hypointense signal on T1 weighted imaging and hypoenhancement in the pancreatic head with restricted diffusion. Findings could reflect lymphoma, especially in the setting extensive retroperitoneal lymphadenopathy, or an inflammatory process such as autoimmune pancreatitis. Metastatic disease or primary pancreatic malignancy are also considerations but the latter is less likely given the absence of upstream pancreatic ductal dilatation. Correlate with biopsy/cytology. Depending on the results, short-term imaging follow-up may be helpful. 2. Extensive retroperitoneal adenopathy, differentials include metastatic disease versus lymphoma. 3. Common bile duct stent in place. Enhancement of the biliary duct and pneumobilia, likely reflect post procedural change. 4. 6 mm pancreatic cystic lesion, likely a side-branch IPMN. 5. Pancreas divisum. ERCP ___ A single stricture that was 15 mm long was seen at the lower third of the common bile duct. There was moderate post-obstructive dilation. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Cytology samples were obtained using a brush in the lower third of the common bile duct. A 8cm by ___ ___ biliary stent was placed successfully in the main duct. Brief Hospital Course: ___ year-old man with a history of bladder cancer with urostomy who presents with acute onset of painless jaundice. CT at OSH showed retroperitoneal lymphadenopathy. An ERCP was performed on ___ and a stent was placed. Brushings were taken from the bile duct. The bilirubin downtrended after stent was placed. An MRCP was performed, which showed a mass in the head of the pancreas. OTHER PROBLEMS ============================ # RP Lymph Nodes: Concern for malignancy. Ongoing discussion and workup as outpatient, consider LN Biopsy as outpatient # Microcytic anemia: Continue home iron # CKD: Renal function at baseline and did not improve with IV fluid # Metabolic acidosis: Likely due to CKD # T2DM: A1C 6.4%. Diet controlled. # Recent UTI: No growth on urine culture on admission. Antibiotics were stopped. TRANSITIONAL ISSUES ============================= - Pt to be discussed at ___ pancreatic conference during the evening of ___. He will be contacted with the f/u plan re: the pancreatic mass and painless jaundice - F/u cytology as outpatient, pending on discharge - F/u CA ___ as outpatient, pending on discharge - Consider RP Lymph Node Biopsy as outpatient - Repeat ERCP in 1 month for assessment of biliary tree and stent removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Cephalexin 500 mg PO Q12H 4. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Obstructive jaundice d/t pancreatic head mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with jaundice (yellow skin), in the setting of having known enlarged lymph nodes. You had an ERCP, a procedure that evaluates your bile ducts. It showed that you had a blockage, and a stent was placed to drain your bile. After the stent was placed, your bilirubin (the chemical that makes your skin yellow) dramatically decreased. You also had an MRI performed, which showed a mass in the head of the pancreas, likely the cause of the obstruction. During the ERCP, samples of the cells in the bile ducts were taken to see if they are cancerous, and what type of cancer they might be (cytology). You will get a phone call about this within 10 days. If you do not hear from anyone in 10 days, please call me at ___. Followup Instructions: ___
10060829-DS-17	10,060,829	29,414,251	DS	17	2173-02-15 00:00:00	2173-02-15 23:25:00	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: None. History of Present Illness: ___ MEDICINE ATTENDING ADMISSION NOTE PCP: ___ MD HPI: ___ year-old man history of alcoholism with many hospitalizations for detoxification, pancreatitis, GERD and HTN; who presents with abdominal pain. He was recently admitted to ___ for alcohol abuse and diagnosed with pancreatitis. Discharged on ___ and has reported diffuse abdominal pain since that time. Describes pain as crampy and different from his previous episode of pancreatitis. No hematemesis. Reports spotting of blood on toilet paper. Dark brown stool. No melena. Has been able to tolerate POs. Last drank yesterday (___). Patient reports usually drinking 30 pack of beers. Reports binge drinking for a couple of days and then taking a few weeks off. Denies CP/SOB. No fevers, + chills. Upon review of OMR, he was last admitted here ___ for acute intoxication. He drank 1 bottle of listerine because money was tight and was found to have an anion gap acidosis, osmolal gap and to be in alcohol withdrawel. His gaps closed with hydration and he left AMA on the same day of that admission and refused inpatient detoxification. This holiday week, the patient is very sad about being apart from his daughter (who is living with her mother). He expresses that he has a lot of disappointment with his current life situation. He turns to binge drinking of alcoholic beverages to numb his pain. He has depression and anxiety. In ER: VS: 98.7 ___ 16 100% ra; ___ abdominal pain PX: A&O x3 Lines & Drains: 20G R Hand Studies: Serum EtOH 213, Benzo Pos; Lipase 24; Lactate 2.5; AST 47, ALT 25 CT abd/pelv: No acute intra-abdominal or pelvis process. Pancreatic head calcifications likely relate to chronic pancreatitis. Fluids given: 1L NS Meds given: Morphine 5mg IV x2, Diazepam 10mg IV x1 Consults called: None VS prior to transfer to the floor: 97.6, 86, 14, 143/97 97%RA , ___ Review of Systems: (+) Per HPI and mild tingling in his fingers and ecchymoses on his abdomen. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies heartburn, diarrhea, constipation, BRBPR, melena. No dysuria, urinary frequency. Denies arthralgias or myalgias. No increasing lower extremity swelling. No muscle weakness in extremities. All other review of systems negative. Past Medical History: -Alcoholism with history of seizures on day 2 of withdrawal. -GERD -Chronic back pain -Broken ankle s/p open reduction and internal fixation in ___ -Depression Social History: Alcohol abuse history: began drinking at age ___ and has been drinking at least 30 beers + ___ daily for the last few months. He has had multiple admissions to ___ ED for alcohol abuse and overdose of benzodiazepines and other medications. He has had ___ periods of sobriety and was once sober for ___ years from ___ while he lived in a half way house (never imprisoned). He has been in AA multiple times over the years and has found help there if he is able to be dedicated to it. Drugs: He denies, OMR notes distant cocaine and marijuana use. Tobacco: ___ PPD ___ years Sexual history: Not currently in relationship. States has had no sexual partners recently. Never been HIV tested, to his knowledge. Worked as a lisenced alcohol ___ for ___ years. Then as a ___ for ___ years. Then at ___ ___ for ___ years. He went to ___. He has been on disability for anxiety/depression since ___. Married for ___ years; divorced in ___. Lives in ___ by himself for the past ___ years; previously has lived with his parents. He has a ___ year-old daughter. ___: eats fast food and does not eat when drunk Does not drive. Family History: Father: ___ and former alcoholic but sober for ___. has cataracts Mother: ___ in remission from ___ Brothers: ___, 50, 48: healthy Sisters: 52, 43: healthy Daughter: 16 healthy Physical Exam: VS: 97.9, 173/113, 110, 22, 94% on room air PAIN: 5 out of 10 RLQ GEN: No acute distress HEENT: EOMI, PERRL, no oral lesions CV: Tachycardic, regular, no murmurs PULM: Clear to auscultation bilaterally GI: Soft, mild RLQ tenderness, non-distended; no guarding or rebound tenderness EXT: No lower extremity edema. SKIN: Multiple ecchymoses on lower abdomen (likely heparin shots from recent hospitalization at ___---pt does not recall receiving any heparin shots). The tenderness is localized to the areas where he has ecchymoses. NEURO: Alert and oriented x3 (although sometimes he thinks he is still at ___, CN ___ intact, strength ___ BUE/BLE, sensory intact (except for tingling sensation in fingertips), fluent speech, normal coordination. Mild tremor. PSYCH: Calm, depressed, denies desire to harm himself or others Pertinent Results: ___ 03:20AM WBC-7.5# RBC-4.71 HGB-12.8* HCT-38.6* MCV-82 MCH-27.1 MCHC-33.1 RDW-18.0* ___ 03:20AM NEUTS-45.3* LYMPHS-47.5* MONOS-3.7 EOS-2.9 BASOS-0.7 ___ 03:20AM PLT COUNT-183 ___ 03:20AM GLUCOSE-71 UREA N-8 CREAT-0.8 SODIUM-145 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-26 ANION GAP-17 ___ 03:35AM LACTATE-2.5* ___ 03:20AM ALT(SGPT)-25 AST(SGOT)-47* ALK PHOS-68 TOT BILI-0.2 ___ 03:20AM LIPASE-24 ___ 03:20AM ALBUMIN-4.5 CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-2.4 ___ 03:20AM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___BD & PELVIS WITH CO 1. No acute intra-abdominal or pelvic process. 2. Pancreatic head calcifications likely relate to chronic pancreatitis. No peripancreatic fat stranding to suggest acute pancreatitis. Brief Hospital Course: ___ year-old male with alcoholism and depression presents with alcohol intoxication and RLQ abdominal pain that localizes to ecchymoses suggesting that there may be small hematomas in his abdominal wall. PROBLEM LIST: # Alcohol intoxication with imminent withdrawal. Patient's last drink was one day prior to admission. Placed on CIWA protocol to manage withdrawal symptoms. Also administer folic acid, multivitamin, and thiamine. Social work consulted to address issues of alcoholism and depression. Pt had withdrawal symptoms for 2 days. He felt that he may benefit from having a small prescription for diazepam for any residual alcohol withdrawal symptoms and for anxiety. # RLQ abdominal pain, NOS. No acute process detected on abdominal CT, although he has findings consistent with chronic pancreatitis. Pts abdominal wall pain is localized to the areas of ecchymoses suggesting that he may have underlying hematomas that are causing his pain. # Depression/Anxiety: Continue paroxetine and propanolol. Social work consult helped with his coping skills and to help plan outpatient therapy. See OMR notes by ___ (social work) for more details. # GERD: Continue home dose of omeprazole. # DVT prophylaxis: Ambulation # Code Status: Full code TRANSITIONAL ISSUES: 1. Refer patient to outpatient social work as well as psychiatry Medications on Admission: Omeprazole 20 mg daily Paroxetine 40 mg PO daily Propranolol 20 mg BID Cyanocobalamin Neurontin 300 mg daily Hydroxyzine 50 mg TID prn anxiety Folic acid 1 mg daily Thiamine 100 mg daily Multivitamin daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. diazepam 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety or withdrawal symptoms for 2 weeks. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: - Alcohol intoxication and withdrawal - Abdominal wall hematoma - Depression - Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of right lower abdominal pain and treatment of alcohol withdrawal. Your abdominal pain is likely caused by severe bruising (hematoma) from heparin shots you received during your recent hospitalization at ___ ___. You also reached out for help with regard to your depression and your alcoholism. Social work provided recommendations for resources you may access to help you in your road to recovery. Continue also attending your AA meetings and meeting with your sponsor. It is very important that you reach out to your sponsor--everyday would be best. We will help arrange for close follow-up with a primary care doctor at ___. Your primary doctor can begin the process of helping to connect you to social work and psychiatric services. MEDICATION INSTRUCTIONS: 1. Diazepam (Valium) 5 mg one tablet every 6 hours as needed for anxiety or alcohol withdrawal symptoms. Followup Instructions: ___
10060863-DS-11	10,060,863	29,850,213	DS	11	2192-05-08 00:00:00	2192-05-09 04:29:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Vioxx / Motrin / phenobarbital Attending: ___. Chief Complaint: palpitations Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old woman with epilepsy, followed by Dr. ___ presents with increased frequency of seizures over two weeks and a change in their character, as well as chest pressure and palpitations. Her seizures began in ___, originally interpreted as psychiatric and diagnosed as epileptic around ___ by Dr. ___. They consist of two basic seizure types: 1. "complex partial seizure" - consisting of left face twitching, unilateral left arm and leg shaking, and some degree of altered sensorium. They also may include bilateral tremors, jaw spasms, back spasms - in the most severe kind for which she occasionally uses a soft collar, but this component does not occur while on medications. She typically is aware of what's going on and can hear voices, but does not always understand the words. Over the past several days these seizures have occurred "constantly" as she comes "into and out of them" and sometimes is not sure when one has happened or not. The episodes are triggered by photostimulation, crowds, too much activity around her, sleep and food deprivation. She reports that these episodes occur daily and they can last for 30 seconds - 20 minutes and that she can feel lethartic for hours after the episodes. She can occasionally predict when one is coming and she will take a klonipin which helps to dull the symptoms. 2. "staring spells" - consist of episodes of "deer in headlights". These last ___ seconds and she stares off and hears what is going on, but has limited responsiveness. She has never lost consciousness. She reports that on "bad days" she will more likely have episodes of shaking and "complex partial" like events that occur throughout the day and on "good days" she will have episodes of disassociation ("absence") that are brief. She reports that as of ___ she will feeling better than she had in years. On ___ she felt that she had an episode of numbness in the roof of her mouth accompanied by inability to swallow water. This event appeared to coincide with one of her "complex partial" seizures and she believes that from that point on, her seizures have worsened in frequency and duration. She spoke to the covering neurologist that day who suggested she start the Keppra dosage (250 mg BID) that her neurologist, Dr. ___ previously discussed with her. For the presenting episode last night, Mrs. ___ recorded the event and symptoms as follows: "About 8PM experienced irregular heartbeat for about 2 hours; heart rate was 94-114. Have had jaw pain on and off for about 2 weeks; ignored it, thought it was seizure related; added new medication Keppra 2 weeks ago ___. Tonight jaw pain, right arm pain, chest pain very light combined with an irregular heartbeat. The irregular heart rate is gone but the jaw and chest pain has not." She took an extra half of a keppra, as well as 200 mg neurontin and 0.5 mg klonipin and 325 mg aspirin. Finally, of note, Mrs. ___ has been taking neurontin for ___ years (up to 600 mg BID) for her seizures and for her pain from her history of cervical stenosis, but ___ years ago she had a few episodes of falling (no loss of consciousness) that were prompted by an innocuous trigger, such as catching her foot on the rug. She refers to this as "loss of the startle reflex" - however it is described as loss of the ability to catch herself or compensate for tripping. She feels this was associated with the neurontin and it was decreased to 400 mg BID ___ mg TID per PCP) and then it was weaned further to 200 mg BID two weeks ago when she started the Keppra. Past Anti-epileptic drug trials: phenobarbitol (tried 1 dose) dilantin (stopped working) depakote (required escalation of dose for effect) tegretol (tried 3 doses and stopped) neurontin klonopin keppra Past Medical History: seizure disorder: see HPI for characterization; see meds for past AED trials gluten allergy (diagnosed ___ cervical stenosis (pain managed with neurontin) lactose intolerance osteopenia Social History: ___ Family History: Mother: grand mal seizures treated with dilantin Physical Exam: Vitals: T: 98.3, HR 61, BP 134/85, RR 16, 100%RA Tmax: 98.3 BP range: ___ General: Awake, cooperative, NAD, sitting up in bed with sneakers on, relaxed. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: regular rate and rhythm, no murmurs, rubs or gallops Abdomen: soft, nontender, nondistended, normal active bowel sounds Extremities: no edema, pulses palpated Neurologic: -Mental Status: Alert, oriented to person, date and place. Circumferentially related history but required prompting to answer questions directly. 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 including pen, collar and lapel. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. The pt. had good knowledge of current events. When asked the meaning of the proverb "don't judge a book by its cover," she said "just read the book." There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus although she reported EOM were "too much stimulation" for her to do. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to tuning fork bilaterally for 20 seconds. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii; unable to perform SCM strength testing because she thought it would trigger her seizure. XII: Tongue protrudes in midline with some movement; unable to hold it steady. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally, however she had constant movement of her fingers. No adventitious movements. Movement of fingers / toes / tongue only when she attending the extremity. When distracted, no movements / tremor. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5- 5 4+ 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, vibratory sense, joint position sense intact. -DTRs: Left patellar reflex had some rebound clonus Bi Tri ___ Pat Ach L 2 2 2 3 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. No ankle clonus. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. Fine motor ability tested and intact with finger tap -Gait: Narrow based, somewhat unsteady, although appears self-induced as she stands back on her heels. Neg Rhomberg. The patient has an event during my exam consisting of bilateral upper extremity non-rhythmic shaking, during which she could talk with a tremulous voice and stared off at the ceiling voluntarily as she said it improved her concentration during the exam. She was able to complete finger to nose testing during the event. It lasted about 45-60 seconds and gradually subsided without subsequent change in mental status. ======================== DISCHARGE EXAM: AF VSS Alert, awake. Patient with fluent, rapid speech, still has tangential speech but directible. Patient relate the overnight event fluently with a lot of emotions, describing the feelings as "deep dark depression/despair in amygdala." and that she could not speak for an hour except for "sad sad" (no EEG correlate noted for this event). On cranial nerve examination, patient has difficulty focusing on tasks, intermittently complaining of monocular diplopia on the left side of her vision, but states that if she focuses, it goes away. Other cranial nerves are intact. With motor examination, there is no pronator drift, but patient displays large, irregular movements on the left hand, stating that her "tremors are worse, see?" Does not appear to be physiologic tremor, and not noted when patient is distracted with questions or other parts of examination. Pertinent Results: ADMISSION LABS: ___ 12:08AM BLOOD WBC-4.5 RBC-4.35 Hgb-14.7 Hct-43.2 MCV-99* MCH-33.7* MCHC-34.0 RDW-12.2 Plt ___ ___ 12:08AM BLOOD Neuts-60.2 ___ Monos-6.5 Eos-3.2 Baso-1.1 ___ 12:08AM BLOOD Glucose-94 UreaN-15 Creat-0.9 Na-145 K-3.8 Cl-103 HCO3-32 AnGap-14 ___ 08:05AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1 CARDIAC ENZYMES: ___ 12:08AM BLOOD cTropnT-<0.01 ___ 06:26AM BLOOD cTropnT-<0.01 UA: ___ 01:30PM URINE Color-Straw Appear-Hazy Sp ___ ___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG URINE TOX: ___ 01:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG STRESS TEST ___: Good exercise tolerance. Non-anginal type symptoms noted late post-exercise in the absence of ischemic ST segment changes. Atrial irritability with brief run of nonsustained PSVT. Appropriate heart rate and blood pressure response with exercise. CXR: No acute chest abnormality. Shallow obliques are recommended for further evaluation of a possible nodule. CXR OBLIQUE: Two oblique views demonstrate no evidence of pulmonary nodule. Lungs are essentially clear with no pleural effusion or pneumothorax. Repeat chest radiograph in three months (PA and lateral) is recommended for assessment of stability of this finding on the radiograph that is most likely representing small areas of atelectasis. EEG PENDING Brief Hospital Course: TRANSITIONAL ISSUE: [] Repeat CXR in 3 months to further evaluate ?pulmonary nodule, as recommended by radiology ___ yo woman with epilepsy consisting of poorly characterized complex partial seizures who presents with chest pain and palpitations, also complaining of increased seizure frequency. Ruled out for MI in the ED with troponin and stress test, but unclear etiology for increased seizures. Her Keppra was increased during this hospitalization and she was monitored on video EEG without EEG correlates for her events. # NEURO: patient with increased seizure frequency, though has history of daily complex partial/simple partial and absence seizures. Patient had couple episodes of speech arrest during this hospitalization without EEG correlate. Her Keppra XR was increased to 500 mg BID after discussion with her outpatient neurologist, Dr. ___. # CV: patient p/w palpitations and ?chest pain, ruled out for MI with negative troponin x2 and stress test in ED. Her electrolytes were monitored and she was monitored on tele without further symptomatic events. # PULM: ?nodule on CXR, repeat shallow CXR without clear nodules, but radiology recommends repeat CXR in 3 months to evaluate. # ID: no leukocytosis or fever, no evidence of infection. # FEN: gluten free diet # PPx: patient refused heparin SQ even after discussion of risk/benefits, placed on pneumoboots instead. Medications on Admission: CLONAZEPAM [KLONOPIN] - Klonopin 0.5 mg tablet 3 Tablet(s) by mouth once a day (No Substitution) (Per patient, she is only taking 0.5 mg 1 tablet QHS and occasionally PRN:seizure) GABAPENTIN [NEURONTIN] - Neurontin 100 mg capsule 2 Capsule(s) by mouth 2 times a day (No Substitution) LEVETIRACETAM [KEPPRA] - Keppra 250 mg tablet 1 Tablet(s) by mouth twice a day (No Substitution) Over the counter: 1000 mg vitamin D 200 mg calcium fish oil Discharge Medications: 1. KlonoPIN NF (clonazePAM) 0.5 mg ORAL HS * Patient Taking Own Meds * 2. Clonazepam NF (clonazePAM) 0.5 mg ORAL BID:PRN anxiety * Patient Taking Own Meds * 3. Keppra NF (levETIRAcetam) 500 mg ORAL BID * Patient Taking Own Meds * 4. Neurontin NF (gabapentin) 200 mg ORAL BID * Patient Taking Own Meds * Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: seizures, palpitations 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 came to the hospital because of fluttering in your chest, and were evaluated in the emergency department for heart attack. You did not have a heart attack, and your stress test did not show evidence of ischemia, though you did have an episode of low blood pressure after your exercise, which resolved on its own. In terms of your seizures, you had an episode of speech arrest and feelings of depression while you are in the hospital, but there was no EEG changes correlated with that episode. Followup Instructions: ___
10061468-DS-6	10,061,468	27,001,293	DS	6	2179-12-09 00:00:00	2179-12-09 22:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reclast / Fosamax Attending: ___. Chief Complaint: Eye burning and blurriness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ yo woman with PMH of temporal arteritis on steroids and DM2 who is transferred to the ___ ED with concern for temporal arteritis flare. Patient was recently admitted to ___ from ___t home. Workup was unrevealing aside from hyponatremia which was corrected with IVF's and she was discharged to ___ rehab on ___. There, she has continued to be very weak with poor excercise tolerance. ESR was noted to be 75, well above her normal baseline. Prednisone was empirically increased to 20mg from 10mg with some initial improvement of subjective symptoms. However, over the past week she has experienced progressive burning sensation in her eyes, right worse than left, initially associated with mild conjuctival erythema and discharge. She was started on erythromycin opthalmic ointment without improvement, followed by lubricating opthalmic ointment without benefit. Over the past ___, she noted worsening vision in her right eye. Her primary rheumatologist Dr. ___ ___ was consulted and recommended urgent opthamologic evaluation in the setting of known giant cell arteritis and she was transferred to ___ for further evaluation. In the ED intial vitals were T 97.7, HR 95, BP 148/45, RR 16, O2 100%. Initial labs were notable for Na of 125, CRP 80.4, ESR 63, and HCT 29.9 with plt 576. Remainder of Chem7 and CBC were unremarkable. Opthalmology was consulted who recommended admission with rheum consult for IV steroids. IOP was 10 and visual acuity was documented at L Eye = ___ Eye = ___ Both = ___. Patient was then admitted to medicine for further management. On the floor, patient reports bilateral eye burning and blurriness as above. She denies any headache. She also denies recent fevers or chills. No CP or SOB. No nausea, vomiting or diarrhea. She does note poor appetite and constipation x4 days. No new rashes or joint pains. Remainder of ROS is unremarkable. Past Medical History: -HLD -Nephrolithiasis -Migraine -Pseudphakia -Vitreous degeneration -Macular degeneration -Blepharatis -Ptosis -GERD -Hiatal hernia -Basal cell carcinoma -Actinic Keratoses -DM2 -BPV -PMR -HTN -Temporal arteritis -Osteoporosis -Iron def anemia -Adrenal insuffeciency Social History: ___ Family History: No known history of autoimmune disease. Physical Exam: ============================= ADMISSION PHYSICAL EXAM: ============================= Vitals- 98.4 165/63 99 16 100%RA General- Alert, pleasant, orientedx4, no acute distress HEENT- Sclera anicteric, dry MM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Nonlabored on RA. Slightly decreased BS at right lung 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 Ext- warm, well perfused, no edema Neuro- AAOx4, CNs2-12 intact, moving all extremities equally . . ============================= OPHTHALMOLOGIC EXAM: ============================= EXAMINATION Visual Acuity; OD (sc): ___ cc near chart OS (sc): ___ cc near chart Mental status: Alert and oriented x 3 Pupils (mm) PERRL Relative afferent pupillary defect: [ X ] none [ ] present OD: 3mm --> 2mm OS: 3mm --> 2mm Extraocular motility: Full ___ Visual fields by confrontation: Full to counting fingers ___ Color Vision (___ pseudo-isochromatic plates): OD: ___ OS: ___ Intraocular pressure (mm Hg): OD: 10.3 OS: 10.3 External Exam: [ X] NL No V1 or V2 hypesthesia Orbital rim palpation: No point-tenderness, deformities, and step-offs ___ Anterior Segment (Penlight or portable slitlamp) Lids/Lashes/Lacrimal: OD: Normal OS: Normal Conjunctiva: OD: White and quiet OS: White and quiet Cornea: OD: Clear, no epithelial defects OS: Clear, no epithelial defects Anterior Chamber: OD: Deep and quiet OS: Deep and quiet ___: OD: Flat OS: Flat Lens: OD: PCIOL trace PCO OS: PCIOL trace PCO Fundus (Indirect Ophthalmoscopy using 20D lens): Dilation approved by patient PLEASE NOTE, PUPILS WILL REMAIN DILATED FOR AT LEAST ___ HRS Media/Vitreous: OD: Clear OS: Clear Discs: OD: pink, sharp margins OS: pink, sharp margins Maculae: OD: multiple soft ___ OS: multiple soft ___ Periphery OD: PRP laser scars OS: PRP laser scars . . ============================= DISCHARGE PHYSICAL EXAM: ============================= Vitals- 97.9 142/46 95 16 99/RA General- Alert, pleasant, orientedx3, no acute distress , somewhat tearful when talking about her family HEENT- Sclera anicteric, dry MM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Nonlabored on RA. Slightly decreased BS at right lung base. CV- Regular rhythm, tachycardic. normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, no edema Neuro- CNs2-12 grossly intact, moving all extremities equally. Bilateral upper extremity tremors Pertinent Results: ============================= ADMISSION LABS: ============================= ___ 08:30PM BLOOD WBC-8.2 RBC-3.47* Hgb-9.3* Hct-29.8* MCV-86 MCH-26.9* MCHC-31.3 RDW-13.3 Plt ___ ___ 08:30PM BLOOD Neuts-70.3* ___ Monos-5.7 Eos-0.7 Baso-0.4 ___ 08:30PM BLOOD ___ PTT-26.5 ___ ___ 08:30PM BLOOD ESR-63* ___ 08:30PM BLOOD Glucose-184* UreaN-18 Creat-0.6 Na-125* K-4.6 Cl-90* HCO3-25 AnGap-15 ___ 08:30PM BLOOD LD(LDH)-137 TotBili-0.2 ___ 08:30PM BLOOD Iron-17* ___ 08:30PM BLOOD CRP-80.4* . ============================= DISCHARGE LABS: ============================= ___ 07:00AM BLOOD WBC-8.8 RBC-3.72* Hgb-10.0* Hct-32.0* MCV-86 MCH-27.0 MCHC-31.4 RDW-13.3 Plt ___ ___ 07:00AM BLOOD Glucose-169* UreaN-26* Creat-0.8 Na-133 K-4.5 Cl-98 HCO3-24 AnGap-16 ___ 07:00AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.2 ___ 07:00AM BLOOD CRP-34.0* . ============================= IMAGING: ============================= CT HEAD W/O CONTRAST Study Date of ___ 10:24 ___ FINDINGS: There is no acute hemorrhage, edema, mass, mass effect, or acute large vascular territorial infarction. The ventricles and sulci are prominent which suggest normal age-related involutional changes. There are periventricular white matter hypodensities consistent with the sequela of chronic small vessel ischemic disease. The basal cisterns are patent, and there is preservation of gray-white matter differentiation. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. The globes are unremarkable. IMPRESSION: No acute intracranial process. . . ============================= URINE: ============================= ___ 10:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 10:20PM URINE RBC-6* WBC-15* Bacteri-FEW Yeast-NONE Epi-<1 . Brief Hospital Course: ============================= PRIMARY REASON FOR ADMISSION ============================= ___ yo F with a history of biopsy-proven giant cell arteritis admitted with elevated inflammatory markers and bilateral blurry vision concerning for flare of arteritis. . ============================= ACTIVE ISSUES ============================= #) Temporal arteritis: The patient presented with elevated inflammatory markers (CRP 80.4, ESR 63 on admission) and blurry vision concerning for GCA flare. She had not improved as an outpatient even after an empiric increase in prednisone from 10 to 20mg. She received one dose of 1g solumedrol and was evaluated by both Opthalmology and Rheumatology. After recieiving the solumedrol pulse, her symptoms subjectively began to improve. Because the opthalamologic exam did not find anterior ischemic neuropathy on funduscopic examination, Rheumatology recommended a four week course of prednisone 50mg. She will need inflammatory markers checked q2-3 days until a steady downtrend is noted (discharge labs:CRP 34). . #) Hyponatremia: The patient has had hyponatremia noted at her ECF, with Na in the 125-130 range that improves with IV saline. Admission Na was 125 that improved to 133 with small NS boluses, her home salt tabs, and improved po intake. . #) Anemia: She has a history of iron deficiency anemia with likely component of chronic inflammation. Normocytic during this admission with stable blood counts. . ============================= TRANSITIONAL ISSUES ============================= - Will need inflammatory markers checked q2-3 days until downtrending - She should have Ophthalmologic evaluation to monitor dry AMD/diabetic retinopathy - She should continue on prednisone 50mg x 4 weeks with atovaquone prophylaxis - Code status: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 2.5 mg PO DAILY 2. Sodium Chloride 1 gm PO BID 3. Docusate Sodium 100 mg PO BID 4. Vitamin D 1000 UNIT PO DAILY 5. Denosumab (Prolia) Dose is Unknown SC Frequency is Unknown 6. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60 unit-2 mg oral daily 7. PredniSONE 20 mg PO DAILY 8. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 9. krill oil ___ ___ unknown 10. Omeprazole 20 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Bisacodyl ___AILY:PRN constipation 13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 14. Fleet Enema ___AILY:PRN constipation Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone [Mepron] 750 mg/5 mL 10 ml by mouth daily Disp #3000 Milliliter Refills:0 2. PredniSONE 50 mg PO DAILY RX prednisone 50 mg 1 tablet(s) by mouth daily Disp #28 Tablet Refills:0 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Sodium Chloride 1 gm PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #30 Tablet Refills:*0 10. Bisacodyl ___AILY:PRN constipation 11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 12. Fleet Enema ___AILY:PRN constipation 13. GlipiZIDE XL 2.5 mg PO DAILY 14. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60 unit-2 mg oral daily 15. krill oil 0 unknown ORAL Frequency is Unknown 16. Denosumab (Prolia) 60 mg SC ASDIR 17. Outpatient Lab Work On ___: please draw CRP, ESR, Na, K, Cl, HCO3, BUN, Cr, Glu and fax results to Dr. ___ at ___ ICD 9 Codes: Giant cell arteritis 446.5, Hyponatremia 276.1 Discharge Disposition: Home With Service Facility: ___ ___: Primary diagnosis: - Temporal arteritis 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 our pleasure participating in your care here at ___. You were admitted on ___ with blurry vision and elevations of blood markers of inflammation. This was concerning for an acute flare of your known temporal arteritis. You were evaluated by Ophthalmology and Rheumatology and will need to continue taking the higher dose of prednisone (50mg) for a total of 4 weeks. You will also need to take a medication called atovaquone to prevent getting a type of pneumonia while you are taking the prednisone. You will need to check the inflammatory markers in your blood tomorrow (___) to make sure these are improving. You will continue to have these checked as your outpatient Rheumatology doctors feels ___. Should you have any other vision changes or worsening of your blurry vision, have headaches, jaw pain, or any other concerning symptoms, please let your doctors ___. It will be very important for you to see your Rheumatologist and Primary Care Doctor after being discharged. It will also be important for you to continue to eat and drink lots of fluids. Again, it was our pleasure participating in your care. We wish you the best of luck, -- Your ___ Medicine Team Followup Instructions: ___
10061468-DS-7	10,061,468	29,932,731	DS	7	2179-12-15 00:00:00	2179-12-15 13:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reclast / Fosamax Attending: ___. Chief Complaint: failure to thrive Major Surgical or Invasive Procedure: none History of Present Illness: ___ with diabetes, temporal arteritis, hypertension who presents for failure to thrive at home. She was admitted to ___ ___ for fall, hyponatremia, malaise. She was discharged to ___. Admitted ___ ___ for worsening vision, found to have temporal arteritis. She was discharged to her son's home after stating she did not wish to return to ___. PCP ___ ___ at which time the patient was lethargic but walking with walker. Her son expressed concerns about caring for her at home. Referred to several ___ resources, discussed possible ECFs. Plan to touch base again ___. On ___, her son reported that she was not eating or drinking, that she was reluctant to get out of bed and was sleeping much of the day. He enquired about TPN or other feeding, and expressed concern that he could not care for her sufficiently at home. EMS called for transport to ___. On admission she was noted to be hyponatremic to 130, with ESR and CRP elevated above recent admission. She also expressed depression and passive SI. This morning she remains very depressed, stating that for the last year since her daughter's death she has had a series of troubles that have changed her life for the worse. She laments that she used to be a happy person, and now everything has changed. She discusses possible ways to hurt herself (pills, falling down stairs), but then says she would not execute these. She states she has been sleeping more, eating less, and rarely gets out of bed. She says her son has dropped her off at the hospital as he can't take care of her anymore and now she has to go to some "facility". She becomes tearful at times. She initially noted some visual blurring, resolved with reading glasses. She has no other physical complaints. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -HLD -Nephrolithiasis -Migraine -Pseudphakia -Vitreous degeneration -Macular degeneration -Blepharatis -Ptosis -GERD -Hiatal hernia -Basal cell carcinoma -Actinic Keratoses -DM2 -BPV -PMR -HTN -Temporal arteritis -Osteoporosis -Iron def anemia -Adrenal insuffeciency Social History: ___ Family History: No known history of autoimmune disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 168/55 89 18 98% RA Weight: 103.8 lbs GENERAL: NAD, awake and alert HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, dry MM. No temporal tenderness. NECK: nontender and supple, no LAD, no JVD, no thyromegaly CARDIAC: RRR, nl S1 S2, no MRG LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength ___ in UEs, ___ in LEs, sensation grossly normal, DTRs 3+ biceps, brachioradialis, patellae. Achilles mute. Discharge Physical Exam: Unchanged Pertinent Results: ADMISSION LABS: ___ 09:00PM BLOOD WBC-11.9* RBC-3.90* Hgb-10.4* Hct-33.5* MCV-86 MCH-26.7* MCHC-31.2 RDW-13.4 Plt ___ ___ 09:00PM BLOOD Neuts-94.7* Lymphs-4.1* Monos-1.1* Eos-0 Baso-0.1 ___ 09:00PM BLOOD Glucose-266* UreaN-23* Creat-0.8 Na-129* K-5.3* Cl-94* HCO3-25 AnGap-15 ___ 07:40AM BLOOD Albumin-3.3* Calcium-7.9* Phos-3.0 Mg-2.3 INTERIM LABS: ___ 07:40AM BLOOD TSH-0.55 ___ 09:00PM BLOOD CRP-40.8* ___ 07:15AM BLOOD CRP-15.8* ___ 09:00PM BLOOD ESR-55* ___ 07:15AM BLOOD ESR-PND ___ 11:55PM URINE Color-Straw Appear-Clear Sp ___ ___ 11:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 03:57AM URINE Hours-RANDOM Creat-22 Na-123 K-15 Cl-120 ___ 03:57AM URINE Osmolal-368 MICROBIOLOGY: ___ BLOOD CULTURE -- NGTD ___ URINE CULTURE -- NO GROWTH ___ BLOOD CULTURE -- NGTD IMAGING: ___ ___: No intracranial hemorrhage or acute territorial infarction. CXR ___: No acute cardiopulmonary process. Discharge Labs: ___ 08:05AM BLOOD WBC-7.9 RBC-3.68* Hgb-9.7* Hct-31.6* MCV-86 MCH-26.5* MCHC-30.8* RDW-14.0 Plt ___ ___ 07:15AM BLOOD ESR-25* ___ 08:05AM BLOOD Glucose-148* UreaN-18 Creat-0.8 Na-132* K-4.3 Cl-98 HCO3-26 AnGap-12 ___ 07:15AM BLOOD Calcium-7.9* Phos-1.7* Mg-2.1 ___ 07:15AM BLOOD VitB12-374 ___ 07:15AM BLOOD CRP-15.8* Brief Hospital Course: ___ with diabetes, temporal arteritis, hypertension who presents for failure to thrive at home, found to be depressed. Active Issues: # Depression: Passive SI expressed in the ED. Patient was seen by psychiatry and found to not be actively suicidal. Psychiatry did feel that the patient was depressed, likely ___ recent loss of daughter, loss of independence and chronic illnesses. She was started on citalopram 20 mg daily per psych recommendations. Her mood and po intake subjectively improved during her hospitalization. The citalopram will likely need to be uptitrated. # Failure to Thrive: Decreased appetite, poor PO intake, and poor ambulation. Toxic/metabolic work-up was unrevealing. Likely at least partially ___ depression. Treatment as above, improved throughout hospitalization. # Hyponatremia: Chronic in nature, stable between 130-132. # Temporal arteritis: Per discussion with patients rheumatologist, she should continue prednisone 50 mg for the next two weeks and then tapar down to 40 mg daily for an additional two weeks. ESR and CRP continued to trend downward throughout the hospitalization. # DM2: Blood glucose was elevated to the 200's throughout the hospitalization. We hypothesize that this is related to recent uptitration of prednisone for temportal arteritis flare. She started on insulin. This was uptitrated with addition of glargine on the day of discharge. She will continue with glipizide and aspirin. # HTN: well-controlled # GERD: continued PPI # Anemia: Hb at baseline. Most recent labs consistent with chronic disease. # Med rec: - continue artificial tears, E-mycin ointment, MVI, vitamin D, bowel regimen with colace/bisacodyl/enema - hold ocuvite, krill oil, Denosumab # Communication: HCP son ___ ___ # Code: DNR/DNI Transitional Issues: - Consider uptitrating citalopram at rehab (would increase to 20 mg) - Please taper prednisone to 40 mg daily in two weeks (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY 2. PredniSONE 50 mg PO DAILY 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Sodium Chloride 1 gm PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Aspirin 81 mg PO DAILY 10. Bisacodyl ___AILY:PRN constipation 11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 12. Fleet Enema ___AILY:PRN constipation 13. GlipiZIDE XL 2.5 mg PO DAILY 14. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60 unit-2 mg oral daily 15. krill oil 0 unknown ORAL Frequency is Unknown 16. Denosumab (Prolia) 60 mg SC ASDIR Discharge Medications: 1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 2. Aspirin 81 mg PO DAILY 3. Atovaquone Suspension 1500 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. Docusate Sodium 100 mg PO BID 6. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID 7. Fleet Enema ___AILY:PRN constipation 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO BID 10. PredniSONE 50 mg PO DAILY 11. Sodium Chloride 1 gm PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Citalopram 10 mg PO DAILY 14. Denosumab (Prolia) 60 mg SC ASDIR 15. GlipiZIDE XL 2.5 mg PO DAILY 16. krill oil 1 pill ORAL DAILY 17. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000 unit-200 mg-60 unit-2 mg oral daily 18. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Depression Secondary: Temporal Arteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted with weakness and decreased appetite. We think this was likely caused by depression. We started a medication for the depression and will have you go to a rehab center to regain your strength. I wish you luck in your recovery. Followup Instructions: ___
10061737-DS-16	10,061,737	25,469,970	DS	16	2126-09-04 00:00:00	2126-09-06 07:15:00	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: ___ Successful post-pyloric advancement of a Dobhoff feeding tube. History of Present Illness: Ms. ___ is a ___ PMHx R-sided nephrectomy, cholelithiasis, COPD, and HTN who is transferred from ___ ___ for ERCP evaluation. She presented to ___ this morning for acute onset RUQ abdominal pain and nausea with multiple episodes emesis this morning; it is unclear if her emesis was bilious/bloody as the patient is blind. She had otherwise been in her USOH. Her HR was initially in the ___ upon arrival, felt to be ___ too much beta-blockade from her home metoprolol but she was HD stable and asymptomatic. At ___, her labs were notable for WBC 8.6, Hgb 15.5, Plt 243, Na 144, BUN 17, Cr 1.5. AST 46, ALT 43, Alk Phos 85, Tbili 0.8, DBili 0.3, INR 0.9. Lactate 2.2. Trop < 0.02, lipase elevated to 436. EKG there showed sinus bradycardia. CXR wnl. RUQ US there showed dilated CBD with cholelithiasis. She received cipro/flagyl and was subsequently transferred to ___ for ERCP evaluation. Upon arrival here, VSS without any fever and HR in the ___. ERCP recommended MRCP. The patient received Unasyn x 1 prior to transfer. Past Medical History: R-sided nephrectomy over ___ years ago (daughter says it was due to congenital issue and that kidney was not working) cholelithiasis HTN COPD Social History: ___ Family History: No history of biliary disease. Physical Exam: Admission Physical Exam: Vitals- 99.0 183 / 72 60 18 94 2l NC GENERAL: AOx3, NAD HEENT: MMdry, NCAT, EOMI, anicteric sclera CARDIAC: RRR, nml S1 and S2, no m/r/g LUNGS: CTAB, no w/r/r, unlabored respirations ABDOMEN: soft, nondistended, moderate TTP of RUQ and epigastrium without rebound/guarding, + bowel sounds EXTREMITIES: no significant pitting edema of BLE GU: Foley in place SKIN: no rash or lesions NEUROLOGIC: AOx2 (to self and month/year, able to name ___ unable to say she was at ___ and state specific date), moving all extremities, fluent speech, following commands. Discharge Physical Exam: VS: 97.5, 128/66, 69, 24, 95% Ra Gen: Frail elderly woman sitting in chair in NAD CV: RRR, nml S1 and S2, no m/r/g Pulm: CTAB, no w/r/r, unlabored respirations Abd: soft, NT/ND Ext: WWP no edema Pertinent Results: ___ 06:37AM BLOOD WBC-9.0 RBC-4.31 Hgb-12.4 Hct-39.3 MCV-91 MCH-28.8 MCHC-31.6* RDW-14.2 RDWSD-47.1* Plt ___ ___ 06:50AM BLOOD WBC-9.1 RBC-4.50 Hgb-12.9 Hct-40.3 MCV-90 MCH-28.7 MCHC-32.0 RDW-14.1 RDWSD-45.3 Plt ___ ___ 06:35AM BLOOD WBC-8.8 RBC-4.68 Hgb-13.8 Hct-41.5 MCV-89 MCH-29.5 MCHC-33.3 RDW-13.8 RDWSD-43.9 Plt ___ ___ 10:20AM BLOOD WBC-9.0 RBC-4.57 Hgb-13.3 Hct-40.6 MCV-89 MCH-29.1 MCHC-32.8 RDW-13.8 RDWSD-44.4 Plt ___ ___ 06:44AM BLOOD WBC-8.5 RBC-4.54 Hgb-13.2 Hct-40.7 MCV-90 MCH-29.1 MCHC-32.4 RDW-13.3 RDWSD-44.2 Plt ___ ___ 07:10AM BLOOD WBC-8.7 RBC-4.44 Hgb-12.8 Hct-40.5 MCV-91 MCH-28.8 MCHC-31.6* RDW-13.4 RDWSD-44.7 Plt ___ ___ 06:35AM BLOOD WBC-10.2* RBC-4.49 Hgb-13.3 Hct-41.1 MCV-92 MCH-29.6 MCHC-32.4 RDW-13.8 RDWSD-46.5* Plt ___ ___ 07:10AM BLOOD WBC-8.9 RBC-4.46 Hgb-13.0 Hct-40.2 MCV-90 MCH-29.1 MCHC-32.3 RDW-13.5 RDWSD-45.1 Plt ___ ___ 08:50PM BLOOD WBC-9.0 RBC-4.84 Hgb-14.2 Hct-43.3 MCV-90 MCH-29.3 MCHC-32.8 RDW-13.4 RDWSD-44.3 Plt ___ ___ 06:40AM BLOOD WBC-8.5 RBC-5.14 Hgb-14.9 Hct-45.5* MCV-89 MCH-29.0 MCHC-32.7 RDW-13.3 RDWSD-43.4 Plt ___ ___ 07:10AM BLOOD ___ PTT-28.5 ___ ___ 06:40AM BLOOD ___ PTT-27.6 ___ ___ 06:37AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-141 K-4.5 Cl-106 HCO3-22 AnGap-18 ___ 06:50AM BLOOD Glucose-111* UreaN-17 Creat-0.8 Na-140 K-4.3 Cl-104 HCO3-22 AnGap-18 ___ 06:35AM BLOOD Glucose-134* UreaN-13 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 ___ 10:20AM BLOOD Glucose-131* UreaN-13 Creat-0.8 Na-135 K-4.1 Cl-102 HCO3-23 AnGap-14 ___ 06:44AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-137 K-4.4 Cl-108 HCO3-21* AnGap-12 ___ 07:10AM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-139 K-4.3 Cl-108 HCO3-24 AnGap-11 ___ 06:35AM BLOOD Glucose-116* UreaN-21* Creat-1.0 Na-141 K-3.7 Cl-106 HCO3-27 AnGap-12 ___ 07:10AM BLOOD Glucose-108* UreaN-23* Creat-1.3* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 ___ 08:50PM BLOOD Glucose-127* UreaN-22* Creat-1.4* Na-140 K-4.0 Cl-105 HCO3-24 AnGap-15 ___ 06:40AM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-145 K-4.2 Cl-107 HCO3-25 AnGap-17 ___ 08:50PM BLOOD ALT-27 AST-27 AlkPhos-64 TotBili-1.8* ___ 06:40AM BLOOD ALT-33 AST-33 AlkPhos-70 TotBili-1.2 ___ 06:37AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.1 ___ 06:50AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 ___ 06:35AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1 ___ 10:20AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8 ___ 06:44AM BLOOD Calcium-7.5* Phos-1.7* Mg-2.2 ___ 07:10AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.7 ___ 06:35AM BLOOD Calcium-8.1* Phos-1.8* Mg-1.8 ___ 07:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.6 ___ 06:40AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.7 ___ 09:00PM BLOOD Lactate-2.0 RADIOLOGY: ___ MRCP: 1. Cholelithiasis with marked surrounding inflammation and loculated fluid centered around the gallbladder. The gallbladder is only moderately distended for the degree of inflammation and there is irregularity and discontinuity of its wall at the fundus which are findings concerning for perforated acute cholecystitis. 2. No choledocholithiasis. 3. Large paraduodenal diverticulum measuring 3.1 cm ___ CT A/P: 1. Normal appearing gallbladder without evidence of acute cholecystitis. 2. Extra luminal retroperitoneal gas lateral and posterior to the second portion of the duodenum extending superiorly into the porta hepatis with minimal retroperitoneal and right perinephric free fluid suggestive of a localized duodenal perforation. ___ CXR: Sequential images demonstrate advancement of a nasogastric tube into the stomach. ___ Upper GI Series: A Dobhoff tube is noted. Water-soluble contrast (Gastrografin) was administered through the nasogastric tube. Gastrografin was seen to pass into the duodenum from the stomach, filling the previously noted diverticulum of the second portion of the duodenum. In subsequent images contrast empties from the diverticulum into the more distal bowel without evidence of extraluminal contrast or leak. MICROBIOLOGY: ___ 4:45 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. 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). Brief Hospital Course: Ms. ___ is a ___ F PMHx R-sided nephrectomy, cholelithiasis, and HTN who is transferred from ___ ___ for ERCP evaluation for possible biliary obstruction. She was initially admitted to medicine service with concern for cholelithiasis with biliary obstruction. Endoscopy showed cholelithiasis with surrounding inflammation concerning for perforated acute cholecystitis. A large paradodenal diverticulum was also seen measuring 3.___bdomen pelvis was obtained that showed duodenal diverticulitis with pockets of gas. Nasogastric tube was placed and she was admitted to the Acute Care Surgery Service for further management of duodenal perforation. On HD4 doboff feeding tube was placed and advanced to post pyloric and post site of perforation on HD5. Once placement confirmed, tube feeds were started and titrated to goal. Abdominal pain was monitored and decreased. Nasogastic tube was maintained on low wall suction and post pyloric tube feeds were advanced to goal with good tolerability. She initially had multiple loose bowel movements negative for c. diff. On HD10 a repeat upper GI contrast study was obtained and showed no evidence of leak. The nasogastric tube was subsequently discontinued and she was given an oral diet. Calorie counts were monitored and once adequate PO intake was obtain, feeding tube was discontinued. On HD12 antibiotics were discontinued. She was seen and evaluated by physical therapy who recommended ___ rehabilitation to regain her strength and endurance. 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 on HD17, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assist, voiding without assistance, and denied pain. The patient was discharged to rehab. 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. Metoprolol Tartrate 25 mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Heparin 5000 UNIT SC BID 3. LOPERamide 2 mg PO QID:PRN diarrhea/loose stools 4. Pantoprazole 40 mg PO Q24H 5. TraZODone 25 mg PO QHS:PRN insomnia 6. amLODIPine 2.5 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q ___ prn wheeze 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Perforated duodenal diverticulum Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Surgery Service on ___ with a perforation in your intestine caused by and infection called diverticulitis. You were given bowel rest and antibiotics. You had a feeding tube placed past the point of injury to continue your nutrition. Once you abdominal pain subsided, repeat imaging was done that showed the injury healed. Your diet was advanced and your nutritional intake was recorded. Once you were able to meet your caloric intake needs, the feeding tube was removed. You are now doing better, tolerating a regular diet, and you are not having any sings or symptoms of infection. 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. Followup Instructions: ___
10062020-DS-3	10,062,020	27,609,979	DS	3	2113-03-13 00:00:00	2113-03-13 13:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: theophylline / Penicillins / Tetracycline Attending: ___. Chief Complaint: Left thigh wound drainage Major Surgical or Invasive Procedure: ___: Removal of hardare, irrigation and debridement with cement antibiotic spacer placement, left femur. History of Present Illness: Ms. ___ is a ___ y/o woman s/p ORIF Left distal femur fracture in ___ at ___ who presents with ~8 days of drainage from her Left knee incision. The patient first noted some swelling over the incision approximately two weeks ago in the absence of warmth or erythema and reports that it "grew to the size of an egg prior to breaking." For the past 8 days, it has been draining "peach-colored" fluid, and she states that so much has been draining that it has begun to form "puddles." She has undergone dressing changes with ___, but the wound has continued to drain. She denies fevers, chills, or significant pain or decreased range of motion in the knee. Of note, she has had a chronic wound over the Left lower leg for the past several months for which she is followed at a wound care clinic; she reports that this has never been infected. Past Medical History: IDDM CAD Atrial fibrillation HTN CKD s/p ORIF Left distal femur fracture, as above Social History: ___ Family History: Mother DM, Father HTN, denies fam hx of CA. Physical Exam: Vitals: 98.0 76 118/69 18 99% RA In general, the patient is a well-appearing woman in no acute distress. On examination of the Left lower extremity, there is diffuse edema of the Left lower leg with stasis dermatitis. There is a 3x4 cm wound over the Left lower leg covered by alginate and non-adhesive dressing. Incision over the lateral thigh is clean, dry, and intact with the exception of a ~5mm area mid-incision that is draining a thick, light-colored liquid. There is no surrounding erythema or swelling. There is painless range of motion of the hip, knee, and ankle. There is no tenderness to palpation over the thigh and leg. Sensation is intact throughout the SPN/DPN/TN/saphenous sural distributions, ___ fire, and there is a palpable DP pulse. Examination of the Right lower extremity and bilateral upper extremities is otherwise unremarkable, with intact skin, intact sensation to light touch, no tenderness to palpation, palpable peripheral pulses, and full, painless range of motion. Pertinent Results: ___ 05:42AM BLOOD WBC-8.5 RBC-3.07* Hgb-9.6* Hct-29.0* MCV-95 MCH-31.4 MCHC-33.2 RDW-17.7* Plt ___ ___ 05:42AM BLOOD Glucose-85 UreaN-62* Creat-3.0* Na-134 K-3.3 Cl-96 HCO3-24 AnGap-17 ___ 05:42AM BLOOD Calcium-8.4 Phos-6.6* Mg-2.4 ___ 07:08PM BLOOD freeCa-1.07* ___ 03:01PM BLOOD Lactate-1.7 ___ 07:08PM BLOOD Type-ART pO2-215* pCO2-43 pH-7.34* calTCO2-24 Base XS--2 Intubat-INTUBATED ___ 06:30AM BLOOD Vanco-17.0 ___ 09:50AM BLOOD Vanco-19.5 ___ 05:59AM BLOOD Vanco-19.6 ___ 05:42AM BLOOD Vanco-18.5 ___ 02:50PM BLOOD CRP-50.6* ___ 06:10AM BLOOD Calcium-8.6 Mg-2.7* ___ 07:53PM BLOOD Calcium-8.2* Phos-6.2* Mg-2.4 ___:36AM BLOOD Calcium-8.3* Phos-5.8* Mg-2.3 ___ 06:30AM BLOOD Calcium-8.7 Phos-6.4* Mg-2.3 ___ 09:50AM BLOOD Calcium-8.5 Phos-7.1* Mg-2.4 ___ 05:59AM BLOOD Calcium-8.4 Phos-6.6* Mg-2.4 ___ 05:42AM BLOOD Calcium-8.4 Phos-6.6* Mg-2.4 ___ 02:50PM BLOOD Glucose-143* UreaN-77* Creat-3.4* Na-140 K-4.1 Cl-98 HCO3-26 AnGap-20 ___ 06:10AM BLOOD Glucose-113* UreaN-75* Creat-3.5* Na-136 K-3.9 Cl-98 HCO3-24 AnGap-18 ___ 6:44 pm TISSUE Site: FEMUR LEFT FEMUR DEEP BONE. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: Reported to and read back by ___ ___ ___ 240PM. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH. Susceptibility testing requested by ___. ___ ___ ___. Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CORYNEBACTERIUM SPECIES (DIPHTHEROIDS) \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 4 S PENICILLIN G---------- 8 R VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 05:36AM BLOOD Glucose-138* UreaN-61* Creat-3.4* Na-137 K-5.2* Cl-101 HCO3-24 AnGap-17 ___ 06:30AM BLOOD Glucose-125* UreaN-61* Creat-3.2* Na-131* K-4.2 Cl-97 HCO3-22 AnGap-16 ___ 09:50AM BLOOD Glucose-92 UreaN-64* Creat-3.1* Na-134 K-3.8 Cl-97 ___ 05:42AM BLOOD Glucose-85 UreaN-62* Creat-3.0* Na-134 K-3.3 Cl-96 HCO3-24 AnGap-17 ___ 02:50PM BLOOD ESR-64* ___ 02:50PM BLOOD ___ PTT-33.3 ___ ___ 02:50PM BLOOD Plt ___ ___ 06:10AM BLOOD ___ PTT-33.3 ___ ___ 06:10AM BLOOD Plt ___ ___ 07:53PM BLOOD ___ PTT-33.8 ___ ___ 07:53PM BLOOD Plt ___ ___ 05:36AM BLOOD ___ PTT-34.2 ___ ___ 05:36AM BLOOD Plt ___ ___ 06:30AM BLOOD Plt ___ ___ 09:50AM BLOOD Plt ___ ___ 05:59AM BLOOD Plt ___ ___ 05:42AM BLOOD Plt ___ ___ 06:10AM BLOOD WBC-8.5 RBC-2.44* Hgb-7.7* Hct-24.8* MCV-102* MCH-31.7 MCHC-31.1 RDW-17.2* Plt ___ ___ 07:53PM BLOOD WBC-14.4# RBC-2.59 Hgb-8.2* Hct-25.1* MCV-97 MCH-31.8 MCHC-32.7 RDW-18.4* Plt ___ ___ 05:36AM BLOOD WBC-13.7* RBC-2.55* Hgb-8.1* Hct-25.6* MCV-100* MCH-31.7 MCHC-31.6 RDW-18.5* Plt ___ ___ 06:30AM BLOOD WBC-9.7 RBC-2.97* Hgb-9.3* Hct-28.3* MCV-95 MCH-31.3 MCHC-32.7 RDW-17.7* Plt ___ ___ 09:50AM BLOOD WBC-10.8 RBC-3.05* Hgb-9.3* Hct-29.8* MCV-98 MCH-30.4 MCHC-31.2 RDW-17.5* Plt ___ ___ 05:59AM BLOOD WBC-9.0 RBC-2.85* Hgb-8.7* Hct-27.1* MCV-95 MCH-30.5 MCHC-32.1 RDW-17.9* Plt ___ ___ 05:42AM BLOOD WBC-8.5 RBC-3.07* Hgb-9.6* Hct-29.0* MCV-95 MCH-31.4 MCHC-33.2 RDW-17.7* Plt ___ Brief Hospital Course: The patient was admitted to the orthopaedic surgery service on ___ with purulent drainage from the left distal femur fracture incision site. Patient was taken to the operating room and underwent left femur removal of hardware and placement of an antibiotics spacer on ___. Patient tolerated the procedure without difficulty and was transferred to the PACU, then the floor in stable condition. Please see operative report for full details. Musculoskeletal: Prior to operation, patient was weight bearing as tolerated. After procedure, patient's weight-bearing status was transitioned to touch down weight bearing in the left lower extremity. Throughout the hospitalization, patient worked with physical therapy. Neuro: Post-operatively, patient's pain was controlled by Dilaudid PCA and was subsequently transitioned to oxycodone with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Hematology: The patient was transfused 4 units of blood for acute blood loss anemia on POD#0 and POD#1. Her hematocrit was stable thereafter. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. GU: The patient has a history of stage IV CKD and her renal function and intake and output were closely monitored and stable. Renal was consulted on POD#4 for assessment of appropriateness of PICC placement given future anticipated need for hemodialysis. They approved placement of a PICC in the dominant (right) arm but the initial PICC line was placed in the left arm and had to be changed to the right arm on ___ prior prior to discharge. ID: Antibiotics were held preoperatively to allow adequate culture specimens to be sent from the OR. Gross purulence was encountered on exploration of her fracture nonunion site. Wound cultures sent from the OR and grew Corynebacterium sensitive to vancomycin. Postoperatively Infectious Disease was consulted and she was started on vancomycin and ceftriaxone. The patient's temperature was closely watched for signs of systemic infection but she remained afebrile. Her ceftriaxone was discontinued after sensitivities returned on her wound cultures on ___. Her vancomycin was dosed by level; daily vancomycin levels were drawn each morning and she was given 1g IV if the level was <20. Prophylaxis: The patient received enoxaparin 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 with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The incision was clean, dry, and intact without evidence of erythema or drainage; the extremity was NVI distally throughout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 2 weeks post-operatively. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO BID HOLD if SBP <100, HR <60 2. Calcitriol 0.25 mcg PO DAILY 3. BuPROPion (Sustained Release) 300 mg PO DAILY 4. Glargine 7 Units Bedtime 5. traZODONE 50 mg PO HS:PRN Insomnia 6. Metolazone 2.5 mg PO EVERY OTHER DAY Give 30 minutes prior to Lasix. 7. Aspirin 81 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Cephalexin 500 mg PO Q6H 11. Furosemide 40 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 300 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Glargine 7 Units Bedtime 7. Metolazone 2.5 mg PO EVERY OTHER DAY 8. Metoprolol Tartrate 25 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. traZODONE 50 mg PO HS:PRN Insomnia 11. Acetaminophen 650 mg PO Q6H 12. Docusate Sodium 100 mg PO BID 13. Enoxaparin Sodium 30 mg SC Q24H Duration: 4 Weeks 14. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC insertion Duration: 1 Doses 15. Senna 1 TAB PO BID 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush 17. Sodium Chloride 0.9% Flush 20 mL IV ASDIR For PICC insertion 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 20. Vancomycin 1000 mg IV ONCE Duration: 1 Doses 21. Outpatient Lab Work Weekly CBC w/Diff, Chem 7, AST/ALT, Alk Phos, Total Bili. Daily Vanco trough. Please fax all results to ___ clinic at ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Lef femur ___. Post operative blood loss anemia Post operataive hypokalemia 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: Wound Care: -Keep Incision dry. -Do not soak the incision in a bath or pool. Activity: -Continue to be touch down weight bearing on your left leg. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - Continue taking the antibiotic as instructed. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room. Followup Instructions: ___
10062617-DS-10	10,062,617	25,754,091	DS	10	2124-03-14 00:00:00	2124-03-15 20:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sulfur dioxide / cephalexin Attending: ___. Chief Complaint: confusion, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ with HFrEF, AS, SSS s/p PPM, and recurrent admissions for aspiration pneumonia brought to ___ by his family for an episode of transient confusion and lethargy. The patient denies fever, chills, or dysuria, but did have an episode of large volume urinary incontinence on the day of admission. The patient endorsed a lingering cough for 3 weeks, but no acute changes in his breathing. In ED, patient was afebrile with no leukocytosis. There was no reported syncope or focal neurologic deficits, and a NCHCT was negative for stroke. Past Medical History: - Chronic dysphagia, multiple admissions for aspiration pneumonia. On pureed diet at home. Enteral feeding not in line with goals of care. - CHF (EF 45%-50% on TTE ___ - Sick sinus syndrome status post pacemaker placement in ___ at ___ (generator change in ___ due to recurrent syncope, found to have premature battery failure and an elevated RV pacing threshold) - Aortic insufficiency - Aortic stenosis, moderate - Thoracic aortic aneurysm - Paroxysmal atrial fibrillation - Stage 3 CKD - Hypertension - Diverticulosis - Colonic adenoma - Benign prostatic hypertrophy - Osteopenia - Dry macular degeneration - Subclinical hypothyroidism - Obstructive sleep apnea - Unsteady gait with history of syncope and falls - Venous stasis - Tremor Social History: ___ Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 134/73 70 18 97 RA General: Elderly, appears well, NAD HEENT: NC/AT. PERRL, EOMI. No icterus or injection. OP moist and clear. Neck: JVP normal. CV: RRR. ___ systolic murmur heard best at RUSB. Back: Marked kyphosis. Lungs: Non-labored. Mild intermittent crackles at right base. No egophony. Abdomen: Soft, NDNT, normal BS. No HSM. Ext: Bilateral hyperpigmentation c/w venous stasis. Somewhat cool. Intact pulses. No edema. Neuro: Alert. Normal speech. Poor memory. Waxing/waning attention, trouble with months of year backwards. CN ___ intact. Strength: Left hand grip ___, right ___ otherwise ___ and symmetric throughout. Reflexes: R biceps 2+, L biceps 1+, ___ patella 2+ Skin: Erythematous lesion at ___ border of upper lip. DISCHARGE PHYSICAL EXAM: VS: 97.4 113/66 70 18 96% RA General: Elderly, appears well, NAD HEENT: NC/AT. PERRL, EOMI. No icterus or injection. OP moist and clear. Neck: JVP normal. CV: RRR. ___ systolic murmur heard best at RUSB. Back: Marked kyphosis. Lungs: Non-labored. Bibasilar crackles. No egophony. Mildly decreased breath sounds on the right. Abdomen: Soft, NDNT, normal BS. No HSM. Ext: Bilateral hyperpigmentation c/w venous stasis. Somewhat cool. Intact pulses. No edema. Neuro: Alert. Normal speech. Poor memory. Waxing/waning attention, trouble with months of year backwards. CN ___ intact. Strength: Left hand grip ___, right ___ otherwise ___ and symmetric throughout. Reflexes: R biceps 2+, L biceps 1+, ___ patella 2+ Skin: Erythematous lesion at ___ border of upper lip. Pertinent Results: ADMISSION LABS ================================== ___:01PM BLOOD WBC-10.9# RBC-3.69 Hgb-11.5* Hct-33.6* MCV-91 MCH-31.2 MCHC-34.2 RDW-13.3 RDWSD-44.3 Plt ___ ___ 09:01PM BLOOD Neuts-79.5* Lymphs-14.9* Monos-4.8* Eos-0.2* Baso-0.1 Im ___ AbsNeut-8.67# AbsLymp-1.63 AbsMono-0.52 AbsEos-0.02 AbsBaso-0.01 ___ 09:01PM BLOOD ___ PTT-26.9 ___ ___ 09:01PM BLOOD Glucose-103* UreaN-28* Creat-1.2 Na-128* K-4.4 Cl-91* HCO3-24 AnGap-17 ___ 09:01PM BLOOD ___ 09:01PM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 ___ 09:37PM BLOOD Lactate-1.3 DISCHARGE LABS ================================== ___ 05:53AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.8* Hct-30.6* MCV-92 MCH-32.4* MCHC-35.3 RDW-13.7 RDWSD-46.0 Plt ___ ___ 05:53AM BLOOD Glucose-99 UreaN-23* Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 ___ 05:53AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0 MICRO ================================== URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ___ Blood Culture, Routine-PENDING ___ Blood Culture, Routine-PENDING STUDIES =================================== ECG ___: Atrioventricular sequential pacing. Compared to the previous tracing of ___ findings are similar. CXR ___: Limited assessment of the lung apices. Patchy opacities in the right lung base may reflect infection or aspiration in the correct clinical setting. Streaky retrocardiac atelectasis. CXR ___: Comparison to ___. Mild pulmonary edema is present on today's examination. New right basal parenchymal opacity, potentially reflecting aspiration. Stable appearance of the cardiac silhouette. Non-contrast CT Head ___: 1. Evaluation is mildly limited by motion. 2. No CT evidence of acute intracranial process. MRI would be more sensitive for evaluation of ischemia. 3. Nonspecific left periventricular white matter lesion stable from ___, may represent a cavernoma. 4. Sinus disease, possible acute right maxillary sinusitis. Brief Hospital Course: Mr. ___ is a ___ with HFrEF, AS, SSS s/p PPM, and recurrent admissions for aspiration brought to ___ by family for transient confusion and lethargy, found to have aspiration pneumonia. ACTIVE ISSUES ========================== # Community acquired pneumonia / food aspiration Patient with several years of dysphagia (on pureed diet with nectar-thick liquids at home) and multiple hospitalizations for aspiration pneumonia. Found to have leukocytosis to 12.8, low-grade fever to 99.8, and evolving RLL opacities on CXRs consistent with aspiration pneumonia. He was treated with levofloxacin 750mg q48 x 5 days (renal dosing, ___ allergic to cephalosporins). He remained hemodynamically stable on room air throughout admission, and fever and leukocytosis resolved with abx. Home pureed diet and aspiration precautions were continued (enteral feeding not consistent with patient's goals of care). # Toxic-metabolic encephalopathy Waxing/waning alertness and attention consistent with hypoactive delirium. Likely secondary to PNA. UA clean and bladder scans negative for retention. No focal deficits and NCHCT negative for stroke. Recent pacer interrogation negative for arrhythmia/dysfunction. Patient continued to have waxing/waning but was discharged at baseline per family. # Acute on chronic renal failure Prerenal ___ resolved with 500cc NS. No evidence for obstruction on exam or bladder scans. # Benign prostatic hyperplasia Patient had large volume urinary incontinence on day of admission and intermittent obstructive symptoms. However, no suprapubic tenderness on exam or retention on bladder scans. Home finasteride was continued. # Acute on chronic hyponatremia Baseline Na 128-130s. Na 128 on admission, improved to 131 with 500cc NS in ED. # Chronic systolic heart failure TTE ___ with EF 30%, moderate-severe AS, mild-moderate AR. No evidence for exacerbation on exam; proBNP ___, stable from ___. Continued home Lasix. # Sick sinus syndrome status post pacemaker Recent interrogation in ___ with no evidence of pacer dysfunction. Repeat interrogation was not done given lack of presyncope, palpitations, or arrhythmias on ECG or tele. CHRONIC ISSUES ============================== # Dermatitis: followed by Dermatology at ___. Continued home prednisone and topical steroids. # GERD: well controlled, continued home PPI. # Hypothyroidism: no acute symptoms, continued home synthroid. TRANSITIONAL ISSUES =============================== - CAP/aspiration: treated with levofloxacin 750mg q48h x 5 days (renal dosing, last day ___ - Aspiration: no safe diet per SpSw but enteral feeding not consistent with patient's goals of care. Advised to continue prior pureed diet and precautions. - Discharge weight: 72.8 kg - Discharge diuretic: furosemide 20 mg # CONTACT: ___ (wife) ___ # CODE: DNR/DNI (MOLST form from ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Furosemide 20 mg PO DAILY 2. PredniSONE 4 mg PO EVERY OTHER DAY 3. PredniSONE 3 mg PO EVERY OTHER DAY 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 12.5 mcg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. PredniSONE 4 mg PO EVERY OTHER DAY 3. PredniSONE 3 mg PO EVERY OTHER DAY 4. Omeprazole 20 mg PO DAILY 5. Levothyroxine Sodium 12.5 mcg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID 11. Vitamin D 1000 UNIT PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Community acquired pneumonia Toxic-metabolic encephalopathy SECONDARY DIAGNOSES Acute on chronic renal failure Chronic systolic heart failure Sick sinus syndrome status post pacemaker placement Chronic hyponatremia Benign prostatic hypertrophy Hypothyroidism Gastrointestinal reflux disease Dermatitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to ___ for pneumonia. The infection was likely caused by some food that went into your lung. We gave you antibiotics and you improved. Instructions for when you leave the hospital: - Continue to take all of your home medications. - Continue your pureed diet. Take small slow bites. Sit upright while eating. - Call your doctor or return to the hospital if you feel any confusion, shortness of breath, chest pain, fevers, chills, or any other symptoms that concern you. It was a pleasure taking care of you! Sincerely, Your ___ Care Team Followup Instructions: ___
10062617-DS-4	10,062,617	27,056,234	DS	4	2119-11-02 00:00:00	2119-11-02 16:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath, confusion, difficulty ambulating Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old male d/c yesterday from rehab facility now with weakness, trouble ambulating, and SOB with exertion. He had been at the rehab facility for a week, admitted directly by his PCP for ___ few episodes of falls. Pt was feeling well after d/c yesterday, walking well and communicating appropriately with wife, then at 9:30 ___ started developing gradual weakness, lethargy, difficulty getting to bathroom overnight. His wife reported that he was ambulating more slowly than usual, was more SOB while climbing the stairs, and was somewhat confused about bathroom location. Denies CP, SOB, abd pain, muscle pain, back pain. In the ED, initial vitals were Temp: 98.7 °F (37.1 °C), Pulse: 73, RR: 14, BP: 94/51, O2Sat: 91%, O2Flow: ra, Pain: ___. He received 40mg IV lasix X 1. The patient was admitted for CHF exacerbation and confusion and transferred to the floor. Past Medical History: Aortic valve insufficiency CHF EF 45% with mild global hypokinesis Hearing loss Cancer Sick/Sinus Bradycardia s/p pacemaker ___ ___ Altrua 60 Paroxysmal supraventricular tachycardia Diverticulosis Colonoic adenoma Benign prostatic hypertrophy, s/p TURP Osteopenia s/p appendectomy s/p tonsillectomy s/p bilateral ear osteomas Social History: ___ Family History: Mom: ___ Son: Type 1 DM Physical Exam: Physical Exam on Admission: Gen: NAD, gentleman younger appearing than age, with wife ___, MMM, nonicteric, PERRL Neck: Supple, no LAD, JVD to 10cm Pulm: Breath sounds in all lung fields, crackles at bases bilaterally, without wheeze or rhonchi Cor: RRR, slight murmur at RSB, no S3/S4 appreciated Abd: Soft, non-distended abdomen, no TTP, (+)BS Extrem: 2+ ___ edema to the ankles, venostatic skin changes L>R LEs, pulses 1+ b/l ___, L>R UE edema Neuro: CN intact, AOx3 Physical Exam on Discharge: VS: T97.7, BP 100s-120s/50s-60s, HR ___, RR 18 97%RA Gen: NAD, gentleman younger appearing than age ___, MMM, nonicteric, PERRL Neck: Supple, no LAD, JVD to 5 cm Pulm: Breath sounds in all lung fields, crackles at bases bilaterally, without wheeze or rhonchi Cor: RRR, slight murmur at RSB, no S3/S4 appreciated Abd: Soft, non-distended abdomen, no TTP, (+)BS Extrem: 2+ ___ edema to the ankles, venostatic skin changes L>R LEs, pulses 1+ b/l ___, L>R UE edema Neuro: CN intact, AOx3 Pertinent Results: Lab results from admission: ___ 06:15AM BLOOD WBC-8.4# RBC-3.46* Hgb-11.2* Hct-33.4* MCV-97 MCH-32.3* MCHC-33.4 RDW-15.2 Plt ___ ___ 06:15AM BLOOD Neuts-90.6* Lymphs-6.6* Monos-2.5 Eos-0.1 Baso-0.2 ___ 06:15AM BLOOD ___ PTT-30.7 ___ ___ 06:15AM BLOOD Glucose-103* UreaN-24* Creat-1.1 Na-131* K-4.5 Cl-95* HCO3-26 AnGap-15 ___ 06:15AM BLOOD ALT-22 AST-29 AlkPhos-73 TotBili-1.8* ___ 06:15AM BLOOD proBNP-3532* ___ 08:20AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:20AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-NEG ___ 08:20AM URINE RBC-29* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 Lab results from discharge: ___ 05:20AM BLOOD WBC-6.5 RBC-3.40* Hgb-10.9* Hct-32.9* MCV-97 MCH-32.1* MCHC-33.2 RDW-15.0 Plt ___ ___ 05:45AM BLOOD ___ ___ 05:45AM BLOOD Glucose-86 UreaN-22* Creat-0.8 Na-132* K-4.1 Cl-98 HCO3-30 AnGap-8 ___ 05:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9 ___ 05:10AM BLOOD VitB12-748 ___ 05:10AM BLOOD TSH-5.2* ___ 09:08PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:15AM BLOOD cTropnT-<0.01 ___ 06:15AM BLOOD proBNP-3532* ___ 05:10AM BLOOD Free T4-0.94 CTHead ___ ICH or calvarial frx. 8-mm hypodensity with central hyperdensity in left frontal lobe periventricular white matter, of uncertain clinical significance and likely non-acute. Differential includes cavernoma, other vascular anomaly, or dystrophic calcification. Please correlate with older imaging. Otherwise, additional imaging may be obtained when clinically appropriate. CT Spine ___ anterolisthesis of C7 on T1 may be degenerative. Please correlate with symptoms at this site. No fracture or prevertebral soft tissue abnormality. ___ US ___ evidence of DVT in left lower extremity. UE US ___ evidence of DVT in the left upper extremity CXR (___): Findings suggestive of congestive failure with moderate bilateral layering effusions Micro: RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. Brief Hospital Course: The patient is a ___ year old male with history of CHF EF45%, AV insufficiency, and sick sinus syndrome here with SOB, difficulty ambulating, confusion. Acute Issues: #Acute CHF Exacerbation: Given the patient's clinical signs (crackles on exam, elevated JVD, edema), elevated BNP, SOB with exertion, and history of CHF on admission, it was thought that the patient was likely in CHF exacerbation. A previous echo in ___ demonstrated an EF of 40-45%, mild global hypokinesis, and mild LV hypertrophy with mild-to-mod aortic regurg. Pt denied CP at time. No rhonchi or dullness on initial exam, no fevers, cough or sputum production to suggest PNA. No wheezing suggestive of obstructive process. The patient was given furosemide 40mg IV, was continued on home lisinopril 2.5mg daily, atenolol 6.25mg, and digoxin 0.125mg daily except ___. He was given a low sodium diet, and fluids were restricted to 1.5L per day. Strict in's-and-out's were maintained, daily weights were established, and a Texas catheter was used to measure urine output. The patient's electrolytes and renal function were monitored BID and the patient was ruled out for MI. After an episode of hypotension his atenolol was discontinued and his BP improved. He was discharged on Furosemide 40mg daily. These medication changes were discussed with the pt's pcp who agreed. His wt on discharge was 89kg. . #Difficulty ambulating: By history, the patient has had difficulty with ambulation and balance for some time. PCP admitted patient to rehab facility for recent falls. Pt was using a 4-pronged cane at home. Wife did not think patient significantly improved after d/c from rehab. No apparent neurologic deficiencies on exam, and he denied ___ weakness. The patient was evaluated by ___ and placed on fall precautions. It was determined that the pt was safe to return home with home ___. . #Confusion: The patient's wife reported that the patient was mildly confused the night before admission, and was found sitting on edge of bed waiting to use bathroom. After using bathroom, patient was confused how to use sink. The patient answered questions appropriately during H&P. CTHead performed on admission did not demonstrate an organic process. No recent trauma during falls were reported. No facial droop, weakness, or slurred speech was found. The patient was afebrile, denied urinary symptoms, and had no signs of PNA, thus not likely infectious. No anticholinergic meds or benzos were prescribed. It was thought that the patient might have had some residual delirium given age and recent stay in rehab facility versus dementia. During the course of his stay, the nursing staff attempted to normalize sleep/wake cycle, provide orientation, reduce loud noises and unnecessary lighting. His confusion quickly resolved during this hospitalization as his clinical status improved with diuresis. . Chronic Issues: #Atrial Fib: The patient was found to be in AFib on EKG at admission and had a history of such in his medical record. He had been on warfarin 3mg daily. He was rate controled with atenolol at home. His INR on admission was appropriate and he remained w/in goal range during this hospital course. It was discussed with his pcp about discontinuing this medication considering his recent falls and risk of bleeding with anticoagulation. His pcp agreed but ultimately determined to continue anticoagulation for the time being and readdress this issue at his next f/u appt. Transitional: 1. f/u appointment with PCP for medication ___ 2. INR check at regularly scheduled intervals as no change was made to coumadin dosing 3. F/u with pcp about incidental ___ lobe hypodensity seen on CT of head. A letter was sent to pcp informing him of this finding. 4. f/u appt with out pt cardiologist Medications on Admission: Lasix 20mg daily Lisinopril 2.5mg daily Tamsulosin 0.4mg daily Atenolol 6.25mg QOD Digoxin 0.125mcg daily except SUN/WED Warfarin 3mg daily Citracal D 315/200mg take two tabs bid preservision 1 tab daily senna 1 tab bid prn Discharge Medications: 1. Furosemide 40 mg PO DAILY hold for sbp <95 RX furosemide 20 mg 2 Tablet(s) by mouth daily Disp #60 Tablet Refills:0 2. Lisinopril 2.5 mg PO DAILY hold for sbp < 100 3. Tamsulosin 0.4 mg PO HS hold for sbp < 100 4. Digoxin 0.125 mg PO 5X/WEEK (___) 5. Warfarin 3 mg PO DAILY16 6. Calcium Carbonate 500 mg PO BID 7. Vitamin D 400 UNIT PO BID 8. PreserVision NF* (vit C-vit E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 226-200-5 mg-unit-mg Oral daily 9. Senna 2 TAB PO DAILY:PRN constipation Patient may refuse. Hold if patient has loose stools. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute Congestive Heart failure exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___, You were hospitalized with complaints of SOB and difficulty walking. Upon admission, it was thought that you had too much water in your body, most likely because of your heart failure. We gave you medications (diuretics) to reduce the amount of water in your body. This has helped to make it easier to breathe. We have increased the dose of your diurectic medication in order to help decrease the amount of fluid build up in your body. We have also stopped one of your blood pressure medications as well because your blood pressure was low on admission. Since stopping this medication your blood pressure has improved. The following changes were made to your medications: STOP: Atenolol INCREASE: Furosemide to 40mg daily Please make sure to weigh yourself daily and call your doctor if you weight increases by more than 3lbs. Also make sure to try and limit your fluid intake to a maximum or 2L per day. Followup Instructions: ___
10062617-DS-8	10,062,617	28,840,277	DS	8	2123-07-03 00:00:00	2123-07-03 18:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sulfur dioxide Attending: ___. Chief Complaint: Malaise/Fatigue with 2 recent falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old male with history of HFrEF (EF 25%-30% on TTE ___, sick sinus syndrome s/p pacemaker, paroxysmal supraventricular tachycardia, and chronic dermatitis on low-dose oral steroid who presents for malaise in the setting of two recent falls. At baseline, patient is able to ambulate with a cane and with the help of his wife. Has aide to assist with activities of daily living. Patient reports being in his usual state of health until he fell two weeks prior from losing his grip on the refrigerator door. Three days ago, had mechanical fall due to missed handle grip on walking down stairs, falling backwards onto lower back with headstrike and possible LOC. Prior to these two episodes, did not have falls since ___. Patient presented to ___ ED on ___ ___nd an episode of worsening bilateral arm tremor. Head CT was negative for intracranial bleed and patient was discharged to home. Patient woke up this morning with temperature of 99.4 measured at home and generalized weakness. Has chronic intermittent cough for past few months. No nausea/vomiting, diarrhea, chest pain. No sick contacts, recent travels. No episode of swallowing with coughing fit although patient has dysphagia at baseline. In the ED, initial vitals: 100.2 60 88/51 16 94%RA Labs were significant for WBC 9.6 (77.9N) Hgb 10.5 Na 128 GFR 62 BUN 23 Cr 1.1 Imaging showed new opacity at the right medial lung base concerning for pneumonia In the ED, he received 1g Tylenol, 1L NS, and vanc/zosyn. Vitals prior to transfer: 98.2 61 104/53 15 96%RA On arrival to the floor, patient was feeling well and asymptomatic except for mild, chronic, intermittent, non-productive cough. Past Medical History: HFrEF (EF 25%-30% on TTE ___ Sick sinus syndrome status post pacemaker placement h/o pacemaker lead failure Aortic insufficiency Thoracic aortic aneurysm Paroxysmal supraventricular tachycardia Hypertension Diverticulosis Colonic adenoma Benign prostatic hypertrophy Osteopenia Dry macular degeneration Subclinical hypothyroidism Obstructive sleep apnea Unsteady gait with h/o syncope and falls Stage 3 CKD Venous stasis Tremor Social History: ___ Family History: Brother with lung cancer. Mother with stroke. Son with type 1 diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.4 104/52 65 17 98%RA GEN: Alert, appears younger than stated age, lying in bed, in NAD HEENT: PEERL, arcus senilis, EOMI, MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD, JVP at collarbone at 45 degrees PULM: Generally CTA b/l with dullness at the R base COR: Distant HR, RRR, (+)S1/S2, no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema, chronic venous stasis changes on hands and legs, no ulcers NEURO: A&O x3 (name, hospital, month and day), CN II-XII grossly intact, motor function grossly normal, high frequency, low amplitude resting tremor on R forearm which extinguishes with intention DISCHARGE PHYSICAL EXAM: Vitals: 98.8 98.8 104/58 59 18 94%RA 111/47 -> 109/47 (lying down to sitting) GEN: Alert, appears younger than stated age, lying in bed, in NAD HEENT: PEERL, arcus senilis, EOMI, MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD, JVP at collarbone at 45 degrees PULM: Rhonchi at bases bilaterally COR: Distant HR, RRR, (+)S1/S2, no m/r/g ABD: Soft, non-tender, non-distended, +BS GU: no foley EXTREM: Warm, well-perfused, no edema, chronic venous stasis changes on hands and legs, no ulcers NEURO: AOx3, high frequency, low amplitude resting tremor on R forearm which extinguishes with intention Pertinent Results: On admission: ___ 07:30AM BLOOD WBC-9.6# RBC-3.13* Hgb-10.5* Hct-30.2* MCV-97 MCH-33.5* MCHC-34.8 RDW-13.5 RDWSD-47.5* Plt ___ ___ 07:30AM BLOOD Neuts-77.9* Lymphs-15.6* Monos-5.8 Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.48* AbsLymp-1.50 AbsMono-0.56 AbsEos-0.01* AbsBaso-0.02 ___ 07:30AM BLOOD ___ PTT-26.9 ___ ___ 07:30AM BLOOD Glucose-107* UreaN-23* Creat-1.1 Na-128* K-4.9 Cl-93* HCO3-26 AnGap-14 ___ 07:30AM BLOOD ALT-15 AST-20 AlkPhos-114 TotBili-1.4 ___ 07:30AM BLOOD cTropnT-0.02* ___ 07:30AM BLOOD proBNP-699 ___ 07:30AM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.1 Mg-1.9 ___ 07:30AM BLOOD Osmolal-265* ___ 07:30AM BLOOD Digoxin-0.6* ___ 07:44AM BLOOD Lactate-1.8 ___ 08:12AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:12AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 08:12AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 ___ 08:12AM URINE Mucous-RARE ___ 08:40AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE In the interim: ___ 06:40AM BLOOD WBC-5.2 RBC-2.95* Hgb-9.7* Hct-29.4* MCV-100* MCH-32.9* MCHC-33.0 RDW-13.5 RDWSD-49.0* Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-132* K-3.9 Cl-100 HCO3-24 AnGap-12 ___ 06:40AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 ___ 03:00PM URINE Hours-RANDOM Creat-68 Na-80 K-59 Cl-74 ___ 03:00PM URINE Osmolal-443 On discharge: ___ 09:11AM BLOOD WBC-6.2 RBC-2.91* Hgb-9.6* Hct-28.7* MCV-99* MCH-33.0* MCHC-33.4 RDW-13.4 RDWSD-48.8* Plt ___ ___ 09:11AM BLOOD Plt ___ ___ 09:11AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-132* K-3.7 Cl-100 HCO3-24 AnGap-12 Microbiology: Blood cx ___ x2): No growth to date Urine cx (___): Mixed bacterial flora (>=3 colony types), consistent with fecal contamination Imaging: CXR (___): New opacity at the right medial lung base is concerning for pneumonia Brief Hospital Course: Mr. ___ is a ___ year-old male with history of HFrEF (EF 25%-30% on TTE ___, chronic dysphagia with aspiration, sick sinus syndrome s/p pacemaker, and dermatitis on chronic ___ oral prednisone presenting with weakness/lethargy in the setting of ___nd found to have RML consolidation on CXR concerning for CAP vs aspiration pneumonia treated with 5 day course of Levaquin 750mg. #Malaise and opacity on CXR: Patient presented with malaise and CXR concerning for consolidation. Most likely etiology was CAP (no recent inpatient admission, no exposure to SNF/LTAC/HD) vs aspiration (history of dysphagia). Patient was given IV vanc/zosyn in the ED and transitioned to PO levofloxacin 750mg daily with plans for course of 5 days (last dose ___. During hospitalization, patient remained afebrile with no leukocytosis and was hemodynamically stable. Patient was discharged on ___ to rehab to complete levofloxacin course. # Compensated HFrEF: The patient has HFrEF (EF ___. BNP was not elevated and patient remained euvolemic on exam, without ___ edema, JVP elevation or hypoxia. Digoxin 125mcg ___ was continued. Discharge weight 164 pounds per bed weight. # Hyponatremia: Patient presented with sodium 128 that was below baseline 130-135. On HD2, hyponatremia improved to 132 with good POs. No mental status changes. No recent vomiting/diarrhea. Not on diuretics. Most likely caused by poor PO intake. # Falls: Two recent mechanical falls. Previous fall in ___. Head CT at ___ on ___ negative for intracranial bleed. ___ evaluation recommended rehab. CHRONIC ISSUES: # Tremor: Patient has chronic resting tremor high frequency, low amplitude resting tremor on R forearm which extinguishes with intention. Given patient's long history of resting tremor, may consider outpatient neurology evaluation. # Dysphagia: SLP recommended nectar thick and soft solids with recognition of aspiration with any PO intake. # Sick sinus syndrome s/p pacemaker: recently checked in ___. No device issues noted. # Chronic normocytic anemia: Patient has hct of ___ at baseline. No melena or hematochezia. Patient did not have evidence of active bleeding and hct remained stable during hospitalization. # CKD stage 3: Cr continued to be 0.9-1.1 at baseline. Levofloxacin dosed q48hrs per renal dosing. TRANSITIONAL ISSUES: - Levofloxacin course to end ___ - Consider outpatient Neurology consultation for dysphagia, weakness, tremulousness and recurrent falls - Code: DNR, okay to intubate per MOLST - Contact: ___, wife/HCP, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Digoxin 0.125 mg PO 4X/WEEK (___) 3. Docusate Sodium 100-200 mg PO BID 4. Ipratropium Bromide Neb 1 NEB IH Q8H 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Senna 8.6 mg PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. PreserVision AREDS (vitamins A,C,E-zinc-copper) 0 mg ORAL DAILY 10. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID 11. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 13. Betamethasone Dipro 0.05% Cream 1 Appl TP BID rash 14. Betamethasone Valerate 0.1% Cream 1 Appl TP BID itching 15. permethrin 5 % topical QPM infection 16. PredniSONE 5 mg PO DAILY Tapered dose - DOWN Discharge Medications: 1. Levofloxacin 750 mg PO Q48H Duration: 4 Days Take one more dose on ___ to complete a ___. PredniSONE 5 mg PO DAILY 3. Ipratropium Bromide Neb 1 NEB IH Q8H 4. Docusate Sodium (Liquid) 100 mg PO BID 5. PreserVision AREDS (vitamins A,C,E-zinc-copper) 0 mg ORAL DAILY 6. permethrin 5 % topical QPM infection 7. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY 8. Aspirin 81 mg PO DAILY 9. Betamethasone Dipro 0.05% Cream 1 Appl TP BID rash 10. Betamethasone Valerate 0.1% Cream 1 Appl TP BID itching 11. Digoxin 0.125 mg PO 4X/WEEK (___) 12. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO BID 15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 16. Senna 8.6 mg PO BID 17. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Pneumonia Secondary: Falls, compensated heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___: You were recently admitted to ___ for pneumonia. We started you on an antibiotic called Levofloxacin (Levaquin) which you should take on ___ to complete your treatment. Because you have been falling recently, we asked our physical therapist to evaluate you and they recommended that you be discharged to rehabilitation ___ to work on your strength and balance. Please take your medications as prescribed and follow up with your physicians as below. We wish you the best, Your ___ care team Followup Instructions: ___
10062981-DS-4	10,062,981	24,520,789	DS	4	2191-02-08 00:00:00	2191-02-13 21:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right hip pain; altered mental status. Major Surgical or Invasive Procedure: none. History of Present Illness: Pt is a ___ PMHx ___, HTN, HLD, and recent diagnosis of Stage IV HSCLC with brain mets s/p Cyberknife to the brain. He was admitted to ___ earlier this month after a 2 week history of nausea and vomiting as well as ataxia. MRI showed numerous brain masses c/b edema and midline shift, most c/w metastatic process for a thoracic primary. Oncologic work-up resulted in diagnosis of primary lung adenocarcinoma, TTF-1 and Napsin positive, negative for p63. He was discharged on a decadron taper (completed on ___, and also recently completed treatment for pan-sensitive E.coli UTI with amoxicillin (completed on ___. He completed cyberknife to the brain and had been improving at rehab. He was most recently see by Dr. ___ on ___ per the clinic note, they discussed that chemotherapy would be palliative, not curative. Initiation of chemotherapy was deferred pending his recovery at rehab and improvement of his performance status. The tentative plan is for eventual chemo with ___ q3 weeks. Since going to rehab he and his report that he was diagnosed with a UTI and was given a course of abx though does not remember the name of the antibiotics. He was apparently making tremendous progress at rehab however one week ago, he and his wife noted that he was very fatigued and tired. This progressively worsened and on ___ while in the bathroom he feel on to his RLE. He remembers the entire event and attributes his fall to being fatigued and weak. Denies chest pain/SOB, nausea/vomiting/diarrhea. Over the weekend he complained of right hip pain. Given symptoms he was brought the ED for evaluation. In the ED, initial VS were 97.9, 86, 129/54, 12, 98% on RA. Physical exam felt to be c/w pelvic fracture. Labs were notable for Cr 1.4 (baseline 1.2-1.4), LFTs wnl, WBC 7, Hgb/Hct 8.8/26.7 (baseline ___, Plt 138. Lact 1.0. Plain film of the hip/pelvis showed no fracture. UA notable for large leuk, + nitr, 100 prot, > 182 WBC, and many bacteria. CT abdomen/pelvis showed large soft tissue lesion c/w bony metastasis involving the right acetabulum with cortical breakthrough with high-risk for fracture. Head CT showed just mildly increased edema of the R cerebellum. Ortho was consulted who recommended non-operative management. Patient recent diagnosed with UTI that grew pansensitive Ecoli. The patient was given 1gm IV ceftriaxone in the ED prior to transfer. On arrival to the floor, patient reports improved pain though still has mild pain. Overall feels weakened but not confused. REVIEW OF SYSTEMS: 10 point review of systems was reviewed and otherwise negative. PAST ONCOLOGIC HISTORY Past Medical History: hyperlipidemia hypertension Type II Diabetes possible ___ Diabetic Neuropathy Kidney disease NOS BPH s/p TURP s/p laser eye surgery for retinopathy Social History: ___ Family History: No family history of cancer. Brother deceased at age ___ of unknown cause - had heart disease. Father deceased at age ___ due to MI. Physical Exam: ADMISSION: VS: 164.2lbs 98.1 106/60 92 18 97% RA Gen: chronically ill appearing NAD HEENT: dry MM EOMI PERRL CV: nl s1s2 RRR Pulm: CTAB Abd: abd, soft NT ND +BS Ext: no edema, Tender on movement of right hip Skin: no clear lesions Neuro: AAOx3 Psych: calm DISCHARGE: VS: 98.2, 127/66, 81, 17, 99% RA Is/Os: ___ last shift; ___ last 24 hours FSBG: 67 this am; 95-174 last 24 hours Gen: NAD, laying comfortably in bed HEENT: NC/AT, MM dry, but no petechiae or oropharyngeal lesions CV: RRR, no m/r/g Pulm: CTAB no fair air movement throughout; no wheezes, rhonchi, or crackles Abd: abd, soft NT, +BS Ext: well perfused, warm, no edema. Skin: dry, no rash Neuro: AAOx3, baseline resting tremor most noticeable in R hand Pertinent Results: ADMISSION LABS: --------------- ___ 11:53AM BLOOD WBC-7.0 RBC-3.25* Hgb-8.8* Hct-26.7* MCV-82 MCH-27.1 MCHC-33.0 RDW-15.8* RDWSD-46.7* Plt ___ ___ 11:53AM BLOOD Neuts-84.7* Lymphs-6.3* Monos-6.3 Eos-2.0 Baso-0.3 Im ___ AbsNeut-5.96 AbsLymp-0.44* AbsMono-0.44 AbsEos-0.14 AbsBaso-0.02 ___ 11:53AM BLOOD Glucose-69* UreaN-26* Creat-1.4* Na-140 K-4.5 Cl-102 HCO3-29 AnGap-14 ___ 11:53AM BLOOD ALT-16 AST-21 AlkPhos-93 TotBili-0.6 DISCHARGE LABS: --------------- ___ 06:40AM BLOOD WBC-7.2 RBC-3.08* Hgb-8.3* Hct-25.5* MCV-83 MCH-26.9 MCHC-32.5 RDW-17.5* RDWSD-50.0* Plt ___ ___ 06:50AM BLOOD Glucose-67* UreaN-29* Creat-1.6* Na-138 K-4.5 Cl-103 HCO3-27 AnGap-13 ___ 06:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 PERTINENT STUDIES: ----------------- ___ 01:05PM URINE RBC-7* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 ___ 06:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 MICRO: ------ ___ Urine Cx ESCHERICHIA COLI AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: -------- ___ MRI Brain 1. Mixed response with interval decrease in the metastatic lesions to the right frontal, left frontal, left parietal lobes and left cerebellar hemisphere, unchanged metastatic lesions in the right cerebellar hemisphere and right parietal lobe, and a new metastatic lesion in the left postcentral gyrus. 2. No evidence of leptomeningeal disease. 3. Unchanged right parietal lobe lesion with susceptibility and faint surrounding enhancement, which may represent a cavernoma. ___ CT ABD/PELVIS 1. Large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough, which is high-risk for fracture. 2. No hematoma or other acute findings. ___ CT HEAD W/O CONTRAST C/w MRI dated ___. Vasogenic edema in the right frontal lobe and right cerebellum secondary to known metastatic lesions. Mildly increased edema in the right cerebellum. No hemorrhage. ___ CXR FINDINGS: AP upright and lateral views of the chest provided.Again seen is a large mass projecting over the right upper lobe measuring 12.5 x 10 cm, grossly unchanged in size from prior study. Remainder of the right lung is clear. Left lung is clear. No large effusion or pneumothorax. Heart size remains within normal limits. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: Large mass in the right upper lung. Otherwise unremarkable. Brief Hospital Course: ___ PMHx ___, HTN, HLD, and recent diagnosis of Stage IV HSCLC with brain mets s/p Cyberknife to the brain who presented from rehab status post fall with confusion found to have large soft tissue lesion consistent with bony metastasis involving the right acetabulum with cortical breakthrough, which is high-risk for fracture of the hip, and persistent E. Coli UTI. # R hip pain/R Acetabular Metastatic Lesions: Secondary to bony metastasis from known primary stage IV lung adenocarcinoma. He was evaluated by orthopedic surgery in the ER, who felt that the patient was at high risk for fracture, but recommended he remain weight bearing as tolerated. Surgery was not offered. He received palliative XRT for a total of 5 fractions with the last session on ___. Pain was managed with standing tylenol and PRN oxycodone. He continued to work with physical therapy during his stay with a goal of home discharge. # UTI: Patient developed his first UTI while at rehab, which was reportedly a pan-sensitive E. coli treated with augmentin for an unknown duration. He was again noted to have a UTI upon presentation to the ED. It is unclear if he ever cleared his previous infection. Cultures again notable for pan-sensitive E. Coli. Rectal Exam not concerning for prostatitis. He received five days of IV ceftriaxone and ultimately cleared his urine, at which time he was transitioned to PO bactrim for a total of 14 days of antibiotics for complicated UTI. Prior to discharge, due to rising Cr, he was transitioned to PO ciprofloxacin with course to be completed on ___. #Acute Toxic Metabolic Encephalopathy: The patient presented with AMS without clear etiology. Differential included mental status change ___ urinary infection, pain from hip lesion, and worsening brain disease with edema noted on CT and MRI showing mixed response to radiation with new lesion in postcentral gyrus, especially in setting of recent steroid taper. Patient also with known ___ Disease, which was likely contributing. He was started on dexamethasone 2mg BID, which was tapered to 2mg daily. Concurrently, his UTI was treated and his mental status improved. He was discharged on dexamethasone 2mg PO daily with final decision regarding duration per neuro-onc follow-up. # Stage IV NSCLC: Per outpatient records, the patient was to start chemotherapy after his performance status improved with rehab. This re-admission further delayed chemotherapy and goals of care ongoing at time of discharge. On discharge, he was to follow up with Atrius Oncology for further management of his cancer. CHRONIC ISSUES: ========================== # ___ disease: The patient was continued on his home dose of sinemet. # T2DM: The patient was continued on lantus and HISS as well as a diabetic diet. Adjustments were made to regimen in setting of poor PO intake and then when steroids were initiated. Please refer to discharge medications for insulin regimen at time of discharge. # HLD: He was continued on his home atorvastatin. # CKD: The patient's Cr was monitored closely during this admission and prior to discharge, he did have rise in Cr ___ bactrim. He was switched to PO cipro for this reason. He was to have repeat Cr drawn at next follow-up. TRANSITIONAL ISSUES: ===================== - Will need to take Cipro 500 BID until ___ - Please repeat GFR at next follow up and evaluate for any new confusion (potential side effect of Cipro) - Discharged on 2mg dexamethasone/day until Neuro-Onc follow up - Atrius Oncology Follow up - Brain Metastases: The question new metastasis in the left postcentral gyrus needs to be followed up. # CODE: DNR/DNI # EMERGENCY CONTACT/HCP: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Carbidopa-Levodopa (___) 1.5 TAB PO Q8AM AND Q12PM 3. Carbidopa-Levodopa (___) 1 TAB PO Q5PM 4. Donepezil 5 mg PO QHS 5. Sertraline 25 mg PO DAILY 6. Vitamin D 5000 UNIT PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Omeprazole 40 mg PO DAILY 9. QUEtiapine Fumarate 50 mg PO QHS 10. Senna 17.2 mg PO QHS 11. TraZODone 50 mg PO QHS 12. FoLIC Acid 1 mg PO DAILY 13. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Artificial Tears 2 DROP BOTH EYES TID 15. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Artificial Tears 2 DROP BOTH EYES TID 2. Atorvastatin 40 mg PO QPM 3. Carbidopa-Levodopa (___) 1.5 TAB PO Q8AM AND Q12PM 4. Carbidopa-Levodopa (___) 1 TAB PO Q5PM 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Senna 17.2 mg PO QHS 10. Sertraline 25 mg PO DAILY 11. Vitamin D 5000 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q8H pain 13. Dexamethasone 2 mg PO DAILY RX dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth Q4 Disp #20 Tablet Refills:0 15. Polyethylene Glycol 17 g PO TID RX polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth twice a day Refills:0 16. Rolling Walker Diagnosis - R53.81 Prognosis - good Length of time - 13mo 17. Ciprofloxacin HCl 500 mg PO Q12H last day ___ RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #11 Tablet Refills:*0 18. Glargine 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary: bony metastasis of right acetabulum; urinary tract infection; encephalopathy. secondary: Stage IV NSCLC; ___ Disease; Diiabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted to the hospital after falling while you were at rehab. Imaging revealed that tumor had spread to your hip. You were evaluated by our orthopedic surgeons who did not feel that surgery was indicated. You were treated with radiation therapy to help improve your pain. You were also restarted on steroids to prevent brain swelling from your known tumors. Additionally, you were found to have a urinary tract infection and treated with antibiotics. Please follow up with all scheduled appointments and continue taking all medications as prescribed. If you develop any of the danger signs below, please contact your health care providers or go to the emergency room immediately. PLEASE SEE THAT YOUR NEW INSULIN DOSE IS LOWER THAN BEFORE We wish you the best. Sincerely, Your ___ team Followup Instructions: ___
10063534-DS-14	10,063,534	26,199,018	DS	14	2151-05-29 00:00:00	2151-05-30 07:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: tamponade Major Surgical or Invasive Procedure: pericardiocentesis ___ History of Present Illness: ___ y/o M w/hx CHF (EF 35%), a fib on coumadin (last INR 2.8 two days ago), s/p pacemaker for bradycardia presenting from rehab with left sided chest pain x4 days, found to have pericardial effusion with tamponade physiology. Patient was recently admitted from ___ with c/o intractable cough, was diagnosed with HCAP and COPD exacerbation, was treated with Vanc/ceftaz and prednisone with improvement, was discharged to rehab. CT imaging during hospitalizaiton incidentally showed bronchopulmonary process concerning for pna vs. neoplasm with interval f/u recommended. Was working with ___ last few days when noticed onset of left sided chest pain, located in the nipple area, describes as dull/nonradiating, worse with exertion and relieved by rest. Was associated with mild dyspnea. No c/o n/v/diaphresis, no palpitations, no dizziness/lightheadedness or syncope. Patient first noticed pain 4d prior to admission, persisted and was transferred to ED tonight. He remained afebrile at rehab with BPs in the 110s. . In the ED, initial vitals: 8 97.6 68 97/51 20 100% ra. Bedside ultrasound showed large pericardial effusion. Patient was tachypneic and placed on 4L 02 NC. Labs were notable for chem-7 with potassium 5.7, Bun/Cr of 61/1.8, INR 4.1, trop 0.08, CBC with H/H 9.1/___.9. u/a showed large lek, nit neg, few bac. CXR showed severe cardiomegaly. Patient received an a-line, 3L NS and 2U FFP. . On arrival to the floor, patient c/o mild left sided chest discomfort, improved from prior. Not c/o sob, dyspnea, lightheadedness. Otherwise feels well. He endorses the above history. Says he is wheelchair bound due to 'his legs', endorses 45 degree orthopnea at baseline. . REVIEW OF SYSTEMS On review of systems, he denies any fevers/chills, no n/v/diarrhea or constipation. No prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism. All of the other review of systems were negative. . Cardiac review of systems is notable for abscence of palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: ___ ___ RV pacer 3. OTHER PAST MEDICAL HISTORY: Atrial fibrillation on coumadion Sick sinus s/p pacemaker single chamber RB ___ (___) CHF with EF 35% (___) Asthma/COPD Obesity Frequent/chronic UTI ESBL Diastolic CHF OSA requiring BIPAP Stage III CKD (b/l Cr 1.5) Suprapubic catheter since ___ (urethral stenosis/BPH) Bladder diverticulum Nec Fasc Lipodermatosclerosis Venous stasis c/b ulcers OA of the forearm HTN/HLD Traumatic finger amputation Spinal stenosis BPH Thrombocytopenia Social History: ___ Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM VS: T96.5 119/66 65 16 100% 4L General: awake, alert, orientedx3, NAD HEENT: EOMI, PERRLA, OMM no lesions Neck: supple CV: RRR, distant heart sounds, no m/r/g appreciated Lungs: course breath sounds bilaterally with crackles LLB, no wheezing Abdomen: large, soft, nontender, BS+, no r/g/r GU: suprapubic catheter in place Ext: nonpitting edema in ___ b/l, skin changes consistent with elephantiasis Neuro: CN II-XII intact, strength ___ in UE and ___ b/l Skin: ___ with changes consistent with elephantiasis . DISCHARGE EXAM General: awake, alert, orientedx3, NAD HEENT: mm moist Neck: supple, JVD about 10 cm. CV: RRR, distant heart sounds, no m/r/g appreciated Lungs: tubular BS, no wheezes Abdomen: large, soft, nontender, BS+, no r/g/r Ext: nonpitting edema in ___ b/l, thickened skin. Neuro: CN II-XII intact, strength ___ in UE and ___ b/l Skin: coccyx with tiny open area, covered with mepiplex. ___ with 1cm open area. Pertinent Results: ADMISSION LABS ___ 11:30PM GLUCOSE-114* UREA N-55* CREAT-1.4* SODIUM-141 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 ___ 11:30PM CALCIUM-7.4* PHOSPHATE-3.9 MAGNESIUM-2.3 ___ 11:30PM ___ PTT-45.8* ___ ___ 08:23PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG ___ 08:23PM URINE RBC-12* WBC-23* BACTERIA-FEW YEAST-NONE EPI-0 ___ 08:23PM URINE HYALINE-39* ___ 08:23PM URINE MUCOUS-RARE ___ 07:26PM LACTATE-1.0 ___ 07:00PM GLUCOSE-108* UREA N-61* CREAT-1.8* SODIUM-138 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-33* ANION GAP-13 ___ 07:00PM cTropnT-0.08* ___ 07:00PM WBC-7.1# RBC-3.53* HGB-9.1* HCT-29.9* MCV-85 MCH-25.8* MCHC-30.5* RDW-15.5 ___ 07:00PM NEUTS-67.4 ___ MONOS-6.4 EOS-1.4 BASOS-0.5 ___ 07:00PM ___ PTT-49.5* ___ . PERTINENT RESULTS ___ 03:00PM OTHER BODY FLUID TotProt-5.9 Glucose-27 LD(LDH)-620 Amylase-20 Albumin-2.6 ___ 03:00PM OTHER BODY FLUID WBC-4200* Hct,Fl-24* Polys-39* Lymphs-55* Monos-5* Eos-1* . DISCHARGE LABS ___ 05:50AM BLOOD WBC-5.3 RBC-3.55* Hgb-9.4* Hct-30.3* MCV-85 MCH-26.5* MCHC-31.1 RDW-16.4* Plt ___ ___ 05:50AM BLOOD ___ ___ 05:50AM BLOOD Glucose-91 UreaN-26* Creat-1.1 Na-142 K-4.3 Cl-98 HCO3-41* AnGap-7* . MICRO ___ 3:00 pm FLUID,OTHER PERICARDIAL FLUID. . GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. . FLUID CULTURE (Final ___: NO GROWTH. . ANAEROBIC CULTURE (Preliminary): NO GROWTH. . ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. . ACID FAST CULTURE (Preliminary): . FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . . REPORTS . ___HEST W/O CONTRAST There are two nodules within the right middle lobe measuring 6 mm (5:181) and 4 mm (5:188) respectively. There are also pleural-based nodules within the right middle and lower lobes measuring 4 mm (5:175) and 6 mm (5:166) respectively. There are moderate-sized bilateral pleural effusions. There is complete atelectasis of the left lower lobe with partial atelectasis of the right lower lobe, likely secondary to compression from the effusions. . There is a small pericardial effusion. A single-chamber pacemaker is noted with its tip in the right ventricle. There is mild cardiomegaly. Multiple subcentimeter mediastinal lymph nodes are noted and are likely reactive. No axillary adenopathy. The thyroid gland is unremarkable. . The visualized upper abdominal viscera is unremarkable. Multilevel degenerative change is noted within the lower thoracic and upper lumbar spine. Osseous structures are otherwise unremarkable. . IMPRESSION: . 1. Multiple subcentimeter nodules as described within the right middle and lower lobes, with the largest measuring 6 mm. Correlation with the previous imaging would be of benefit to ensure stability. Follow-up CT in ___ months is recommended as per ___ society recommendations. . 2. Moderate-sized bilateral pleural effusions. . 3. Small pericardial effusion. . ___ Imaging CHEST (PORTABLE AP) IMPRESSION: New bilateral pleural effusions and moderate pulmonary edema. Left retrocardiac opacity may reflect atelectasis or pneumonia in the correct clinical setting. . ___ Cardiovascular ECHO . There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. . ___ Cardiovascular ECHO . LV systolic function appears depressed. Right ventricular chamber size is normal. with borderline normal free wall function. There is abnormal septal motion/position. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . IMPRESSION: Depressed biventricular function. Small amount of pericadial fluid seen posterior to the left ventricle. Abnormal septal motion suggestive of effusive/constrictive physiology. No evidence of tamponade. . Cardiovascular Report Cardiac Cath Study Date of ___ . COMMENTS: 1. Pericardiocentesis was performed via the subxiphoid approach. 850 mL of serosanguinous fluid was drained. The opening pericardial pressure was noted to be 16 mmHg. after fluid removal the pericardial pressure was 0 mmHg. . FINAL DIAGNOSIS: 1. Tamponade physiology 2. Successful pericardiocentesis . ___ Cardiovascular ECHO LV systolic function appears depressed. Right ventricular chamber size is normal. with borderline normal free wall function. There is abnormal septal motion/position. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . IMPRESSION: Depressed biventricular function. Small amount of pericadial fluid seen posterior to the left ventricle. Abnormal septal motion suggestive of effusive/constrictive physiology. No evidence of tamponade. . Compared with the prior study (images reviewed) of ___, both ventricles are larger in size. There is no evidence of tamponade physiology on the current study. . ___ Cardiovascular ECHO Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. LV systolic function appears depressed (ejection fraction ? 30 percent). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a large pericardial effusion. The effusion appears circumferential. There is intermittent right ventricular diastolic collapse, consistent with impaired fillling/early tamponade physiology. . Compared with the prior study (images reviewed) of ___ a large circumferential pericardial effusion, with echocardiographic signs of early cardiac tamponade, is present. Contractile function of the right and left ventricles appears impaired. . ___ Cytology PERICARDIAL FLUID Pericardial effusion: . NEGATIVE FOR MALIGNANT CELLS. . Lymphocytes, neutrophils, histiocytes and red blood cells. Brief Hospital Course: ___ y/o M w/hx CHF (EF 35%), a fib on coumadin (last INR 2.8 two days ago), s/p pacemaker for bradycardia presenting from rehab with left sided chest pain x4 days, found to have pericardial effusion with tamponade physiology . # Pericardial effusion/tamponade: unclear etiology although was noted on prior ___ hospitalization with possibility of lung malignancy noted on CT scan. Patient underwent ECHO with evidence of tamponade in the emergency room. He was admitted to the ICU and taken for pericardiocentesis on ___. Pericardial fluid studies were negative for maligancy. Of note, repeat CT chest demonstrated persistent subcentimeter nodules sin the right middle and lower lobes, recommendation for interval f/u CT scan in ___ months. Patient underwent surveillence ECHOs post pericardiocentesis that did not show reaccumulation of fluid and was discharged to rehab hemodynamically stable. . # Afib: patient was persistently vpaced in the ___ during admission, underlying rhythmn was afib. INR was supratherapeutic on arrival, patient received multiple units FFP as well as 5mg PO vitamin K to facilitate normalization of INR given need for emergent pericardiocentesis. INR drifted down to therapeutic range. He was restarted on coumadin and continued on metoprolol. . # Acute on Chronic CHF: EF 30% in ___ as per recent d/c summ. On 120mg of lasix daily at home. Patient was noted to be mildly volume overloaded post-procedure lkely in the setting of fluid boluses and FFP. He was diuresed with 60 mg IV lasix at a time and his supplemental oxygen was weaned. He was transitioned to daily torsemide for continued diuresis. . # CKD: stage III, Cr on presentation was 1.8 and decreased to ___ s/p drainage of effusion and diureses with lasix. Patient started on low-dose lisinopril. . # Asthma/COPD: continued albuterol/ipratropium nebs PRN . TRANSITIONAL ISSUES - patient needs repeat CT chest to evaluate for resolution of subcentimeter nodules in 6 months. - Pt will need an echo in a few weeks to check to see if the effusion is accumulating again Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 2.5 mg PO DAILY16 2. Furosemide 80 mg PO QAM 3. Furosemide 40 mg PO QPM 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Pravastatin 20 mg PO HS 7. DuoNeb NF (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation BID 8. Calcium Carbonate 500 mg PO QID:PRN stomach upset 9. Docusate Sodium 100 mg PO BID 10. Omeprazole 40 mg PO BID 11. Finasteride 5 mg PO DAILY 12. Gabapentin 100 mg PO HS 13. Vitamin D 1000 UNIT PO DAILY 14. Ferrous Sulfate 325 mg PO DAILY 15. Guaifenesin ___ mL PO Q6H:PRN cough 16. Fluticasone Propionate 110mcg 2 PUFF IH BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Finasteride 5 mg PO DAILY 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Gabapentin 100 mg PO HS 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Omeprazole 40 mg PO BID 7. Pravastatin 20 mg PO HS 8. Warfarin 1.5 mg PO DAILY16 9. Lisinopril 2.5 mg PO DAILY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Sarna Lotion 1 Appl TP QID:PRN pruritis 12. Torsemide 40 mg PO DAILY 13. Calcium Carbonate 500 mg PO QID:PRN stomach upset 14. DuoNeb NF (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation BID 15. Ferrous Sulfate 325 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: pericardial effusion Acute on Chronic systolic heart failure Atrial fibrillation Hypertension Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, uses lift Discharge Instructions: It was a pleasure taking care of ___ at ___ ___ were admitted with chest pain and trouble breathing. A fluid collection was found around your heart and this was removed twice. An echocardiogram done on ___ did not show that the effusion was returning. ___ will need to have another echocardiogram in a few weeks to check again. There was no evidence of infection or cancer cells in the fluid. However, there are a few nodules that was noted on your chest CT scan that should be checked again in a few months. ___ coumadin level was high when ___ were admitted and the coumadin was held, then restarted. ___ INR level is at goal today. WE have given ___ additional lasix while ___ are here and torsemide was started instead of furosemide pills from now on. This medicine may work better for ___ than the torsemide. Weigh yourself every morning, call Dr. ___ weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. ___ weight at discharge is 251.6 pounds. Followup Instructions: ___
10063848-DS-2	10,063,848	21,345,067	DS	2	2177-08-06 00:00:00	2177-08-07 08:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex Attending: ___. Chief Complaint: abdominal pain, nausea, non-bilious emesis, abdominal distension Major Surgical or Invasive Procedure: ___: Exploratory laparotomy with enterotomies and small bowel resection with Dr. ___ ___ of Present Illness: ___ who presented with abdominal pain, nausea, distension, and multiple bouts of bilious, non bloody emesis. Her pain started the evening of ___, and was described as sharp, continuous, along mid abdomen. She had taken minimal PO and her pain worsened the day prior to presenting to the ER, which prompted her to seek treatment. She had not passed flatus since ___ and her last bowel movement was 3 days prior to presentation. She has had previous bowel obstructions that caused similar symptoms. She has a hx of an open cholecystectomy, appendectomy, and hysterectomy in the distant past as well as a LOA and SBR for an SBO in the ___. Her last SBO was in ___ at the time of her last surgery. Past Medical History: PMH: ___ disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in ___ (last SBO), right shoulder dislocation s/ p repair ___ Social History: ___ Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISSION PHYSICAL EXAM: Phx: 98.5 78 142/75 18 100% 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, distended, TTP along mid abdomen and right side, no rebound, + guarding, well healed lower abdominal, RLQ, and subcostal incisions Ext: No ___ edema, ___ warm and well perfused DISCHARGE PHYSICAL EXAM: VS: 97.4 PO 94 / 48 R Sitting 95 18 96 RA General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi. Decreased breath sounds at the bases. CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: soft, slightly tender in right quadrants, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Surgical scar midline with wound vac in place GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ ___ edema bilaterally Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS ============== ___ 11:45PM BLOOD WBC-12.2* RBC-4.89 Hgb-14.3 Hct-44.2 MCV-90 MCH-29.2 MCHC-32.4 RDW-15.2 RDWSD-50.3* Plt ___ ___ 11:45PM BLOOD Neuts-81.3* Lymphs-10.5* Monos-7.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.88* AbsLymp-1.28 AbsMono-0.92* AbsEos-0.03* AbsBaso-0.03 ___ 11:45PM BLOOD Plt ___ ___ 07:30AM BLOOD ___ PTT-27.7 ___ ___ 01:15PM BLOOD FacVIII-208* ___ 01:15PM BLOOD VWF AG-190* VWF ___ ___ 11:45PM BLOOD Glucose-130* UreaN-28* Creat-0.9 Na-142 K-4.1 Cl-99 HCO3-26 AnGap-21* ================ RADIOLOGY: ___ CT A/P: 1. High grade small bowel obstruction likely caused by adhesions -with the transition point at the level of the umbilicus within the right anterior abdominal wall with upstream dilation of small bowel loops which are fluid filled, with complete collapse of the distal small bowel loops . Surgical consultation is recommended. 2. No bowel perforations. ___ Portable abdomen: 1. Nonspecific bowel gas pattern without evidence of obstruction. 2. NG tube is visualized with the tip terminating at the gastric antrum. 3. Second catheter projecting over the superior mediastinum for which clinical correlation is recommended, as above. ___ CXR: Mild pulmonary edema and bibasilar atelectasis. ___ CT A/P: 1. Focal small bowel ileus involving loops of small bowel leading up to the new surgical anastamosis. No bowel obstruction as suggested by distal passage of orally ingested contrast beyond the anastomosis. 2. No extraluminal contrast seen to suggest anastomotic leak. 3. New bibasilar opacities and small bilateral pleural effusions. This likely represents atelectasis, aspiration pneumonitis is also a consideration. 4. Nonobstructing 5 mm left lower pole nephrolithiasis. ___ CXR: 1. Nasogastric tube terminates in the distal stomach. 2. Interval improvement of pulmonary edema and left basilar atelectasis. ___ CXR PICC: after advancement IMPRESSION: Right PICC line tip in mid SVC. ___: ECHO Suboptimal image quality - poor apical views. Ascites. Conclusions The left atrium is normal in size. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Ascites is present. ___: CXR IMPRESSION: The left-sided PICC line has the distal tip in the distal SVC. Heart size is prominent but unchanged. There is again seen a left retrocardiac opacity and atelectasis at the lung bases. There is coarsening of the bronchovascular markings without overt pulmonary edema. There are no pneumothoraces. ___: LUNG VQ scan: IMPRESSION: 1. Low likelihood of acute pulmonary embolism. Mild irregularity on perfusion images and moderate to severe defects on ventilation defects likely representing airways disease. 2. Right lung is foreshortened compared to the left lung which is not accounted for on chest radiograph ___. Chest radiograph is recommended to rule out a pleural effusion. ============================= MICROBIOLOGY: ___ 9:53 am URINE Source: Catheter. *FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 09:53AM URINE Blood-TR Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM Pathology:======================================== ___: small bowel resection - segment f small bowel with areas of ischemic necrosis, edema, acute inflammation, perforation, and extensive serosal adhesions - one margin (blue ink) with serositis - three lymph nodes, no malignancy identified DISCHARGE LABS: =============== ___ 04:03AM BLOOD WBC-9.2 RBC-2.91 Hgb-8.3* Hct-26.3* MCV-90 MCH-28.5 MCHC-31.6* RDW-15.8* RDWSD-52.3* Plt ___ ___ 04:03AM BLOOD Plt ___ ___ 04:03AM BLOOD Glucose-98 UreaN-12 Creat-0.5 Na-139 K-4.0 Cl-102 HCO3-27 AnGap-14 ___ 04:03AM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.7 Mg-2.2 Brief Hospital Course: Ms. ___ is a ___ female with a history of ___ ___ disease who was admitted to the hospital with a small bowel obstruction requiring urgent open laparotomy and found to have mild pulmonary hypertension. #SBO s/p Open Laparotomy. Ms. ___ was admitted to ___ ___ after evaluation in the Emergency Department where she was found to have a small bowel obstruction on CT in the setting of previous abdominal surgeries and prior SBO. She was admitted to the Acute Care Surgery service overnight ___ for conservative management of her high grade bowel obstruction with low threshold for operative intervention. A nasogastric tube was placed for decompression and she had bowel rest with IV hydration and serial abdominal exams. In the evening of the same day, she was taken to the operating room for exploration with an exploratory laparotomy and lysis of adhesions, small bowel resection after failure of conservative management. Findings include 2 areas of dense matted adhesions of knotted small bowel loops, more proximally in the mid ileum and about one foot distally in the LLQ bowel was adhered to the rectus muscle. There was chronic thickening of the bowel wall between these sections with matting and this section was resected and a primary anastomosis was completed. #Acute Hypoxic Respiratory Failure: Unclear etiology but could be multifactorial from a component of pulmonary HTN and volume overload. Patient was diuresed with 10 mg IV Lasix BID with resolution of hypoxia. #SVT #Pulmonary Hypertension: She was transferred to the SICU with hypotension and SVT. She received 5mg metoprolol IV for SVT, an NGT was placed, and she had a CT A/P with PO contrast. This imaging found focal small bowel ileus with no obstruction as oral contrast passed the anastomosis, with no evidence of extravasation to support a leak. However, she was seen to have bibasilar opacities and small bilateral pleural effusions and an incidental left lower pole nephrolithiasis. On ___, she had a transthoracic echocardiogram for SVT with findings that included demonstrated hyperdynamic left ventricle (EF 75%), hypertrophied right ventricle with abnormal septal motion consistent with right volume overload, as well as severe pulmonary artery hypertension and significant pulmonic regurgitation, moderate tricuspid regurgitation, with thickened valves and ascites. She was diuresed with IV 10 Lasix BID. Because of frequent episodes of SVT, she was started on metoprolol tartrate 12.5 mg po BID that was then switched to metoprolol succinate 25 mg. Right heart catherization showed mild pulmonary hypertension with no immediate need for inpatient treatment and follow up in clinic. #CAUTI: Urine culture shows pansensitive E. Coli. She received 2 days of Bactrim before switching to macrobid in the setting of diarrhea to complete a 7-day course. #Thrombocytopenia: Patient developed thrombocytopenia. Per hematology, this could be a side effect from Bactrim and her peripheral smear was negative for schistocytes or platelet clumping. She had a negative PF4. TRANSITIONAL ISSUES =================== -SVT: Patient was started on metoprolol succinate 25 mg daily. Patient could have had SVT because of stress of surgery. Please re-assess need. -Patient was evaluated for home O2 and met criteria due to desats to 88% with ambulation in the setting of pulmonary hypertension. -Pulmonary Hypertension: Patient will need to be followed up in pulmonary hypertension clinic in ___ months for possible treatment. # CONTACT: Name of health care proxy: ___ Relationship: Husband Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. LOPERamide 2 mg PO QID:PRN diarrhea RX loperamide 2 mg 2 mg by mouth four times a day Disp #20 Capsule Refills:0 2. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Acetaminophen ___ mg PO PRN Pain - Mild 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5.___, commode Please provide walker and commode. Diagnosis: I27.0, ___ Prognosis: Good, Length: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Small bowel obstruction pulmonary hypertension impaired wound healing UTI nonobstructing left lower pole nephrolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Surgery Team at ___ with abdominal pain and found to have an obstruction in your intestine. You were taken to the operating room for an exploratory laparotomy, lysis of adhesions, and small bowel resection to take out a piece of your small intestine that was stuck together and causing a blockage. After this, you had care in the ICU for rapid heart rate and low blood pressure. There, you had an echocardiogram to look at your heart, which found evidence of pulmonary hypertension (high blood pressure in an artery from the right side of your heart to your lungs). You also had extra fluid, which was slowly relieved by giving you furosemide which caused you to urinate off extra fluid. The pulmonary service was involved in your care for this new diagnosis of pulmonary hypertension and they recommend a right heart catheterization. You had mild pulmonary hypertension and you should follow up with the lung doctors ___ ___ months for possible treatment. Your abdominal incision had minor redness, and some of your staples were removed and a new dressing was placed. After a few days, a wound vacuum dressing was put on to help heal your wound faster and remove the fluid there. You were also found to have a urinary tract infection, which was treated with antibiotics. 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 and should continue to walk several times a day. 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 You may shower with covering your vacuum dressing*****. You may wash over your staples, allowing the warm water to run over the incision. Pat dry, do not rub. Do not bathe, soak, or swim until cleared by your surgeon. MAY DIFFER DEPENDING ON VAC ETC o Your incisions may be slightly red around the staples. 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. 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. We wish you the best, Your care team at ___ Followup Instructions: ___
10063848-DS-3	10,063,848	26,880,153	DS	3	2177-08-19 00:00:00	2177-08-24 04:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: azithromycin / Cipro / Fosamax / sulfur dioxide / Sulindac / keflex / Keflex Attending: ___. Chief Complaint: Fistula Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ who presented with prior SBO now 3 weeks s/p exploratory laparotomy, lysis of adhesions, and small bowel resection (90 cm) presenting from clinic with concern for small bowel erosion into wound bed without signs of fistulous development. Mrs. ___ was discharged home with services, as she declined rehab placement, on ___ and presented to her follow up appointment today where her vac dressing was taken down, revealing small bowel serosa per report. Therefore, she was sent to the ED for plans to admit for wound management. Past Medical History: PMH: ___ disease, syringomyelia, muscle spasms, rotator cuff tear, small bowel obstruction PSH: hysterectomy, appendectomy, open cholecystectomy, SBR and LOA for SBO in ___ (last SBO), right shoulder dislocation s/ p repair ___ Social History: ___ Family History: father had abnormal bleeding with surgery, easy bruising 2 brothers with OSA sister with pulmonary hypertension (requires IV therapy) Physical Exam: ADMISISON EXAM ------------------- Vitals: 96.9 93 100/48 16 100% 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, obese, nontender, no rebound or guarding, midline wound open with two discrete areas of fascial dehiscence superiorly and inferiorly; the inferior aspect of the wound display frank feculent output Ext: No ___ edema, ___ warm and well perfused WOUND NURSE EXAM ___ Stoma Assessment: Type of Ostomy: Colostomy ( ) Ileostomy( ) Urostomy ( ) Fistula ( X ) Wound: 15 x 5 x 5.5 cm EC fistula opening in inferior wound bed 3 x 2 x 5.5 cm EC fistula not stomatized Superior wound opening 6 x 3 x 2 cm Wound bed: pink, granular Edges: attached Periwound: intact, no erythema, no induration Exudate; from fistula, milky brown Odor: drainage with malodor pain; with cleansing DISCHARGE EXAM ------------------- Vitals: 98.7 ___ GEN: AOx3, NAD HEENT: No scleral icterus, moist mucous membranes CV: RRR PULM: Clear to auscultation b/l ABD: Soft, midline wound open with two areas of fascial dehiscence superiorly and inferiorly. Ostomy device in place. Ext: No ___ edema Pertinent Results: Hematology COMPLETE BLOOD COUNTWBCRBCHgbHctMCVMCHMCHCRDWRDWSDPlt Ct ___ 04:42AM 8.73.138.728.09027.831.115.249.3183 ___ 05:35AM 6.62.958.226.59027.830.915.149.0171 ___ 01:17PM 9.83.379.330.39027.630.715.350.3208 DIFFERENTIALNeutsBandsLymphsMonosEosBasoAtypsMetasIm GranAbsNeutAbsLympAbsMonoAbsEosAbsBaso ___ 01:17PM 56.3 27.513.90.80.6 0.95.492.691.360.080.06 BASIC COAGULATION ___, PTT, PLT, INR)Plt Ct ___ 04:42AM 183 ___ 05:35AM 171 ___ 01:17PM 208 Chemistry RENAL & GLUCOSEGlucoseUreaNCreatNaKClHCO3AnGap ___ 04:42AM ___ ___ 05:35AM ___ ___ 02:48PM ___ ___ 01:17PM ___ CHEMISTRYTotProtAlbuminGlobulnCalciumPhosMgUricAcdIron ___ 04:42AM 7.93.11.8 ___ 05:35AM 8.33.62.2 ___ 02:48PM 8.23.62.0 Blood Gas WHOLE BLOOD, MISCELLANEOUS CHEMISTRYLactate ___ 01:33PM 1.6Import Result ___ 05:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:00PM URINE RBC-4* WBC-0 Bacteri-FEW Yeast-NONE Epi-3 ___ 05:00PM URINE Mucous-FEW ___ 5:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ---------- ___ CT ABD & PELVIS WITH CO 1. Midline dehiscence of the abdominal wall; caudally it extends into the peritoneal cavity where a 2.5 cm focus of (organizing fluid) is demonstrated just deep to the dehiscence (2:68, 601b:20, 602b:40). 2. Extra luminal gas extending from the superior aspect of the anastomosis site is worrisome for perforation and/or anastomotic leak, as described above. It is possible that this pocket of air communicates with a collapsed loop of small bowel however this is not well delineated. ___ consider CT abdomen and pelvis with oral contrast if this will alter management. 3. Focal dilatation of the small bowel loop proximal to the anastomosis could be secondary to postoperative ileus or partial/early small bowel obstruction with the anastomosis site serving as the transition point. 4. Fatty liver. RECOMMENDATION(S): Extra luminal gas extending from the superior aspect of the anastomosis site is worrisome for perforation and/or anastomotic leak, as described above. It is possible that this pocket of air communicates with a collapsed loop of small bowel however this is not well delineated. ___ consider CT abdomen and pelvis with oral contrast if this will alter management. Brief Hospital Course: ___ 3 weeks s/p exploratory laparotomy with small bowel resection presented with foul smelling feculent discharge from her wound with areas concerning for fascial dehiscence and enterocutaneous fistula. # Entero-cutaneous fistula: # Fascial Dehiscence: On presentation, exam was concerning for feculence in wound. CT scan was notable for fascial dehiscence at the wound site and also there was concern for an anastomotic leak. On HD 2, a methylene blue test was done confirming an enterocutaneous fistula. Patient was seen by the wound care nurse and fitted with an ostomy appliance over her open wound and EC fistula. She was set up with home ___ to assist with dressing changes and was provided teaching on her ostomy device. Prior to discharge patient's pain was controlled, she was tolerating a regular diet, and patient was ammenable to ___ services and caring for her new ostomy appliance. TRANSITIONAL ISSUES [] will need re-assessment of wound by Dr. ___ in one week. [] Patient discharged with ostomy appliance with ___ for home dressing changes. WOUND CARE RECOMMENDATIONS Equipment:one piece drainable ( ) one piece convex drainable ( ) two piece drainable ___ ( ) two piece drainable ___ ( ) one piece urostomy ( ) two piece urostomy ___ ( ) two piece urostomy ___ ( ) Supplies: Coloplast mini wound ___ ___ # ___ ___ # ___ Coloplast paste strips PS# ___ ___ # ___ Instructions: Pouch change twice weekly ___ or for leakage cleanse wounds with Commercial wound cleanser set on spray and pat dry with dry gauze, remove all cleanser cleanse periwound with warm water using disposable wash cloths, pat dry (template with patient) trace pouch opening Apply paste strips to pouch opening and mold in Apply pouch to abdomen, use hot packs to activate seal Attach window Use air pump to inflate bolster Close drain tap Empty pouch when ___ full Monitor output and pouch integrity closely Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 3. LOPERamide 2 mg PO QID:PRN diarrhea 4. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO PRN Pain - Mild 2. LOPERamide 2 mg PO QID:PRN diarrhea 3. Metoprolol Succinate XL 25 mg PO DAILY 4. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you speak with your primary care doctor. Has increased risk for ulcers/bleeding Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Surgical Wound with an Entero-cutaneous Fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You presented to the hospital with small bowel eroding into your wound. You were admitted to the hospital for wound management. In the hospital, - A methylene blue test revealed that you have a fistula in your wound, which is leaking enteric content (small bowel content). - You were seen by our wound care specialist. - An ostomy appliance was placed to help with wound healing and help prevent infections. - You received teaching to care for your wound. - ___ was set up to help mange your wound. When you leave the hospital - Record your Ostomy output daily. When it is ___ full, empty the pouch. - If the Ostomy output starts to increase significantly, call your MD and/or seek medical attention. - If you develop fevers, chills, nausea, worsening abdominal pain, or other concerning symptoms seek medical attention. Further "Danger Signs" are listed for you in this document. For your reference, we have provided dressing change instructions for you. It was a pleasure taking care of you, -Your ___ Care Team. CARE INSTRUCTIONS 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 and should continue to walk several times a day. 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 10 lbs until cleared by your surgeon. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children. 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/showers 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 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 You may have sponge baths with covering your ostomy appliance. Pat dry, do not rub. Do not shower, bathe, soak, or swim until cleared by your surgeon o You may gently wash away dried material around your incision. o Avoid direct sun exposure to your wound. o Do not use any ointments on the incision unless you were told otherwise. 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 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 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: ___
10063856-DS-10	10,063,856	28,403,663	DS	10	2178-09-28 00:00:00	2178-09-29 17:41:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Attending: ___. Chief Complaint: Headache, dizziness, gait suffling, loss of appetite Major Surgical or Invasive Procedure: bronchoscopy with biopsy with Dr. ___ on ___ History of Present Illness: Patient is a ___ year old female who presented to an OSH for evaluation at the urging ___ PCP as she was experinecing 2 weeks of headaches different from her normal migraines, dizziness, shuffling gait, loss of appetite and subjective visual changes. Iamging at the OSH showed scatterd supra and infra tentorial lesions, largest being in the left cerebellar with some mass effect on the ___ ventricle. She denies vomiting, changes in speech, changes in bowel or bladder function Past Medical History: Ulcerative colitis, GERD, status post abdominal colectomy and ileorectal anastomosis as described above, migraines, thyroid nodule, breast lump, tubal ligation and thyroidectomy. Social History: ___ Family History: Strong family history of ulcerative colitis and Crohn's disease Physical Exam: On admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact without nystagmus Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. 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, 4mm to 2mm bilaterally. Visual fields are grossly 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 Coordination: LUE dysmetria on FNF On discharge: VS: 98.9 ___ ___ ___ 98-99% RA GEN: AOx3, NAD HEENT: PERRLA. MMM. Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes, good air movement b/l Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___ sign Extremities: wwp, no edema Neuro: CNs II-XII intact. Strength ___ in extremities b/l. Fine touch sensation diminished over left thigh but in tact everywhere else. Gait slow with small shuffled steps, unassisted. Pertinent Results: ADMISSION LABS ___ 10:38PM BLOOD WBC-11.0* RBC-4.15 Hgb-11.0* Hct-34.1 MCV-82 MCH-26.5 MCHC-32.3 RDW-15.2 RDWSD-45.6 Plt ___ ___ 10:38PM BLOOD Neuts-67.9 ___ Monos-9.2 Eos-0.5* Baso-0.5 Im ___ AbsNeut-7.46* AbsLymp-2.35 AbsMono-1.01* AbsEos-0.06 AbsBaso-0.05 ___ 10:38PM BLOOD ___ PTT-26.6 ___ ___ 10:38PM BLOOD Glucose-92 UreaN-21* Creat-1.3* Na-137 K-4.6 Cl-100 HCO3-24 AnGap-18 ___ 10:38PM BLOOD estGFR-Using this ___ 10:38PM BLOOD Calcium-9.9 Phos-4.5 Mg-2.1 DISCHARGE LABS ___ 07:50AM BLOOD WBC-18.2* RBC-3.97 Hgb-10.4* Hct-32.9* MCV-83 MCH-26.2 MCHC-31.6* RDW-17.0* RDWSD-50.2* Plt ___ ___ 06:50AM BLOOD Neuts-81.9* Lymphs-9.2* Monos-7.0 Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.11* AbsLymp-1.70 AbsMono-1.30* AbsEos-0.00* AbsBaso-0.02 ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-95 UreaN-23* Creat-0.8 Na-135 K-4.1 Cl-101 HCO3-26 AnGap-12 ___ 07:50AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.1 OTHER IMPORTANT RESULTS ___ 11:56 am PLEURAL FLUID PLEURAL FLUID. *FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ 11:56AM PLEURAL WBC-838 RBC-4650* Hct,Fl-ERROR Polys-5* Lymphs-66* Monos-2* ___ Meso-1* Macro-17* Other-9___ 11:56AM PLEURAL TotProt-4.0 Glucose-99 LD(LDH)-167 Albumin-2.3 Cholest-98 Pleural fluid cytology + for lung adenocarcinoma, not enough specimin to yield further characterization ___ BLOOD CULTURES NEGATIVE X 2 MRI ___: IMPRESSION: 1. Multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. One lesion demonstrates increased susceptibility, which could be secondary to hemorrhage or mineralization. Differential diagnosis is broad an includes metastatic disease, intracranial abscess, intracranial and toxoplasmosis if patient is immunocompromised. 2. Focal left frontal dural thickening and enhancement, meningioma vs leptomeningeal disease. CXR ___: IMPRESSION: Left upper lobe collapse, with large hilar mass and small pleural effusion. No pneumothorax. RENAL U/S ___: IMPRESSION: A 1.5 x 1.4 x 1.2 cm isoechoic solid-appearing lesion is seen in the lateral interpolar region of the left kidney. Otherwise, the multiple lesions seen on CT from the day prior are not well of visualized on ultrasound. RECOMMENDATION(S): Further evaluation of multiple renal lesions with MRI is recommended. Brief Hospital Course: ___ hx UC, GERD, breast mass and significant smoking history presenting with cough, dizziness, ataxia found to have ring enhancing lesions on MRI and a lung nodule c/f metastatic disease. Mrs. ___ was admitted to the Neurosurgery service on ___ for further work-up of her multiple intracranial lesions. The patient was started on Keppra for seizure prophylaxis and decadron to minimize intracranial (intraparenchymal) vasogenic edema. A CT of the torso was obtained and revealed bilateral renal cysts. As recommended by radiology, renal ultrasounds were ordered. A MRI of the head was ordered on the same day to qualify the patient's intracranial lesions. The MRI on ___ showed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres. On ___ Med-Onc was consulted for transfer of care given the patient had multiple lesions and would require further oncological workup and planning. Radiation oncology was consulted and began therapy to brain lesions. She received three out of five planned fractions while inpatient. Thoracentesis of pleural fluid positive for lung adenocarcinoma, but not enough tissue available for molecular typing. Therefore underwent bronchoscopy with biopsy on ___ for additional tissue. She was stable post-bronchoscopy on room air and is therefore discharged to outpatient follow-up for further care. # Brain/lung lesions: Metastatic lung adenocarcinoma. Pleural fluid + for metastatic disease. Neuro exam stable. She is now on radiation to brain lesions and will follow up concerning biopsy/pathology results with ___. # GERD: continued home omeprazole # DVT prophylaxis: patient refused heparin/lovenox injections. We discussed her increased risk of blood clots in the setting of probably malignancy. She prefers Pneumoboots/walking, but continues to refuse injections. Risk/benefits explained to patient and daughter (alternative HCP) who voiced understanding. TRANSITIONAL ISSUES: ============================ - steroid taper, dose decreased to 4 mg BID dex at discharge - on omeprazole and PCP prophylaxis given steroids, stop as indicated - will receive 2 more outpatient radiation treatments - molecular analysis of bronchoscopy sample - follow-up with Dr. ___ - consideration of follow-up with Dr. ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. B Complete (vitamin B complex) oral DAILY 2. Ascorbic Acid ___ mg PO DAILY 3. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 4. Vitamin D ___ UNIT PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. red yeast rice 600 mg oral DAILY 8. Sumatriptan Succinate Dose is Unknown PO DAILY:PRN migraine Discharge Medications: 1. Hospital Bed Semi-electric hospital bed with siderails and mattress Duration: one year Diagnosis: metastatic lung cancer 2. Omeprazole 20 mg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Cepastat (Phenol) Lozenge 2 LOZ PO Q2H:PRN cough/sore throat 5. Ascorbic Acid ___ mg PO DAILY 6. B Complete (vitamin B complex) 0 ORAL DAILY please resume home dose 7. Atovaquone Suspension 1500 mg PO DAILY take with meals, for infection prevention RX atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:3 8. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain RX acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #90 Tablet Refills:3 9. Dexamethasone 4 mg PO Q12H RX dexamethasone 2 mg 2 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 10. LeVETiracetam 500 mg PO BID RX levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:6 11. Multivitamins 1 TAB PO DAILY 12. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 13. red yeast rice 600 mg oral DAILY 14. Ondansetron 4 mg PO Q8H:PRN nausea 15. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:6 16. Docusate Sodium 100 mg PO BID hold for loose stools RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:6 17. Lorazepam 0.5 mg PO QHS:PRN insomnia take at night RX lorazepam [Ativan] 0.5 mg 1 tablet by mouth at bedtime Disp #30 Tablet Refills:3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: metastatic lung adenocarcinoma brain metastases Discharge Condition: Stable, ambulate ad lib using support as necessary Discharge Instructions: Dear ___, ___ were admitted for headache, nausea, and vomiting. ___ were found to have lesions in your brain as well as in your lung that represent metastatic lung cancer. ___ were maintained on steroids to minimize swelling in your brain and ___ were started on radiation therapy while inpatient. Fortunately, your symptoms have been well controlled. We are glad ___ were able to get your bronchoscopy with biopsy, as this will help everyone understand the options for how to proceed once genetic tests are done on the sample. ___ will follow-up as an outpatient with Dr. ___, as ___ requested. This is in the process of being scheduled, will likely happen ___, and ___ should hear from her office. If ___ do not in the next day, please call ___. Please go to the emergency department if ___ experience worsening headache, fever/chills, nausea, vomiting or other symptoms listed below. ___ may also call ___ and ask to speak to the hematology/oncology fellow on call to discuss any concerns after hours. During the day, ___ may call the above number for Dr. ___. We wish ___ the best, Your ___ team Followup Instructions: ___
10063856-DS-12	10,063,856	22,345,354	DS	12	2179-01-08 00:00:00	2179-01-08 18:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Attending: ___. Chief Complaint: Bradycardia and Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. The patient states she has been feeling very tired and weak and has had dizziness and lightneadedness when she walks. She has fallen twice recently. She has found by a home health nurse to have a heart rate as low as the ___ and a blood pressure as low as the ___ systolic. She went to her local ED and recieved a dose of atropine and antibiotics and was transferred to the ED here. The patient states that about a week ago she started having some dysuria. In the last couple of days she has had urinary frequency as well. She reports having a UTI a month ago and her symptoms did get better before these started again last week. She denies any fevers, cough, shortness of breath, nausea, or change in ostomy output. REVIEW OF SYSTEMS: - All reviewed and otherwise negative. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Presented to office of Primary Care Physician in ___ with two weeks of new headaches, dizziness, abnormal gait, visual changes, and loss of appetite. She was subsequently evaluated in an outside Emergency Department with imaging that revealed multiple intracranial lesions. 2. Patient was transferred to ___ on ___. She was started on Keppra and dexamethasone. A MRI of the head revealed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. 3. A CT scan of the chest on ___ revealed a likely primary lung neoplasm obliterating the left upper lobe bronchus with secondary left upper lobe. There was a small to moderate simple left layering pleural effusion with adjacent subsegmental atelectasis. A CT scan of the abdomen/pelvis on the same day revealed an enlarged rounded left iliac chain lymph node measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral renal hypodense lesions. 4. Patient underwent left thoracentesis on ___. Pathology was consistent with lung adenocarcinoma. For purposes of molecular testing, patient underwent EBUS with biopsy of level 4 and level 7 lymph nodes. Molecular testing returned positive for KRAS mutation. EGFR mutation was not detected. Rearrangements in ALK and ROS1 were not detected. 5. Patient initiated whole brain external beam radiation while hospitalized. She completed three out of five planned fractions. Patient was discharged home on ___. 6. Patient completed whole brain radiation therapy on ___. Total dose ___ cGY. 7. Patient was re-admitted at ___ on ___ with symptoms of headache, nausea, emesis, and gait instability in the setting of steroid taper. CT scan of the head on admission showed stable to slightly improved vasogenic edema. 8. A bone scan on ___ showed left frontal bone, left posterior parietal bone, and right sacroiliac joint increased uptake, consistent with metastatic disease. Patient received B12 injection sometime between ___ and ___. Folate was also initiated during hospitalization. She was discharged home with open-access hospice services and increased dose of dexamethasone on ___. 9. Cycle 1 of palliative carboplatin/pemetrexed administered on ___. Dexamethasone tapered off between cycles 1 and 2. Cycle 2 administered on ___. PET imaging revealed stable disease. Cycle 2 was complicated by anorexia and excessive fatigue. Dexamethasone resumed at dose of 4 mg daily on ___ with improvement in symptoms. Cycle 3 administered on ___. Cycle 4 ___. PAST MEDICAL HISTORY: Metastatic lung adenocarcinoma as above Ulcerative colitis Gastroesophageal reflux disease Thyroid nodule Migraines Breast cyst Plantar fasciitis Abdominal colectomy and ileorectal anastomosis Thyroidectomy Tubal ligation Social History: ___ Family History: Mother: ___ degeneration. Father: ___ bowel disease, CVA. Maternal grandfather: CVA. Brother: ___ bowel disease. Sister: DM. Physical Exam: PHYSICAL EXAM: General: NAD VITAL SIGNS: T 97.2 HR 42 BP 95/55 O2 100%RA HEENT: MMM CV: Bradycardia PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly, ostomy present with brown stool output. LIMBS: No edema, clubbing, tremors, or asterixis SKIN: Superficial abrasion to left arm. NEURO: Alert and oriented, no focal deficits. Pertinent Results: ___ 06:35AM GLUCOSE-88 UREA N-13 CREAT-0.7 SODIUM-133 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 ___ 06:35AM ALT(SGPT)-22 AST(SGOT)-27 ALK PHOS-41 TOT BILI-0.3 ___ 06:35AM cTropnT-<0.01 ___ 06:35AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.7 ___ 06:35AM WBC-6.2 RBC-2.98* HGB-8.8* HCT-27.3* MCV-92 MCH-29.5 MCHC-32.2 RDW-23.1* RDWSD-76.7* ___ 07:34PM LACTATE-2.0 Portable Chest X-ray ___: IMPRESSION: Persistent left upper lobe collapse without evidence of pneumonia. Decreasing mass, left hilus and left upper lobe. Possible pulmonary metastasis, right lower lobe. This examination neither suggests nor excludes the diagnosis of pulmonary embolism. Brief Hospital Course: ___ yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. Concern for UTI: U/A at ___ concerning for UTI with ___ WBC, ___ RBC, 0 Epis, 2 + bacteria, moderate ___, - nitrites but culture growing mixed bacteria consistent with contamination. U/a and culture here negative. She was initially put on ceftriaxone which was discontinued. C. Diff: C. diff positive with some increased watery ostomy output. Started on PO vancomycin for 14 day course. Hypotension: possibly due to infection, adrenal insufficiency or dehydration. Her baseline systolic blood pressures in clinic appears to be 100-120. She did not appear significantly hypovolemic on examination and infection overall did not appear severe enough to be causing this degree of hypotension. She was placed on stress dose steroids with hydrocortisone with improvement in her blood pressure. She was transitioned back to her home dose of decadron prior to discharge. BP's on day of discharge 120's systolic. Bradycardia: she has chronic sinus bradycardia for years, no changes on ECG, no evidence of conduction disease on telemetry or ECG. She does report increased falls and ? syncopal episode at home. Her bradycardia may be contributing but she is not interested in an intervention such as a pacemaker. TSH normal. Chest pressure: Atypical chest pressure since she fell, likely musculoskeletal (reproducible on exam), no ischemic ECG changes, troponin negative and resolved. Could also be due to lung mets. Thrush Continued home clotrimazole. Metastatic Lung Cancer S/p cycle 4 premetrexed/carboplatin ___. She is finished with carboplatin, per oncology plan to continue with maintenance premetrexed. Continued home atovaquone, dronabinol, folic acid, keppra, ativan, omeprazole, pampazine, and trazadone. FEN: Regular diet PAIN: Continued home oxycontin at night and PRN ultram. DVT PROPHYLAXIS: Heparin 5000 units SC CODE STATUS: - DNR/DNI Pt was discharged back home to resume her already arranged hospice care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LeVETiracetam 500 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. B Complete (vitamin B complex) 0 ORAL DAILY 7. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 8. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraZODone 50 mg PO QHS:PRN Insomnia 12. Clotrimazole 1 TROC PO QID 13. Atovaquone Suspension 1500 mg PO DAILY 14. Dexamethasone 4 mg PO DAILY 15. Dronabinol 2.5 mg PO BID 16. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Clotrimazole 1 TROC PO QID 3. Dexamethasone 4 mg PO DAILY 4. Dronabinol 2.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LeVETiracetam 500 mg PO BID 7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Vitamin D ___ UNIT PO DAILY 14. Vancomycin Oral Liquid ___ mg PO Q6H RX vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #48 Capsule Refills:*0 15. B Complete (vitamin B complex) 1 tablet ORAL DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C. difficile infection Adrenal insufficiency 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 low blood pressure and low heart rates. You were found to have recurrent c. diff and are being treated with Vancomycin by mouth. Your blood pressure improved and you had no further episodes of dizziness. Followup Instructions: ___
10063856-DS-13	10,063,856	29,364,646	DS	13	2179-01-19 00:00:00	2179-01-21 12:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole Attending: ___ Chief Complaint: Lightheadness, shaking, near fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/metastatic lung CA, last chemo ___, who presents with lightheadedness. Pt was admitted ___ after with sinus bradycardia to ___, SBP to ___, with presyncopal episodes at home. No interventions in house, patient declined interventions such as pacemaker. Etiology unclear, negative troponins in house. She was found to have C. diff while in house, started on 14 day PO Vancomyocin course. This morning was walking with a walker, entire body felt tremulous and she felt lightheaded. Called for her husband who lowered her to the ground. No headstrike or LOC. Later in the afternoon ___ attempted a standing BP and she felt similar symptoms, no LOC or headstrike. No HAs. No fevers chills or cough. Has been having constant CP and mild exertional dyspnea for 2 weeks after a fall (had negative cardiac enzymes and EKGs last admission). Pt has ileostomy (s/p C diff colitis), output has not been increased since discharge. No vomiting. The lightheadedness feel similar to her recent admission symptoms, however the tremors/weakness are new and what concerns her most. In the ED, initial VS were: 97.8 55 133/75 19 95% RA Labs were notable for: lactate 2.7, K 3.1, Ca: 9.1 Mg: 1.4 P: 2.5, wbc ct 3.2 (___ ___), h/h 8.8/26.7, platelets 124. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): 1. Presented to office of Primary Care Physician in ___ with two weeks of new headaches, dizziness, abnormal gait, visual changes, and loss of appetite. She was subsequently evaluated in an outside Emergency Department with imaging that revealed multiple intracranial lesions. 2. Patient was transferred to ___ on ___. She was started on Keppra and dexamethasone. A MRI of the head revealed multiple ring-enhancing lesions in bilateral cerebral and cerebellar hemispheres with associated FLAIR signal abnormality, and restricted diffusion. 3. A CT scan of the chest on ___ revealed a likely primary lung neoplasm obliterating the left upper lobe bronchus with secondary left upper lobe. There was a small to moderate simple left layering pleural effusion with adjacent subsegmental atelectasis. A CT scan of the abdomen/pelvis on the same day revealed an enlarged rounded left iliac chain lymph node measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral renal hypodense lesions. 4. Patient underwent left thoracentesis on ___. Pathology was consistent with lung adenocarcinoma. For purposes of molecular testing, patient underwent EBUS with biopsy of level 4 and level 7 lymph nodes. Molecular testing returned positive for KRAS mutation. EGFR mutation was not detected. Rearrangements in ALK and ROS1 were not detected. 5. Patient initiated whole brain external beam radiation while hospitalized. She completed three out of five planned fractions. Patient was discharged home on ___. 6. Patient completed whole brain radiation therapy on ___. Total dose ___ cGY. 7. Patient was re-admitted at ___ on ___ with symptoms of headache, nausea, emesis, and gait instability in the setting of steroid taper. CT scan of the head on admission showed stable to slightly improved vasogenic edema. 8. A bone scan on ___ showed left frontal bone, left posterior parietal bone, and right sacroiliac joint increased uptake, consistent with metastatic disease. Patient received B12 injection sometime between ___ and ___. Folate was also initiated during hospitalization. She was discharged home with open-access hospice services and increased dose of dexamethasone on ___. 9. Cycle 1 of palliative carboplatin/pemetrexed administered on ___. Dexamethasone tapered off between cycles 1 and 2. Cycle 2 administered on ___. PET imaging revealed stable disease. Cycle 2 was complicated by anorexia and excessive fatigue. Dexamethasone resumed at dose of 4 mg daily on ___ with improvement in symptoms. Cycle 3 administered on ___. Cycle 4 ___. PAST MEDICAL HISTORY: Metastatic lung adenocarcinoma as above Ulcerative colitis Gastroesophageal reflux disease Thyroid nodule Migraines Breast cyst Plantar fasciitis Abdominal colectomy and ileorectal anastomosis Thyroidectomy Tubal ligation Social History: ___ Family History: Mother: ___ degeneration. Father: ___ bowel disease, CVA. Maternal grandfather: CVA. Brother: ___ bowel disease. Sister: DM. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== GENERAL: NAD HEENT: NC/AT, EOMI, PERRL, MMM CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: A&O x 3, CN II-XII intact SKIN: Warm and dry, without rashes ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: T98.0 \| ___ \| 112/75-132/70 \| 16 \| 98% RA General: NAD. Pleasant, A+O x3. HEENT: MMM. Balding. No OP lesions. CV: RRR, NL S1/S2 no murmurs. Markedly decreased pain with palpation over and around sternum. PULM: Clear GI: BS+, soft, NTND, no masses or hepatosplenomegaly. Has ostomy with brown liquid stool LIMBS: No edema SKIN: No rashes or skin breakdown NEURO: Oriented, ___ strength upper and lower extremities Pertinent Results: ================ ADMISSION LABS: ================ ___ 02:30PM BLOOD WBC-3.2* RBC-2.92* Hgb-8.8* Hct-26.7* MCV-91 MCH-30.1 MCHC-33.0 RDW-22.6* RDWSD-74.2* Plt ___ ___ 02:30PM BLOOD Neuts-67.3 ___ Monos-6.4 Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.10 AbsLymp-0.78* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00* ___ 02:30PM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-137 K-3.1* Cl-98 HCO3-27 AnGap-15 ___ 02:30PM BLOOD ALT-77* AST-58* AlkPhos-40 TotBili-0.2 ___ 02:30PM BLOOD Lipase-37 ___ 02:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 08:10AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:30PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.5* Mg-1.4* ___ 02:32PM BLOOD Lactate-2.7* ___ 01:38PM BLOOD Lactate-3.0* ___ 11:15AM BLOOD Lactate-2.4* ___ 08:10AM BLOOD Cortsol-0.4* ___ 08:30AM BLOOD VitB12-908* ================= DISCHARGE LABS: ================= ___ 07:55AM BLOOD WBC-3.2* RBC-2.77* Hgb-8.6* Hct-26.6* MCV-96 MCH-31.0 MCHC-32.3 RDW-24.4* RDWSD-80.9* Plt ___ ___ 07:55AM BLOOD Glucose-84 UreaN-17 Creat-0.6 Na-138 K-4.0 Cl-101 HCO3-29 AnGap-12 ___ 07:45AM BLOOD ALT-80* AST-37 LD(LDH)-264* AlkPhos-44 TotBili-0.2 ___ 07:55AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.8 ============ KEY IMAGING: ============ ___ MRI Head w/,w/o contrast:FINDINGS: Since the prior study, there has been interval appearance of multiple foci with diffusion weighted signal intensity in the right frontal lobe (502:24, 25), some of which correspond to associated FLAIR signal intensity (07:19, 20). A single focus of left frontal peripheral diffusion-weighted hyperintense signal is also new (series 502, image 72). Another tiny focus of right parietal cortical FLAIR/diffusion signal hyperintensity also demonstrates postcontrast enhancement (502:20, 7:16, 10:16), and is also new since the prior study. Otherwise, known enhancing lesions in the infratentorial brain are stable compared to the prior study, and include a lower left cerebellar hemispheric lesion (900:24), anterior inferior right cerebellar hemisphere lesion (900:28), and an 11 x 8 mm medial left cerebellar hemispheric lesion (900:41). Other supratentorial lesions previously described are also stable, including a left occipital lesion (10:14), anterior right frontal lobe lesion (10:18), and an 8 mm left temporal lobe lesion (900:54). Punctate hemorrhagic foci are stable in the left parietal and posterior right frontal and anterior right frontal lobes. No new hemorrhage is identified. There is no shift of the normally midline structures. Ventricles and sulci remain unchanged in size and configuration. The major intracranial vascular flow voids are preserved, and the major dural venous sinuses appear patent. The paranasal sinuses are clear. The orbits are unremarkable. The left mastoid air cells are clear. IMPRESSION: 1. Multiple new right frontal cortical foci in a single left frontal focus of likely reflect sites of acute/subacute infarction of embolic origin, given distribution and small size and rapid development since prior examination of ___. However, in the context of known metastatic disease, underlying malignancy cannot be completely excluded. 2. A similar tiny focus in the right parietal cortex exhibits mild enhancement. Likely etiology is again acute/subacute infarction, but malignancy cannot be excluded. 3. Numerous other supra and infratentorial metastatic lesions are stable since the recent prior study, as described above. RECOMMENDATION(S): 1. Continued follow-up imaging is recommended for findings described in IMPRESSION #'s 1 and 2. Brief Hospital Course: ___ with stage IV lung cancer with known brain mets s/p cycle 4 of pemetrexed/carboplatin (last cycle ___ who is admitted with 2 episodes of "shaking" and weakness at home, found to have new brain lesions. ============== ACTIVE ISSUES: ============== # Lightheadedness/Shaking episode: Possible presyncope with hypotension vs. seizure. Seizures initially felt unlikely as patient maintained consciousness and could recall the entire episode and with bland inpatient EEG. However, MRI brain showed new lesions that may represent embolic infarcts vs. new metastatic foci. Neuro-oncology was consulted and proposed seizure on stroke impact as unifying explanation of patient's presentation. Orthostasis or weakness/muscle spasm due to electrolyte derrangements also considered, but no significant hypotension or electrolyte abnormalities documented at time of hospitalization. Over 48 hours of continuous telemetry showed no atrial fibrillation. During hospitalization, increased Keppra from 500mg bid to ___ BID. Started aspirin 81mg daily for secondary stroke prevention. Home dexamethasone was continued. Full stroke workup was deferred as it was felt unlikely to change patient's management and invasive/intensive testing was not consistent with patient's goals of care. # Headaches: Patient was awoken by ___ bifrontal headache on at least two nights. No associated neurological signs or symptoms. Head imaging showed new findings as above but no acute change in edema or other culprits for increased intracranial pressure. Got tramadol with some relief, later patient was transitioned to dilaudid and long-acting analgesics were up-titrated with no further complaint of headaches. # Chest pain: Present for several weeks prior to admission, intermittent. Pleuritic with deep inspiration and exacerbated by movement, straining. Reproducible w/ palpation. Most likely secondary to metastatic disease affecting bones of chest wall, as demonstrated by prior imaging. Treated symptomatically with increased long-acting opioid plus dilaudid prn with good relief. # Back pain: Has been chronic. MRI T/L spine showed benign appearing T10 compression fracture. Neurosurgery consulted and recommended Soft TLSO brace for activity and HOB>45 degrees. Pain control as above. # Vulvovaginal Candiadiasis: Recurrent issue for patient. Of note, patient is allergic to fluconazole. Started Miconazole Vaginal suppository for ___ased on symptom resolution. Patient noted significant improvement in symptoms and miconazole was discontinued at discharge. # Thrombocytopenia: Platelets decreased to 75 on ___, counts have been lower than prior. Likely chemotherapy effect with recent carboplatin exposure. Platelets began to increased on ___ and had improved by discharge. =============== CHRONIC ISSUES: =============== # Anemia: likely due to chemotherapy and inflammatory block in setting of malignancy. Hemoglobin largely stable since recent admission and continued to be stable while inpatient. No history of bleeding or melena. # Metastatic lung cancer: s/p cycle 4 premetrexed/carboplatin (last ___. Held chemotherapy while inpatient. Further chemotherapy would be palliative and can be restarted at the discretion of the primary oncology team. # C. Difficile: C. diff positive on ___ with some increased watery ostomy output. Started on PO vancomycin for 14 day course on ___, which was continued while inpatient. Patient was maintained on contact precautions. Plan to continue PO vancomycin until ___. ==================== TRANSITIONAL ISSUES: ==================== CODE STATUS: DNR/DNI, confirmed CONTACT: husband/HCP ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY 2. Clotrimazole 1 TROC PO QID 3. Dexamethasone 4 mg PO DAILY 4. Dronabinol 2.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LeVETiracetam 500 mg PO BID 7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain 12. TraZODone 50 mg PO QHS:PRN Insomnia 13. Vitamin D ___ UNIT PO DAILY 14. Vancomycin Oral Liquid ___ mg PO Q6H 15. B Complete (vitamin B complex) 1 tablet ORAL DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY 2. Dexamethasone 4 mg PO DAILY 3. Dronabinol 2.5 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. LeVETiracetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:5 6. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. TraZODone 50 mg PO QHS:PRN Insomnia 12. Vitamin D ___ UNIT PO DAILY 13. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:4 14. B Complete (vitamin B complex) 1 tablet ORAL DAILY 15. Clotrimazole 1 TROC PO QID 16. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 17. Vancomycin Oral Liquid ___ mg PO Q6H Last day ___ 18. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain RX hydromorphone 2 mg ___ tablet(s) by mouth every six (6) hours Disp #112 Tablet Refills:0 19. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7 Days RX miconazole nitrate [Miconazole 7] 2 % 1 app VG at bedtime Disp #1 Package Refills:3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: - Metastatic Lung Cancer - Brain lesions, infarct versus metastatic disease - Compression fracture, T10 vertebra SECONDARY DIAGNOSES: - Candidiasis, vulvovaginal - C. difficile colitis, on treatment - Ulcerative colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, ___ was a pleasure to care for ___ here at ___. ___ were admitted after an episode of shaking and nearly falling down at home. While we can't be certain exactly what happened, we believe ___ may have had a seizure due to small strokes or brain metastatic lesions. We also cannot rule out near fainting from low blood pressure. During your hospital stay, ___ had no seizures or episodes of low blood pressure. ___ remained steady on your feet while walking. During your hospitalization, imaging studies showed possible new strokes in your brain or progression of metastases in your brain. Imaging of your back showed a benign compression fracture of the T10 vertebral bone. This is most likely the cause of your back pain. It is not related to your cancer. The chest pain ___ had is most likely a result of lung cancer. All of this pain was controlled with some strong pain medicines that we will give ___ at discharge. ___ will have follow up appointments with oncology and your other doctors. ___ have more imaging studies scheduled to assess how your cancer is progressing. Your Keppra dose was increased. Thank ___ for letting us participate in your care, Your ___ team Followup Instructions: ___
10063991-DS-4	10,063,991	25,007,733	DS	4	2148-01-30 00:00:00	2148-01-30 19:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Voice weakness, facial weakness and difficulty walking Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. ___ is a ___ yo M w/no significant PMHx who presents with acute onset L> right facial weakness, nasal voice, ophthalmoplegia, and vertical diplopia in setting of recent campylobacter infection. 2 weeks ago patient had diarrheal illness, confirmed campylobacter at ___, and was prescribed an antibiotic. Diarrhea resolved. ___ he began having paresthesias of left face. He felt his voice was weak. ___ he noted his voice had a nasal quality, his vision felt "off", he had transient tingling in his hands, and began experiencing vertical diplopia when trying to look up. He also is intermittently having the feeling fluids are coming back up through his nostrils when drinking. He was admitted to ___ where he had a MR head w/out acute abnormalities. LP on ___ with 13 RBC, 3 WBC, 54 protein, 43 glucose. He was evaluated by SLP who said he was safe to eat. NIF/VC monitored and he never reported difficulty breathing or shortness of breath. As he thought his symptoms had plateaud and he wanted to go back home to his wife and child, he was discharged from ___ ___. He walked home and felt off and light headed the walk back. This AM when he woke up, his eyes felt heavier and he represented to ___ ED. On neuro ROS, the pt has slight headache around his temples. Denies loss of vision,dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness. No bowel or bladder incontinence or retention. Denies difficulty with gait. Past Medical History: None Social History: ___ Family History: Unknown, patient adopted. Physical Exam: Admission Physical Exam ======================= Vitals: T: 98, BP: 118/70 HR 52 RR 16 02 96% RA NIF: less than -60 General: Awake, cooperative, uncomfortable HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Card: warm and well perfused Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. 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. Speech is not dysarthric but has nasal quality. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI with bilateral impaired upgaze, restricted abduction of right eye. Normal saccades. V: Facial sensation intact to light touch. VII: L>R ptosis, weakness of left eye closure, smile symmetric VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: LT 80% of normal on ___ outer thighs, but normal on PP. No DSS. -DTRs: Bi Tri ___ Pat Ach L 0 1 1 0 0 R 0 1 1 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. ' Discharge Physical Exam ======================== General: Awake, cooperative, uncomfortable HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Card: Audible S1 and S2. RRR. No rubs/murmurs/gallops Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert. Language is fluent. Normal prosody. Speech is not dysarthric but has nasal quality. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. III, IV, VI: EOMI with bilateral impaired upgaze, restricted abduction, however able to cross midline. On upgaze, right eye able to easily cross midline about 30 degrees, left eye only barely able to cross midline. Able to fully adduct on individual testing. V: Facial sensation intact to light touch. VII: Able to rise eyebrows, shut eyes, puff cheeks and smile. Forced eye closure on the left was slightly weaker than the right, but only on confrontation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: Symmetrical bilaterally to light touch. -DTRs: Bi Tri Bracioradialis Pat L 0 0 0 0 R 2 2 0 0 -Coordination: No intention tremor. Normal finger to nose. -Gait: appears normal but slow, pt states that he feels weak in left knee Pertinent Results: Admission Lab Results ===================== ___ 03:41PM BLOOD WBC-6.2 RBC-4.65 Hgb-13.9 Hct-41.9 MCV-90 MCH-29.9 MCHC-33.2 RDW-13.4 RDWSD-43.7 Plt ___ ___ 03:41PM BLOOD Neuts-64.6 ___ Monos-5.1 Eos-2.1 Baso-1.4* Im ___ AbsNeut-4.02 AbsLymp-1.65 AbsMono-0.32 AbsEos-0.13 AbsBaso-0.09* ___ 03:41PM BLOOD ___ PTT-37.1* ___ ___ 03:41PM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-145 K-3.9 Cl-109* HCO3-23 AnGap-13 ___ 03:41PM BLOOD ALT-17 AST-13 AlkPhos-40 TotBili-0.8 ___ 03:41PM BLOOD cTropnT-<0.01 ___ 03:41PM BLOOD TotProt-6.5 Albumin-4.0 Globuln-2.5 Discharge Lab Results ===================== None collected on the day of discharge Imaging ======= MRI orbits: IMPRESSION: 1. No imaging evidence for optic neuritis or other orbital abnormalities. 2. No evidence abnormal enhancement along the cranial nerves. Unremarkable appearance of the cavernous sinuses. 3. No evidence for dural venous sinus thrombosis. 4. No evidence for intracranial mass or acute intracranial abnormalities. Specifically, no signal abnormalities in the brainstem. 5. Right frontal developmental venous anomaly. Brief Hospital Course: Mr. ___ is a ___ y/o previously healthy male who developed voice weakness, facial weakness, ataxia and bilateral hand numbness iso recent campylobacter infection. Patient LP at OSH on ___ with 13 RBC, 3 WBC, 54 protein, 43 glucose. The CSF likely was drawn early, resulting in lack of the albuminocytologic dissociation likely due to LP being drawn within one week of onset of symptoms. He was completed a 5 day course of IVIG with some improvement in his symptoms. There was no evidence of respiratory compromise during this admission. One interesting finding was the presence of red color desaturation during his admission. Given that this is likely not c/w MF GBS, an MRI was performed which did not reveal any evidence of optic neuritis or other pathology that might explain this phenomenon. The finding was not present on later exams, and was perhaps spurious. He remained stable if not with some slight improvement in his left CN3 palsy. He had return of biceps and triceps reflex on his right hand (___). remaining reflexes 0. He was discharged with planned neurology followup. Transitional Issues =================== [] GQ1b Antibodies pending [ ] Neurology f/u within ___ months, we will call to schedule. If you do not hear, call ___ to schedule. Medications on Admission: Flonase prn Discharge Medications: Flonase prn Discharge Disposition: Home Discharge Diagnosis: ___ variant of Guillian ___ syndrome Discharge Condition: Alert and Oriented to person, place and time. Vital signs stable. Discharge Instructions: It was a pleasure taking care of you at ___. You were admitted to ___ given the constellation of your symptoms including facial weakness, voice weakness and difficulty walking. These symptoms, in addition to your physical exam findings of absent reflexes and impaired vertical gaze is consistent with a subtype of Guillian ___ Syndrome called ___ Syndrome. This likely occurred as a result of your immune system's reaction to your recent diarrheal illness. We treated you with intravenous immunoglobulin and your symptoms showed some gradual improvement. We expect that this will continue over the coming weeks and months. We also monitored your breathing and there were no concerns with your respiratory status. To help confirm our diagnosis, we ruled out other possible causes for your weakness with an MRI. You were discharged in stable condition. Please follow-up with ___ Neurology as scheduled. Thank you for allowing us to participate in your care, ___ Neurology Followup Instructions: ___
10064049-DS-10	10,064,049	25,054,827	DS	10	2163-05-23 00:00:00	2163-05-29 15:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Near syncope Major Surgical or Invasive Procedure: ___ skin biopsy ___ flex sigmoidoscopy History of Present Illness: Mr. ___ is a ___ gentleman with PMHx significant for MDS RAEB - 2, status post allogeneic stem cell transplant from matched related donor, currently D+120 with recent anemia requiring transfusion and bone marrow biopsy concerning for pure red cell aplasia as well as Afib not on coumadin who presents after presyncopal episode this morning. Pt states that this morning he was standing up in the kitchen when he began to feel lightheaded like he was going to faint. He noted flashes of color across his vision. This lasted for several minutes. No associated chest pain, palpitations, SOB or diaphoresis. After sitting down he felt the urge to have a bowel movement. He went to the bathroom and had a bowel movement with relief of his symptoms. BM was large but nonbloody, no melena. No associated fever, chills, N/V, abdominal pain or diarrhea. Notes urine output in excess of intake over past several days with normal appetite. Only other recent symptom is nonproductive cough. No sick contacts or recent travel. Has been taking his medications as prescribed. He called his doctor and was instructed to come to the ED for evaluation. Of note, he was diagnosed with MDS in the setting of multifocal pneumonia and WBC count of 47. Bone marrow biopsy in ___ showed changes consistent with MDS RAEB -2. He is s/p 4 cycles of decitabine with a decrease from 10% to 7% blasts in his marrow and normalization of his WBC, which was initially 47k. He decided to proceed with an elective allo-transplant with a MRD ___ match from his brother with a reduced-intensity non-myeloablative transplant with Flu/BU conditioning regimen with day 0 on ___. Over the last several months he has been noted to have persistent anemia with absence of red cell precursors consistent with pure red cell aplasia based on bone marrow biopsy. He was treated with transfusions requiring about a unit a week, most recently on ___. His cyclosporine was tapered until discontinuation on ___. During his most recent clinic visit with Dr. ___ on ___ plan had been to monitor for improvement in cell count after discontinuation of immunosuppression then consider pheresis and/or rituximab. He was also noted to have developed tingling and pruritus concerning for GVH of the skin soon after discontinuation of immunosuppression. He was treated with benedryl and hydroxyzine as an outpatient. On arrival to the ED, his initial VS were 98.7 86 104/69 16 99%. Orthostatics were negative. Initial workup revealed CBC w/ WBC 2.3, hgb 4.9, hct 14, plt 84. Repeat CBC (prior to any intervention) showed WBC 3.9, Hgb 6.8, hct 19.4, plt 83. Hemolysis labs revealed normal INR, haptoglobin and LDH. LFTs were normal, Cr 1.2 (lower than recent baseline). Troponins were neg x 2. CXR was unremarkable. He was treated with 1L NS and given his home medications. Case discussed with ___ with recommendation for admission. On arrival to the floor, pt denies any dizziness or lightheadedness. Notes non-productive cough persists. Reports that his only bothersome symptom is itchy red rash on trunk and upper extremities. Otherwise no CP, SOB, abdominal pain or diarrhea. Past Medical History: --Diagnosed with MDS based on BMBx ___. --TREATMENT HISTORY: ___: C1 Decitabine ___: C2 Decitabine ___: C3 Decitabine ___: C4 Decitabine --___: Allo, MRD, reduced-intensity flu/Bu. Relatively uncomplicated course with slow count recovery and mild GVHD of the skin. --BMBx ___ revealed absence of erythroid precursors c/w pure red cell aplasia PAST MEDICAL/SURGICAL HISTORY: Atrial fibrillation with RVR HTN basal cell carcinoma sleep apnea on CPAP pAfib GERD s/p EGD s/p inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: EXAM ON ADMISSION: ================= Vitals: 98.6, 108/62, 92, 20, 100%RA Gen: Pleasant, calm gentleman in NAD. HEENT: + conjunctival pallor. No icterus. Mildly dry MM. OP clear. NECK: No JVD. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclavicular LAD CV: Irregularly irregular rhythm. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No masses, guarding or rebound. EXT: WWP. Trace ___ edema bilaterally. SKIN: On bilateral upper extremities there is a pruritic papular pink rash with areas of confluent blanching erythema on back and chest without pustules or bullae. No mucosal involvement. No petechiae/purpura or ecchymoses. NEURO: A&Ox3. LINES: ___ right chest wall, no surrounding erythema or purulence. EXAM ON DISCHARGE: ================= Vitals: 97.7 124/89 86 18 100% on RA Gen: sitting in chair, NAD HEENT: + conjunctival pallor. No icterus. MMM. OP clear. NECK: No JVD. Normal carotid upstroke without bruits. LYMPH: No cervical or supraclavicular LAD CV: Irregularly irregular rhythm. No murmurs. LUNGS: No increased WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, ND, mildly tender to palpation throughout. No masses, guarding or rebound. EXT: WWP. Trace ___ edema bilaterally up to knees SKIN: No rash. No mucosal involvement. No petechiae/purpura or ecchymoses. NEURO: A&Ox3. Pertinent Results: LABS ON ADMISSION: ================= ___ 12:55PM BLOOD WBC-3.9# RBC-2.33# Hgb-6.8# Hct-19.4# MCV-84 MCH-29.3 MCHC-35.1* RDW-14.0 Plt Ct-83* ___ 10:35AM BLOOD Neuts-65.6 Lymphs-14.9* Monos-9.3 Eos-9.5* Baso-0.7 ___ 11:55AM BLOOD ___ PTT-24.8* ___ ___ 10:35AM BLOOD Glucose-103* UreaN-25* Creat-1.2 Na-138 K-4.1 Cl-104 HCO3-22 AnGap-16 ___ 10:35AM BLOOD ALT-34 AST-28 LD(LDH)-211 AlkPhos-126 TotBili-0.3 ___ 10:35AM BLOOD TotProt-5.6* Albumin-3.7 Globuln-1.9* Calcium-9.0 Phos-3.4 Mg-1.7 LABS ON DISCHARGE: ================= ___ 12:00AM BLOOD WBC-3.9* RBC-2.86* Hgb-9.8* Hct-27.6* MCV-97 MCH-34.2* MCHC-35.4* RDW-24.8* Plt Ct-95# ___ 12:00AM BLOOD Neuts-85.1 Lymphs-4.7* Monos-9.9 Eos-0 Baso-0.4 ___ 12:00AM BLOOD Ret Aut-6.3* ___ 12:00AM BLOOD Glucose-140* UreaN-27* Creat-1.1 Na-127* K-4.0 Cl-91* HCO3-22 AnGap-18 ___ 12:00AM BLOOD ALT-296* AST-47* AlkPhos-139* TotBili-1.3 ___ 12:00AM BLOOD Albumin-4.0 Calcium-8.3* Phos-2.8 Mg-1.8 MICROBIOLOGY: ============ ___ 11:50 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:59 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. ___ 8:12 pm STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 8:30 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 12:00 am BLOOD CULTURE Source: Line-hickman. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:00 am Immunology (___) Source: Line-hickman. FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. IMAGING: ======= Flex sigmoidoscopy ___: Normal mucosa in the whole sigmoid colon (biopsies taken) Otherwise normal sigmoidoscopy to splenic flexure CT ___ ___: 1. Fluid filled non-dilated loops of large and small bowel with mild mesenteric stranding inferiorly, nonspecific but suggestive of enteritis. No definite evidence of graft versus host disease. 2. Sequelae of generalized edematous state, including mild subcutaneous edema, trace free simple pelvic fluid, and diffuse periportal edema. 3. Distended gallbladder relates to NPO status. 4. Hiatus hernia. CT sinus ___: 1. Minimal bilateral maxillary sinus mucosal thickening 2. Otherwise unremrakable CT sinus examination. CT Chest ___: No focal consolidation, pleural effusion, or other evidence of pulmonary infection. CXR ___: No acute cardiopulmonary abnormality. CXR ___: No acute cardiopulmonary process. PATHOLOGY: ========= COLONIC BIOPSY ___: Random colon, biopsy: Colonic mucosa, within normal limits SKIN BIOPSY ___: Pauci-inflammatory interface dermatitis with patchy involvement of epidermis and mid-upper hair follicle, consistent with graft versus host disease in the appropriate clinical setting (see note). Note: While less likely, a viral exanthem and drug reaction cannot be entirely excluded. This diagnosis was called to Dr. ___ (Dermatology) by Dr. ___ on ___. Brief Hospital Course: Mr. ___ is a ___ gentleman with past medical history significant for MDS RAEB - 2, status post allogeneic stem cell transplant from matched related donor in ___ with recent anemia requiring transfusion and bone marrow biopsy concerning for pure red cell aplasia who presents after presyncopal episode, found to be anemic so was admitted for further work-up and management of PRA now s/p treatment with several sessions of pheresis and Rituxan. He developed skin rash and diarrhea in the setting of immunosuppressant taper consistent with GVHD of the skin and gut treated with high dose steroids and restarting cyclosporine. # GVHD of skin/GI tract: Pruritic papular rash on admission exam concerning for grade 2 GVHD given given clinical appearance of rash and biopsy in the setting stopping cyclosporine on ___. Rash resolved with steroids. No ocular or liver involvement. Developed diarrhea the day after admission. Amount of liquid stool per day was consistent with grade I GVHD of the gut. C diff was neg x 2. GI symptoms initially improved with steroids and bowel rest and he was advanced from clear liquid to phase 3 diet. On ___ he developed recurrent symptoms including abdominal cramping and loose stool so he returned to ___ steroids, budesonide and bowel rest. CT ___ without evidence of colitis but possible enteritis for which he was started on flagyl. Flex sigmoidoscopy was unremarkable, biopsies returned showing normal colonic mucosa. After his abdominal cramping and diarrhea had improved his diet was gradually re-advanced as per GVHD protocol. His cyclosporine levels were monitored with dosing adjustments as needed. He was discharged on stage IV diet with plans to advance to stage V ~ 1 week after discharge. # Anemia/Pure red cell aplasia: Slow count recovery after transplant followed by anemia requiring weekly blood transfusion in the last month prior to admission. Bone marrow biopsy in ___ concerning for pure red cell aplasia, which he is at risk for given the ABO mismatch of his allogeneic bone marrow transplant. Admission labs revealed WBC of 3.9, Hgb 6.8 (from 6.8-7.9) and plt 83 (from 140's in ___. Low Hgb as well as downward platelet trend consistent with PRA diagnosis. His cyclosporine had been tapered in the outpatient setting, prompting the GVHD as above, without significant improvement in his counts so it was restarted shortly after admission. He received a total of 4U PRBC (last ___ during this admission. Furthermore, he was treated with rituximab on ___ and then 6 sessions of plasmapheresis with improvement in his blood counts including retic count. # MDS/s/p MRD allo SCT: Pt was diagnosed with MDS in ___ now s/p 4 cycles of decitabine and MRD allo SCT in ___ (day >120 on admission) with reduced intensity flu/bu. Recent WBC stable with persistent anemia and downtrending plts with pure red cell aplasia on bone marrow as above. Post-transplant course is now also complicated by GVHD of the skin and gut as above. Immunosuppression was restarted with cyclosporine during this admission. Ursodiol was discontinued due to diarrhea. Prophylaxis was continued with acyclovir, bactrim and voriconazole while on high dose steroids. Fungal ppx was switched to mycafungin several days prior to discharge secondary to elevated LFTS; he was discharged on IV mycafungin. # Afib: History of atrial fibrillation not on anticoagulation given low CHADS score and low platelets. On metoprolol and diltiazem for rate control at baseline. He remained in irregular rhythm on exam. Early in his hospital course he had several episodes of atrial fibrillation with RVR that responded to an additional dose of PO diltiazem. Home diltiazem and metoprolol were continued. # Pre-syncopal episode: Episode of near-syncope on the morning of admission. Possibly vasovagal given urge to have BM versus hypovolemic given anemia and history of poor oral intake. Troponins were negative x 2 in the ED. CXR, UA, BCx and C diff were negative for infection. He was transfused as above and rehydrated with IVF with relief of symptoms. # GERD: Possibly component of laryngospasm based on worsening of GERD in the setting of steroids. Home omeprazole was continued and ranitidine was initiated with good effect. TRANSITIONAL ISSUES: ==================== # Cyclosporine dose at time of discharge: 50QAM, 25QPM # Steroid dose at time of discharge: 45 mg daily, with plan for very slow taper # Will follow up with Dr. ___ Dr. ___ on ___ # Discharged on mycafungin because LFTs were elevated in the setting of Voriconazole # Plan for next rituxan dose ___ # ursodial was discontinued in the setting of diarrhea, which was subsequently believed to be GVHD: consider restarting in the future # Metoprolol XL dose increased from 50 to 100 daily for better rate control during his hospitalization (had multiple episodes of Afib with RVR).Dose ___ need to be adjusted in the future # CODE: Full # EMERGENCY CONTACT: Wife (___) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 3. Fluconazole 400 mg PO Q24H 4. FoLIC Acid 1 mg PO DAILY 5. HydrOXYzine 25 mg PO Q8H:PRN itching 6. Lorazepam 0.5 mg PO Q8H:PRN anxiety, nausea 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Ursodiol 300 mg PO BID 12. Magnesium Oxide 400 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Simethicone 80 mg PO QID:PRN gas, bloating 15. Diltiazem Extended-Release 180 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Cyclosporine 0.05% Ophth Emulsion 2 drops Other BID 3. Diltiazem Extended-Release 180 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. HydrOXYzine 25 mg PO Q8H:PRN itching 6. Lorazepam 0.5 mg PO Q8H:PRN anxiety, nausea 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Simethicone 80 mg PO QID:PRN gas, bloating 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Budesonide 3 mg PO TID RX budesonide 3 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:3 12. Calcium Carbonate 500 mg PO QID:PRN heartburn RX calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth QID:PRN Disp #90 Tablet Refills:3 13. CycloSPORINE (Neoral) MODIFIED 50 mg PO QAM RX cyclosporine modified 50 mg 1 capsule(s) by mouth QAM Disp #30 Capsule Refills:3 14. CycloSPORINE (Neoral) MODIFIED 25 mg PO QPM RX cyclosporine modified 25 mg 1 capsule(s) by mouth QPM Disp #30 Capsule Refills:3 15. Micafungin 50 mg IV Q24H RX micafungin [Mycamine] 50 mg 1 vial IV Q24H Disp #30 Vial Refills:3 16. PredniSONE 45 mg PO DAILY RX prednisone 20 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 RX prednisone 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 17. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 18. Magnesium Oxide 400 mg PO BID 19. Multivitamins 1 TAB PO DAILY 20. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Graft versus host disease Secondary: Myelodysplastic syndrome status post allogeneic bone marrow transplant Pure red cell aplasia Atrial fibrillation with rapid ventricular response Pre-syncope 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. You came to the hospital because you nearly fainted. You were found to have low red cell counts requiring blood transfusion. While you were here you had several sessions of pheresis and received a medication called rituximab to help maintain your red cell counts. You developed a skin rash and diarrhea caused by the cells from the bone marrow transplant attacking your own cells (graft-versus-host disease) after stopping your immunosuppressive medication cyclosporine. You were treated with high dose steroids and restarted on cyclosporine. We gave you intravenous nutrition while your bowel was recovering. You slowly advanced back to solid foods before discharge. Please take your medications as directed and follow-up with your doctors as ___ below. You should continue your current diet for 1 week after discharge, and if this is going well (no cramping/diarrhea) you should advance to the phase V GVHD diet. Sincerely, Your ___ Team Followup Instructions: ___
10064049-DS-19	10,064,049	22,275,203	DS	19	2164-04-12 00:00:00	2164-04-13 10:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with hx of MDS, ___ allogeneic stem cell transplant in ___, on IVIG, h/o Afib, CHF who presents with weakness and lightheadedness. Pt notes about a week ago he had a fall with headstrike. Denies syncope or LOC but states he tripped on a curb. He went to ___ where he reports having a normal head CT. Over the past week he has noted feeling more weak and fatigued. He also notes an increase in usual diarrhea to up to 3 BM per today. His torsemide and rate control agents have been recently modified multiple times. In brief, he was initially changed from Lasix 60 mg daily to torsemide 20 mg daily. He then lost ___ lbs quickly with symptomatic hypotension. His diuretic was subsequently held and his metop and dilt decreased to q8h from q6h with improvement in BP. He regained about 7 lbs (179 to 186 lbs) off diuretics. He was then seen on ___ by ___ NP service in the office and was noted to be volume overloaded. He was restarted on torsemide 10 mg daily and increased metoprolol and diltiazem to q6h from q8h. However, on ___, his weight decreased 186 lbs down to 177 lbs in 3 days and so torsemide was held. He also notes that he ran out of his metop and dilt earlier in week so did not take for several days. Today, pt was at heme/onc visit for IVIg (did not receive). He reported feeling unwell, lightheaded and weak. His HR was in 140s with BP 80/50 and so was sent to ED for further management. In the ED initial vitals were: T 97.3 HR 125 BP 98/62 RR 18 100% RA EKG: coarse afib, ventricular rate 98, left axis deviation. Labs/studies notable for: WBC 1, H/H 7.6/22.9, platelet count of 25, Creatinine 2.5 (bl cr 1.1-2.1). K+ 3.0. Imaging notable for CXR with No acute cardiopulmonary process Patient was given: 40 mg po K+, home metop tartate 50 mg x2, home diltiazem 60 mg po, and 250 ccs NS On the floor, pt states he feels improved. Denies any CP or SOB. ROS: On review of systems, + worsening diarrhea, chronic nonproductive cough, occasional dysuria Past Medical History: PAST ONCOLOGIC HISTORY: Per outpatient oncology notes BONE MARROW BIOPSY ___: Markedly hypercellular marrow with increased blasts and dysplasia consistent with MDS RAEB -2. CYTOGENETICS ___: 45X -Y, Negative for common abnormality seen in MDS. ___ for FLT3 TKD mutation and FLT3 ITD mutation. BONE MARROW BIOPSY ___: HYPERCELLULAR BONE MARROW WITH MYELOID DYSPLASIA AND INCREASED BLASTS CONSISTENT WITH CONTINUED INVOLVEMENT BY THE PATIENT'S KNOWN MYELODYSPLASTIC SYNDROME (RAEB-2) (SEE NOTE). Note: By count blasts number 14% and 18% in the peripheral blood and bone marrow aspirate respectively. Flow cytometric analysis revealed a small population of CD34(+) events (7% total events). This is consistent with the above diagnosis. Correlation with cytogenetics and continued close follow-up is recommended. Cytogenetics unchanged. CYTOGENETICS ___: NEGATIVE for CBFB REARRANGEMENT, NEGATIVE for RUNX1T1-RUNX1 FUSION, NEGATIVE RESULT for the COMMON ABNORMALITIES OBSERVED in MDS, 45,X,-Y[20], FLT3 negative, NPM1 negative. BONE MARROW ___: Prelim results show 7% blasts TREATMENT HISTORY: - ___: C1 Decitabine - ___: C2 Decitabine - ___: C3 Decitabine - ___: C4 Decitabine - ___: Allo, MRD, reduced-intensity flu/Bu. Course complicated by pure red cell aplasia requiring pheresis (x7) and rituximab (x4), acute GVHD of the gut Peripheral engraftment ___: 99% donor Bone marrow engraftment ___: 98% donor *Peripheral engraftment ___: 99% donor Peripheral engraftment ___: 100% donor Peripheral engraftment ___: 100% donor Bone arrow engraftment ___: 100% donor Peripheral blood engraftment ___: 100% donor Peripheral blood engraftment (cytogenetics done at ___, ___: FISH: X 5.5%, XY 94.5%. 189 of 200 (94.5%) interphase peripheral blood cells examined had the male probe signal pattern of the bone marrow donor. 11 of 200 (5.5%) cells had a probe signal pattern with the Y chromosome signal missing that corresponds to the recipient's pre-transplant 45,X,-Y[20] karyotype. Peripheral blood engraftment ___: 100% donor Other events: --___: Admitted for GVHD of the gut --___: Admitted, found to have stenotrophomonas and aspergillus in BAL --___: Admitted with hypotension in setting of ?afib with RVR, started on digoxin --___: Started on posaconazole for fungal prophylaxis --___: Admitted with blood cultures + for GNR, citrobacter, likely in setting of infected line, on meropenem --> cefepime --> completing a 2 week course of outpatient cipro --___: Admitted in setting of afib with RVR and shortness of breath, found to have RLL consistent with nocardia nova, on imipenem and minocycline for likely a 2 month course --___: Changed to CTX/minocycline --___: Minocycline and posaconazole on hold due to elevated LFTs ADDITIONAL TREATMENT: - ___: C1: IVIG - ___: C2: IVIG - ___: C3: IVIG - ___: C4 IVIG - ___: IVIG Voriconazole stopped on ___ *Posaconazole started on ___, on hold since ___ PAST MEDICAL/SURGICAL HISTORY: - pAtrial fibrillation with RVR - HTN - Basal cell carcinoma - Sleep apnea on CPAP - GERD ___ EGD - ___ inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.9, 90/62, HR 110s-130s, 100% on RA GENERAL: well appearing, NAD HEENT: L forehead abrasion, now healing, MMM CARDIAC: ___, tachycardiac LUNGS: no wheezes, crackles or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: ___ ___ edema bilaterally SKIN: multiple erythematous macules and papules on chest and upper extremities DISCHARGE PHYSICAL EXAM: GENERAL: well appearing, NAD HEENT: L forehead abrasion, now healing, MMM, L subconjuctival hemorrhage improving CARDIAC: ___, tachycardiac LUNGS: no wheezes, crackles or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ ___ pretibial edema bilaterally SKIN: multiple erythematous macules and papules on chest and upper extremities Pertinent Results: ADMISSION LABS: =============== ___ 10:55AM BLOOD WBC-1.0 RBC-2.52* Hgb-7.6* Hct-22.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-20.3* RDWSD-64.0* Plt Ct-15* ___ 10:55AM BLOOD Neuts-61 Bands-2 Lymphs-14* Monos-20* Eos-3 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-0.63* AbsLymp-0.14* AbsMono-0.20 AbsEos-0.03* AbsBaso-0.00* ___ 05:32AM BLOOD ___ PTT-25.2 ___ ___ 10:55AM BLOOD Ret Aut-0.9 Abs Ret-0.02 ___ 10:55AM BLOOD Glucose-130* UreaN-60* Creat-2.4* Na-138 K-3.0* Cl-105 HCO3-23 AnGap-13 ___ 10:55AM BLOOD ALT-79* AST-31 LD(LDH)-219 AlkPhos-541* TotBili-0.7 ___ 10:55AM BLOOD cTropnT-0.02* proBNP-5968* ___ 05:32AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:55AM BLOOD TotProt-4.7* Albumin-3.0* Globuln-1.7* Calcium-8.3* Phos-4.8* Mg-1.6 UricAcd-13.7* ___ 10:55AM BLOOD Hapto-250* ___ 01:15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:15PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 ___ 01:15PM URINE CastHy-7* ___ 01:15PM URINE Mucous-RARE OTHER PERTINENT/DISCHARGE LABS: =============== ___ 11:32AM URINE Hours-RANDOM UreaN-845 Creat-72 Na-57 K-35 Cl-48 ___ 06:10AM BLOOD WBC-1.2* RBC-2.60* Hgb-8.1* Hct-23.8* MCV-92 MCH-31.2 MCHC-34.0 RDW-19.0* RDWSD-58.9* Plt Ct-38* ___ 06:00AM BLOOD WBC-1.2* RBC-2.39* Hgb-7.2* Hct-21.9* MCV-92 MCH-30.1 MCHC-32.9 RDW-19.8* RDWSD-62.4* Plt Ct-13* ___ 06:10AM BLOOD Plt Ct-38* ___ 05:00PM BLOOD Plt Ct-54# ___ 06:00AM BLOOD Plt Ct-13 ___ 05:32AM BLOOD ___ PTT-25.2 ___ ___ 12:58PM BLOOD Glucose-137* UreaN-26* Creat-1.3* Na-141 K-3.7 Cl-110* HCO3-23 AnGap-12 ___ 06:10AM BLOOD ALT-71* AST-43* LD(LDH)-233 AlkPhos-608* TotBili-0.6 ___ 05:32AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:55AM BLOOD cTropnT-0.02* proBNP-5968* ___ 12:58PM BLOOD Calcium-8.1* Phos-2.2* Mg-2.5 ___ 10:55AM BLOOD Hapto-250* ___ 05:32AM BLOOD Digoxin-1.1 ___ 11:32AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:32AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 11:32AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 11:32AM URINE CastHy-1* ___ 11:32AM URINE Mucous-RARE IMAGING: =============== ___ CXR Right lower lobe pulmonary nodule was better assessed on prior CT. No new focal consolidation seen. MICROBIOLOGY: =============== ___ - blood culture x1 - pending ___ - urine culture - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ - stool c diff PCR - negative Brief Hospital Course: ___ yo M h/o MDS ___ alloSCT ___, h/o Afib, HFpEF who presents with fatigue, found to be in Afib with RVR and hypotensive. #Afib with RVR: etiology either medication noncompliance or changes in medication. No evidence of infection. Loaded with digoxin when first admitted as he was hypotensive and unable to tolerate home metoprolol or diltiazem. He eventually tolerated metoprolol and diltiazem and was discharged with heart rates in the 80-90s. He is not anticoagulated for a-fib due to thrombocytopenia (platelets 15) #Hypotension: Patient typically runs in systolic BP of ___. Continued home fludrocortisone in addition to treatment of afib as above. #HFrEF: patient with history of HF, has preserved EF on most recent TTE in ___ have a component of diastolic HF, which was unable to be assessed on most recent TTE. Multiple recent changes in outpatient diuretic regimen. He appeared volume overloaded on admission and was restarted on diuresis with torsemide when blood pressures and heart rates were better controlled. Patient instructed to call Cardiology office with weight fluctuations of 3lbs or more for instructions on adjusting outpatient diuretic regimen. ___: Bl creatinine 1.1, recently elevated in the last few weeks, now at 2.4. Likely secondary to cardiorenal etiology given poor forward flow vs prerenal given intermittently overdiuresed over this time period as well as well as worsening diarrhea. Improved quickly with rate control and holding diuresis. Stable with resumption of diuresis. #Diarrhea: chronic, due to graft vs host disease (GVHD). Negative c diff and negative recent adenovirus and CMV viral loads. #Nocardia - recent chest CT on ___ showing slowly involuting RLL nodule due to nocardia. Continued on clarithromycin. Discontinued Bactrim and started minocycline on ID recommendations per below. #MDS ___ alloSCT - continued on prophylactic posaconazole (hx of aspergillosis), prophylactic acyclovir, ursodiol, prednisone 5mg - pt evaluated by inpatient hem/onc at request of outpatient oncologist who recommended against IVIG administration while inpatient. Felt pancytopenia may be due to sulfa drugs (Bactrim) and recommended discussing with infectious disease about alternative treatment regiments for Nocardia. Inpatient infectious disease team was consulted on the request of outpatient ID physician. Team recommended d/c Bactrim and starting minocycline. Arranged for interval outpatient LFTs and outpatient ID follow-up #Pancytopenia -per hem/onc, likely medication side effect rather than graft failure. -per hem/onc, pt received 1U pRBC and 1U platelets with appropriate rise. Transfused with 20g IVIG prior to discharge as he missed usual dose due to hospitalization. Hem/Onc team to arrange outpatient follow-up -no DVT prophylaxis given thrombocytopenia -monitored daily CBC for transfusion needs TRANSITIONAL ISSUES: - -Full code -HCP: ___ (wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. FoLIC Acid 5 mg PO DAILY 3. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 4. Multivitamins 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. PredniSONE 5 mg PO DAILY 7. Simethicone 80 mg PO QID:PRN gas and bloating 8. Ursodiol 300 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Diltiazem 60 mg PO Q6H 11. Metoprolol Tartrate 50 mg PO Q6H 12. Posaconazole Delayed Release Tablet 300 mg PO DAILY 13. Acyclovir 400 mg PO Q8H 14. Sulfameth/Trimethoprim SS 1 TAB PO BID 15. Clarithromycin 500 mg PO Q12H 16. Docusate Sodium 100 mg PO BID 17. Fludrocortisone Acetate 0.1 mg PO DAILY 18. Fluticasone Propionate NASAL 1 SPRY NU BID 19. Guaifenesin 10 mL PO Q6H:PRN cough 20. Psyllium Powder 1 PKT PO DAILY:PRN constipation 21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. FoLIC Acid 5 mg PO DAILY 7. Guaifenesin 10 mL PO Q6H:PRN cough 8. Multivitamins 1 TAB PO DAILY 9. Posaconazole Delayed Release Tablet 300 mg PO DAILY 10. PredniSONE 5 mg PO DAILY 11. Simethicone 80 mg PO QID:PRN gas and bloating 12. Ursodiol 300 mg PO BID 13. Vitamin D ___ UNIT PO DAILY 14. Hydrocortisone Acetate Suppository ___AILY PRN hemorrhoids 15. Psyllium Powder 1 PKT PO DAILY:PRN constipation 16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 17. Diltiazem 60 mg PO TID RX diltiazem HCl 60 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 18. Clarithromycin 500 mg PO Q12H 19. Pantoprazole 40 mg PO Q24H 20. Metoprolol Succinate XL 150 mg PO BID RX metoprolol succinate 50 mg 3 tablet(s) by mouth twice daily Disp #180 Tablet Refills:0 21. Minocycline 100 mg PO BID You will need liver tests to ensure they are stable. RX minocycline 100 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:*0 22. Outpatient Lab Work Liver function tests (LFTS) On ___. ICD-10 J18.9. Send results to Dr ___ fax ___, tel ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: atrial fibrillation with rapid ventricular response acute kidney injury Secondary: heart failure with reduced ejection fraction Myelodysplastic Syndrome with Refractory Anemia with Excess Blasts Type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted with fast heart rate, known as atrial fibrillation with rapid ventricular response. While you were here, we gave you medications to control your heart rate. Additionally, we gave you diuretics, which are medications to help you urinate. At discharge, you weighed 78.6kg (173lbs). It is very important that you weigh yourself every morning before getting dressed and after going to the bathroom. Call your doctors if your ___ goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days. Please STOP taking Bactrim and start taking minocycline. You will need to follow up with Dr. ___ to discuss further treamtents for your Nocardia infection. We wish you all the best, Your ___ Cardiology team Followup Instructions: ___
10064049-DS-8	10,064,049	26,336,999	DS	8	2162-08-27 00:00:00	2162-08-28 12:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain, dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with a history of pAfib was sent to the ED today by his PCP for chest pain and progressive DOE and was found in the ED to have imaging concerning for multifocal PNA including lung nodules as well as abnormal CBC with WBC 47 and a population of atypical cells concerning for leukemia versus leukemoid reaction. The patient reports that around mid ___ he started experiencing dyspnea on exertion and band-like chest pain. The chest pain is non-exertional. He saw his PCP and initially the impression was he was having exacerbation of reflux which he describes as severe in the past. His Omeprazole was increased. At that time he had night sweats. He also started experiencing calf pain, dyspepsia, bloating and belching and particularly progressive dyspnea on exertion. Prior to this, at his baseline he swam weekly, walked on the treadmill and used the stationary bike. He does not recall feeling feverish. He had anorexia which resolved. He traveled to ___ and continued to have DOE and upon returning yesterday presented to his PCP who was concerned about angina and sent him to the ED. The patient additionally remarks that he was told in the past about a problem with his WBC count. His last bloodwork was in ___ by his PCP. In the ED T 99.3, HR 88, BP 141/77, HR 20, SpO2 100%. Patient desated to 88% and was placed on nasal cannula. CTA of the chest did not show PE but did show pulmonary nodules and changes concerning for multifocal PNA. ___ U/S did not show DVT. He was dosed Ceftriaxone and Azithromycin. Past Medical History: HTN basal cell carcinoma sleep apnea on CPAP pAfib GERD s/p EGD s/p inguinal hernia repair w/ mesh Social History: ___ Family History: - Mother: alive at ___ - Father: deceased at ___ from cardiac problems, hx of lung CA - Malignancies: as above and sister had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: T 98.9, BP 148/72, HR 85, RR 26, SpO2 95% 2L NC General: Fairly well-appearing man in NAD HEENT: NC/AT, PERRL, MMM, lesions on the hard palate, no cervical, supraclavicular, or axillary adenopathy CV: RR, NL S1S2 no S3S4 MRG PULM: breathing comfortably, coarse crackles at bilateral bases, moving air well ABD: +BS, distended, tympanic on percussion, ttp of RUQ, liver palpated 3 finger breadths below costal margin, spleen not palpated LIMBS: + pedal edema, no calf ttp SKIN: No rashes or skin breakdown NEURO: A&OX3, strength and sensation intact DISCHARGE PHYSICAL EXAM: VITAL SIGNS: T 98.4, BP 112/74, HR 94, RR 20, SpO2 96% on RA General: overweight white male in NAD HEENT: NC/AT, PERRL, MMM CV: irregularly irregular, no M/R/G PULM: CTAB ABD: +BS, non-tender, non-distended LIMBS: bilateral 1+ lower extremity edema SKIN: No rashes Pertinent Results: ___ 05:00PM GLUCOSE-128* UREA N-7 CREAT-0.8 SODIUM-132* POTASSIUM-3.1* CHLORIDE-96 TOTAL CO2-24 ANION GAP-15 ___ 05:00PM LD(LDH)-319* ___ 05:00PM CK-MB-2 cTropnT-<0.01 proBNP-1687* ___ 05:00PM CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-1.7 URIC ACID-5.8 ___ 05:00PM TSH-2.1 ___ 05:00PM WBC-60.4* RBC-2.42* HGB-8.5* HCT-26.8* MCV-111* MCH-35.3* MCHC-31.8 RDW-17.4* ___ 05:00PM NEUTS-57 BANDS-6* LYMPHS-3* MONOS-5 EOS-3 BASOS-0 ___ METAS-4* MYELOS-2* PROMYELO-1* BLASTS-19* OTHER-0 ___ 05:00PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-OCCASIONAL ___ 05:00PM PLT SMR-VERY LOW PLT COUNT-31* ___ 05:00PM ___ ___ 12:20PM CK-MB-2 cTropnT-<0.01 ___ 12:20PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE ___ 12:20PM HIV Ab-NEGATIVE ___ 12:20PM HCV Ab-NEGATIVE ___ 12:20PM WBC-54.3* RBC-2.27* HGB-7.8* HCT-25.0* MCV-110* MCH-34.6* MCHC-31.4 RDW-17.1* ___ 12:20PM NEUTS-67 BANDS-1 LYMPHS-5* MONOS-7 EOS-1 BASOS-1 ___ MYELOS-1* BLASTS-17* OTHER-0 ___ 12:20PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ ENVELOP-OCCASIONAL ___ 12:20PM PLT SMR-VERY LOW PLT COUNT-36* ___ 12:20PM ___ PTT-31.0 ___ ___ 12:20PM ___ ___ 12:20PM RET AUT-6.8* ___ 09:45AM BONE MARROW CD33-DONE CD41-DONE CD56-DONE CD64-DONE CD71-DONE CD117-DONE CD45-DONE ___ A-DONE KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD11C-DONE CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE LAMBDA-DONE CD5-DONE ___ 09:45AM BONE MARROW CD34-DONE CD3-DONE CD4-DONE CD8-DONE ___ 09:45AM BONE MARROW IPT-DONE ___ 08:26AM RET AUT-6.8* ___ 08:26AM IPT-CANCELLED ___ 06:40AM GLUCOSE-100 UREA N-9 CREAT-0.9 SODIUM-135 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-25 ANION GAP-16 ___ 06:40AM ALT(SGPT)-45* AST(SGOT)-26 LD(LDH)-330* ALK PHOS-303* TOT BILI-0.9 ___ 06:40AM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-1.8 URIC ACID-6.9 ___ 06:40AM VIT B12-1167* ___ 06:40AM WBC-53.9* RBC-2.51* HGB-8.7* HCT-28.5* MCV-114* MCH-34.7* MCHC-30.5* RDW-17.4* ___ 06:40AM NEUTS-50 BANDS-1 LYMPHS-5* MONOS-14* EOS-6* BASOS-0 ___ MYELOS-6* PROMYELO-0 BLASTS-18* OTHER-0 ___ 06:40AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL ELLIPTOCY-OCCASIONAL ___ 06:40AM PLT SMR-VERY LOW PLT COUNT-33* ___ 06:40AM ___ PTT-31.0 ___ ___ 06:40AM ___ 06:40AM RET AUT-6.5* ___ 03:53AM D-DIMER-1676* ___ 03:10AM URINE HOURS-RANDOM ___ 03:10AM URINE HOURS-RANDOM ___ 03:10AM URINE UHOLD-HOLD ___ 03:10AM URINE GR HOLD-HOLD ___ 03:10AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 02:20AM cTropnT-<0.01 ___ 08:15PM estGFR-Using this ___ 08:15PM GLUCOSE-122* UREA N-14 CREAT-1.1 SODIUM-131* POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-11 ___ 08:15PM ALT(SGPT)-46* AST(SGOT)-28 LD(LDH)-267* ALK PHOS-277* TOT BILI-0.8 ___ 08:15PM cTropnT-<0.01 ___ 08:15PM LIPASE-29 ___ 08:15PM proBNP-1831* ___ 08:15PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.8 URIC ACID-7.4* ___ 08:15PM HAPTOGLOB-116 ___ 08:15PM WBC-47.0* RBC-2.19* HGB-7.9* HCT-24.8* MCV-113* MCH-36.1* MCHC-31.9 RDW-16.7* ___ 08:15PM NEUTS-57 BANDS-9* LYMPHS-2* MONOS-6 EOS-2 BASOS-0 ___ METAS-1* MYELOS-5* PROMYELO-2* BLASTS-16* OTHER-0 ___ 08:15PM I-HOS-AVAILABLE ___ 08:15PM PLT SMR-VERY LOW PLT COUNT-38* ___ 08:15PM ___ PTT-29.6 ___ Brief Hospital Course: Mr. ___ is a ___ gentleman with history of pAfib, HTN, GERD, OSA on CPAP who presented with fatigue, chest pain, dyspnea on exertion, found to have leukocytosis, anemia, and thrombocytopenia, confirmed to be secondary to MDS. ___ hospital course was complicated by AFib with RVR that required a brief stay in the ICU. ========== ACTIVE PROBLEMS ========== # Myelodysplastic Syndrome On presentation, Mr. ___ was found to have leukocytosis, anemia, and thrombocytopenia along with elevated peripheral blasts. Bone marrow biopsy was performed the morning after presentation, which eventually showed refractory anemia with excess blasts-2 (RAEB-2), consistent with myelodysplastic syndrome. He was started on the ___ cycle of decitabine on ___. He received the first 3 days, but the treatment was held for 3 days due to ___. He received the last 2 days on ___ and ___. He did well with the treatment and discharged the following day. He was given allopurinol for TLS prophylaxis and discharged on a 2 week course. He also received acyclovir for prophylaxis. # Atrial Fibrillation The patient went into AFib on ___ with rapid ventricular response to HR in 120s-150s. The HR was refractory to 15 mg total of IV metoprolol and 10 mg of IV diltiazem, and he was transferred to the MICU. The etiology was thought to be multifactorial with a combination of stress from pneumonia and hypoxemia. Patient also had a history of pAFib and reports drinking 6 glasses of wine per night. In the ICU, his diltiazem was uptitrated to 90 mg QID, and he was stabilized. On the floor, he was titrated to metoprolol of 75 mg daily, and he was digoxin loaded and maintained on 0.125 mg daily. His thrombocytopenia was a contraindication for anticoagulation. At the time of discharge, his heart rate was well controlled at ___ to ___. # Hypoxemic Respiratory Failure The patient presented with multifocal pneumonia with O2 requirement up to 6L. He was initially started on azithromycin, cefepime, and vancomycin. Urine legionella, galactomannan, and beta-D-glucan were negative. His pneumonia was likely secondary to poor immunologic function from leukemia. TTE showed EF of 60% but given new hypoxemia with pleural effusions, there was thought to be a component of diastolic heart failure exacerbated by tachycardia and AFib. He improved on a full course of vancomycin and cefepime. # Acute Kidney Injury The patient's Cr rose to a peak of 1.8 on ___. The etiology was thought to be poor hemodynamic perfusion from AFib and possibly AIN from cefepime. His Cr improved to 1.3 at discharge with improvement of heart rate. # Hyponatremia The patient developed hyponatremia to a nadir of 125 that was thought to be hypervolemic hyponatremia secondary from heart failure. With improvement of AFib, the patient improved to a Na of 136 at discharge. ========== CHRONIC PROBLEMS ========== # Hypertension Patient's amlodipine was held while uptitrating diltiazem. Given that his BP was appropriate with diltiazem and metoprolol, amlodipine was not restarted. # Alcohol Abuse Patient reported drinking ~6 glasses of wine per night. He was monitored on CIWA scale and did not show signs/symptoms of withdrawal. # GERD His omeprazole was increased to 40mg PO BID given concern of aspiration during hospitalization. ========== TRANSITIONAL ISSUES ========== - Aspirin was held due to thrombocytopenia - Found to have bilateral peripapillary retinal hemorrhages by ophthalmology, will need follow up Medications on Admission: 1. Amlodipine Dose is Unknown PO DAILY 2. Aspirin 81 mg PO DAILY 3. Omeprazole 40 mg PO BID 4. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Omeprazole 40 mg PO BID RX omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:1 2. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:1 3. Allopurinol ___ mg PO DAILY RX allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily Disp #7 Tablet Refills:0 4. Digoxin 0.125 mcg PO DAILY RX digoxin 125 mcg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 5. Diltiazem Extended-Release 360 mg PO DAILY RX diltiazem HCl 360 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 6. Docusate Sodium 100 mg PO BID:PRN constipation RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:1 7. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 8. Furosemide 20 mg PO DAILY Stop taking if you feel lightheaded or dizzy. RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 9. Metoprolol Succinate XL 75 mg PO HS RX metoprolol succinate 50 mg 1.5 tablet(s) by mouth at bedtime Disp #45 Tablet Refills:1 10. Benzonatate 100 mg PO TID cough RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #30 Capsule Refills:1 11. Bisacodyl 10 mg PO DAILY:PRN constipation RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #30 Tablet Refills:1 12. Caphosol 30 mL ORAL QID:PRN dry mouth 13. Simethicone 40-80 mg PO QID:PRN bloating RX simethicone 80 mg 1 tablet by mouth four times a day Disp #60 Tablet Refills:1 14. TraZODone 25 mg PO HS:PRN insomnia RX trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #15 Tablet Refills:*1 15. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Myelodysplastic Syndrome Secondary: Atrial Fibrillation, Pneumonia 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 initially after being diagnosed with a pneumonia, for which you were treated with a long course of antibiotics during your stay. During this hospitalization, you had concerning laboratory results that lead to a bone marrow biopsy, which lead to a diagnosis of myelodysplastic syndrome, which is a type of leukemia or cancer. We gave you the first round of chemotherapy during the hospitalization. Your hospital course was complicated by the development of atrial fibrillation that resulted in a very fast heart rate. You briefly required a stay in the medical intensive care unit to control your heart rate, which we will manage you as an outpatient with 3 medications: metoprolol, diltiazem, and digoxin. Please make sure to take your new medications and to keep all of your follow up appointments. It was a pleasure to take care you during your stay. Sincerely, Your ___ Oncology Team Followup Instructions: ___
10064390-DS-17	10,064,390	23,328,727	DS	17	2137-11-25 00:00:00	2137-11-25 10:48:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: Mechanical fall resulting in subarachnoid hemorrhage Major Surgical or Invasive Procedure: ___ ACDF of C5-C6 with Dr. ___ ___ of Present Illness: Mr. ___ is a ___ year old gentleman who sustained a fall on ___ after slipping on ice while walking his dog. He was down for an unknown amount of time until his wife found him at the bottom of his driveway. He was found to be awake, although not moving his upper or lower extremities and was amnestic to the event. The patient was taken to ___ ___ where he was able to weakly raise his BLE, and had minimally weak movement to his BUE. The patient stated that he had decreased sensation to his lower body from below his nipple line, and endorsed double vision. A NCHCT was performed and was consistent with a perimesencephalic SAH with extension into the fourth ventricle. A CT C-spine was performed and was concerning for c5-c6 posterior osteophyte. The patient was intubated at the OSH for declining mental status and was transferred to ___ via MED Flight for further care and evaluation. Neurosurgery was consulted, the patient was examined and images were reviewed. A repeat NCHCT/CTA was performed to assess for vascular abnormality and interval change, and a CT of the chest abdomen and pelvis was done in the setting of trauma and was negative for injuries or fractures. Past Medical History: HTN, HLD, restless leg syndrome Social History: ___ Family History: ___ contributory Physical Exam: Exam on admission ___: Intubated. EO spont. Follows commands. Hyper-reflexive with increased tone on all extremities. + clonus and + hoffmans bilaterally. Pinpoint pupils on sedation. Shows thumb/2 fingers on R. ___ withdraws to deep noxious. BLE withdraw to noxious. Decreased rectal tone. On Discharge: Alert and oriented, follows complex commands, endoreses paresthesias to all 5 fingers on bilateral hands to front and back of fingers, incision OTA w/ steri strips Motor Exam: Delt Trap Bi Tri Grip IP Q H AT ___ ___ Right 4 5 5 4 1 4 5 4 5 5 5 Left 4 5 4 3 1 4 5 4 5 5 5 Pertinent Results: ___: CTA Head Subarachnoid hemorrhage in the basal cisterns predominant on the right, with some redistribution from prior exam. No new focus of hemorrhage or infarction. ___: MRI c-spine 1. Study is mildly degraded by motion. 2. Severe C5-C6 spinal canal stenosis with focal cervical spinal cord signal abnormality. While findings may represent myelomalacia, acute cord injury is not excluded on the basis of this examination. 3. Within limits of study, no definite acute cord infarct identified. 4. Multilevel multifactorial degenerative disease of the cervical spine, worst at C5-C6, where there is severe spinal canal and bilateral neural foramen stenosis. 5. Severe neural foramen stenosis at C4-C5 and C6-C7 as described. ___: Chest xray Previous moderate pulmonary edema has improved. Given the lung volumes are greater, there is more consolidation at the left lung base, presumably atelectasis. The severity of right basal consolidation is stable. This is either atelectasis or pneumonia. Small pleural effusions are presumed. Heart size normal. ET tube in standard placement. ___: NCHCT Subarachnoid hemorrhage in the basal cisterns, predominantly on the right and similar in appearance to prior exam. Interval redistribution of blood products to the sulci and ventricular system. No new acute findings. ___ CERVICAL SINGLE VIEW IN OR 5 intraoperative plain films were obtained without a radiologist present. These depict anterior fusion at C5-C6 with anterior plate, screws, and interbody spacer. For further information, please refer to operative report in ___ Brief Hospital Course: On ___ Pt arrived to ___ ED via medflight from ___ s/p unwitnessed fall where he was found down in his driveway by his wife while he was out walking his dog. He was down for an unknown amount of time and was initially found to be unable to move all extremities. He also had decreased sensation from his nipple line down. Due to question of posturing and possible seizure he was given 1G Keppra at OSH and intubated for change of mental status. A head CT at the OSH shows SAH CT of c-spine was concerning for posterior osteophyte at C5-C6. Patient was placed in a c-collar, transferred to ICU. MRI c-spine ordered for today. Repeat NCHCT ordered for tomorrow morning. On ___ the MRI C Spine was reviewed by Dr. ___ it is believed the findings are chronic changes, therefore no OR intervention is needed. The patient remains intubated and in hard c-collar. Patient has been febrile today, blood and urine cultures are pending. Chest xray is concerning for pneumonia and patient was started on antibiotics. An xray of the R hand was negative for fracture. Non-contrast head CT shows a stable SAH with interval redistribution of blood. On ___, the patient remained neurologically and hemodynamically stable. CXR was consistent with pneumonia, and BAL was obtained. He was treated empirically and remained intubated. He was restarted on subcutaneous heparin for DVT prophylaxis. On ___, the patient remained neurologically and hemodynamically stable. On ___, the patient remained neurologically and hemodynamically stable. Antibiotics were discontinued. Potential C5-C6 ACDF was discussed with the family. On ___, the patient remained neurologically and hemodynamically stable. He was febrile to 102.3 and cultures were repeated. On ___, the patient was extubated in the early afternoon. He remained neurologically and hemodynamically stable and it was determined he would be transferred to the floor with telemetry and was placed on continuous O2 monitoring. He failed a voiding trial and his foley catheter was replaced. He was noted to have increased secretions later in the day. On ___, the patient remained neurologically stable on examination. A Speech Swallow Evaluation was consulted for questionable aspiration and strict NPO was recommended until swelling improves. A Dobhoff was placed, confirmed with chest X-ray and tube feeds were started. He was also started on gabapentin for pain management. He continued to mobilize with nursing and ___ and was out of bed to the chair. On ___ Mr. ___ exam remained stable. His strength in lower extremities continues to improve. A Dobhoff remained in place and he is awaiting a speech and swallow re-evaluation today. He again failed Speech and swallow eval later in the day. On ___ he was offered a bed at rehab which was accepted. He was discharged to rehab with instructions for followup and all questions were answered prior to discharge. Medications on Admission: Hydrochlorothiazide Atorvastatin Multivitamin Fish oil Vitamin E Vitamin D Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. CefePIME 2 g IV Q12H 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg IV Q12H 6. Gabapentin 300 mg PO TID 7. Heparin 5000 UNIT SC BID 8. HydrALAzine 10 mg IV Q6H:PRN SBP >160 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. LeVETiracetam 500 mg IV BID 11. Morphine Sulfate 1 mg IV Q3H:PRN pain 12. Ondansetron 4 mg IV Q8H:PRN nausea / vomting 13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 14. Pramipexole 0.125 mg PO QID 15. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: SAH, C5-C6 spinal stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ** Instructions for Traumatic Subarachnoid Hemorrhage Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Instructions for Cervical Spine Injury ** Your incision is closed with dissolvable sutures underneath the skin and steri strips. You do not need suture removal. Do not remove your steri strips, let them fall off. Please keep your incision dry for 72 hours after surgery. Please avoid swimming for two weeks. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Do NOT smoke. Smoking can affect your healing and fusion. Medications Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc for 2 weeks. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Followup Instructions: ___
10064678-DS-17	10,064,678	21,638,060	DS	17	2183-06-15 00:00:00	2183-06-15 16:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Diagnostic paracentesis (multiple) History of Present Illness: Ms. ___ is a ___ yo F with PMH of HCV cirrhosis and diuretic-controlled ascites who underwent an open cholecystectomy on ___ ___ symptomatic cholelithiasis. She was recently admitted on ___ with abdominal pain, diarrhea, and inadvertent removal of her JP drain. She was treated with hydration and her fevers, abdominal pain, and diarrhea resolved. She was discharged to home on ___. She represents today after seeing her PCP who expressed concern that the patient was tachycardic with low grade fevers to 100.4 and a distended and tender abdomen. She was sent to the ED at ___ and then transferred here. She reports diffuse abdominal pain, diarrhea approximately four times, and subjective fevers. Abdominal pain worsened 2 days ago along with nausea and diarrhea. Patient reports subjective fevers. She also reports feeling SOB which is consistent with notes from her previous stay. In the ED, initial vital signs were 99.4, 107, 130/74, 16, 93% RA. Labs were remarkable for baseline anemia, hyponatremia to 128, and mild elevations and AST and lipase. TBili 1.3, INR 1.6, and Cr 0.8. UA grossly positive. CXR and RUQ US were unremarkable. Patient was treated with morphine, Zofran, and nebs with some improvement in her symptoms. On the floor, initial vital signs were stable. Past Medical History: - HCV cirrhosis - Diuretic-controlled ascites - Type II diabetes - Obesity - Depression - Edema - History of C. diff colitis - Open CCY ___ Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION EXAM VS: 99.2, 109, 127/62, 16, 95% RA General: Alert, mild distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear Neck: Supple, JVP not elevated CV: RRR, nl S1/S2, no MRG Lungs: CTAB, no wheezes/rales/rhonchi Abdomen: Soft, diffusely tender, distended, no rebound, guarding, right-sided drain site clean/dry/intact, RUQ surgical scar GU: Deferred Ext: Warm, 2+ non-pitting lower extremity edema bilaterally Neuro: CN II-XII grossly intact Skin: Bruising on abdomen DISCHARGE EXAM VS: 98, 114, 134/70, 20, 97% 2 L General: Alert, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated CV: RRR, nl S1/S2, no MRG Lungs: Faint crackles at bases Abdomen: Soft, mild suprapubic tenderness, stably distended, no R/G, positive bowel sounds GU: Deferred Ext: Warm, tender, 3+ pitting lower extremity edema bilaterally, wrapped in ace bandages Neuro: CN II-XII grossly intact, mild asterixis Skin: Bruising on abdomen Pertinent Results: ADMISSION LABS ___ 01:15PM BLOOD WBC-11.8# RBC-3.29 Hgb-10.7* Hct-33.7* MCV-102* MCH-32.6* MCHC-31.9 RDW-14.7 Plt ___ ___ 01:15PM BLOOD Neuts-86.9* Lymphs-7.5* Monos-4.1 Eos-0.8 Baso-0.7 ___ 01:37PM BLOOD ___ PTT-40.9* ___ ___ 01:15PM BLOOD Glucose-261* UreaN-15 Creat-0.8 Na-128* K-4.5 Cl-97 HCO3-22 AnGap-14 ___ 01:15PM BLOOD ALT-36 AST-49* AlkPhos-56 TotBili-1.3 ___ 01:15PM BLOOD Lipase-90* ___ 01:15PM BLOOD Albumin-2.5* ___ 01:25PM BLOOD Lactate-2.5* ___ 02:10PM URINE Color-Orange Appear-Hazy Sp ___ ___ 02:10PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-TR ___ 02:10PM URINE RBC-9* WBC-5 Bacteri-FEW Yeast-NONE Epi-6 TransE-<1 PERTINENT LABS ___ 07:55PM ASCITES WBC-___* RBC-800* Polys-71* Lymphs-22* Monos-7* ___ 07:55PM ASCITES Albumin-1.0 ___ 11:12AM ASCITES WBC-6050* RBC-850* Polys-84* Lymphs-16* ___ 11:12AM ASCITES Albumin-2.1 ___ 12:45PM ASCITES ___-___* RBC-___* Polys-62* Lymphs-19* ___ Mesothe-1* Macroph-18* ___ 12:45PM ASCITES TotPro-4.5 Glucose-168 Amylase-18 TotBili-1.2 Albumin-3.2 ___ 03:30PM ASCITES WBC-1200* RBC-2495* Polys-32* Lymphs-33* Monos-8* Mesothe-1* Macroph-26* ___ 03:30PM ASCITES TotPro-4.4 Albumin-3.1 ___ 02:30PM ASCITES WBC-575* RBC-8600* Polys-60* Lymphs-28* Monos-0 Eos-2* Macroph-10* ___ 02:30PM ASCITES TotPro-3.8 Glucose-126 LD(LDH)-178 Albumin-2.2 ___ 04:04PM URINE Hours-RANDOM Creat-286 Na-<10 K-17 Cl-<10 ___ 04:04PM URINE Osmolal-360 ___ 03:59PM URINE Hours-RANDOM Creat-141 Na-<10 K-14 Cl-<10 HCO3-<5 ___ 03:59PM URINE Osmolal-396 DISCHARGE LABS ___ 06:00AM BLOOD WBC-4.7 RBC-2.24* Hgb-7.4* Hct-24.4* MCV-109* MCH-33.2* MCHC-30.4* RDW-21.5* Plt Ct-56* ___ 06:00AM BLOOD ___ PTT-51.9* ___ ___ 06:00AM BLOOD Glucose-169* UreaN-26* Creat-0.9 Na-134 K-4.2 Cl-102 HCO3-25 AnGap-11 ___ 06:00AM BLOOD ALT-7 AST-42* AlkPhos-44 TotBili-1.4 ___ 06:00AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1 MICROBIOLOGY Peritoneal fluid culture (___): Methicillin-sensitive S. aureus SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S All other blood and peritoneal fluid cultures negative. Urine cultures remarkable yeast several times. IMAGING CXR (___): As compared to the previous radiograph, there is unchanged evidence of a relatively extensive right pleural effusion with subsequent areas of atelectasis. A minimal left pleural effusion is also present. Mild cardiomegaly with mild pulmonary edema. Known calcified right upper lobe granulomas are constant. No evidence of new parenchymal changes. No pneumothorax. HIDA scan (___): No evidence of biliary leak. CT abdomen/pelvis (___): Increased moderate ascites from the prior CT at ___ without significant peritoneal enhancement. No walled off or complex collection in the abdomen or pelvis to suggest abscess. Evidence of portal hypertension including splenomegaly, varices and upper abdominal venous collaterals. Status post cholecystectomy with stable collection of fluid and air in the gallbladder fossa compared to ___. Multiple prominent lymph nodes in the pre-pericardial, perigastric, portocaval, retroperitoneal and external iliac stations are a nonspecific finding but may be reactive. Generalized anasarca. CXR (___): Right basal atelectasis. RUQ US (___): No evidence of biliary ductal dilation. No evidence of choledocholithiasis. Coarse liver echotexture with nodular contour is compatible with underlying chronic liver disease. Moderate amount of ascites is slightly increased in size compared with prior CT abdomen allowing for difference in techniques. Brief Hospital Course: ___ yo F with PMH of HCV cirrhosis and diuretic-controlled ascites who recently underwent an open cholecystectomy for symptomatic cholelithiasis who presented from PCP with fevers, abdominal pain, and diarrhea. Peritoneal fluid consistent with peritonitis and is growing MSSA. ACTIVE ISSUES # Spontaneous bacterial peritonitis: Paracentesis on ___ was consistent with bacterial peritonitis given 3375 WBCs with 71% PMNs for which patient was started on ceftriaxone and albumin per SBP protocol. Peritoneal fluid culture grew out S. aureus for which patient was started on vancomycin in addition to this. Flagyl was added for anaerobic coverage given concern for perforation or biliary leak. CT abdomen/pelvis on ___ was not consistent with either of these etiologies of secondary peritonitis. Sensitivities revealed MSSA for which patient was switched to cefazolin on ___. Repeat paracenteses on ___ and ___ showed persistent be slowly resolving SBP for which patient was continued on cefazolin. Failure to improve more quickly with antibiotics again raised concern for a secondary etiology of peritonitis. Because of this a HIDA scan was obtained on ___ which showed no evidence of biliary leak. Repeat paracentesis on ___ showed resolution of infection. Cefazolin was discontinued and patient was started on prophylactic Bactrim which she will need to take daily going forward. # Hepatorenal syndrome: Several days after admission patient's renal function began to progressively worsen. There was concern for HRS type 1 given an extremely Na avid state per urine lytes. Patient was managed with midodrine, octreotide, and albumin. Home diuretics were held. Renal was consulted and their impression was that worsening azotemia was most likely in the setting of CT scan with contrast and fluid removal from multiple paracenteses. They recommended moderation of fluid removal and continuing management for HRS. This resulted in gradual improvement in patient's renal function. Blood pressures were stably acceptable for which midodrine and octreotide were discontinued on ___. Renal function trended down. It reached baseline on ___ and remained there for the remainder of hospitalization. # Hepatic encephalopathy: Patient mildly confused, talking in sleep, and with positive asterixis on exam during second week of hospitalization. Lactulose was increased to hepatic encephalopathy dosing at Q2H. Continued on home rifaximin. There interventions resulted in significant improvement in mental status to baseline per her family. # Anemia: Hct 33.7 on admission. This steadily trended down to 22.5 on ___ for which patient received 1 unit pRBCs. Attributed to Hct drop in the setting of active infection, hepatic, and renal dysfunction and anemia of chronic disease given iron studies. # Transplant listing: Workup for transplant was started while during admission. Patient underwent TTE, PFTs, and a number of laboratory studies. Social work met with patient and family extensively during hospitalization. Ultimately, the transplant team came to the conclusion that patient lacked the support at home to be a candidate for liver transplant. This was discussed with patient and family at a family meeting on ___. CHRONIC ISSUES # Cirrhosis: Secondary to chronic HCV infection. Complicated by ascites which had been managed with diuretics. No history of hepatic encephalopathy or varices but patient became encephalopathic while in hospital which was managed as above. Considered for transplant as above. Determined that she was not a candidate given social support. # Type II diabetes: Continued home regimen including Lantus and sliding scale. Blood sugars were well-controlled. # Shortness of breath: Likely COPD. Continued home inhaler regimen and oxygen as needed for comfort. Added albuterol nebs as needed. # Edema: Held home Lasix initially given ___ and HRS. Restarted on ___ given normalization of renal function and volume overload. # Depression: Continued home citalopram. TRANSITIONAL ISSUES - Patient is not a candidate for liver transplant - No evidence of SBP on discharge per diagnostic paracentesis - Started on Bactrim for SBP prophylaxis - Started on lactulose and rifaximin for prevention of hepatic encephalopathy - Doubled spironolactone to 50 mg daily - Discontinued omeprazole given increased risk of SBP - Vital signs per routine - Daily labs. Please check CBC, lytes with Ca/Mg/Phos, BUN/Cr, ALT, AST, AP, TBili. - Encourage PO intake - Oxygen therapy to comfort. Goal sat > 92%. - If SOB can give IV Lasix but be careful with renal function - Physical therapy - Occupational therapy - Follow-up with Liver Clinic scheduled - Follow-up with PCP scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Acetaminophen 325 mg PO Q12H:PRN pain 4. Citalopram 20 mg PO DAILY 5. Spironolactone 25 mg PO DAILY 6. Glargine 40 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Albuterol-Ipratropium 2 PUFF IH Q6H 8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 9. emollient 1 application Topical bid arms/legs 10. FoLIC Acid 3 mg PO DAILY 11. Loratadine 10 mg PO DAILY 12. mometasone 0.1 % Topical qd affected areas 13. Oxymetazoline 1 SPRY NU PRN nose bleed Discharge Medications: 1. Acetaminophen 325 mg PO Q12H:PRN pain 2. Albuterol-Ipratropium 2 PUFF IH Q6H 3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 4. Citalopram 20 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Glargine 40 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Loratadine 10 mg PO DAILY 8. Spironolactone 50 mg PO DAILY 9. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN SOB, wheezing 10. Lactulose 30 mL PO TID 11. Rifaximin 550 mg PO BID 12. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. emollient 1 application Topical bid arms/legs 15. FoLIC Acid 3 mg PO DAILY 16. mometasone 0.1 % Topical qd affected areas 17. Oxymetazoline 1 SPRY NU PRN nose bleed Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: - HCV cirrhosis - Spontaneous bacterial peritonitis - Hepatorenal syndrome - Hepatic encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, ___ was a pleasure caring for you during your hospitalization. You were admitted to ___ for fevers, abdominal pain, and diarrhea. During your hospitalization you were diagnosed with an infection of the fluid in your abdomen and were treated with 17 days of antibiotics. You also developed problems with your renal function and your home diuretics were held. Your kidney function improved and you are currently back to normal levels. There was also an accumulation of fluid in your lungs which is likely the reason you had increasing difficulty breathing. We restarted the diuretics which will allow you to eliminate fluid and improve your breathing and the swelling in your legs. During your time here we also noticed that there was a period of time that you became confused and gave you medication to help you regain your mental function. Lastly, you were evaluated for placement on the transplant list but did not qualify and the reasons were explained to you and your family during the family meeting. You will be discharged on your home medications plus an antibiotic to help prevent future infections of the abdominal fluid. You will be sent to a rehabilitation center which will allow you the oportunity to improve your strength before returning home. Querida Senora ___, ___ un placer cuidar de ___ ___ hospital. ___ porque tenia fievre, dolor abdominal, y diarrhea. Mientras ___ una infection en el fluido abdominal por lo ___ 17 ___ de antibioticos. Tambien desarollo dificultad con sus rinones por lo ___ detubimos sus diureticos. ___ de ___ y ___ niveles normales. Tuvo acumulacion de liquido en ___ y ___ una ___ por ___ tuvo dificultad al respirar. ___ de nuevo ___ y esperamos que ___ ayude con ___. Tambien tubo un episiodo de confusion ___ de ___ y ___ lactulose ___ ___ de pensar. Finalmente, ___ evaluada para ___ de transplante de ___ no califico y ___ explicado a ___ familia ___ familiar. ___ ___ de ___ con sus medicinas originales y antibiotico para prevenir infecion del liquido del abdomen y al mandaremos a un centro de rehabilitacion para ayudarla a mejorarse antes de regresar a casa. . Followup Instructions: ___
10065057-DS-7	10,065,057	21,928,958	DS	7	2119-05-01 00:00:00	2119-05-01 14:05:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Unwitnessed fall Major Surgical or Invasive Procedure: 1. Intubation for MRI (___), pacemaker inactivation History of Present Illness: ___ with long history of multiple falls and multiple resulting fractures, lives in group home due to cognitive delay, now presents to ___ in transfer from ___ after having a fall at ~8pm. Her fall was not witnessed. Unknown LOC. Was found by staff who heard her yelling for help. Patient is unable to give a description of the fall, cannot explain the surrounding events, and per her group home worker who accompanied her to the ED this is about baseline. Trauma surgery is now consulted. Past Medical History: Mental retardation Right hip replacement Pelvic fracture Depression Frequent falls with left hip fracture and replacement Herpes zoster Social History: ___ Family History: Mother: CHF, ___ Brother: MI (___) Brother: valvular disease Multiple family members with cardiovascular disease and HLD Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: Temp 98.0 BP 150 / 72 HR 78 RR 18 PO2 93 Ra Physical exam: Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, non-tender, non-distended, normal bs. Ext: No edema, warm well-perfused Pertinent Results: ADMISSION LABS: ___ 02:40AM BLOOD WBC-15.0* RBC-3.75* Hgb-11.6 Hct-36.1 MCV-96 MCH-30.9 MCHC-32.1 RDW-13.7 RDWSD-48.0* Plt ___ ___ 02:40AM BLOOD Neuts-87.9* Lymphs-5.3* Monos-5.8 Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.14* AbsLymp-0.80* AbsMono-0.87* AbsEos-0.00* AbsBaso-0.01 ___ 02:40AM BLOOD Glucose-128* UreaN-12 Creat-0.4 Na-137 K-3.8 Cl-100 HCO3-25 AnGap-12 ___ 02:40AM BLOOD cTropnT-<0.01 ___ 05:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2 ___ 02:52AM BLOOD Glucose-128* Creat-0.4 Na-136 K-3.6 Cl-103 calHCO3-24 DISCHARGE LABS: RADIOLOGY: MRI Head, ___: IMPRESSION: 1. Study is mildly degraded by motion. 2. Question approximately 1 mm left parietal subdural hemorrhage versus artifact, as described. 3. Punctate left precentral gyrus foci of chronic blood products versus mineralization. 4. Previously demonstrated hyperdensity within the right perimesencephalic cistern not definitely seen on current study. Question interval redistribution of blood products. 5. 5 mm left parietal subgaleal hematoma. 6. Interval progression in size of previously noted parotid mass, now measuring up to 2.5 cm, compared to ___ prior exam. 7. Global volume loss and probable microangiopathic changes as described. 8. Paranasal sinus disease and minimal bilateral nonspecific mastoid fluid, as described. MRI C, T Spine, ___: IMPRESSION: 1. Study is degraded by motion and limited by patient positioning. 2. Abnormal fluid signal with effacement of the central inferior endplate of the L3 vertebral body as described, with no definite peripherally enhancing collection. While findings are suggestive of acute Schmorl's node, differential considerations of phlegmonous change or early discitis osteomyelitis is not excluded on the basis ex of this amination. Recommend follow-up imaging to resolution. 3. Acute to subacute L5 vertebral body fracture, as described. 4. Central and vertically oriented fracture through the sacrum, which is incompletely evaluated. A dedicated sacral MR can be considered if further characterization is warranted. 5. Anterior height loss of the C7 vertebral body is unchanged since ___. 6. Probable chronic T7 and T8 anterior compression deformities, as described. 7. Multilevel cervical spondylosis as described, most pronounced at C3-4, where there is moderate to severe vertebral canal, mild left and moderate right neural foraminal narrowing. 8. Additional multilevel thoracic and lumbar spine spondylosis as described without definite evidence of moderate or severe vertebral canal narrowing. 9. Within limits of study, no definite evidence of spinal cord lesion. Multilevel spinal cord probable remodeling as described. 10. Small bilateral pleural effusions as described. If clinically indicated, consider correlation with dedicated chest imaging. 11. Cholelithiasis. 12. Known right parotid cystic mass better characterized on same day brain MR. 13. Please see concurrently obtained brain MRI for description of cranial structures. Brief Hospital Course: Ms. ___ was admitted to the ___ ___ after ___. Her injuries included: a small subarachnoid hemorrhage, left superior and inferior pubic rami fractures, acute L5 vertebral body fracture and multiple left sided rib fractures. On admission she was given a regular diet. Orthopedics was consulted and recommended weight bearing as tolerated to both her lower extremities and a walker as needed. In terms of the subarachnoid hemorrhage, neurosurgery was consulted and recommended TBI pathway, starting subcutaneous heparin 24 hours after admission, and aspirin on ___ which occurred. Spine was also consulted due to a series of findings on the CT spine that were of uncertain chronicity and recommended an MRI. She was bedrest with a hard cervical collar until the MRI occurred. A great deal of care coordination was spent to schedule the MRI due to the need for intubation (given her baseline cognitive delay) and electrophysiology was involved for the pacemaker. She finally got the MRI on ___ which revealed only an acute L5 vertebral body fracture. Per neurosurgery's recommendations, the cervical collar was removed, the patient was liberalized and got out of bed and her diet was advanced to a regular diet. Her foley catheter was discontinued and she voided spontaneously thereafter. She worked with physical therapy on ___ and recommended rehab. She was eventually discharged to a rehabilitation facility on ___. She voiced understanding of the discharge plan and appropriate follow up was set in place, Of note the MRI of her head did note a small right parotid mass that was slightly increased compared to prior which will need to be followed up as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO QPM 2. Aspirin 325 mg PO DAILY 3. Vitamin D 800 UNIT PO DAILY 4. Docusate Sodium 100 mg PO DAILY 5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 6. Bisacodyl ___AILY 7. PredniSONE 15 mg PO DAILY 8. Acetaminophen 650 mg PO Q8H Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY Please hold for loose stools 2. Senna 17.2 mg PO HS Please hold for loose stools 3. TraMADol 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #10 Tablet Refills:0 4. Acetaminophen 1000 mg PO TID 5. Docusate Sodium 100 mg PO BID 6. Aspirin 325 mg PO DAILY 7. Bisacodyl ___AILY 8. Pravastatin 40 mg PO QPM 9. PredniSONE 15 mg PO DAILY 10. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Subarachnoid hemorrhage 2. Left superior and inferior pubic rami fractures 3. Acute L5 vertebral body fracture 4. Left sided rib fractures 5. Right parotid cystic mass 6. Complete AV block 7. Cognitive delay 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 ___ after you had an unwitnessed fall at your group home, you were found to have a small brain bleed a small pelvic fracture and some new ( and old) rib fractures). You were seen by physical therapy who recommended rehab. You are now stable for discharge to rehab to continue your recovery. Please follow the following instructions to aid in your recovery - You do not need to follow up with neurosurgery, who saw you in the hospital. You may continue your Aspirin 325mg Rib Fractures: Your injury caused multiple rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. 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. 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 * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Best Wishes, Your ___ Surgery Team Followup Instructions: ___
10065584-DS-16	10,065,584	20,108,164	DS	16	2150-07-14 00:00:00	2150-07-14 23:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Patient told to come to ED by neurologist whom found right internal carotid occlusion and right posterior circulation infarction. Major Surgical or Invasive Procedure: None History of Present Illness: ___ Is a ___ man with no significant past medical history who presents after discovery of a right PCA territory infarct on an MRI that was performed the day of presentation. The history is obtained from the patient. He reports that for the past 14 months, he has had "ocular migraines". He describes these as visual changes, mostly involving the right eye (although he did not do his cover-uncover test) where he would have intermittent loss of vision in the right eye, or part of his vision missing in his left visual field, including either the top medial portion of his vision, the lower medial portion of his vision, or the entire nasal visual field. He was evaluated by ophthalmology intermittently, who did not discover any abnormal findings with the eye, and gave him the diagnosis of ocular migraines. On ___, he developed A different sort of headache, which involved a dull holoacranial pressure-like sensation, which was very severe. This was associated with nausea and vomiting, as well as lightheadedness, photophobia. He initially presented to an outside hospital, and was again given the diagnosis of migraines. He underwent a CT at the outside hospital, which was reportedly normal. Given the new onset of migraines, he was referred to neurology as an outpatient. He saw an outpatient neurologist on ___, who reportedly did not find any abnormal findings on neurologic exam, and ordered an MRI to evaluate for structural causes of headache. For multiple reasons, this MRI was not done until ___, which was done with an MRA with and without contrast. This discovered a totally occluded right ICA as well as a cut off in the right proximal PCA, with a subacute appearing infarct in the right PCA territory. The patient was advised to immediately come to ___ for further workup. Regarding his risk factors, the patient reports that he has had multiple traumas, from old ___'s and football injuries. However the last ones that he had were about ___ years ago. None of these events were associated with the development of unilateral neurologic symptoms. Of note, he developed palpitations in ___, and reportedly underwent a workup including a Holter monitor and transthoracic echo, revealing PVCs but no evidence of atrial fibrillation or other tachyarrhythmias. He is not sure if he has an ASD or PFO. He does admit to snoring, and his wife at bedside attests to frequent episodes of apnea. He does not have any daytime somnolence. He has not had a sleep study. No current constitutional symptoms. Past Medical History: No past medical history. Social History: ___ Family History: Father died of unclear causes in his early ___. No history of early stroke or MI in the family. Maternal grandmother had some kind of cancer. No history of hypercoagulability in the family. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T: 97.5 HR: 70-103 BP: 147/94 RR: 15 SaO2: 99% on room air General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. Able to register 3 objects and recall ___ at 5 minutes. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. There is left upper quadrantanopia. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [___] L 5 5 5 5 ___ 5 5 5 5 5 R 5 5 5 5 ___ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [___] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Sensory: No deficits to light touch, pin, or proprioception bilaterally. No extinction to DSS. No graphesthesia bilaterally. - Coordination: No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait: Deferred DISCHARGE PHYSICAL EXAMINATION: Vitals: Temperature: 98.6 Blood pressure: 109/71 Heart rate: 69 Respiratory rate: 14 Oxygen saturation 96% on RA General physical examination: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic examination: Mental status: Patient is alert and oriented to name, place, and location. Patient is able to provide his history of present illness and is able to follow commands during examination. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Left upper quadrantanopia. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 Sensory: No deficits to light touch, proprioception throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: A1C: 5.4% LDL: 118 TSH: 3.0 CT/CTA: 1. Complete occlusion of the right internal carotid artery just superior to the bifurcation with reconstitution at the paraclinoid segment corrseponding to findings on MRA (3:169, 3:175, 4:277). 2. Fetal subtype right PCA with highly attenuated and possibly occluded right P2 segment (3:294, 295). 3. Patent circle of ___, bilateral ACA, M1, and MCA arborization. MRI Brain from outside facility: Right posterior circulation infarction. TTE: No thrombus or PFO. Brief Hospital Course: Patient is a ___ year old male with no past medical history whom presented to ___ ED ___ after his neurologist notified him of abnormal image findings from studies done on ___. Patient found to have complete occlusion of the right internal carotid artery superior to the bifurcation and an acute/subacute stroke in right posterior circulation. Patient's neurologic examination remarkable for left upper quadrantanopia. Plan for DAPT for 3 months with clopidogrel and aspirin and then to resume aspirin thereafter. Patient has also been started on atorvastatin for high cholesterol. Patient had unremarkable TTE. Patient encouraged to stop smoking. Patient given numbers for follow up with PCP and stroke team. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL =118 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (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 ] 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () 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: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:5 2. Atorvastatin 80 mg PO QPM HLD RX atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:5 3. Clopidogrel 75 mg PO DAILY Duration: 3 Months Please take for only 3 months then discontinue RX clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Right posterior cerebral artery infarct Occlusion of right internal carotid artery Hypoplastic right posterior cerebral artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, During this admission, you presented at the recommendation of your neurologist because your imaging revealed complete occlusion of an artery on the right side of your head/neck that is important to bringing blood to your brain and because there was a recent stroke identified. For the occluded vessel, there is no surgical correction indicated, and your body has developed alternative vessels to bring blood to the portion of the brain normally supplied by the occluded vessel. The stroke (low blood flow to the brain) affected a region of the brain that is important in vision, and on examination, you have a small visual field cut (loss of vision). You might have difficulty with vision when looking up and to the left. Our goal now is to prevent you from having development of other occlusions in important brain blood vessels and to prevent another stroke. First, we have started you on aspirin 81 mg daily and clopidogrel 75mg daily. After 3 months, you can stop the clopidogrel. These medications, which helps to prevent blood clotting, has been shown to reduce risk of stroke recurrence. You were also found to have high cholesterol and have been started on a cholesterol lowering medication, atorvastatin 40 mg daily. The ultrasound (echocardiogram) of your heart did not demonstrate a hole or a clot in your heart. In addition to starting the above two medications, we highly recommend that you stop smoking cigarettes as this is a major risk factor for stroke. We also recommend a heart healthy diet and engaging in regular physical activity. Thank you for allowing us to care for you, ___ Stroke Team Followup Instructions: ___
10065656-DS-14	10,065,656	27,129,771	DS	14	2119-11-11 00:00:00	2119-11-14 01:03:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Erythromycin Base Attending: ___. Chief Complaint: "seizure" Major Surgical or Invasive Procedure: none History of Present Illness: HPI: ___ is a ___ year-old left-handed boy who presents with as a transfer for "events" concerning for seizure. ___ went to school today and went to his after school job in IT at his local ___. His father who also does volunteer work at the ___ got a call at 5:03 that he had placed his head down on the table and seemed confused, after which he became unresponsive to voice. His father told them to call EMS. On the ambulance ride over he had a spell. Then severeal more at an outside hospital. He was given a total of 6 mg of ativan. He continued to be unresponsive during this time. However upon transfer to ___ he started to make coherent conversation but then started having more events. I have witnessed 3 events. They consist of generalized shaking, nonrhthmic, shaking both arms and legs alternating, truncal thrashing, eyes closed tightly. . he has no risk factors for seizure (no head trauma, cns infections, no fam hx of seizure, developmental delay, no febrile seizures, cns tumors, or vascular disease, or sign med hx). No current infections or fevers. On neuro ROS (per parents), the pt has daily headache, blurred vision, tinnitus, and left sided numbness. He has had no diplopia, dysarthria, dysphagia, lightheadedness, vertigo, or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, No bowel or bladder incontinence or retention. . On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: PMH: -chronic headaches, He has tried trigger point injections, massage therapy, acupuncture, physical therapy, biofeedback as well medications such as hydroxyzine, zonisamide, naproxen, cyproheptadine, Imitrex, amitriptyline, propanolol and tizanidine. Social History: ___ Family History: No family history of seizures, anxiety, depression or other neurologic issues Physical Exam: Vitals: T:97 P:120 R: 18 BP:122/80 SaO2:98% General: drowsy, but will intermittently open eyes HEENT: NC/AT, Neck: Supple, No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: no rashes or lesions noted. . Neurologic: -Mental Status: drowsy, but arrousable occasionally to voice, will state his name, place (hospital), month and year. Language when speaking is fluent with intact repetition and comprehension. Normal prosody. Pt. was able to name both high and low frequency objects on the stroke card. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. . -Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 2mm and brisk. + corneals bilateral. . -Motor: will maintain anti gravity on the right arm, but will not avoid his face when dropping the left arm. normal tone throughout. . -Sensory: doesn't react to noxious in any of the four extremities -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. At the time of discharge: Pertinent Results: ___ 09:30PM PLT COUNT-343 ___ 09:30PM NEUTS-68.8 ___ MONOS-4.2 EOS-0.2 BASOS-0.5 ___ 09:30PM WBC-9.8 RBC-5.42 HGB-15.7 HCT-44.8 MCV-83 MCH-28.9 MCHC-34.9 RDW-12.7 ___ 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 09:30PM ALBUMIN-4.6 CALCIUM-9.6 PHOSPHATE-4.2 MAGNESIUM-1.8 ___ 09:30PM ALT(SGPT)-88* AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.5 ___ 09:30PM GLUCOSE-93 UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13 ___ 09:50PM URINE MUCOUS-MANY ___ 09:50PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 09:50PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 09:50PM URINE HOURS-RANDOM ___ 09:56PM LACTATE-1.7 Brief Hospital Course: Neuro: ___ was admitted to the Neurology- Epilepsy service under Dr. ___. He was monitored by EEG for multiple events. The EEG was found to have no epileptic events. As these events appear non-epileptic and were not found to have an EEG correlate, no changes were made to ___ medications. Psychiatry: consulted during admission and recommended the following: -Though these seizure activity likely do not have electrical origins, would suggest minimizing stigma by by not using phrases suggesting pt can stop these on his own - these episodes are unlikely consciously manufactured -Analogy of IBS is helpful to family for understanding of how stress/anxiety/depression can cause physical symptoms. -Attending, Dr. ___ will attempt to make referral to psychiatrist specializes in nonelectrical seizures -pt should continue with his current therapist -would not initiate psychotropics at this time. -pls page ___ during the day with concerns/questions. Page ___ nights/weekends. Cardio/Pulm: as ___ was found to have some increased heart rate and decreased O2 saturations during these events, he continued on telemetry. While there was variation in his vitals during these seizures these changes were self-limited and did not require treatment. FENGI: Initially ___ was kept NPO as he was not at baseline. As he became more alert, his diet was advanced as tolerated ID: There were no signs of infection during this hospitalization and no antibiotics were started Social: mom was present throughout the course of his hospitalization and both mom and the pt understood the plan. Medications on Admission: Medications: -gabapentin 600 mg TID -Divalproex ___ mg q ___ -Tramadol 50 mg PRN (took 100 mg last night) Discharge Medications: 1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: Non-epileptic seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to ___ on ___ for evaluation of seizure like activity. We monitored you with EEG to determine if these were epileptic or nonepileptic seizures. We found that these seizures did not have a correlation to epileptic seizures. For this reason no changes were made to your medications at this time. We made the following changes to your medications: 1) Per your request we stopped your DEPAKOTE. If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay. Followup Instructions: ___
10065767-DS-11	10,065,767	25,730,443	DS	11	2122-01-08 00:00:00	2122-01-16 22:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril / Azathioprine Attending: ___ Chief Complaint: anorexia, weakness and fatigue x 10 days Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with CAD s/p muliple PCIs sCHF (EF 25%), HLD, HTN, and ILD/Sjogren syndrome on pred and azathioprine (since ___ p/w anorexia, weakness and fatigue x 10 days. Pt was seen by cardiology on ___. Noted to be orthostatic so lasix reduced from 40 to 20 mg at that visit. Noted to be further hypotensive to ___ spb at pulmonology visit on ___. Was noted to be leukopenic and anemic as well, likely from Azathioprine, which is now being held since 2 days ago. Per cardiology telephone note, lasix and spironolactone have been d/c'ed of yesterday with halving of dose of metoprolol and diovan. His bp's at baseline in clinic are in the ___ systolic. He was seen for repeat bloodwork today by rheum and noted to be hypotensive to ___ systolic and to have persistent anemia. Referred to ED from ___ clinic. On presentation to the ED, vs were 97.6 83/55 16. He got hydrocort 100mg daily, zosyn, and was volume rescuscitated with improvement to 100s systolic. CXR with no acute cardiopulm process. IVC flat on bedside echo. Heme negative. LFTs at baseline and cre 1.6 above baseline 1.2. Anemia relatively stable over past few days. On arrival to the MICU, pt was afebrile 65 88/43 18 100%. He denies f/c/abd pain/n/v/rhinorhea/night sweats/diarrhea/constipation/bleeding from GI source/dysuria. Reports that he has no appetitie and that food doesn't taste good. No pain with eating or dysphagia. REVIEW OF SYSTEMS: Otherwise negative in detail Past Medical History: 1) Myocardial infarction x 5 - first being in ___ and the last in ___. He underwent several percutaneous coronary interventions with stent placement with the last being in ___. He is s/p biventricular ICD ___ GEM III ___ model ___) placed ___ years ago. 2) Ischemic cardiomyopathy 3) Type 2 diabetes 4) Hypercholesterolemia 5) Hypertension 6) Obstructive sleep apnea Social History: ___ Family History: FH: Daughter with anti-phospholipid antibody and now on Coumadin. Physical Exam: PHYSICAL EXAM: afebrile 65 88/43 18 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, very dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: dry crackles at the bases b/l, occasional eew Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly 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, finger-to-nose intact DISCHARGE EXAM afebrile 62 98/52 18 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: dry crackles at the bases b/l, Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly 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, finger-to-nose intact Pertinent Results: ADMISSION ___ 11:30AM BLOOD WBC-1.7* RBC-2.65* Hgb-9.1* Hct-26.8* MCV-101* MCH-34.4* MCHC-34.1 RDW-25.4* Plt ___ ___ 11:30AM BLOOD Neuts-77* Bands-2 ___ Monos-2 Eos-0 Baso-0 ___ Myelos-0 ___ 11:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Burr-1+ Tear ___ ___ 11:30AM BLOOD ___ PTT-27.8 ___ ___ 11:30AM BLOOD Ret Man-1.4 ___ 05:57AM BLOOD Ret Aut-0.9* ___ 11:30AM BLOOD UreaN-22* Creat-1.5* ___ 02:04PM BLOOD Glucose-140* UreaN-24* Creat-1.6* Na-136 K-4.6 Cl-100 HCO3-26 AnGap-15 ___ 11:30AM BLOOD ALT-36 AST-31 LD(LDH)-286* TotBili-1.2 ___ 02:04PM BLOOD Lipase-25 ___ 02:04PM BLOOD cTropnT-<0.01 ___ 11:30AM BLOOD Iron-150 ___ 02:04PM BLOOD Albumin-3.4* ___ 11:30AM BLOOD calTIBC-202* VitB12-547 Folate-GREATER TH ___ Ferritn-415* TRF-155* ___ 02:00PM BLOOD Lactate-2.1* DISCHARGE ___ 04:55AM BLOOD WBC-1.6* RBC-2.75* Hgb-8.9* Hct-26.2* MCV-95 MCH-32.3* MCHC-33.9 RDW-26.5* Plt ___ ___ 04:55AM BLOOD Neuts-45.4* Lymphs-45.5* Monos-2.3 Eos-6.7* Baso-0.1 ___ 04:55AM BLOOD Glucose-95 UreaN-16 Creat-1.1 Na-142 K-3.9 Cl-110* HCO3-24 AnGap-12 ___ 04:55AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0 CXR No acute process Urine, blood cx, and stool studies negative Brief Hospital Course: ___ year old male with five myocardial infarctions, congestive heart failure, hypertension, hypercholesterolemia, interstitial lung disease, and Sjogren syndrome ACUTE #) Hypotension - Likely ___ to hypovolemia in the setting of overdiuresis and poor po intake. Pt reports that aneroexia has improved since d/c'ing imuran 2 days ago. He reports good PO intake while in ED, compared to prior. Distrubitive vs cardiogenic process remains in the differential but pt has no localizing signs or sympoms. EKG and CXR without change from prior. Additionally, no e/o GI bleed. Received stress dose steroids in ED. Pt was admitted to ICU for hypotension, and continued on home prednisone, given IVF. We held home diuretics, and ACEI initially for hypotension. Pt developed profound dilutional anemia and was transfused 2U PRBCs with appropriate improvment in HCT noted. Subsequent HCTs were stable. BPs remained in the high ___ with discontinuation of home BP meds and diuretics. Pt was discharged on lower dose of home metoprolol. . #) fatigue/anorexia - likely multifactorial in the setting of anemia and imuran use. As above, no localizing signs of infection, neurologic, and cardiac process. ___ be mild viral syndrome. TSH stable on most recent check. Imuran was held while he was in the ICU. #) Anemia/leukopenia - anemia relatively stable over the course of ___ and ___, although downtrending since ___ from ___. ANC >1200 on admission althout did trend down while in house. He remained afebrile however. Felt to be ___ to imuran which was held by outpatient providers as of 2 days ago. CHRONIC #) CTD-ILD - known anca pos vasculitis. ___ CT showed bilateral ground-glass opacities including a nodular area in anterior right upper lobe that has significantly improved since prior exam. His fibrotic interstitial lung disease in lower lobes is unchanged over the past year. Has been on imuran and pred since ___. Pt was continued on prednisone and imuran was held. Rheumatology followed the pt while he was in the ICU. Pt was given nebs prn and continued on bactrim ppx. . #) CHF - ___ to ischemic cardiomyopathy s/p ICD placement. He has had 5 MI's first being in ___ and the lastin ___. He underwent several percutaneous coronary interventions with stent placement with the last being in ___. Pt was continued on ASA/plavix while in ICU, but diuretics and ACEI were held for hypotension initially in ICU. . #) HLD - continued on home simvastatin . #) HTN - on metop, valsartan, and diuretics. Hypotensive on arrival to ICU but near baseline. Blood pressure meds held while in house and restarted on metop succ 25 daily on discharge. . #) OSA - on home cpap . #) Gout - home allopurinol was continued #) Depression - home citalopram was continued TRANSITIONAL #) f/u with outpatient providers to discuss CTD treatment and blood pressure treatment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN chest pain 6. Omeprazole 20 mg PO DAILY 7. Simvastatin 40 mg PO DAILY 8. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 9. Allopurinol ___ mg PO DAILY 10. azelastine NF 137 mcg NU BID 2 Puffs 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 12. Metoprolol Succinate XL 37.5 mg PO DAILY hold for sbp <100 or hr < 60 13. Valsartan 40 mg PO DAILY hold for sbp<100 14. Citalopram 20 mg PO DAILY 15. PredniSONE 10 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Nitroglycerin SL 0.4 mg SL PRN chest pain 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. azelastine NF 137 mcg NU BID 2 Puffs 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 12. Citalopram 20 mg PO DAILY 13. PredniSONE 10 mg PO DAILY 14. Metoprolol Succinate XL 25 mg PO DAILY hold for sbp <100 or hr < 60 RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___-- It was a pleasure taking care of you at the ___ ___. You were admitted with fatigue and found to have low blood counts (white blood cells, red blood cells). This was most likely the result of one of your medications (azathioprine). We discussed your case with blood doctors (___) and your outpatient rheumatologist, who felt that STOPPING your azathioprine was the best management. You were monitored and your blood counts began to rise. You are now ready for discharge home. You will follow up with your rheumatologist Dr. ___ on ___. Also, we have stopped your diovan and reduced the dose of your metoprolol. You should continue to stop your diuretics (lasix and spironolactone) as well. Continue your other medications as prescribed. Followup Instructions: ___
10065767-DS-12	10,065,767	20,620,437	DS	12	2122-01-27 00:00:00	2122-01-28 11:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril / Azathioprine Attending: ___. Chief Complaint: Shortness of breath Fever Major Surgical or Invasive Procedure: Flexible sigmoidoscopy with biopsy on ___ History of Present Illness: Mr. ___ is a ___ with ischemic CM (LVEF ___, CAD c/b MI, interstitial lung disease on prednisone/azathioprine, pANCA vasculitis, Sjogren's disease, T2DM, HTN, and OSA initially admitted to the MICU for SOB following recent FICU admission for ___ and leukopenia attributed to hypovolemia (prompting discontinuation of home valsartan) and chronic immunosuppression (prompting discontinuation of home azathioprine), respectively. He developed T to 102, shortness of breath, and cough productive of white/clear sputum on the day of admission (___) in the absence of weight gain or PND/orthopnea, as well as progressive diarrhea (5 large watery BMs per day), which began around the time of his FICU stay. In the ED, T was 98.5-102.8 with HR 129, BP ___, RR 22, sat 95% RA. Admission labs were notable for Cr 1.9 (baseline 1.1-1.5), proBNP 953, and lactate 1.2. Despite no clear focal opacity on CXR, he received vancomycin/levofloxacin/cefepime/Tamiflu for presumed HCAP and possible influenza, as well as 600cc IVF. In the MICU, broad-spectrum antibiotics for HCAP were discontinued, and vancomycin/Flagyl was initiated briefly for empiric coverage of C. difficile until stool assay was found to be negative. Rheumatology was consulted, with low suspicion for recurrence of interstitial lung disease. He ruled out for ACS on the basis of serial enzymes. Home metoprolol, held initially in the setting of hypotension, was resumed once pressures remained stable. At the time of transfer, he reports mild shortness of breath at rest, consistent with baseline. He was able to ambulate to the commode without difficulty. He is concerned that his loose stools, seemingly now quiescent, will recur, given abdominal "rumbling." His appetite remains robust. Past Medical History: 1) Myocardial infarction x 5 - first being in ___ and the last in ___. He underwent several percutaneous coronary interventions with stent placement with the last being in ___. He is s/p biventricular ICD ___ GEM III ___ model 7275) placed ___ years ago. 2) Ischemic cardiomyopathy 3) Type 2 diabetes 4) Hypercholesterolemia 5) Hypertension 6) Obstructive sleep apnea Social History: ___ Family History: Daughter with anti-phospholipid antibody syndrome, now on Coumadin. Physical Exam: On admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, dry MM Neck: supple, JVP difficult to assess but does not appear elevated, right IJ CVL in place CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles at the bases bilaterally Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, strength and sensation grossly intact Discharge: Vitals: 97.5, 91/55, 59, 18, 99% General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, PERRL, healing lesion at left upper vermilion border Neck: supple, JVP not elevated, right IJ CVL removed with dressing c/d/i and no associated tenderness/erythema CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breath sounds diffusely Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley, mild erythema near urethral meatus Ext: warm, well perfused, 2+ pulses, 1+ pitting edema bilaterally Neuro: CNII-XII intact, strength and sensation grossly intact Pertinent Results: On admission: ___ 04:05PM BLOOD WBC-2.9# RBC-3.05 Hgb-10.6* Hct-31.2* MCV-103* MCH-34.7* MCHC-33.8 RDW-27.3* Plt ___ ___ 04:05PM BLOOD ___ PTT-27.7 ___ ___ 04:05PM BLOOD Glucose-196* UreaN-23* Creat-1.8* Na-135 K-3.9 Cl-103 HCO3-21* AnGap-15 ___ 04:05PM BLOOD ALT-33 AST-32 CK(CPK)-53 AlkPhos-57 TotBili-0.4 ___ 04:05PM BLOOD cTropnT-0.02* ___ 09:07PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:17PM BLOOD Type-CENTRAL VE pO2-32* pCO2-39 pH-7.42 calTCO2-26 Base XS-0 ___ 04:31PM BLOOD Lactate-2.8* ___ 06:17PM BLOOD Lactate-1.2 At discharge: ___ 06:26AM BLOOD WBC-4.7 RBC-2.70* Hgb-9.2* Hct-28.9* MCV-107* MCH-34.2* MCHC-31.9 RDW-24.7* Plt ___ ___ 06:15AM BLOOD CD3 %-64.5 CD3Abs-771 CD5 %-64.9 CD5Abs-777 ___ 06:26AM BLOOD Glucose-94 UreaN-22* Creat-1.0 Na-138 K-4.1 Cl-106 HCO3-30 AnGap-6* ___ 06:26AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 ___ 06:15AM BLOOD IgG-1112 IgA-<5* IgM-23* ___ 01:05PM BLOOD THIOPURINE METHYLTRANSFERASE (TPMT), ERYTHROCYTES-PND Microbiology: Blood cultures x2 (___): No growth Urine culture (___): <10,000 organisms Urine Legionella antigen (___): Negative Viral DFA (___): Negative for influenza A/B Stool (___): Negative for C. difficile CMV (___): Viral load 341 Stool (___): Negative for enteric gram negative rods, Salmonella/Shigella, Campylobacter, virus, Cryptosporidium/Giardia, ova/parasites. CMV (___): Negative for IgM/IgG, viral load 732. Urine culture (___): Yeast. Blood cultures x2 (___): Pending Viral DFA (___): Negative for influenza A/B Catheter tip (___): Negative RPR (___): Negative DFA of lip (___): POSITIVE FOR HERPES SIMPLEX TYPE 1 (HSV1) Imaging: EKG (___): Baseline artifact. Probable sinus tachycardia. Late precordial R wave transition. Compared to the previous tracing ventricular ectopy is absent but the rhythm is quite a bit faster, likely still sinus. IntervalsAxes ___ ___ Portable CXR (___): Limited, negative. Portable CXR (___): Portable AP upright chest radiograph obtained. There has been interval placement of a right IJ central venous catheter with its tip residing in the mid SVC. No pneumothorax is seen. Otherwise, no change. Portable CXR (___): No acute interval changes to suggest pneumonia. CXR PA/lateral (___): Mild-to-moderate cardiomegaly is unchanged. Pacemaker leads are in standard position. Right IJ catheter tip is in the lower SVC. Interstitial opacities in the mid and lower lungs, larger on the right side, consistent with patient's known interstitial lung disease is unchanged. There are no new lung lesions, pneumothorax or pleural effusion. There are mild-to-moderate degenerative changes in the thoracic spine. CT Torso (___): IMPRESSION: 1. No acute abnormality to explain diarrhea. No evidence of acute infection. 2. Fibrotic interstitial lung disease involving primarily the lower lobe, unchanged from comparison. 3. Cardiomegaly and borderline enlargement of both the ascending aorta and pulmonary trunk. Brief Hospital Course: Mr. ___ is a ___ with ischemic CM (LVEF ___, CAD c/b MI, interstitial lung disease on prednisone/azathioprine, pANCA vasculitis, Sjogren's disease, T2DM, HTN, and OSA initially admitted to the MICU for SOB and transient hypotension. (1)Fever: Following temperature to 102.8 in the ED, he developed fever to 102.2 on the morning of ___. Source of fever was not entirely clear initially in the absence of focal infiltrate on CXR, line-associated infection, or significant growth on blood, urine, or stool cultures. The infectious disease service was advised and suggested CT torso in the setting of CMV viremia which did not show evidence of colitis or other sources of infection. The gastroenterology service was consulted and performed a flexible sigmoidoscopy. Pathology results are pending. The patient was noted to have vesicular lesions on his lip and penis. DFA was positive for HSV 1 of the lip, while the penile sample was inadequate. The patient was treated with a 5 day course of azithromycin. (2)Shortness of breath: Despite concern for healthcare-associated pneumonia on admission, CXR was negative for focal infiltrate, and empiric antibiotics initiated in the ED, namely vancomycin/cefepime/levofloxacin, were discontinued. Similarly, empiric Tamiflu was discontinued after viral DFA resulted as negative for influenza. He met SIRS criteria on admission on the basis of leukocytosis, tachypnea, fever, and tachycardia, initially presumed secondary to pulmonary source. He required intermittent supplemental oxygen (up to 2 liters) for comfort in the setting of known interstitial lung disease and received Tessalon perles and guaifenesin for cough suppression. Close follow-up was arranged with his outpatient pulmonologist. (3)Loose stools: Chronic loose stools were felt to reflect residual effects of azathioprine treatment for interstitial lung disease in the absence of C. difficile or stool culture positivity; tTG IgA was negative. TPMT level and stool elastase are pending. He initially received empiric vancomycin/Flagyl until C. difficile study resulted as negative. In the setting of CMV viremia, abdominal CT was obtained which did not show signs of colitis. The gastroenterology service was consulted and performed a flexible sigmoidoscopy. Pathology results are pending. He received cholestyramine and loperamide, with good effect, and tolerated a lactose-free, low-residue diet. Diarrhea resolved prior to discharge. (4)Hypotension: He was found to be hypotensive to ___ systolic on admission and remained intermittently asymptomtically hypotensive to ___ systolic throughout admission in the setting of ongoing gastrointestinal losses and poor forward flow due to ischemic cardiomyopathy. In the setting of chronic prednisone use, morning cortisol was normal (5.2). Metoprolol succinate 25mg daily was continued as patient's blood pressures remained stable in 90-100s systolic. (5)Acute kidney injury: Creatinine was elevated to 1.8 on admission, likely reflecting prerenal azotemia in the setting of gastrointestinal losses, and had improved to baseline of ___ with diarrheal treatment and IV/PO hydration by the time of discharge. (6)Ischemic cardiomyopathy: Reportedly hypovolemic on admission, he developed volume overload following gentle IV hydration and was allowed to autodiurese and given compression stockings for symptomatic control. Furosemide was avoided in the setting of intermittent hypotension as above. Home aspirin/Plavix and metoprolol were continued throughout admission. Weight was 89kg at discharge. Close cardiology follow-up was arranged. (7)Coronary artery disease: He ruled out for myocardial infarction on admission on the basis of serially negative cardiac enzymes and reassuring EKGs. Home aspirin/Plavix and metoprolol were continued throughout admission. (8)Mental health: He endorsed low mood, sometimes wishing to "throw in the towel" due to multiple medical comorbidities, denying active suicidal ideation. He was seen by the social work service, with good effect. He had been on citalopram in the past, but declined reinitiation in-house. (9)Macrocytic anemia: Hematocrit remained 27 to 33 throughout admission, consistent with recent baseline, in association with MCV of 102-108. Further evaluation may be indicated in the outpatient setting. (10)Neutropenia: He was neutropenic on admission in the setting of recent azathioprine use, with resolution over the course of admission. CMV viremia may have also contributed. Inactive Issues: (1)Interstitial lung disease: Home prednisone and prophylactic Bactrim were continued. Close pulmonology follow-up was arranged. (2)Type 2 diabetes mellitus: He received gentle Humalog insulin sliding scale in-house. (3)Obstructive sleep apnea: He used CPAP nightly and was placed on continuous oxygen monitoring in-house. Transitional Issues: - Patient was found to have HSV 1 of the lip and was started on acyclovir 800mg 5x/day for 5 day course (day ___ - Pending studies: TPMT, pancreatic elastase, flex sig biopsy pathology results - Code status: Full. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Nitroglycerin SL 0.4 mg SL PRN chest pain 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. azelastine NF 137 mcg NU BID 2 Puffs 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 12. Citalopram 20 mg PO DAILY 13. PredniSONE 20 mg PO DAILY 14. Metoprolol Succinate XL 25 mg PO DAILY hold for sbp <100 or hr < 60 Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. PredniSONE 20 mg PO DAILY 8. Simvastatin 40 mg PO DAILY 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 11. Acyclovir 800 mg PO 5X/DAY RX acyclovir 800 mg 1 tablet(s) by mouth 5 times a day Disp #13 Tablet Refills:0 12. Guaifenesin ___ mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL ___ mL Liquid(s) by mouth every six (6) hours Disp #1 Bottle Refills:0 13. Nystatin Cream 1 Appl TP BID RX nystatin 100,000 unit/gram Apply to affected area twice a day Disp #1 Tube Refills:0 14. Metoprolol Succinate XL 25 mg PO DAILY hold for sbp <100 or hr < 60 15. Nitroglycerin SL 0.4 mg SL PRN chest pain 16. azelastine NF* 137 mcg NU BID 2 Puffs 17. Citalopram 20 mg PO DAILY 18. Benzonatate 100 mg PO TID RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #15 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ ___: Primary: Hypotension Secretory diarrhea, likely secondary to Imuran or cytomegalovirus Secondary: Interstitial lung disease Ischemic cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care during your admission to ___. As you know, you were admitted for fever, shortness of breath, loose stools, and low blood pressure. The cause of your shortness of breath remained unclear, but was felt not to be due to pneumonia or your interstitial lung disease; your shortness of breath resolved off antibiotics and with continuation of your home prednisone regimen. You were evaluated by the gastroenterology doctors for ___ ___, which were felt to be due to Imuran; there was no evidence of infection in your gut. It is also possible that you had a viral infection when your immune system was low. It is likely that it will take some time for your gut to recover. In the event that your loose stools do not resolve, you may need further studies of your upper and lower gastrointestinal tracts in the outpatient setting. With respect to your low blood pressure, it was likely due to gastrointestinal losses in the setting of loose stools, as well as your known heart disease. Given your known heart disease, please weigh yourself every morning and call Dr. ___ if your weight goes up more than 3 pounds. You are started on a new medication called acyclovir to treat the herpes on your lips. You can take guaifenesin and benzonatate for cough. You can also use Nystatin for the fungal rash in your groin. You will have home physical therapy to help you to regain your strength from the long hospital stay. Followup Instructions: ___
10065997-DS-4	10,065,997	25,252,424	DS	4	2205-12-02 00:00:00	2205-12-02 16:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PODIATRY Allergies: cephalexin / Bactrim Attending: ___. Chief Complaint: Right ___ toe infection Major Surgical or Invasive Procedure: ___: 1. Right Foot ___ toe debridement 2. Right ___ PIPJ arthroplasty History of Present Illness: Ms. ___ is a ___ with PMHx of DM c/b neuropathy, CHF, HTN presenting to the ED with c/o infection to the R ___ toe. She has been on 2 courses of 10 days of clindamycin without improvement. Pt endorses some improvement while finishing clindamycin a few days ago but now with dark eschar, persistent redness/pain. She has some numbness at the bottom of her feet from chronic neuropathy but able to walk even with painful second toe. She was instructed by her PCP two weeks ago to see podiatry about this issue but did not because of insurance issues. She reports mild fevers / chills at home the last few days. No chest pain/SOB. Total body joint pain which is chronic for many years. Past Medical History: PAST MEDICAL HISTORY: DM (c/b peripheral neuropathy) Hyperlipidemia Obesity CAD (cardiac catheter in ___: Reports not available, gets CP rarely. Has seen dr ___ in the past, cannot see Dr ___ due to insurance issues) CHF HTN Anxiety/depression PAST SURGICAL HISTORY: hysterectomy Social History: ___ Family History: Mother had diabetes and neuropathy. No family history of cancers or coronary disease. Her son just passed, they are doing an autopsy, unsure of cause of death. Her niece diagnosed with stage 4 melanoma, (it was her father who just died), not handling it well. Physical Exam: On Admission: VITALS: 97.3 71 137/68 16 99% RA GEN: NAD, AOx3 RESP: CTA ABD: obese, soft, ___ FOCUSED: ___ pulses palpable bilaterally. cap refill < 3 sec to the digits/ mild edema to the R ___ toe. Mild peripheral edema noted. R 2md toe with ulceration to the dorsal aspect of the PIPJ with dry eschar covering, underlying fibrotic tissue with exposed bone. No purulence or fluctuance noted. R ___ toe with erythema and warmth. hammertoe deformity to the ___ toe b/l. mild pain with palpation of the ulcerated area. NEURO: light touch sensation diminished to the ___ b/l. On Discharge: AVSS GEN: NAD, AOx3 CHEST: RRR RESP: CTA, no resp distress ABD: obese, soft, ___, non-distended, no rebounding or guarding ___ FOCUSED: ___ pulses palpable bilaterally. cap refill < 3 sec to the digits/ mild edema to the R ___ toe. Right ___ digit sutures intact with no signs of dehiscence. Erythema improved. No drainage. No malodor. Mild peripheral edema noted. No TTP to the ___ toe. No signs of any other open lesions. Able to wiggle all toes x 10 NEURO: light touch sensation diminished to the ___ b/l. Pertinent Results: On Admission: ___ 04:45PM BLOOD WBC-9.4 RBC-5.11 Hgb-14.8 Hct-42.8 MCV-84 MCH-29.0 MCHC-34.6 RDW-11.9 RDWSD-36.2 Plt ___ ___ 04:45PM BLOOD Glucose-214* UreaN-12 Creat-0.6 Na-135 K-4.3 Cl-96 HCO3-27 AnGap-16 ___ 05:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9 ___ 04:53PM BLOOD Lactate-1.8 . On Discharge: ___ 09:15AM BLOOD WBC-7.1 RBC-4.89 Hgb-14.2 Hct-42.1 MCV-86 MCH-29.0 MCHC-33.7 RDW-12.0 RDWSD-37.6 Plt ___ ___ 09:15AM BLOOD Plt ___ ___ 09:15AM BLOOD Glucose-268* UreaN-14 Creat-0.6 Na-136 K-4.7 Cl-100 HCO3-24 AnGap-17 ___ 09:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 Imaging: Right Foot Xray ___: No acute fractures or dislocation are seen. There are no erosions. A small plantar calcaneal spur is noted. . Right Foot Xray ___: In comparison with study of ___, there has been resection of bone about the PIP joint of the second digit. . CXR ___: The cardiomediastinal and hilar contours are normal. Lungs are clear. There is no evidence of pulmonary edema, pleural effusion, or pneumothorax. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. . Microbiology: GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH . Pathology: Tissue: BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE Procedure Date of ___ Report not finalized. Assigned Pathologist ___, MD ___ in only. PATHOLOGY # ___ BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE . Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ED on ___ for a R ___ toe infection. On admission, she was started on broad spectrum antibiotics. She was taken to the OR for Right ___ toe ulcer debridement and PIPJ arthroplasty on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. . Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. She was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with doxycycline. Her intake and output were closely monitored and noted to be adequtae. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. She worked with ___ during admission who recommended discharge home with partial weight bearing heel status. The patient was subsequently discharged to home on ___. 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. Furosemide 80 mg PO DAILY 2. Gabapentin 600 mg PO BID 3. LORazepam 1 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing or shortness of breath 5. amLODIPine 10 mg PO DAILY 6. GlyBURIDE 10 mg PO BID 7. Losartan Potassium 50 mg PO DAILY 8. Pravastatin 20 mg PO QPM 9. Spironolactone 25 mg PO DAILY 10. Vitamin D 5000 UNIT PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 12. Carvedilol 12.5 mg PO BID 13. Citalopram 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve (12) hours Disp #20 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth Q4-6H Disp #30 Tablet Refills:0 5. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin RX insulin lispro [Humalog] 100 unit/mL AS DIR Up to 6 Units QID per sliding scale Disp #1 Vial Refills:*2 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing or shortness of breath 7. amLODIPine 10 mg PO DAILY 8. Carvedilol 12.5 mg PO BID 9. Citalopram 40 mg PO DAILY 10. Furosemide 80 mg PO DAILY 11. Gabapentin 600 mg PO BID 12. GlyBURIDE 10 mg PO BID 13. LORazepam 1 mg PO BID 14. Losartan Potassium 50 mg PO DAILY 15. Pravastatin 20 mg PO QPM 16. Spironolactone 25 mg PO DAILY 17. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right ___ toe osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Requires assistance with can or crutches Discharge Instructions: It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service for treatment of your right foot infection. You were given IV antibiotics while here. You were taken to the OR on ___ for resection of infected bone. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain weight bearing to the heel only on your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. WOUND CARE: Please leave the dressing to the Right Foot intact until your follow up appointment. Keep the Right Foot dry. If the dressing gets wet it must be changed. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___
10066039-DS-5	10,066,039	24,763,357	DS	5	2189-10-23 00:00:00	2189-10-23 19:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / morphine Attending: ___. Chief Complaint: humeral fracture, fall Major Surgical or Invasive Procedure: n/a History of Present Illness: The pt is a ___ year old female w/ htn, p/w trauma 1 day ago w/ resultant R humeral fracture, noted to have increased confusion and ? facial asymmetry after prolonged stay in the ED daughter states that pt fell at home on ___ night around 930pm. pt ambulates with walker. fall was unwitnessed. per pt, she fell onto her buttocks, no headtrike, but injured shoulder. She presented to ___. daughter states that OSH attempted several times to relocate shoulder unsuccessfully. pt with R knee pain, daughter states this is baseline, but pain has increased since fall. ROM affected due to pain. unclear if pain is in R hip or R knee. Upon transfer to ___ ED, initial vitals were: 97.7 72 181/73 18 95% RA Labs were notable for: Hgb 9.6 (last known baseline was 12.1 in ___ She was seen by Orthopedic surgery who recommended nonoperative management. She was being observed in the ED when over the course of the day ___, she was noted to be progressively more confused and disoriented. She was given olanzapine, with poor response. She was subsequently found to have mod leuk in her UA, and so was given nitrofurantoin. ED chart review reveals she has also received lorazepam and several doses of IV hydromorphone (presumably for her orthopedic pain). At around 11pm on ___, her daughter at bedside noticed her left eyelid was droopy. At that point a code stroke was called. Patient unable to provide history as she is confused and believes she is in a car by the park. According to her daughter, this is very different from her baseline, at ___ she is alert, oriented, and has no problems with her memory. She lives alone in an apartment but receives home care 5 hours/day and her children provide assistance as well. She has been confused for the most part of today and has been sleep deprived while in ED. She verbalizes that she wishes to go home repeatedly, believes she is in the park, and is progressively less redirectable. Past Medical History: Depression Hypertension Insomnia Anxiety Social History: ___ Family History: NC Physical Exam: ON ADMISSION: ================ Vitals: T: 97.9 BP: 140/70s P: 80s R: 18 O2: 96% RA General: Alert, oriented(self/place/season and year), no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung fields clear CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2 mm reactive pupil on left side, 1 mm sluggishly reactive pupil on right side. EOMI. Cranial nerves intact although difficult for pt to move R arm. Hand grip strength intact. Sensation intact. ON DISCHARGE: ============= Vitals: Tm 98.5 112-169/51-70 ___ 18 95%RA General: Alert, oriented(self/place/season and year), no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung fields clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2 mm reactive pupil on left side, 1 mm sluggishly reactive pupil on right side. EOMI. Cranial nerves intact although difficult for pt to move R arm. Hand grip strength intact. Sensation intact. Pertinent Results: ON ADMISSION: ============= ___ 01:48AM BLOOD WBC-8.9 RBC-3.27* Hgb-9.6* Hct-30.0* MCV-92 MCH-29.4 MCHC-32.0 RDW-13.8 RDWSD-46.9* Plt ___ ___ 01:48AM BLOOD Neuts-74.0* Lymphs-15.2* Monos-7.9 Eos-2.1 Baso-0.2 Im ___ AbsNeut-6.58* AbsLymp-1.35 AbsMono-0.70 AbsEos-0.19 AbsBaso-0.02 ___ 01:48AM BLOOD ___ PTT-27.5 ___ ___ 01:48AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-23 AnGap-14 ___ 02:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:00AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD ___ 02:00AM URINE RBC-2 WBC-26* Bacteri-FEW Yeast-NONE Epi-3 TransE-2 ___ 02:00AM URINE CastHy-1* ___ 02:00AM URINE Mucous-RARE PERTINENT LABS: ================ ___ 10:20AM BLOOD WBC-10.4* RBC-3.31* Hgb-9.8* Hct-30.5* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.8 RDWSD-46.7* Plt ___ ___ 08:15AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.7* Hct-30.4* MCV-93 MCH-29.6 MCHC-31.9* RDW-14.2 RDWSD-48.0* Plt ___ ___ 07:50AM BLOOD WBC-7.9 RBC-3.25* Hgb-9.4* Hct-30.4* MCV-94 MCH-28.9 MCHC-30.9* RDW-14.4 RDWSD-48.8* Plt ___ DISCHARGE LABS: =============== NOT OBTAINED ON DAY OF DISCHARGE MICRO: ========= ___ 4:00 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 2:00 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ========== HEAD CT 1. No definitive acute intracranial abnormality on noncontrast head CT. There is no intracranial hemorrhage. 2. Nonspecific asymmetric hypodensity of the left pons is slightly more prominent on the current exam, which may be secondary to artifact. If there no contraindications, MRI would be more sensitive for acute infarcts. CT RIGHT SHOULDER 1. Minimally displaced right acromion fracture. 2. Fracture through the base of the coracoid process with 1.6 cm of anterior distraction of the bony fragment segment. 3. Mild anterior subluxation of the humeral head at the glenohumeral joint without frank dislocation. 4. Large subacromial and subcoracoid joint effusion. RIGHT SHOULDER X RAY Anterior glenohumeral dislocation. Fractures are better evaluated on subsequent CT shoulder. HIP/PELVIS X RAY Evaluation is limited by overlying soft tissues. No fracture or dislocation is seen. There is significant femoroacetabular joint space narrowing bilaterally, right greater than left. Evaluation of the sacrum is somewhat limited by overlying bowel gas. No radiopaque foreign body seen. IMPRESSION: Limited evaluation for fracture. If there is suspicion for fracture, cross-sectional imaging should be performed. RIGHT KNEE X-RAY: No fracture or dislocation is detected. There is narrowing in the medial compartment. Chondrocalcinosis is most prominent in the lateral compartment. No suspicious lytic or sclerotic lesion is identified. No joint effusion is seen. Vascular calcifications are seen. No radio-opaque foreign body is detected. The bones are demineralized. CT SPINE: Alignment is normal. No fractures are identified.There is no significant canal narrowing.There is no prevertebral edema. There are mild changes of degenerative disk disease without spinal canal or neural foraminal encroachment. There is diffuse osteopenia suggesting osteoporosis. The thyroid and included lung apices are unremarkable. IMPRESSION: No evidence of fracture or malalignment. Mild degenerative disc disease without canal or foraminal encroachment Brief Hospital Course: ___ yo ___ woman presenting with right humeral fracture s/p mechanical fall, found to have iatrogenic delirium and facial changes concerning for ?carotid dissection. # R anterior shoulder dislocation: not reducible, per discussion with pt's daughter, electing for nonoperative management and healing over ___ weeks. Pt will require rehab after discharge from hospital. She will follow up with Dr. ___ on ___. Her pain was managed with Tylenol. # AMS: most likely ___ iatrogenic delirium d/t administration of multiple sedatives and deliriogenic medications. Stroke/TIA less likely based on head CT and neuro exam. Found to have a positive UA with sx, so was treated for 3 days with IV CTX, but this medication was d/c'ed because her urine culture returned negative. Her home Ambien and Ativan were stopped. # Facial asymmetry: pt presented with miosis and eyelid droop on the right side, which is the same side as her humeral fracture. Head CT negative for acute changes. Neurology was consulted, and felt that her sx were likely due to a palpebral muscle dehiscence, so did not recommend further workup. The pt was started on 81 mg ASA for stroke ppx. *Transitional issues: - blood pressure was elevated to 169/70 on discharge, asymptomatic, continued home medication valsartan 160 BID, no further interventions, reevaluate if this is a persistent problem - stopped medications: pt was taken off home Ativan and Ambien due to concern for inducing delirium. She did not display anxiety or request sleep medications during her stay. - pain medications: started patient on Tylenol for pain management. She responded well to this. If needs further medications, consider low-dose Tramadol. - pt started on 81 mg ASA for stroke prophylaxis. - pt was started on antibiotics for presumed UTI and completed a 3 day course of Ceftriaxone - humeral fracture: pt will follow up with Dr. ___ on ___ for further management of humeral fracture and shoulder dislocation. She may wear shoulder sling for comfort. DNR/DNI* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO QAM 2. Valsartan 160 mg PO BID 3. Lorazepam 0.5 mg PO DAILY:PRN anxiety 4. Zolpidem Tartrate 10 mg PO QHS insomnia 5. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN 6. Proctosol HC (hydrocorTISone) 2.5 % rectal DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Artificial Tears 1 DROP BOTH EYES DAILY 9. Multivitamins 1 TAB PO DAILY 10. Bisacodyl ___ mg PO QHS Discharge Medications: 1. Artificial Tears 1 DROP BOTH EYES DAILY 2. Bisacodyl ___ mg PO QHS 3. Citalopram 10 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Valsartan 160 mg PO BID 7. Acetaminophen 650 mg PO TID 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Proctosol HC (hydrocorTISone) 2.5 % rectal DAILY 11. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: - Minimally displaced right acromion and coracoid process fracture - Anterior right humeral head dislocation - Toxic-metabolic encephalopathy due to medications Secondary diagnoses: - Hypertension - Depression - Anxiety - Chronic back pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you dislocated your shoulder and broke your arm. Initially there was concern that you had a stroke, but our neurology team evaluated you and did not find evidence of one. You should follow up with Dr. ___ expect your arm to heal in ___ weeks. It was a pleasure taking care of you and we wish you the best at rehab! Sincerely, Your ___ team Followup Instructions: ___
10066149-DS-16	10,066,149	20,842,875	DS	16	2138-01-02 00:00:00	2138-01-04 14:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p motor vehicle collision Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ who presents to ___ ED on ___ s/p MVC into 2 telephone poles found to have left temporal bone fracture and R posterior parietal fracture with small amount of adjacent pneumocephalus and exceedinly small R apical pneumothorax as seen on CT Chest. Patient was an intoxicated driver of the vehicle. Serum ETOH 193 on arrival to ED. Patient reports he was wearing his seatbelt. Denies LOC however is unable to describe mechanism of injury and unsure if patient is accurate historian. Reports posterior headache. No visual changes. Denies CP/SOB, abdominal pain, N/V/D, fevers/chills. Past Medical History: PMH: diabetes mellitus Type 2 PSH: - s/p L knee ORIF for comminuted L tibial fracture s/p motorcycle accident ___ Social History: ___ Family History: reviewed and noncontributory Physical Exam: Admission Physical Exam: Vitals: 98.2 BP: 102/78 HR: 110 RR: 21 O2 Sat: 98%RA Gen: A&Ox3, in NAD HEENT: Multiple abrasions to R forehead/face and anterior neck/chest, TTP along L lateral skull; No scleral icterus, mucus membranes moist Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, no rebound/guarding, no palpable masses Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Discharge Physical Exam: Vitals: 99.7 99.2 99 123/74 18 96% RA Gen: A&Ox3, well-appearing male, in NAD HEENT: several well-healing abrasions to R forehead/face and anterior neck/chest, TTP along L lateral skull; No scleral icterus, mucus membranes moist Pulm: CTAB, no w/r/r CV: NRRR, no m/r/g Abd: soft, NT/ND, no rebound/guarding, no palpable masses Ext: WWP bilaterally, no c/c/e, no ulcerations Neuro: moves all limbs spontaneously, no focal deficits Pertinent Results: ============== ADMISSION LABS ============== ___ 04:25AM BLOOD WBC-19.1* RBC-4.86 Hgb-14.5 Hct-43.7 MCV-90 MCH-29.8 MCHC-33.2 RDW-13.2 RDWSD-43.2 Plt ___ ___ 04:25AM BLOOD ___ PTT-22.6* ___ ___ 04:25AM BLOOD Lipase-38 ___ 04:25AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:33AM BLOOD Glucose-254* Lactate-2.9* Na-143 K-3.7 Cl-106 calHCO3-24 ======== IMAGING ======== ___ CXR: IMPRESSION: Tiny right pneumothorax seen on CT chest is not visualized on radiograph. ___ CT Head w/o contrast: IMPRESSION: 1. Complex calvarial fracture, including a transversely oriented occipital bone fracture extending from the right occipital/mastoid suture through the occipital bone and into the left mastoid, and a right parasagittal occipital bone fracture. 2. 3 mm extra-axial hematoma along the left occipital and posterior temporal lobes, contiguous with the left transverse sinus. Possible additional 3 mm extra-axial hematoma in the left posterior fossa contiguous with the transverse sinus, versus asymmetric appearance of the left sigmoid sinus. 3. Partial opacification of left superior mastoid air cells, likely hemorrhagic given the left mastoid fracture. 4. Periapical lucency ___ 3. Please correlate clinically whether active dental inflammation may be present. RECOMMENDATION(S): 1. CT venogram to assess patency of the left transverse sinus. 2. Temporal bone CT for better assessment of left inner ear and middle ear structures. ___ CT C spine: IMPRESSION: No cervical spine fracture or malalignment. ___ CT Chest/Abdomen/Pelvis with contrast: IMPRESSION: 1. Tiny right pneumothorax. 2. No acute trauma in the abdomen or pelvis. ___ CT orbit/sella/IAC w/o contrast: IMPRESSION: 1. Fracture of the occipital bone, longitudinal fractures of the left temporal bone. No fractures of the right temple bone. 2. Opacified left mastoids, middle ear cavity. 3. The known extra-axial hematoma about torcula and venous sinuses are better seen on the same-day CT venogram exam. ___ CT Head venogram: IMPRESSION: 1. Extra-axial hematoma along the posterior margin of the superior sagittal, and medial bilateral transverse sinuses causing moderate to severe narrowing of sinuses, without occlusion few air locule is within the sinus, likely related to left temporal bone fractures. No change in the size of hematoma. Consider venous sinus injury as source of hemorrhage, close imaging follow-up recommended. 2. Stable acute occipital bone, left temporal bone fractures. Brief Hospital Course: Mr. ___ was admitted to the Acute Care Surgery Service under the care of Dr. ___ for further assessment and clinical management of his injuries following his motor vehicle collision. His initial injuries identified during his work up in the Emergency department included a left temporal skull fracture with associated pneumocephalus as well as an exceedingly small right pneumothorax without any associated rib fractures. He was evaluated by the the Neurosurgery Service regarding his skull fracture and pneumocephalus and given that he had no associated neurologic sequelae, it was decided that he did not require any surgical intervention. He underwent additional imaging at the suggestion of the Radiology Department to further characterize intracranial structures not well seen on initial imaging - a CT venogram identified moderately to severely narrowed bilateral transverse sinuses possibly resulting from compression via his extra-cranial hematoma. A Neurology consult was obtained to assess the need for possible anticoagulation as prophylaxis in the setting of stenosis - it was deemed that he did not require any anticoagulation as this imaging finding may have been related to chronic hypoplastic transverse sinuses. It was instead recommended that he undergo repeat imaging and revisit in the Neurology/Stroke Clinic in ___ weeks to assess stability of the narrowing as well as possible progression of any neurologic symptoms. On the evening of HD2, the patient was tolerating a regular diet, voiding and ambulating without difficulty, his pain was well controlled with PO pain medications, his wounds were clean, dry and intact without any evidence of infection, and he remained afebrile, hemodynamically stable, and neurologically intact. He was thus deemed ready for discharge home with follow up in the Acute Care Surgery Clinic in 2 weeks and was instructed to contact the Neuro/Stroke Center to undergo repeat CT venogram and follow up visit. The patient expressed understanding and agreed to the aforementioned plan at the time of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Do not exceed 4000mg in 24 hours. 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #30 Capsule Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Do not drink or drive while taking. Please discard extra. RX oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp #10 Tablet Refills:0 4. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: left temporal bone fracture pneumocephalus possible hypoplastic transverse sinus right pneumothorax 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 ___ for close monitoring following a motor vehicle accident after your Emergency Room imaging confirmed that you sustained a skull fracture and air inside your skull (pneumocephalus), which can be dangerous. You were seen by the Neurosurgery Service who determined that you did not have any injuries that required surgery. You did have additional CAT scans of your head that showed narrowed veings in the brain that were concerning for high risk of blood clot in the brain (venous thrombosis). Neurology determined that you do not need any blood thinners for this, but recommended that you follow up in the Neuro/Stroke Clinic with repeat CAT scan to make sure you're recovering well. Additionally, your imaging showed a very small amount of air in your lung cavity (pneumothorax). This resolved on its own after repeat your chest xray the following day and you did not require any additional interventions. You will be seen in Acute Care Surgery Clinic to make sure you are recovering well from your overall trauma. You are now ready to be discharged home. Please see below for additional 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. 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. Pain control: 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. * 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. Thank you very much for the opportunity to participate in your care. Best wishes for a speedy recovery! Followup Instructions: ___
10066209-DS-11	10,066,209	27,826,282	DS	11	2121-07-11 00:00:00	2121-07-12 08:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Chief Complaint: altered mental status REASON FOR MICU ADMISSION: hypotension Major Surgical or Invasive Procedure: ___: intubation ___: extubation History of Present Illness: Ms. ___ is a ___ with PMH significant for COPD and ischemic stroke with no residual who was transferred from ___ after for further management of hypotension, sepsis and seizures. history per son (not the one present with the patient during the episode): 8pm on ___ the pt needed to use the bedside commode. went once and returned to the bed with assistant of her daughters. She asked to go to the commode again 5 min later. while on the common and the duagheters away, they heard an odd sounds after which they found her unresponsive with her eyes "rolling to the back of her head". they also noted left sided facial drooping and convulsive-like symptoms. no tongue biting, urine incontinent. the daughter did report diarrhea. however, it is not clear whether this represents stool incontinence. They were tapping her cheeks with no response. Minutes later the patient regained her responsiveness and the facial drooping improved. She was noted to be little incoherent and retained a white complexion in her skin. By that time the EMS had arrived. On presentation to ___-M: Temperature: 97.9 F (36.6 C). Pulse: 75. Respiratory Rate: 18. Blood-pressure: 73/52. Oxygen Saturation: 91%. finger stick 173. 135 92 41 ----------< 133 4.6 28 1.6 AG= 15. Ca: 9.1 CT scan did not show evidence of bleeding. There tele-neuro stroke consult did not favor a stroke but rather a seizure. Noted to be hypotensive with SBPs ranging from ___. Was given 4.5L of IVF and a left femoral CVL was inserted in preparation for starting levophed. However her blood pressure improved with fluids. She was given Keppra. On presentation to ED, difficult to obtain history as patient has baseline dementia. Per EMS, unchanged from baseline. Complaining of diffuse abdominal pain. WBC 3 at OSH increased to ___ here. In the ED, initial vitals: 95.02 98 84/56 18 94% RA - Her exam was notable for; Diffuse abdominal tenderness. Mottled ___ - Labs were notable for VBG: pH 7.14 pCO2 72 pO2 45 HCO3 26 Color Yellow Appear Hazy, SpecGr1.022 pH6.5, Urobil 2, Bili Neg, Leuk Lg, Bld Neg, Nitr Neg, Prot 30, Glu Neg, Ket Neg, RBC 4, WBC 30, Bact Few YeastFew Epi 1 Other Urine Counts CastHy: 64 CastCel: 5 Mucous: Rare Lactate:1.9 137 107 35 AGap=15 -------------< 117 4.7 20 1.5 ALT: 25 AP: 178 Tbili: 0.3 Alb: 2.9 AST: 45 LDH: Dbili: TProt: ___: Lip: 54 13.1 MCV 101 21.5 >------< 217 42.5 N:89.3 L:3.3 M:6.3 E:0.2 Bas:0.3 ___: 0.6 Absneut: 19.25 Abslymp: 0.70 Absmono: 1.35 Abseos: 0.04 Absbaso: 0.06 - Imaging showed ___ CT Abd & Pelvis With Contrast 1. Near pancolitis with relative sparing of the cecum, most likely infectious or inflammatory. 2. Approximately 50% loss of height at T11, chronicity indeterminate. 3. Note that left kidney is atrophic. EKG-=NSR @ 88 - Patient was given: -- IV Piperacillin-Tazobactam 4.5 g -- IV Vancomycin 1000 mg -- IV Morphine Sulfate 2 mg -- IV MetRONIDAZOLE (FLagyl) 500 mg -- foley inserted in the ED On arrival to the MICU, the patient is alert and responsive. Her speech is not full coherent. counts the day of the week forward but not backward. is oriented to the type of building. Past Medical History: history of ischemic colitis with admission in ___. history of AF on warfarin which was stopped after she was admitted with GIB on ___ Hypertension Hyperlipidemia Scoliosis DJD hx wrist surgery dyslipidemia chronic neuropathy Arthritis colonosocpy in ___- polyps and villous adenoma on pathology Social History: ___ Family History: none contributory to her current presentation. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: Hr= 111 BP= 85/41 RR=20 O2 sat 81-> 94% on NC GENERAL: sleepy, oriented to place, resting tremor, no acute distress. dry mucus membranes. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: 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: Mottled ___ . ======================= DISCHARGE PHYSICAL EXAM ======================= VS: 98, 155/86, 98, 20, 95%2L Gen: sitting in bed, comfortable-appearing, less somnolent Eyes - EOMI ENT - OP clear, dry Heart - RRR no mrg Lungs - CTA bilaterally, no wheezes, rales, ronchi Abd - soft, obese, nontender, normoactive bowel sounds Ext - 1+ edema to midshin Skin - large L heel blister; no buttock/sacral wounds Vasc - 1+ DP/radial pulses Neuro - A&Ox2- "hospital" and ___ Psych - pleasant Pertinent Results: ADMISSION LABS: ================= ___ 11:00PM BLOOD WBC-21.5* RBC-4.19 Hgb-13.1 Hct-42.5 MCV-101* MCH-31.3 MCHC-30.8* RDW-15.3 RDWSD-57.8* Plt ___ ___ 11:00PM BLOOD Neuts-89.3* Lymphs-3.3* Monos-6.3 Eos-0.2* Baso-0.3 Im ___ AbsNeut-19.25* AbsLymp-0.70* AbsMono-1.35* AbsEos-0.04 AbsBaso-0.06 ___ 05:22AM BLOOD ___ PTT-27.0 ___ ___ 11:00PM BLOOD Glucose-117* UreaN-35* Creat-1.5* Na-137 K-4.7 Cl-107 HCO3-20* AnGap-15 ___ 11:00PM BLOOD ALT-25 AST-45* AlkPhos-178* TotBili-0.3 ___ 05:22AM BLOOD CK-MB-10 cTropnT-0.09* ___ 05:22AM BLOOD Albumin-3.1* Calcium-7.5* Phos-3.9 Mg-1.6 ___ 01:00AM BLOOD ___ pO2-45* pCO2-72* pH-7.14* calTCO2-26 Base XS--6 ___ 05:30AM BLOOD Lactate-2.2* MICRO: ======= ___ Blood culture negative ___ 11:30 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___, ___ @ 02:08AM (___). ___ 1:03 pm BRONCHOALVEOLAR LAVAGE FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. ___ 9:40 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final ___: RARE GROWTH Commensal Respiratory Flora. ___ 7:28 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:22 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated IMAGING: ========== Radiology Report CHEST (PORTABLE AP) Study Date of ___ 4:46 AM IMPRESSION: Compared to chest radiographs ___ through ___ at 05:24. Lower lung volumes exaggerates the severity of new pulmonary edema. Moderate cardiomegaly is stable but pulmonary vasculature and mediastinal veins are more dilated. Pleural effusion is likely but not large. No pneumothorax. Final Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST IMPRESSION: 1. Near pancolitis with relative sparing of the cecum, most likely infectious or inflammatory. 2. Approximately 50% loss of height at T11, chronicity indeterminate. 3. Note that the left kidney is atrophic. ___ ECHOCARDIOGRAPHY REPORT ___ Conclusions The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad, although a pericardial effusion cannot be excluded with this suboptimal study. No diastolic RV collapse to suggest tamponade. Brief Hospital Course: This is an ___ year old female with past medical history of COPD, prior stroke, admitted with sepsis thought secondary to infectious colitis, course notable for hypoxic respiratory failure requiring intubation, delirium, clinically improved and transferred to the medical floor # Sepsis / Infectious Colitis - patient was admitted with weakness and focal neurologic deficits in the setting of ___, hypotension, hypothermia, leukocytosis and imaging concerning for pan colitis. Given imaging and report of recent diarrhea, patient was felt to have infectious colitis. Additional workup for infection was negative. Patient was treated with broad spectrum antibiotics with subsequent improvement. She will complete 2 weeks cipro/flagyl for infectious colitis. # Metabolic Acidosis / Acute on chronic hypoxic respiratory failure - Patient intermittently on 2L nasal cannula at home, who in the setting of above sepsis and acidosis, was intubated. With treatment of infection she was able to be extubated and remained intermittently between room air and 2L nasal cannula. # Syncope / Initial Neurologic Deficits - per reports, initially had unresponsive episode in setting of diarrhea, with concern for new neurologic deficits; these resolved with treatment of above sepsis; head CT without acute process. Presenting symptoms were suspected to recrudescence of prior stroke in setting of her acute illness and metabolic derrangements. Symptoms did not recur. # Acute metabolic encephalopathy - Patient course complicated by lethargy, felt to be ICU delirium secondary to sedating medications and severe illness above. Improved with delirium precautions, avoiding of sedating medications # Hypertension - continued home lisinopril # Hyperlipidemia - continued ASA, statin # Acute Kidney Injury - Cr 1.6 on presentation, suspected to be hydration. Resolved to 0.6 with IV fluids and treatment of above sepsis # Adv care planning: Lives with ___ and ___. Goal is ultimately for her to go back home with them. ___ is HCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Albuterol Inhaler 2 PUFF IH Q6H 3. Ascorbic Acid ___ mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Acetaminophen 650 mg PO Q4H:PRN pain 6. Lisinopril 20 mg PO DAILY 7. Meclizine 12.5 mg PO TID:PRN dizziness 8. Vitamin E 1000 UNIT PO DAILY 9. Amitriptyline 25 mg PO QHS 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Lisinopril 20 mg PO DAILY 5. Amlodipine 5 mg PO DAILY 6. Ciprofloxacin HCl 500 mg PO Q12H 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. MetroNIDAZOLE 500 mg PO Q8H 9. Albuterol Inhaler 2 PUFF IH Q6H 10. Amitriptyline 25 mg PO QHS 11. Ascorbic Acid ___ mg PO DAILY 12. Gabapentin 600 mg PO TID 13. Meclizine 12.5 mg PO TID:PRN dizziness 14. Vitamin E 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Colitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___: It was a pleasure caring for you at ___. You were admitted with diarrhea and a low blood pressure. CT scan showed inflammation in your intestines concerning for an infection. You were treated with fluids and antibiotics. You improved and are now ready for discharge. You are being discharged to Marina Bay, for additional physical therapy. Followup Instructions: ___
10066489-DS-11	10,066,489	26,697,349	DS	11	2141-07-29 00:00:00	2141-07-29 16:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ F with recent admission for subdural hematoma s/p craniotomy presents from rehab with 4hrs RUQ pain unrelated to food, no nausea/vomiting, no diarrhea though has had some discomfort prior to onset of pain. No fevers. She received an enema and had a large bowel movement, after which she felt better. She was referredto the ED from rehab. In the ED, vitals were stable. Labs at her recent baseline. No stool in the vault, received another enema with some stool output. Given cipro/flagyl and admitted for possible mid bowel impaction. On arrival to the floor, patient reports feeling well, no abd pain. ROS: Per HPI, otherwise negative 10pts including no weakness/numbness. Past Medical History: Depression, GERD, Left ___ Social History: ___ Family History: No history of bowel disease. Physical Exam: 97.3 BP 98/48 HR 67 RR 18 O2 96%RA Gen: Well appearing HEENT: Moist membranes, abrasion bridge of nose, craniotomy scar c/d/i. Neck: No LAD Heart: RRR, ___ systolic murmur Lungs: CTA bilaterally Abd; Soft, nontender to deep palpation throughout, normoactibve BS GU: No foley Ext: Warm, well perfused, DP pulses 1+ bilaterally Neuro: pupils react symmetrically, speech fluent DISCHARGE EXAM T 98.2 Tm 98.2 119/7- HR 75 RR 16 O2 99%RA Abd: Soft, nontender to deep palpation, normoactive bowel sounds EXam otherwise unchanged Pertinent Results: ___ 10:32PM BLOOD WBC-12.0* RBC-2.72* Hgb-8.1* Hct-25.0* MCV-92 MCH-29.8 MCHC-32.4 RDW-14.5 RDWSD-49.2* Plt ___ ___ 09:58AM BLOOD WBC-9.9 RBC-2.80* Hgb-8.5* Hct-26.3* MCV-94 MCH-30.4 MCHC-32.3 RDW-14.6 RDWSD-50.0* Plt ___ ___ 06:09AM BLOOD WBC-10.4* RBC-2.67* Hgb-8.0* Hct-25.0* MCV-94 MCH-30.0 MCHC-32.0 RDW-14.6 RDWSD-49.4* Plt ___ ___ 06:51AM BLOOD WBC-8.1 RBC-2.64* Hgb-8.0* Hct-24.9* MCV-94 MCH-30.3 MCHC-32.1 RDW-14.4 RDWSD-49.6* Plt ___ ___ 10:32PM BLOOD Glucose-102* UreaN-14 Creat-0.7 Na-134 K-3.8 Cl-100 HCO3-26 AnGap-12 ___ 09:58AM BLOOD Glucose-152* UreaN-13 Creat-0.8 Na-135 K-3.4 Cl-101 HCO3-26 AnGap-11 ___ 01:00PM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-136 K-3.7 Cl-102 HCO3-26 AnGap-12 ___ 06:09AM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-135 K-4.1 Cl-103 HCO3-25 AnGap-11 ___ 10:32PM BLOOD ALT-15 AST-20 AlkPhos-155* TotBili-0.4 ___ 09:58AM BLOOD ALT-18 AST-21 AlkPhos-141* TotBili-0.3 ___ 09:58AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0 ___ 10:32PM BLOOD Albumin-3.0* ___ 10:42PM BLOOD Lactate-1.0 URINE ___ 11:18AM URINE RBC-45* WBC->182* Bacteri-FEW Yeast-FEW Epi-4 IMAGING: CT Abd Pelvis ___. Rectal fecal impaction with rectal wall thickening, surrounding stranding and small volume free pelvic or presacral fluid suggestive of stercoral colitis. 2. Moderate-sized hiatal hernia. RUQ u/s: Mildly suboptimal abdominal ultrasound within normal limits. . No evidence of acute cholecystitis. CT head ___. Interval subdural drain removal with stable subdural hematoma when compared to prior imaging with improvement in associated pneumocephalus. 2. Interval improvement of rightward shift of midline structures with decreased compression of the left lateral ventricle. 3. No new hemorrhages or infarcts. Brief Hospital Course: ___ year-old female without significant PMH admitted from ___ to ___ for traumatic left convexity acute SDH s/p fall. The ___ was stable on repeat imaging, and she was discharged to rehab in stable condition with no focal neurologic deficits, and then to home. She returned to the ED on ___ with headache and difficulty ambulating and was found to have increased size of the subdural hematoma with increasing midline shift. On ___ she underwent left-sided craniotomy for resection, intraoperative evacuation, adhesiolysis, fenestration of membranes, and duraplasty for implantation of subcutaneous drain. Her post-operative course was unremarkable, her drain was removed, and she was discharged to rehabilitation on ___. She now returns with fecal impaction and CT showing rectal wall thickening, surrounding stranding and small volume free pelvic fluid suggestive of stercoral colitis. In the ED she was started empirically on cipro/flagyl for colonic inflammation and rebound on exam. FECAL IMPACTION/STERCORAL COLITIS: Based on CT findings, empiric cipro flagyl x48 hrs, improved exam, so abx stopped. HYPONATREMIA: Patient with hyponatremia during recent hospitalization, likely related to CNS trauma, and discharged on salt-tabs which were dc'd, no hyponatremia. HYPERTENSION: Mild hypotension; hold labetolol. DEPRESSION: Stable, continue celexa. RECENT SDH: Stable, continue prophylactic keppra, had repeat CT head which was unremarkable. NUTRITION: Regular as tolerated UTI: Had urinary retention, foley placed with 700cc output, UA >180 WBC, continued on PO cipro for 5 day course, foley to be DC'd and voiding trial ___. TRANSITIONAL ISSUES: -Disctontinue Foley for voiding trial ___ -UA showed UTI, culture pending, was discharged with PO cipro x5 days, last day ___. -Labetolol was stopped due to systolic pressures in the 110's -Salt tabs were stopped, serum sodium was within normal limits -Bisacodyl PR and senna were added to bowel regimen -Oxycodone was stopped since it may have contributed to constipation and she has no pain -Follow up urine culture for cipro sensitivity Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Citalopram 20 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Heparin 5000 UNIT SC BID 6. LeVETiracetam 500 mg PO BID 7. Labetalol 100 mg PO TID 8. OxycoDONE Liquid 2.5-5 mg PO Q4H:PRN pain 9. Sodium Chloride 1 gm PO BID 10. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever 2. Citalopram 20 mg PO DAILY 3. LeVETiracetam 500 mg PO BID 4. Omeprazole 40 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Heparin 5000 UNIT SC BID 7. Senna 8.6 mg PO DAILY 8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 9. Bisacodyl ___AILY constipation 10. Ciprofloxacin HCl 250 mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Ischemic colitis Constipation 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 participating in your care at ___ ___. You were admitted with abdominal pain and some inflammation of your colon. This is likely due to constipation and mild dehydration. You have passed several stools and have not had any pain. You were briefly on antibiotics for the inflammation, and they have been stopped. You had another cat scan of your head, and your operation is healing well. Finally, you were not able to pee, and a urine catheter was placed and you were found to have a urinary tract infection. You will need two more days of ciprofloxacin. MEDICATION CHANGES: STOP- Labetolol, restart if you have high blood pressure at rehab STOP- Salt tabs STOP- Oxycodone START- Bisacodyl PR daily prn constipation START- Senna daily Followup Instructions: ___
10066737-DS-13	10,066,737	20,634,740	DS	13	2162-06-14 00:00:00	2162-06-14 18:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending: ___ Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ year-old female who sustained a fall down stairs and subsequently had neck pain and left lateral arm pain. Past Medical History: Hypothyroidism, COPD, HTN, s/p ACL repair on R, R ulnar neuropathy with numbness on right ___ digits. Family History: Non-contributory Physical Exam: On discharge: AAO x 3, sensation intact throughout. Deltoids ___, left bicep/tricep ___. Full strength throughout otherwise. Full strength in lower extremities. Pertinent Results: ___ 06:55AM BLOOD WBC-4.9 RBC-3.99* Hgb-14.2 Hct-42.2 MCV-106* MCH-35.7* MCHC-33.8 RDW-13.0 Plt ___ ___ 01:51AM BLOOD WBC-5.8 RBC-4.09* Hgb-14.7 Hct-42.7 MCV-104* MCH-35.9* MCHC-34.4 RDW-12.9 Plt ___ ___ 01:51AM BLOOD Neuts-50.6 ___ Monos-7.9 Eos-3.3 Baso-0.8 ___ 06:55AM BLOOD ___ PTT-32.7 ___ ___ 06:55AM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-132* K-4.0 Cl-91* HCO3-33* AnGap-12 ___ 01:51AM BLOOD Glucose-87 UreaN-12 Creat-0.6 Na-132* K-4.1 Cl-91* HCO3-30 AnGap-15 ___ 06:55AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.8 ___ 01:51AM BLOOD Calcium-9.7 Phos-2.9 Mg-1.8 ___ Left humerus film: No acute fracture is identified. No concerning lytic or sclerotic osseous abnormality is demonstrated. Imaged aspect of the left shoulder and left elbow are grossly unremarkable. Visualized left lung is grossly clear. IMPRESSION: No humeral fracture identified. ___ CT c-spine without contrast: 1. Minimally displaced fractures of the C5 left lateral mass, left lamina, left inferior articular process with extension into the left C5/6 facet joint. 2. Fracture of the posterior superior aspect of the C6 vertebral body as well as fractures involving the C6 left lateral mass, left articular pillar, and left transverse process with extension into the transverse foramen. Further assessment with CTA or MRA is recommended to exclude left vertebral artery injury. 3. Mild prevertebral soft tissue swelling from C4 through C6 with mild C3 on C4 and C5 on C6 anterolisthesis. Findings are concerning for ligamentous injury and further assessment with MRI is recommended. 4. Centrilobular emphysema with 2 mm right upper lobe nodule. Follow up chest CT in ___ year is recommended. ___ MRI c-spine without contrast (prelim read): Fractures of the C5 and C6 vertebral are better demonstrated on prior CT scan. Prevertebral fluid is seen from C5 through C6. There is injury of the interspinous ligaments at C4-C5 and C5-C6 and focal disruption of the Preliminary Reportligamentum flavum at C5-C6. The anterior longitudinal ligament cannot be well visualized at these levels secondary to prevertebral fluid and tear cannot be excluded. Multilevel degenerative changes as detailed above which are most severe at C5-C6 and C6-C7. There is no abnormal cord signal. ___ MRA neck (prelim): The common, internal and external carotid arteries appear normal. There is no evidence of stenosis by NASCET criteria. The origins of the great vessels, subclavian and vertebral arteries appear normal bilaterally. Brief Hospital Course: Mrs. ___ was admitted the Neurosurgery service on ___ for further work-up of her C4-C5 lateral mass fractures and possible perched facet. Through further diagnostic testing, she was found to not have a perched facet. She was therefore placed in a ___ collar and discharged home with follow-up with Dr. ___ in two weeks. The patient should have repeat AP and lateral films of her cervical spine prior to that appointment. At the time of discharge, Mrs. ___ was neurologically and hemodynamically stable. She was discharged with a prescription for low-dose narcotic analgesics and instructed to take non-narcotic analgesics, such as acetaminophen, for pain relief. Medications on Admission: FOLIC ACID 1MG Daily CITALOPRAM 20MG SYMBICORT 160/4.5MCG INL TWO PFS PO BID. VENTOLIN HFA 90 MCG INHALER 2 PUFFS PO Q 4 TO 6 H PRN. NICOTINE 7 MG/24HR PATCH LEVOTHYROXINE 88 MCG Daily HYDROCHLOROTHIAZIDE 25MG daily Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, Wheeze 2. Citalopram 20 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION BID 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:*0 8. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Fracture of C5 lateral mass, left lamina in C5/C6 facet joint Posterior C6 vetebral body fracture, C6 left lateral mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ Neurosurgery service for further assessment and management of your cervical spine injury. You were found to have ligamentous injury of vertebrae C5-C6. As a result, you are instructed to wear a cervical collar ___ J) at all times (unless for hygiene purposes) until your follow-up with Dr. ___ in 2 weeks. You may resume taking all your prior home medication. Please do not take non-steroidal anti-inflammatories, such as Advil, Naproxen, ibuprofen until your follow up with Dr. ___. Followup Instructions: ___
10067195-DS-12	10,067,195	21,564,201	DS	12	2181-08-28 00:00:00	2181-08-29 00:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Chief Complaint: acute blood loss anemia Major Surgical or Invasive Procedure: ERCP with biliary and CBD stenting (___) EGD (___) History of Present Illness: ___ female with a history of PE, pancreatic cancer with metastases to the liver currently on chemotherapy, recent MI 2 weeks ago w/ PCI, transferred from outside hospital with acute weakness found to be acutely anemic. Patient reports 1 week of gradual worsening general weakness, also worsening jaundice. On the day of admission, she developed bilious vomiting and significant weakness. She went to an outside hospital where vitals were notable for hypotensive to ___, labs notable for H/H ___, WBC 22, guaiac positive stool. She received a blood transfusion and was transferred here for intensive care. Patient was recently diagnosed with pancreatic cancer in ___ after being diagnosed with a PE, found to have pancreatic cancer with metastases to liver. 2 weeks ago, while in ___ clinic developed acute chest pain was diagnosed with MI. Patient has been on Xarelto for PE since diagnosis. Denies melena or bloody stools. Denies hematemesis, active chest pain, or shortness of breath. Oncologic History (per ___ records): - ___: CTAP showed 2.4x1.6 mass of the uncinate process of the pancrease, multiple hepatic metastases - ___: CT angio of chest with multiple bilateral PEs, especially to the right base. Patient placed on Xarelto - ___ was > 200,000 - ___ Liver biopsy (core needle): adenocarcinoma. NextGen sequencing showing pancreatobiliary source. -___: readmitted with left flank pain, CT AP stable, but showing possible left lung infarct. Port-A-Cath placed. Due to residual DVTs of the lower extremity, an IVC filter was placed. Xarelto continued. Ultrasound of the liver showed new mild intrahepatic ductal dilatation (CBD 12.5mm). No evidence gallstones or cholecystitis. Pancreatic duct dilated to 5mm. Plan was for stent with Dr. ___ at ___, however, she developed a STEMI and this was deferred. Patient underwent PCI and was placed on DAPT. -___: C1 Folfirinox -___: C1D1 Gemzar (weekly x3, with 1 week off). Pt was noted to have rising bilirubin, jaundice, for which she was sent for RUQUS to evaluate for obstruction. In the ED, - Initial Vitals: T 97.8 70 BP 106/64 RR 20 SpO2 97% RA - Exam: jaundiced abdomen soft, non tender, no ascites on POCUS no leg edema - Labs: INR 10 Tbili 12 Dbili 9.7 ALP 1317 ALT: 178 AST: 504 WBC 20 Trop-T 0.05 Lactate:1.1 - Imaging: ___ RUQUS: 1. Patent portal vasculature. 2. The known pancreatic head mass is partially seen, measuring approximately 1.5 x 2.0 x 1.7 cm, with associated biliary and pancreatic ductal dilatation. 3. Multiple ill-defined predominantly hypoechoic to isoechoic hepatic lesions are presumed metastasis. 4. Sludge is demonstrated in the gallbladder. No evidence of acute cholecystitis. - Consults: GI who recommended cross-sectional imaging to eval for intra-abdominal source of bleeding, further work up of anemia (including possible chemotherapy reaction), agree with resuscitative measures, call/page for unstable bleeding. - Interventions: 3 units of pRBCs ___ 04:55 IV Pantoprazole 40 mg ___ 07:21 IV Ondansetron 4 mg ___ 07:21 IV Phytonadione - Transfer labs: T 98.1 HR 69 BP 103/56 RR 16 SpO2 96% RA Past Medical History: - Left ACL repair (___) - Hysterectomy / BSO for uterine fibroids (___) - Pancreatic Adenocarcinoma Social History: ___ Family History: not obtained Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.2 66 100/65 20 94% on RA GEN: jaundiced woman in NAD EYES: icteric, PERRLA HENNT: no LAD CV: RRR, holosystolic murmur best appreciated at the apex RESP: unlabored, CTAB GI: abd soft, non-distended, no palpable masses, normal BS MSK: warm, no edema SKIN: jaundiced, scattered small ecchymoses NEURO: AAOx3, normal sensation, mild weakness throughout (4+/5) due to overall fatigue PSYCH: depressed mood, evidence of denial regarding diagnosis DISCHARGE PHYSICAL EXAM GEN: jaundiced woman in NAD EYES: icteric, PERRLA HENNT: no LAD CV: RRR, holosystolic murmur best appreciated at the apex RESP: CTAB GI: abd soft, tenderness to palpation in RUQ, non-distended, no palpable masses, normal BS MSK: warm, no edema SKIN: jaundiced, scattered small ecchymoses NEURO: AAOx3, normal sensation, mild weakness throughout (4+/5) due to overall fatigue PSYCH: depressed mood, evidence of denial regarding diagnosis Pertinent Results: ADMISSION LABS ___ 03:48AM BLOOD WBC-20.2* RBC-1.93* Hgb-5.8* Hct-18.2* MCV-94 MCH-30.1 MCHC-31.9* RDW-16.7* RDWSD-54.9* Plt ___ ___ 03:48AM BLOOD ___ PTT-34.0 ___ ___ 03:48AM BLOOD Glucose-133* UreaN-22* Creat-0.6 Na-135 K-4.4 Cl-99 HCO3-23 AnGap-13 ___ 03:48AM BLOOD ALT-178* AST-504* LD(LDH)-610* AlkPhos-1317* TotBili-12.1* DirBili-9.7* IndBili-2.4 ___ 03:48AM BLOOD cTropnT-0.05* ___ 10:55AM BLOOD CK-MB-2 cTropnT-0.06* ___ 03:48AM BLOOD Albumin-2.3* Calcium-8.2* Phos-3.4 Mg-1.9 ___ 11:42AM BLOOD ___ pO2-34* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 ___ 03:56AM BLOOD Lactate-1.1 ___ 11:42AM BLOOD Lactate-1.8 MICRO UCx (___): skin contamination, otherwise no growth BCx x2 (___): 1 bottle NGTD, 1 bottle w GPC in pairs/clusters: ___ 3:48 am BLOOD CULTURE # 1 VENI. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___ AT 1808 ON ___. IMAGING RUQ US ___ 1. Patent portal vasculature. Please note that the SMV, splenic, and arterial vasculature are not evaluated with this technique. 2. Enlarged peripancreatic lymph node. 3. A few ill-defined iso-to-hypoechoic hepatic lesions and one discrete hyperechoic lesion are incompletely characterized, but concerning for metastatic disease, not optimally evaluated with this technique. 4. Sludge is demonstrated in the gallbladder. No evidence of acute cholecystitis. EGD ___: - esophagitis was seen in distal esophagus - large hiatal hernia seen in stomach with an area of active oozing seen in proximal part of hiatal hernia - several areas of active oozing in duodenum - successful ERCP with biliary metal stent placement Recommendations: 1. follow up with referring physician 2. PPI 40 mg twice daily 3. ongoing control of coagulopathic state 4. repeat ERCP in 2 weeks. If repeat EGD is planned, the PD stent can be pulled out during that exam. TTE ___ Right atrial mass (see above). Normal left ventricular cavity size with mild regional systolic dysfunction most consistent with coronary artery disease (LCx distribution). Moderate functional mitral regurgitation (Carptenier IIIb). No prior TTE available for comparison but imaging at OSH reported this finding according to requisition. Recommend review of prior imaging to see if TEE or CMR performed. DISCHARGE LABS ___ 06:06AM BLOOD WBC-20.7* RBC-3.01* Hgb-9.0* Hct-26.2* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.5 RDWSD-47.2* Plt Ct-71* ___ 02:01AM BLOOD ___ PTT-22.6* ___ ___ 02:01AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-131* K-4.1 Cl-97 HCO3-22 AnGap-12 ___ 02:01AM BLOOD ALT-145* AST-374* LD(LDH)-609* AlkPhos-1483* TotBili-15.6* ___ 02:01AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9 Brief Hospital Course: PATIENT SUMMARY =============== Ms. ___ is a ___ year-old woman with a PMH of newly diagnosed pancreatic cancer and known liver metastases, currently receiving chemotherapy, who presented with fatigue and vomiting, found to have acute anemia (Hg 3.8), admitted to the ICU for close monitoring and resuscitation. She was transfused 3 units in total with recovery of Hg to 8.9. She underwent EGD with epinephrine injection of an area of oozing near a hiatal hernia. She concurrently underwent ERCP with placement of a bare metal stent and a PD stent to relieve her biliary obstruction. Her Xarelto was held throughout the admission given UGIB. The decision regarding restarting it will require further discussion with cardiology. Finally, a family meeting was held with palliative care to discuss prognosis and goals of care (she will ultimately need to decide whether to continue chemotherapy or not). #Acute Blood Loss Anemia Patient had guaiac positive stool in the ED. GI bleed was in the setting of DAPT + xarelto, but no history of prior GIBs, and drinking history in past but never diagnosed with cirrhosis. Hemolysis labs negative. She was placed on IV PPI. She received a total of 3 units pRBCs and 1 unit plasma. GI was consulted and performed EGD during ERCP, which showed GEJ oozing with no obvious lesions and oozing from several erosions in the small intestine with no clear lesion. She was transfused for threshold of Hg <8 given recent MI. #Pancreatic Cancer, Stage IV #Transaminitis #Hyperbilirubinemia #Abdominal Pain / Constipation #Malnutrition Prior to hospitalization, patient had biopsy of liver metastasis revealing adenocarcinoma of pancreaticobiliary origin. She is followed by Dr. ___ at ___. S/p Fosfirinox x1, which was poorly tolerated. She was switched to ___ on ___. She had known biliary/pancreatic duct obstruction, and had been planning for ERCP/stent placement on ___ at ___, but this was delayed due to anticoagulation requirement. ERCP was performed on ___ at ___ along with EGD, biliary stents were placed and obstruction was relieved. Her pain was treated with morphine and dilaudid. Nausea was treated with Zofran, prochlorperazine. She continued to receive lorazepam, senna, docusate. Nutrition consult was placed for malnutrition. A 5 day course of Unasyn was started due to concern for cholangitis. Patient had improvement of symptoms after ERCP. Encouraged PO intake as tolerated. #Hx PE #Intracardial clot #Elevated INR Provoked in setting of active malignancy. INR 10 on admission, s/p Vit K with improvement in coagulopathy. Likely contribution of poor PO intake and cholestasis-induced liver injury. No hypoxia or calf tenderness on admission. IVC filter in place. Reported history of intracardiac clot. TTE on ___ with possible thrombus vs tumor at the IVC/RA junction. Prior TEE from ___ showed intracardial clot, consistent with this TTE finding. Given this, she will likely need to continue anticoagulation on discharge. ___ was held on discharge from ___. Will require conversation to assess risks and benefits of restarting anticoagulation. #Leukocytosis: #Single positive blood culture Patient currently on chemotherapy, last WBC was 6.4 on ___. Currently without clear localizing cause. Has chronic abdominal pain, which has not changed over past week. Most likely from cholestasis as there was finding of thickened bile prior to relief of biliary obstruction on ERCP. One blood culture from ___ turned positive on the ___ prior to transfer, growing GPCs in pairs and clusters. Patient has been afebrile and clinically improving, therefore suspect contamination. Unasyn continued for anticipated 5d course #___ Patient with recent diagnosis of metastatic cancer. She has had a difficult time coping with the diagnosis and dealt with a lot of denial. In addition, she lives with her sister who explains that she is having difficulty caring for her at home. Brother is concerned about her home situation. Palliative care and social work were consulted. During an extensive family meeting, several options were laid out: 1) return home with increased ___ services to help offload family members 2) nursing home 3)as her disease progresses, consideration of hospice whether inpatient or outpatient. No unified decision was made. Patient understand the role of palliative care in helping improve her quality of life a bit better and will require very close outpatient follow up once she is discharged. She will additionally need to follow up closely with her oncologist regarding expectations surrounding cancer diagnosis. #CAD s/p MI w PCI Developed STEMI while hospitalized at ___ in ___. Mild troponin elevation 0.05, flat on re-check, with normal MB. No chest pain. She was continued on aspirin 81, Plavix 75. Metoprolol was held during this hospitalization. #Anxiety: She was continued on Sertraline and Bupropion daily TRANSITIONAL ISSUES ===================== #Biliary obstruction s/p stenting [] Will need repeat ERCP in 2 weeks at ___ for possible PD stent removal [] Unasyn 5d course (___) #Hx PE and atrial clot on AC [] Anticoagulation (home Xarelto) was held in the setting of GI bleed, will need to have conversation regarding risks of holding anticoagulation in the setting of intracardial clot vs risk of rebleeding if it is restarted. Patient has known atrial clot discovered on TTE/TEE at ___. #Palliative Care / Advanced Care Planning [] Recommend inpatient palliative care consult with transition to outpatient pall care. Family was specifically interested in being connected with a specialized social worker to help patient/family cope with diagnosis. [] Will require close follow up with her oncologist Dr. ___ ___ expectations for her prognosis to assist in advanced care planning. [] Patient's family has been struggling to provide adequate care at home (lives with sister, patient wants to be very independent). They will benefit from increased ___ services and discussion of possible placement in SNF. Ultimately hospice will be a good option for patient, particularly if her oncologist reports a poor prognosis. #CAD [] Metoprolol was held on discharge in the setting of low SBPs. Was likely initiated for cardioprotection s/p MI, consider the value of this medication given overall poor prognosis from pancreatic cancer. #Code: full code for now (will require further discussion as disease progresses) #Contact: brother ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Morphine SR (MS ___ 15 mg PO Q12H 2. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 3. Senna 8.6 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 5. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 6. LORazepam 0.5 mg PO Q6H:PRN anxiety 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 8. Sertraline 100 mg PO DAILY 9. BuPROPion XL (Once Daily) 300 mg PO DAILY 10. Clopidogrel 75 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Rivaroxaban 15 mg PO DAILY 13. Metoprolol Tartrate 12.5 mg PO BID Discharge Medications: 1. Ampicillin-Sulbactam 3 g IV Q6H Duration: 5 Days 2. Pantoprazole 40 mg PO Q12H 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. Aspirin 81 mg PO DAILY 5. BuPROPion XL (Once Daily) 300 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate 8. LORazepam 0.5 mg PO Q6H:PRN anxiety 9. Morphine SR (MS ___ 15 mg PO Q12H 10. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line 11. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 12. Senna 8.6 mg PO DAILY 13. Sertraline 100 mg PO DAILY 14. HELD- Metoprolol Tartrate 12.5 mg PO BID This medication was held. Do not restart Metoprolol Tartrate until your doctor tells you to 15. HELD- Rivaroxaban 15 mg PO DAILY This medication was held. Do not restart Rivaroxaban until your doctor tells you to Discharge Disposition: Extended Care Discharge Diagnosis: metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: It was a pleasure caring for you at ___! Why did you come to the hospital? You came to the hospital because you felt weak and were noted to have very low blood levels. When this was noticed, you were transferred from ___ to the ___ ICU for intensive care. What did we do for you while you were here? We gave you several units of blood to help increase your blood levels. The gastroenterologists did a procedure and placed stents to help relieve the obstruction in your liver. You felt much better so you were discharged back to ___ so you could be closer to home and with your primary doctors. What should you do when you leave the hospital? You should be sure to follow up with the gastroenterologists. They have recommended that you return for a repeat of the procedure in 2 weeks to make sure that the obstruction continues to be open. You should also follow closely with the palliative care doctors. Followup Instructions: ___
10067821-DS-3	10,067,821	25,685,371	DS	3	2165-11-02 00:00:00	2165-11-02 11:04:00	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 a history of uncomplicated diverticulitis, Hep C presents to the ___ ER with a one day history of abdominal pain. Patient states the pain started at 2:30 in the morning as a dull ache. She continued to sleep and woke up at 10 and the pain was much more sharp and severe. The pain continued to worsen over the course of the day, therefore she made arrangements to be evaluated by her PCP. Her PCP ordered ___ CT scan which revealed complicated diverticulitis with a phlegmon in the LLQ. She was otherwise in her usual state of health prior to today, denies fever, chills, BRBPR or melena. She is passing flatus and has been having bowel movements with the help of organic supplements. Past Medical History: Past Medical History: Diverticulitis, Hepatitis C Past Surgical History: ___ Left knee arthroscopic partial lateral meniscectomy Social History: ___ Family History: Family History: No history of colon cancer, IBD Physical Exam: On Admission: Vitals: T 99.2 P 88 BP 124/83 RR 16 O2 100%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, nondistended, tenderness to minimal palpation in the LLQ with rebound and guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused On Discharge: T 98.6 98.6 64 126/78 18 100% RA Gen: A&Ox3, NAD Abd: soft, nondistended, barely any tenderness in LLQ, non-tender in all other quadrants Pertinent Results: ___ 09:45PM GLUCOSE-104* UREA N-12 CREAT-1.1 SODIUM-133 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 ___ 09:45PM WBC-10.8# RBC-5.34 HGB-12.0 HCT-39.3 MCV-74* MCH-22.5* MCHC-30.5* RDW-15.0 ___ 03:37PM WBC-9.7# RBC-5.69* HGB-12.6 HCT-42.7 MCV-75* MCH-22.2* MCHC-29.6* RDW-15.6* ___ 03:37PM PLT SMR-NORMAL PLT COUNT-237 CT A/P - Descending colon diverticulitis with adjacent pericolonic phlegmon Brief Hospital Course: ___ with a history of uncomplicated diverticulitis, Hep C presented to the ___ ER on ___ with a one day history of abdominal pain. Patient states the pain started at 2:30 in the morning as a dull ache. She continued to sleep and woke up at 10 and the pain was much more sharp and severe. The pain continued to worsen over the course of the day, therefore she made arrangements to be evaluated by her PCP. Her PCP ordered ___ CT scan which revealed complicated diverticulitis with a phlegmon in the LLQ. She was otherwise in her usual state of health prior to day of admission, denies fever, chills, BRBPR or melena. She is passing flatus and has been having bowel movements with the help of organic supplements. In the ED, she had very focal pain with no signs of gross contamination of the peritoneal cavity. She was admitted to the ___ service for conservative management with IV antibiotic, pain control, and serial abdominal exam. She was started on IV Flagyl 500mg q8h and Cipro 400mg BID. She remained hemodynamially stable on the floor. Her abdominal pain seemed to lessen greatly over the day of ___. Her only pain was minimal tenderness in the LLQ. Her urine outputs, vitals, and routine labs were recorded and remained within normal limits. The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. 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 received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. On ___, patient was feeling very well and looking forward to her regular diet. Patient tolderated po well and was d/c'ed home. Prophylaxis: Medications on Admission: MVI Iron Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours Disp #24 Tablet Refills:0 2. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #36 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Recurrent diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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, changes location, or moves 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 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. Followup Instructions: ___
10067859-DS-22	10,067,859	23,598,978	DS	22	2113-03-07 00:00:00	2113-03-09 16:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Symptomatic enlarging Abdominal Aortic Aneurysm with dissection flap Major Surgical or Invasive Procedure: ___: Endovascular Aortic Aneurysm Repair History of Present Illness: ___ is a ___ w/ hx of Crohn's disease and AAA who is presenting as a txf'r from ___ w/ 3day hx of LLQ pain radiating to back and found to have interval increase in size of AAA as well as dissection of the aneurysm. Per report, 4 mo ago a surveillance scan showed diameter to be 4.5 cm. He presented to his GI doctor who obtained a CT A/P, which showed AAA diameter to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had LLQ in the past that he associates w/ his Crohn's flares, but this pain is of a different quality. ROS is o/w -ve except as noted above. He was hypertensive at ___ and was started on an esmolol gtt. Past Medical History: Crohn's colitis AAA Appendectomy Social History: ___ Family History: No FMH of Crohns or UC, father with colon ca at age of ___ Physical Exam: Phys Ex: VS - 98.1 82 129/87 16 95% RA Gen - NAD CV - RRR, palpable b/l ___ & DP pulses Pulm - non-labored breathing, no resp distress Abd - obese, soft, nondistended, mild LLQ ttp w/ no guarding or rebound MSK & extremities/skin - no leg swelling observed b/l Pertinent Results: Pertinent Admission Labs: ___ 04:02PM BLOOD WBC-11.8* RBC-4.79# Hgb-13.4# Hct-40.8# MCV-85 MCH-28.0 MCHC-32.8 RDW-13.2 RDWSD-41.4 Plt ___ ___ 04:02PM BLOOD Neuts-81.3 Lymphs-11.2* Monos-6.7 Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.60# AbsLymp-1.32 AbsMono-0.79 AbsEos-0.00 AbsBaso-0.04 ___ 04:02PM BLOOD Plt ___ ___ 04:02PM BLOOD Glucose-121* UreaN-16 Creat-0.6 Na-139 K-4.4 Cl-101 HCO3-22 AnGap-16 ___ 04:02PM BLOOD ALT-12 AST-18 AlkPhos-58 TotBili-0.3 ___ 04:02PM BLOOD Lipase-42 ___ 04:02PM BLOOD cTropnT-<0.01 ___ 04:02PM BLOOD Albumin-4.0 ___ 04:10PM BLOOD Lactate-1.4 Pertinent Discharge Labs: ___ 05:46PM BLOOD Hct-36.9* ___ 04:24PM BLOOD Neuts-79.8* Lymphs-12.0* Monos-7.5 Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.74* AbsLymp-1.31 AbsMono-0.82* AbsEos-0.00* AbsBaso-0.03 ___ 04:24PM BLOOD Plt ___ ___ 03:13AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-139 K-3.8 Cl-102 HCO3-24 AnGap-13 ___ 04:24PM BLOOD ALT-13 AST-33 AlkPhos-55 TotBili-0.4 ___ 04:24PM BLOOD Lipase-46 ___ 10:10PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 03:13AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7 Imaging: FEMORAL VASCULAR US LEFT ___ IMPRESSION: Normal sonographic appearance of the groin, without evidence of hematoma, pseudoaneurysm, or AV fistula. Brief Hospital Course: ___ is a ___ w/ hx of Crohn's disease and AAA who is presenting as a txf'r from ___ w/ 3day hx of LLQ pain radiating to back and found to have interval increase in size of AAA as well as dissection of the aneurysm. Per report, 4 mo ago a surveillance scan showed diameter to be 4.5 cm. He presented to his GI doctor who obtained a CT A/P, which showed AAA diameter to be 5.8 cm w/ dissection flap in aneurysm. He notes he has had LLQ in the past that he associates w/ his Crohn's flares, but this pain is of a different quality. ROS is o/w -ve except as noted above. He was hypertensive at ___ and was started on an esmolol gtt. Patient was taken urgently to OR for EVAR procedure for symptomatic/dissected infrarenal AAA. For the details of the procedure, please see the surgeon's operative note. He received ___ antibiotics. He was admitted to the ___ on ___ post-operatively. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Post-operatively, he did well. He was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. Patient did have a little burning on urination that resolved spontaneously and some tenderness to his left groin incision site. Patient had a urinalysis sent and an ultrasound taken of his left groin. Both tests came back negative for any concerning findings. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions. He will follow up with Dr. ___ in 1 month with a CTA. Medications on Admission: -Humira -Prednisone 10 mg PO DAILY -Other medication unable to remember name ___: 1. ___ EC 81 mg PO DAILY RX aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:0 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #18 Capsule Refills:0 3. Simvastatin 20 mg PO QPM RX simvastatin 20 mg 1 tablet(s) by mouth QPM Disp #30 Tablet Refills:*0 4. Mesalamine 1000 mg PO QID 5. PredniSONE 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis/es 1. Dissected infrarenal abdominal aortic aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions MEDICATIONS: Take Aspirin 325mg (enteric coated) once daily Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT AT HOME: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: When you go home, you may walk and go up and down stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: ___ Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Followup Instructions: ___
10068304-DS-12	10,068,304	23,499,122	DS	12	2149-07-12 00:00:00	2149-07-17 21:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Naprosyn / Nsaids / Statins-Hmg-Coa Reductase Inhibitors / Niaspan Starter Pack / Lisinopril / Biaxin / Fosamax / adhesive tape / Bactrim / doxycycline / Ditropan / General Anesthesia / latex Attending: ___. Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: 1) EGD (___) 2) Colonoscopy (___) 3) Capsule endoscopy (___) History of Present Illness: ___ female with a past medical history notable for polycythemia ___, systolic heart failure s/p bioprosthetic mitral valve replacement in ___, recent hospitalization requiring ICU admission for GI bleed (___), who presented with 1 week of weakness. The patient additionally reports several episodes of dark stools over the past week. The patient was seen by her PCP earlier on the day of admission and found to be profoundly anemic and was sent to the ED for further evaluation. The patient also reported significant dyspnea on exertion, which had been steadily worsening. Despite her history of CHF, she had not been taking her home lasix for some time. She denied any fever/chills, chest pain, abdominal pain, and dysuria. Rectal exam showed guaiac positive stools. Of note, patient had been recently admitted from ___ for hematochezia. At that time, patient had a CTA abdomen/pelvis with and without contrast which showed "linear area of hyperdensity at level of right anus on arterial phase, best seen on the coronal views, which disseminates and enlarges on the delayed phases." Anoscopy showed thrombosed internal hemorrhoids. During that hospitalization, received 4 units pRBC and underwent banding of internal hemorrhoids by anoscopy--banded x 2 (left posterior and anterior midline). In the ED, initial VS were 96.4 116 104/52 16 100% RA. Exam notable for pallor and guaiac positive stool on rectal. She also had bilateral lower extremity edema. Labs showed hemoglobin/hematocrit of 6.3/19.7 Chest X-ray showed small bilateral pleural effusions and mild interstitial edema. Received pantoprazole gtt. Transfer VS were 99/4, 118, 98/49, 26, 99% on RA GI was consulted in the ED and followed the patient through initial hospital course. Past Medical History: Medical History: -sCHF (EF=25%) -Mitral Valve replacement ___ Mitral regurgitation and prolapse -GI bleed (?upper vs. lower) -Polycythemia ___ -Basal Cell Carcinoma s/p Mohs Surgery of right cheek in ___ -DCIS s/p lumpectomy & radiation -Hyperlipidemia -Hypertension -Hypothyroidism -Osteoarthritis -Squamous Cell Carcinoma -Urinary Tract Infections, recurrent -Varicose Veins s/p venous stripping b/L ___ Surgical History: -Lumpectomy for DCIS -___ surgery, right cheek (___) -Prolapsed bladder surgery, failed -Rotator cuff surgery (___) -Salpingo-oophorectomy for dermoid cyst in ___, right -Total abdominal hysterectomy w/ removal of left ovary (___) -Vein stripping bilateral legs Social History: ___ Family History: Positive for lung cancer in one sister. Another sister died of cardiac disease. Physical Exam: =================== ADMISSION PHYSICAL: ------------------- Vitals: 97.8, 99/69, 118, 24, 97% on RA. General: Elderly appearing, pale appearing female, laying in bed, dry cough. HEENT: Sclera anicteric, PERRL, EOMI, pale conjunctiva. Neck: Supple, elevated JVD. CV: Irregularly irregular rhythm, S1 and S2, prominent prosthetic sound in apex. Lungs: Minimal bibasilar crackles, no wheezes. Abdomen: soft, non-tender, non-distended, no rebound or guarding, normoactive bowel sounds. Ext: 1+ pitting edema in bilateral lower extremities. Varociose veins appreciated in bilateral lower extremities. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. =================== DISCHARGE PHYSICAL: ------------------- VS- Tm 98.6 Tc 98.6 HR 110-113 BP 110/69 RR ___ 02 97% RA ___ over last 8h Weight: 69.3kg (from 70.8kg standing on ___ General: Elderly female, NAD. Less pallid compared to admission. HEENT: MMM. PERRLA. EOMI. Neck: Supple, JVP not appreciated. CV: Irregular rhythm, not tachycardic. +S1/S2, prominent prosthetic sound in apex with ___ systolic murmur. Lungs: +Rales b/L in lower to mid lung fields. No wheezes, no rhonchi. Lung sounds diminished in right base. Abdomen: Soft, non-tender, non-distended, no rebound or guarding. Normoactive bowel sounds. Ext: Minimal edema in bilateral lower extremities. Varociose veins appreciated in bilateral lower extremities. ___ stockings. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. Pertinent Results: =============== ADMISSION LABS: --------------- ___ 01:55PM BLOOD WBC-8.3# RBC-1.95* Hgb-6.3* Hct-19.7* MCV-101* MCH-32.3* MCHC-32.0 RDW-19.9* RDWSD-70.1* Plt ___ ___ 01:55PM BLOOD Neuts-75* Bands-2 Lymphs-15* Monos-2* Eos-0 Baso-3* Atyps-1* Metas-2* Myelos-0 AbsNeut-6.39* AbsLymp-1.33 AbsMono-0.17* AbsEos-0.00* AbsBaso-0.25* ___ 01:55PM BLOOD UreaN-28* Creat-0.8 Na-135 K-5.0 Cl-101 HCO3-23 AnGap-16 ___ 01:55PM BLOOD ALT-10 AST-13 AlkPhos-117* TotBili-0.4 DirBili-0.2 IndBili-0.2 ___ 01:55PM BLOOD TotProt-7.2 Albumin-3.9 Globuln-3.3 Calcium-9.0 Phos-4.3 Mg-2.6 =============== KEY LABS: --------------- ___ 05:25PM BLOOD WBC-7.2 RBC-1.85* Hgb-6.1* Hct-18.7* MCV-101* MCH-33.0* MCHC-32.6 RDW-20.1* RDWSD-68.9* Plt ___ ___ 07:00AM BLOOD ___ PTT-28.3 ___ ___ 07:00AM BLOOD Glucose-104* UreaN-22* Creat-1.0 Na-139 K-3.7 Cl-104 HCO3-19* AnGap-20 ___ 06:40AM BLOOD Glucose-107* UreaN-17 Creat-1.0 Na-137 K-4.4 Cl-105 HCO3-21* AnGap-15 =============== DISCHARGE LABS: --------------- ___ 07:00AM BLOOD WBC-5.9 RBC-2.62* Hgb-8.1* Hct-25.2* MCV-96 MCH-30.9 MCHC-32.1 RDW-17.6* RDWSD-59.0* Plt ___ ___ 07:00AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-139 K-4.2 Cl-102 HCO3-27 AnGap-14 ___ 07:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.3 =============== IMAGING: --------------- ___ CHEST XR: IMPRESSION: 1. Small bilateral pleural effusions with bibasilar atelectasis. 2. Mild interstitial pulmonary edema. ___ CHEST XR: IMPRESSION: Heart size and mediastinum are stable including cardiomegaly. Mild vascular enlargement is demonstrated but no overt pulmonary edema is seen. Bilateral pleural effusions are most likely present, small to moderate. ___ CHEST XR: IMPRESSION: In comparison with the study of ___, there is continued enlargement of the cardiac silhouette with only minimal elevation of pulmonary venous pressure that is unchanged from previous studies. No acute focal pneumonia. Brief Hospital Course: ___ female with history of polycythemia ___, systolic CHF complicated by mitral regurgitation and mitral valve prolapse now s/p recent mitral valve replacement in ___, as well as recent admission & ICU stay for GI bleed presented with weakness and dyspnea x1 week with dark, guaiac positive stools. Found to be profoundly anemic in ED and tranfused 2U PRBC, then transfused a third unit on ___. After transfusions, patient's anemia was improved and she had no active bleeding during hospitalization. She was also treated for volume overload in the setting of acute on chronic congestive heart failure. ============================ ACTIVE ISSUES: # GI bleed: GI bleeding most likely cause of patient's significant anemia. No signs of active bleeding since admission. Recently discharged from admission for hematochezia, felt secondary to hemorrhoids, s/p banding during that hospitalization. Initially believed likely upper GI source on this admission due to presence of melanic stool, but EGD was unrevealing. Colonoscopy showed diverticulosis and large internal hemorrhoids s/p banding but no active bleed. Capsule study was incomplete as capsule never left the stomach; this will have to be repeated as outpatient. Hemodynamically stable and good response to transfusions. Patient to follow up with GI after discharge for discussion of further workup and long term managament. # Systolic Heart Failure: Patient's most recent echocardiogram was 25% in ___. Patient currently experiencing dyspnea. During prior hospitalization, she became volume overloaded requiring diuresis in setting of receiving blood products. Goal to diurese to dry weight per last discharge. Discharged at 69.3 kg with maintenance dose of lasix 40mg PO BID. Restarted long-acting metoprolol succinate 50mg qd (compared to BID home dose). # Dyspnea: Likely multifactorial, with anemia vs. CHF. Subjectively improved after transfusion (each unit fullowed by lasix). Dyspnea, especially paroxysmal nocturnal dyspena, responded well to diuresis. O2 sats were satisfactory and stable on room air. Noted some rales at bases (L>R) even after extensive diuresis. No history of pulmonary disease. # ST Depressions on EKG: Patient had ST depressions V5, V6 at admission. ___ be secondary to stress-induced ischemia in the setting of anemia. Troponin drawn next morning was <0.01. # Prior History of UTI: During prior hospitalization diagnosed with E. coli urinary tract infection. treated with ciprofloxacin. Patient not endorsing dysuria. Patient has history of yeast infections following treamtents for UTI's. Repeat UA negative. Finished course of Monistat 7 (end date ___ which she takes for yeast infections/dysuria at home. #Hyperkalemia: Resolved. Down to 4.5 from 5.3 on admission. No EKG changes. Was not a significant issue over hospitalization. CHRONIC ISSUES ============== # Polycythemia ___: During prior hospitalization, hydrodyxurea was held in setting of anemia. Communicated with Dr. ___ & fellow who agreed that patient will be left off hydroxyurea until she can be reassessed at her next hematology appointment. # Hypothyroidism: Continued levothyroxine 75 mcg PO daily. # Concern for Arterial-middle hepatic vein fistula: CTA during prior hospitalization concerning for arterial to middle hepatic vein fistula, likely due to hepatic congestive disease. LFTs were otherwise unremarkable. The patient will need further workup and surveillance imaging for this incidental finding. ====================== TRANSITIONAL ISSUES: # Patient was started on furosemide 40mg PO BID. Please check Chem 10 and CBC at PCP ___ appointment. # Patient's metoprolol succinate was consolidated to 50mg daily (from 25mg BID) # Consider starting ACE inhibitor ___ given heart failure with reduced EF, if her BP can tolerate # Patient must follow up with GI to discuss repeating capsule study as an attempt to identify another source of bleeding. NB: Unclear if capsule has left stomach since ingestion or if it is still retained and will require removal. # ___ heterogeneously enhancing liver, with a probable arterial to middle hepatic vein fistula, and splenomegaly, which was incidentally found on an imaging study at her prior hospitalization in ___. # Patient to hold on restarting hydroxyurea until ___ with her hematologist, Dr. ___. Hematology office visit has been scheduled for ___ and Dr. ___ his fellows are aware of this. Dr. ___ was in touch with the inpatient team via email. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H:PRN pain/temp 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Metoprolol Succinate XL 25 mg PO BID 5. Ranitidine 150 mg PO BID 6. Aspirin EC 81 mg PO DAILY 7. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain/temp 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. Furosemide 40 mg PO BID RX furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ---------------- # GI BLEED # Acute anemia # Acute on chronic systolic congestive heart failure SECONDARY: ---------------- # Polycythemia ___ ___ Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Thank you for choosing to get your care at ___! You were admitted with anemia ("low blood counts") and dark stools, which were concerning for GI bleeding. The GI specialists were consulted and perfermed endoscopic studies including an EGD and a colonoscopy. Your EGD was unrevealing, and the colonoscopy showed some possible sources of bleeding but no active bleeds. A capsule study was performed but was incomplete because the capsule never left your stomach. This test can be performed again outside the hospital. You have a scheduled ___ appointment with the GI doctors to discuss this further. During your hospitalization, you were found to be having some problems with the amount of water in your body because of your Congestive Heart Failure (CHF). This had caused some problems with your breathing as is typical for this condition. You were treated with diuretics to remove the extra water. As we did this, your breathing was better and your kidney function improved. You will be discharged on a new dose of the diuretic furosemide. You should follow up with your cardiologist as an outpatient to make sure this is the right dose for you. In the meantime, you should weigh yourself every morning and call your doctor if weight goes up more than 3 lbs. Also let your doctor know if you are having difficulty breathing, especially when you are lying down or in the middle of the night. You were not treated for your polycythemia ___ during this hospitalization because your blood counts were low and Dr. ___ ___ already been holding your hydroxyurea. You have a follow up appointment with your hematologists scheduled, at which point you can discuss this further. We wish you the best of future health! Sincerely, Your ___ care team Followup Instructions: ___
10068741-DS-20	10,068,741	22,137,833	DS	20	2156-01-08 00:00:00	2156-01-08 19:49:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath and weight gain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ woman with hypertension, chronic atrial fibrillation, mildly dilated ascending aorta and aortic arch, valvular heart disease, who presented with dyspnea for 1 week. The patient lives alone, and has her son intermittently check on her. She has been intermittently noncompliant with home medications, including furosemide. She herself reports poor compliance over the preceding few days and complains of bilateral lower extremity edema, dyspnea and lower back pain. Of note, she recently returned from a trip to ___. She denied any recent fevers, chills, or productive cough. She does have a non-productive cough. During this trip, she ate out at many restaurants while in ___ for 3 weeks. Her son also adds that she drinks a lot of water at home. In the ED, initial VS were: pain ___, T 97, HR 140, BP 148/111, R 24, SpO2 100%/NC. Discussion with translator was difficult, as patient speaks a rural dialect of ___, per her son. - On arrival, she was in AF with RVR, which responded well to IV diltiazem and diuresis. - Labs were significant for pro-BNP 7933, AST/ALT 55/33, ALP 45, total bilirubin 1.3, Na 138, K 3.6, Cr 1.1, Phos 4.9, lactate initially 3.1, though trended down to 1.9 post diuresis, WBC 8.2, INR 1.2 - CXR showed right middle lobe opacity obscuring the right heart border concerning for collapse/consolidation and marked cardiomegaly without overt edema. - Given ASA 324, nitroglycerin SL, furosemide 40 mg IV, diltiazem 10 mg IV - She had 1.3 L urine output to the 40 mg IV furosemide dose On arrival to the floor, patient reports no complaints. Past Medical History: - Chronic diastolic heart failure - Hypertension - Atrial fibrillation, CHADS-Vasc 4, on dabigatran - Mildly dilated ascending aorta (4 cm) and aortic notch (3.2 cm) - Valvular heart disease, characterized by ___ MR & 2+ TR Social History: ___ Family History: no known family history of cardiac disease Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VITALS: T 98, BP 137/105, HR 109, R 20, Spo2 100%/2L NC, admission weight 53.8 kg, UOP 170 cc (after 1.3L emptied in ED, after 40 mg IV furosemide) GENERAL: mildly uncomfortable appearing, pleasant, laying in bed at 30 degree angle HEENT: PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK: prominent, yet reducible bulge noted on the lower R aspect of the neck (likely large distension of the EJV), with JVP visible above the ear lobe CARDIAC: irregular, normal S1 & S2 without murmurs PULMONARY: crackles bilaterally, up to half way up lung fields ABDOMEN: soft, tender in RUQ, though negative ___ sign, hepatomegaly, no splenomegaly, normal bowel sounds EXTREMITIES: 3+ pitting edema to the knee, all extremities warm, DP pulses 2+ bilaterally NEURO: alert & oriented to name, month/year, hospital, ___ - face symmetric, tongue protrudes midline, palate elevates midline, moves all extremities well DISCHARGE PHYSICAL EXAM: ========================= VITALS: 97.7 108/72 (99-118/68-78) 74 (70-130s) 18 94% RA Wt: 45.0<--45.3<--45.8<--45.7<--46.8<--47.7<-48.2<--49.2<--admission weight 53.8 kg I/O: 180/500; ___ GENERAL: Sitting comfortably in bed, N.C in place, NAD HEENT: PERRL, EOMI, sclerae anicteric, MMM NECK: Supple, JVP mild elevated 8 cm CARDIAC: irregularly irregular, normal S1 & S2 without murmurs PULMONARY: poor inspiratory effort, CTAB, no wheezes ABDOMEN: soft, ND, NTTP, +BS EXTREMITIES: trace edema to the mid-shin, all extremities warm, DP pulses 2+ bilaterally NEURO: CN II-XII grossly intact, moving all extremities with purpose, non-focal exam Pertinent Results: ADMISSION LABS: ================ ___ 11:15PM BLOOD WBC-8.2# RBC-5.21* Hgb-16.0* Hct-48.4* MCV-93 MCH-30.7 MCHC-33.1 RDW-15.8* RDWSD-52.3* Plt ___ ___ 11:15PM BLOOD Neuts-78.4* Lymphs-13.9* Monos-6.7 Eos-0.1* Baso-0.4 Im ___ AbsNeut-6.44* AbsLymp-1.14* AbsMono-0.55 AbsEos-0.01* AbsBaso-0.03 ___ 11:15PM BLOOD ___ PTT-33.3 ___ ___ 11:15PM BLOOD Glucose-203* UreaN-25* Creat-1.2* Na-131* K-GREATER TH Cl-100 HCO3-21* ___ 11:15PM BLOOD ALT-46* AST-171* AlkPhos-33* TotBili-1.5 ___ 11:15PM BLOOD proBNP-7933* ___ 11:15PM BLOOD cTropnT-0.04* ___ 11:15PM BLOOD Albumin-4.3 Calcium-8.7 Phos-5.7* Mg-2.4 Troponin Trend: ================ ___ 03:30AM BLOOD cTropnT-0.05* proBNP-6574* ___ 02:35AM BLOOD CK-MB-4 cTropnT-0.05* ___ 08:40AM BLOOD cTropnT-0.04* Lactate Trend: ================= ___ 11:24PM BLOOD Lactate-4.9* K-8.5* ___ 01:05AM BLOOD Lactate-3.1* ___ 03:37AM BLOOD Lactate-1.9 ___ 02:40AM BLOOD Lactate-3.1* ___ 11:08AM BLOOD Lactate-2.5* ___ 05:07PM BLOOD Lactate-2.9* ___ 08:16AM BLOOD Lactate-2.2* Other Pertinent Labs: ======================= ___ 12:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE ___ 12:45AM BLOOD HCV Ab-NEGATIVE Micro: ======= ___ 10:22 am URINE Source: Catheter. *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Imaging: ========= ___ CXR Right middle lobe opacity obscuring the right heart border concerning for collapse/consolidation and marked cardiomegaly without overt edema. TTE ___: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation.] The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is mildly increased. [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 to moderate sized circumferential pericardial effusion without evidence of hemodynamic compromise. IMPRESSION: Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. Pulmonary artery hypertension. Mild-moderate aortic regurgitation. Right ventricular cavity dilation with preserved free wall motion. Dilated ascending aorta. Compared with the prior study (images reviewed) of ___, the severity of mitral regurgitation has increased and the pericardial effusion is slightly smaller. The estimated PA systolic pressure is now slightly lower. RUQ U/S ___: 1. No focal liver lesion identified. Hepatopetal flow in the main portal vein which is noted to be hyperdynamic which can be seen in the setting of CHF. 2. Small bilateral pleural effusions and scant trace of ascites in the abdomen. 3. Small nonobstructing stone incidentally noted in the right kidney. DISCHARGE LABS: ================ ___ 05:56AM BLOOD WBC-8.8 RBC-4.65 Hgb-14.3 Hct-42.9 MCV-92 MCH-30.8 MCHC-33.3 RDW-15.1 RDWSD-50.0 Plt ___ ___ 05:56AM BLOOD Plt ___ ___ 05:56AM BLOOD ___ PTT-35.7 ___ ___ 05:56AM BLOOD Glucose-81 UreaN-29* Creat-0.7 Na-143 K-3.5 Cl-97 HCO3-37* AnGap-13 ___ 05:56AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1 MICRO: ====== Urine Culture x 2: No growth. Blood Culture x 2: NGTD (___) Brief Hospital Course: Ms. ___ is an ___ year old female with PMH chronic atrial fibrillation, hypertension and diastolic heart failure who presented with dyspnea and worsening lower extremity edema consistent with an acute on chronic exacerbation of CHF in the setting of dietary and medication non-compliance. Upon admission, BNP 6574 and troponin trend 0.05, 0.05, 0.04. EKG notable for atrial fibrillation, but no evidence of active ischemia. Repeat TTE showed LVEF >55% with mod-severe MR, mod-severe TR, PA HTN and dilated RV. She was successfully diuresed with lasix 40mg IV daily to BID which was later transitioned to 20 mg PO daily (her home dose) Of note, the patient has chronic atrial fibrillation. During her hospital stay, her dabigatran was changed to apixaban due to a more favorable safety profile. In addition her metoprolol was increased to 100mg BID and diltiazem ER 120 mg was added for rate control. She felt well on the day of discharge. # ACUTE ON CHRONIC DIASTOLIC HEART FAILURE. The patient presented with a one week history of worsening shortness of breath and lower extremity edema consistent with an acute exacerbation of her dCHF in the setting of dietary and medication non-compliance. Of note, the patient was recently in ___ where she was eating out a lot, drinking lots of water, and not taking her medications as prescribed. When she returned to the ___, her dyspnea and ___ worsened at which point she presented to the hospital. Upon admission, BNP eleavted to ___ with CXR showing e/o pulmonary edema. Troponins flat at 0.05, 0.05 and 0.04 and EKG negative for evidence of acute ischemia. TTE showed preserved LVEF >55% with mod-severe MR, TR and pulmonary hypertension. Nutrition saw the patient and outlined a low sodium diet for the patient and her family and the importance of dietary and medication compliance was emphasized. She was successfully diuresed with lasix 40mg IV once to twice daily with close monitoring of her daily weights and I/O's. She was transitioned to lasix 20 mg PO upon discharge. In addition, lisinopril 15mg daily was added and her metop was uptitrated to 100mg BID. Discharge weight: 45 kg (99 lbs) # ATRIAL FIBRILLATION CHADs-vasc 6. The patient has a history of chronic atrial fibrillation initially on dabigatran and metoprolol for rate control. Upon presentation, the she was noted to be in Afib with RVR with rates in the 140s which responded well to diltiazem 10mg IV. Throughout her hospital stay, the patient's metoprolol was up-titrated to 100mg BID and diltiazem ER 120 was added for better rate control. In addition, her dabigatran was changed to apixaban 2.5mg BID for anticoagulation given the more favorable safety profile. She is on low dose due to her age > ___ and her weight < 60 kgs. # ELEVATED TRANSAMINASES. The patient's LFTs were elevated upon admission in the setting of recent travel abroad and acute dCHF exacerbation. RUQ ultrasound unremarkable and hepatitis serologies negative. Likely congestive hepatopathy from acute on chronic diastolic heart failure and her LFTs downtrended with diuresis. # HYPERTENSION. The patient was admitted with diastolic BP >100 in the setting of medication non-compliance. Her pressures normalized with the initiation of lisinopril 15mg daily and diltiazem ER 120 daily. Her metoprolol was up-titrated to 100mg BID. # ?UTI: UA upon admission concerning for urinary tract infection. She was initiated on ceftriaxone which was later discontinued on ___ when urine culture returned negative. Transitional Issues: ===================== -Patient speaks a rural dialect of ___ only -Continued home dose Lasix 20 mg after adequate diuresis. -Increased metoprolol to 100mg XL BID and added Diltiazem 120 mg ER for better rate control -Started lisinopril 15mg daily -Changed dabigatran to apixaban 2.5mg BID for anticoagulation given more favorable safety profile (reason for reduced [2.5mg] dosing is due to age > ___ and weight less than 60kg) -Discharge weight: 45.0 kg (99 lbs) -Code: Full -Contact: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:3 2. Metoprolol Succinate XL 100 mg PO Q12H RX metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 3. Apixaban 2.5 mg PO BID RX apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 4. Diltiazem Extended-Release 120 mg PO DAILY RX diltiazem HCl [Cardizem CD] 120 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:3 5. Lisinopril 15 mg PO DAILY RX lisinopril 30 mg 0.5 (One half) tablet(s) by mouth once a day Disp #15 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on Chronic Diastolic Congestive Heart Failure, Atrial Fibrillation Secondary: 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: Dear Ms. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted for the shortness of breath and weight gain you were experiencing. Your symptoms were due to an exacerbation of your congestive heart failure. Throughout your hospital stay, you were given medication to help remove the extra fluid from your body. In addition, you were placed on a different blood thinner, called apixaban for your atrial fibrillation. To help control your fast heart rate, we have increased your metoprolol to 100mg twice daily and added a new medication called diltiazem. It is very important to take your water pill, or lasix, and heart medications everyday to help prevent fluid from building back up in your body. In addition, eating a diet that is low in salt and limiting your fluid intake to 2L per day will also help prevent your symptoms from recurring. Please weigh yourself everyday and call the doctor if you gain >3 lbs. Best Wishes, Your ___ Team Followup Instructions: ___
10069692-DS-15	10,069,692	25,846,597	DS	15	2148-06-01 00:00:00	2148-05-31 09:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right Hip Pain Major Surgical or Invasive Procedure: R hip hemiarthroplasty ___, ___. History of Present Illness: ___ with no significant PMH p/w displaced right femoral neck fracture after an unwitnessed mechanical fall at home. The patient is ___ speaking and the history was obtained from her daughter. The patient states that she was getting up to go the bathroom this morning around 6 AM when she fell. She cannot recall all of the details about the fall but does not think she lost consciousness. Her daughter heard a thud from the other room, and found her on the floor, conscious. Patient denies HS/LOC. CT head/Cspine negative in ___ ED. Isolated injury. The patient lived independently in an apartment in ___ until 2 weeks ago. She can walk 2 flights of stairs slowly without shortness of breath according to the patient and her daughter. She recently moved in with her daughter due to frequent falls with plans to move to an assisted living facility on ___. According to her daughter she has fallen between 6 and 8 times since ___. She has seen her PCP for this problem, most recently 1 week ago. She is partially blind in the right eye which is believed to contribute to her falls. She ambulates with a cane at baseline. No medications on a daily basis. Past Medical History: None Social History: ___ Family History: NC Physical Exam: On admission General: Well-appearing female in no acute distress. C-spine: No midline tenderness to palpation Able to rotate head 45 degrees left and right Right lower extremity: - skin intact, leg ___ - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM at hip, knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP On discharge General: Frail-appearing, breathing comfortably CV: Pink and well perfused Abd: Soft, non-tender, and non-distended Lower Extremity: Skin clean & intact; dressing c/d/i No deformity or ecchymosis Unable to examine due to non-cooperation due to dementia Toes warm & well perfused Pertinent Results: ___ 05:05AM BLOOD WBC-6.4 RBC-2.28* Hgb-7.4* Hct-22.8* MCV-100* MCH-32.5* MCHC-32.5 RDW-14.6 RDWSD-52.9* Plt ___ ___ 05:05AM BLOOD Glucose-112* UreaN-37* Creat-1.2* Na-140 K-4.2 Cl-106 HCO3-23 AnGap-11 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hip hemiarthroplasty, 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. On POD1, the patient was found to have a bump in her Creatinine. This resolved with improved hydration via increased PO intake and IV fluids. 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 weight bearing as tolerated 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. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID RX heparin (porcine) 5,000 unit/mL 5000 units SQ twice a day Disp #56 Vial Refills:0 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 2.5-5 mg by mouth every four (4) hours PRN Disp #15 Tablet Refills:0 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID 8. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right femoral neck fracture Discharge Condition: Mental Status: Alert but demented at baseline. Level of Consciousness: Minimally 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: -Weightbearing as tolerated; Range of motion as tolerated 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 subcutaneous heparin daily for 4 weeks WOUND CARE: - You may shower. Please keep the wound clean and dry. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please cover the incision with a dry dressing and change it daily. If there is no drainage from the wound, you can leave the incision open to the iar. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing; range of motion as tolerated Encourage turn, cough and deep breathe q2h when awake; Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Call your surgeon's office with any questions. Followup Instructions: ___
10069871-DS-20	10,069,871	26,257,265	DS	20	2148-06-27 00:00:00	2148-06-27 15:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Zithromax / Zofran Attending: ___. Chief Complaint: SOB and chest pain, here for ___ opinion surgical evaluation Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o opioid use disorder w/history of injection drug use, currently in remission since ___, with complex history of TV endocarditis, presenting with c/o chest pain, SOB (?fever) 2 days after leaving ___, where she was being treated for recurrent TV endocarditis. Her history is as follows, though some of the timelines are somewhat unclear: In ___, she was admitted to ___ with MSSA bacteremia, TV endocarditis, R hip septic arthritis. Treated with antibiotics (unclear what specifically), washout of the R hip, and ultimately TV bioprosthetic valve replacement in ___. She was subsequently discharged off antibiotics, and reports that about 1.5 weeks later, she began to have fevers, nausea, SOB, chest pain. She may have had another ___ admission after that, but the records are unclear to that point, and indicate that she did get admitted to ___ on ___ with these complaints, and was found to have MSSA and Strep mitis bacteremia and vegetation on the prosthetic valve. She was presumably treated with antibiotics at ___ for an unclear amount of time, then was transferred to ___, where treatment was continued apparently with vanc/gent/rifampin, until she left on ___ and presented to ___. At ___, she was started on cefazolin on ___ based on the MSSA from ___ gent was given for the first two weeks, and RIF was started ___. She had multiple TTE's (details below) showing TV vegetations, as well as a TEE which was not complete due to severe desat during the procedure, but also showed a complex of vegetation at the TV/RA. Subsequent TTEs over time showed decreasing size of the veg; she also was shown to have a PFO. She had a CT chest on ___ which showed multiple pulmonary emboli, ?septic. She left ___ on ___ due to concerns over behavioral issues. She was discharged with Bactrim, rifampin and Augmentin, which she did take. However, on the day of presentation here (___), she suffered a fall and hit her head, was feeling very weak, nauseated, and with significant pleuritic chest pain and shortness of breath. She states that she would like to continue antibiotics longer to "give me a better chance." At ___, she was seen by cardiothoracic surgery, who recommended no surgical intervention until she could show 6 months free of IV drug use. Her prior CT surgeon at ___ was contacted as well. In the ED here, CT chest showed several foci of peripheral parenchymal opacities in the RLL and LLL, with subtle lucent focus adjacent to the RLL consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli. She was initially given a dose of vanco and cipro, but these were stopped on admission to the floor and she was started on Bactrim, augmentin and rifampin. Blood cultures were drawn and have been negative to date. She has had no fevers. Today she reports ongoing nausea and pleuritic chest pain. Past Medical History: Tricuspid valve endocarditis s/p bioprosthetic valve c/b reinfection Opiate use disorder Hepatitis C Right hip septic arthritis s/p wash out Social History: Obtained a GED after dropping out of ___ grade. Went to ___ school. Did hair, makeup and nails. Got married, had 5 kids ___ years old). Got into an unfortunate car accident ___, was prescribed high doses of opioids which started her addiction, switched to IV heroin (reports shes been on IV heroin for only ___ years). Left the 5 kids in ___ with mother in law and moved to ___ to care for her sister in law who suffers from mental illness and to start a new life with her husband. Got sick in ___ with IE with complicated hospital stay. Has been sober since. Was on suboxone, no longer on it. Husband started opioids because wife was on it, has been clean as well for 7 months and currently on suboxone. Both are homeless and she has her luggage with her, prior to this they were living with the sister in law, currently sleeping in parks and shelters, surviving off of food stamps, pan handling. No longer does things for money anymore, did not want to go into detail about what things she use to do. Husband just a new job installing alarm systems in home. Of note, patient has been taking 9 tabs of 2mg hydromorphone a day (about 4mg q6H) buying off the streets. smoker ___ pack since ___, food stamps, money through panhandling and husband just got a job. No drinking, IVDU since ___ Mother was a drug addict- cocaine Brother- poly substance Father- prison for life Family History: maternal grandmother- suicidal, mental illness, strokes paternal grandparents: died, unclear cause Whole family is drug addicts. The rest she is not sure about. Physical Exam: ADMISSION PHYSICAL: VITALS:98.8 PO 137 / 90 L Lying 75 20 100 Ra Wt 81kg, 178lb ___: Alert, oriented, no acute distress, tearfull, itchy HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP 11cm, poor dentition CARDIOVASCULAR: Regular rate and rhythm, tachycardic, normal S1 + S2 with splitting of s2, unable to characterize it due to tachycardia, no murmurs, rubs, gallops LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi, decreased at right base more than left ABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Excoriations and track marks throughout body, most prominent in upper and lower extremity NEURO: Face grossly symmetric. Moving all limbs with purpose against gravity. Pupils equal and reactive, no dysarthria. DISCHARGE EXAM: Vitals: T max 98.1, BP 102/70, HR 64, RR 16, O2 97% RA ___: 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, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 11:30AM BLOOD WBC-8.3 RBC-4.14 Hgb-9.8# Hct-33.9 MCV-82 MCH-23.7* MCHC-28.9* RDW-23.3* RDWSD-69.5* Plt ___ ___ 11:30AM BLOOD Neuts-78.1* Lymphs-15.6* Monos-4.0* Eos-1.3 Baso-0.5 Im ___ AbsNeut-6.44* AbsLymp-1.29 AbsMono-0.33 AbsEos-0.11 AbsBaso-0.04 ___ 11:30AM BLOOD ___ PTT-31.3 ___ ___ 11:30AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-142 K-4.8 Cl-103 HCO3-21* AnGap-18* ___ 11:30AM BLOOD proBNP-1285* ___ 11:30AM BLOOD D-Dimer-1792* DISCHARGE LABS: ___ 06:25AM BLOOD WBC-3.0* RBC-3.71* Hgb-8.9* Hct-31.0* MCV-84 MCH-24.0* MCHC-28.7* RDW-22.6* RDWSD-69.7* Plt Ct-92* ___ 06:25AM BLOOD Glucose-81 UreaN-30* Creat-0.8 Na-137 K-4.7 Cl-103 HCO3-20* AnGap-14 ___ 06:25AM BLOOD Calcium-9.1 Phos-5.4* Mg-1.7 IMAGING: CTA CHEST (___): 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Several foci of peripheral parenchymal opacities are noted in the right lower lobe and left lower lobe, with subtle lucent focus adjacent to the right lower lobe consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli, though nonspecific infectious or inflammatory conditions remain differential possibilities. 3. Patient is status post tricuspid valve replacement. ECHO (___): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. A bioprosthetic tricuspid valve is present. The gradients are higher than expected for this type of prosthesis. There is a moderate to large-sized (at least 1 x 1.2) vegetation on the tricuspid prosthesis, with partial destruction of the prosthetic leaflets. There is no evidence of annular abscess. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Prosthetic tricuspid valve endocarditis. Moderate to severe prosthetic tricuspid regurgitation. Normal biventricular systolic function. No vegetations seen on the other valves. Brief Hospital Course: ___ y/o F w/ h/o IVDU, hepatitis C, infective endocarditis c/b R hip septic arthritis s/p washout and s/p TV replacement (stented bioprosthetic Epic; ___ at ___ c/b reinfection of new bioprosthetic valve who presented with pleuritic chest pain and SOB 2 days after leaving AMA from ___, where she was being treated for recurrent TV endocarditis. She presented to ___ with hopes of being evaluated for candidacy for a TV replacement. During this hospitalization, we obtained a CTA and Echo to evaluate possibly worsening pulmonary emboli or worsening tricuspid vegetations compared to her findings at ___. We determined that both the emboli and vegetations were stable, and determined that she completed an appropriate antibiotic course and no longer needs further antibiotic suppression. Our CT surgery team agreed with the operative plan established at ___ by Dr. ___ (6 months of abstinence from drugs prior to re-evaluation for TV replacement). She was discharged with plans to follow-up with primary care and CT surgery at ___, and with plans to follow-up with a ___ clinic. A more detailed hospital course by problem is outlined below: #MSSA prosthetic tricuspid valve endocarditis: She was recently managed at ___ (left AMA on ___ w/ IV cefazolin/gent (day 1: ___ and rifampin (day 1: ___ with a plan to continue to ___, but since she left AMA she was transitioned to PO meds Augmentin 875 mg BID, Rifampin 300 mg BID, Bactrim 800-160 mg BID, which she did not continue as o/p. Her BCx showed no growth during her entire ___ hospitalization. Dr. ___ surgeon at ___, had agreed to re-evaluate her for a possible TVR in 6 months if the patient remains clean (___). At ___, her BCx continued to show no growth. We obtained a TTE at ___ to evaluate possible progression of endocarditis, and consulted our CT surgery team to see if they would provide a different operative plan from their ___ colleagues. We initially continued Ms. ___ on bactrim, rifampin, and augmentin, then transitioned her to IV cefazolin before stopping all abx at discharge once conferring with our CT surgery team and confirming that pt will follow-up at ___ for a possible future surgery. #Chest pain ___ septic emboli: A CT PE on ___ at ___ showed evolving pulmonary infarcts and pulmonary arterial filling defects. At ___, there was no evidence of thrombotic PE on CTA (___). She had not been managed with any anticoagulation at ___, and we did not initiate anticoagulation here. Her pain was managed with methadone 20mg TID and Ketorolac. #Syncope: There is no clear proximate cause of pt's reported syncope, and it's unclear whether she even syncopized given that her initial story prior to admission is inconsistent with the ___ record. Orthostatics on ___ were negative. #Asymptomatic bacteriuria: ED urine cultures were shown to grow Enterobacter Aerogenes. However, since she has been asymptomatic we decided not to provide abx. #Opioid abuse: Although the patient claims to be clean since ___, track marks on her arms and the history from ___ suggest more recent use. We continued treatment with 20mg methadone TID and transitioned her 30mg BID, ultimately to be on 60mg daily. She was referred to a ___ clinic for follow-up. Her QTc on ___ on a stable amount of methadone was 462. TRANSITIONAL ISSUES: # CODE: Full # CONTACT: Husband, ___ - does not have a phone [ ] MEDICATION CHANGES: - Added: Methadone 60mg PO daily, metoprolol succinate 25mg daily, ASA 81mg daily - Stopped: PO hydromorphone, metoprolol tartrate [ ] METHADONE TREATMENT: - Pt will be followed by the Habit ___ clinic on ___. She will have her next-day dosing on ___. - Her last dose of methadone was 60mg PO. It was given at 0952 on ___. - QTc on ___ was 426 by ECG. [ ] ENDOCARDITIS FOLLOW-UP: - Pt has a follow-up appointment scheduled with Dr. ___ at ___ on ___. A discharge summary will be sent to his office in anticipation of this appointment. - Pt needs close follow-up to ensure adherence to methadone treatment and abstinence from drug use, required 6mo of being clean in order to be evaluated again by ___ CT Surgery (last evaluated ___ next surgical consideration may be ___. - Per previous discharge planning from ___, Pt does not need anticoagulation for her sterile pulmonary emboli. - Per discussions with their team: Pt will be evaluated for a revision of the tricuspid valve after a 6-month period of sobriety. She does not require suppressive antibiotics during this time. [ ] DISCHARGE PLANNING: - Pt provided with resources for shelters at discharge. She is going to be discharged into the care of her sister-in-law for the afternoon/evening of ___. - Her husband ___ lives at the ___, where she can stay in a separate wing of the facility. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate Dose is Unknown PO Frequency is Unknown 2. Aspirin 81 mg PO DAILY 3. FLUoxetine 20 mg PO BID 4. HYDROmorphone (Dilaudid) ___ mg PO ___ PRN Pain - Moderate Discharge Medications: 1. Methadone 60 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 3. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 4. FLUoxetine 20 mg PO BID RX fluoxetine 20 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Tricuspid valve endocarditis complicated by septic emboli SECONDARY DIAGNOSES: Septic pulmonary emboli, improved Asymptomatic bacteriuria Opioid use disorder 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 ___. WHY WERE YOU ADMITTED? You were admitted for evaluation and management of chest pain, shortness of breath, and an episode of losing consciousness, in addition to wanting to receive another opinion on management of your tricuspid valve endocarditis. WHAT DID WE DO FOR YOU? - To manage your endocarditis, we continued the antibiotics (Augmentin, Rifampin, and Bactrim) that you had left ___ with. We then switched you to intravenous Cefazolin after speaking with our infectious disease team. Our infectious disease team determined that you had completed your antibiotic course, and did not need other antibiotics at home. - We managed your chest pain with an IV anti-inflammatory drug, and then continued you on methadone to manage both pain and your previous opioid use. You were discharged on a dose of 60mg once daily. The last dose of your methadone was given at 9:52AM on ___. - We obtained an echo image of your heart to evaluate whether surgery (tricuspid valve replacement) would be appropriate at this point. Our cardiac surgery team agreed with your operative plan at ___, that you would need to demonstrate 6 months of not using drugs in order to be re-considered for valve replacement WHAT SHOULD YOU DO FOR FOLLOW-UP? - Set up follow-up with a primary care physician at ___: ___, or online ___/ - Follow up with the ___ clinic (Habit Opco) as scheduled below. - Follow up with Dr. ___ office as scheduled below. - Follow up with our infectious disease team as scheduled below. It was a pleasure taking care of you. We wish you all the best. -Your ___ team Followup Instructions: ___
10070011-DS-19	10,070,011	29,479,314	DS	19	2177-05-20 00:00:00	2177-05-20 22:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: physohex Attending: ___ Chief Complaint: Hypotension Major Surgical or Invasive Procedure: ___: Cardiac catheterization History of Present Illness: Ms. ___ ___ yo female with hx hypertension, hyperlipidemia, COPD, and active ___ smoker referred from her PCP's office for hypotension and new TWI on ECG. The patient reports that for the past 9 months she has felt nauseous every morning, with associated diaphoresis, which lasts for about 30 minutes. She also reports generalized fatigue which has also been going on for months. In the afternoon on ___ she took her inhaler and went into the shower. She developed burning right-sided chest pain and extreme fatigue which lasted for about one hour. Following this episode she had no other symptoms. This AM she presented to her PCP's office, Dr. ___ routine ___. During the visit she was noted to have a low blood pressure at 96/60. ECG was checked which showed inferior q waves, and STE V1-V6 with terminal TWI. She was referred to the ED for concern of STEMI. In the ED, initial vitals were 99.3 101 122/75 18 98%. Troponin was elevated to 0.23. CXR was clear. She was started on heparin and given ASA 325mg po x 1, and referred to cath lab. In the cath lab, right radial access was attempted but it was difficult to pass guidewire so procedure was converted to femoral approach on the right side. Coronories were normal without evidence of significant CAD. LV was noted to have apical ballooning concerning for takatsubos cardiomyopathy. On review of symptoms she denies any worsening cough or shortness of breath from baseline, vomiting, abdominal pain, diarrhea, constipation, fevers, chills. She has had a reported weight loss of 5 lbs over a year with decreased appetite. She also reports depression. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Hypercholesterolemia Osteoporosis COPD Eustachian tube dysfunction Benign positional vertigo Social History: ___ Family History: Mother who had hypertension and died from aortic dissection and CVA, father who died from lung cancer in his ___ and was a heavy smoker, and a sister and aunt who died from lung cancer at age ___. She has a sister and half brother who are alive and well. There is no other family history of heart disease. Physical Exam: ADMISSION EXAM: VS: Tc:98.1 BP:97/69 HR:79 RR:18 O2 sat:94% RA General: Well-appearing female lying comfortably flat in bed. NAD. HEENT: PERRLA, NAD Neck: Supple, unable to sit pt up to evaluate JVP CV: S1S2 RRR, no murmurs/rubs/gallops Lungs: Mild wheezing over anterior lung fields; Poor air movement; no rales, or rhonchi Abdomen: Soft, nontender, nondistended, +BS Ext: Warm, no cyanosis or edema Neuro: Grossly intact Skin: Right groin with dressing intact; No palpable mass or evidence of hematoma. No bruit. Pulses: DP 2+ bilaterally, equally DISCHARGE EXAM: Vitals: , Tm:98.1, HR:78-92, BP:116/69(103-112/71-76), RR:18, O2:96%RA, ___ General: distressed, teary eyed female lying comfortably in bed. NAD. HEENT: PERRLA, NAD Neck: Supple, JVP not elevated CV: S1S2 RRR, no murmurs/rubs/gallops Lungs: Diffuse wheezing throughout lung fields; no rales, or rhonchi Abdomen: Soft, nontender, nondistended, +BS Ext: Warm, no cyanosis or edema Neuro: Grossly intact Pulses: DP 2+ bilaterally, equally Pertinent Results: ADMISSION LABS: ___ 12:40PM BLOOD WBC-13.5* RBC-4.27 Hgb-14.6 Hct-42.7 MCV-100* MCH-34.1* MCHC-34.1 RDW-13.2 Plt ___ ___ 12:40PM BLOOD Neuts-66.1 ___ Monos-3.8 Eos-0.9 Baso-0.3 ___ 02:15PM BLOOD ___ PTT-33.1 ___ ___ 12:40PM BLOOD Glucose-118* UreaN-10 Creat-0.6 Na-137 K-5.0 Cl-99 HCO3-23 AnGap-20 ___ 12:40PM BLOOD cTropnT-0.23* ___ 07:05AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.0 OTHER PERTINENT LABS: ___ 06:50AM BLOOD WBC-8.6 RBC-3.53* Hgb-12.0 Hct-36.6 MCV-104* MCH-33.9* MCHC-32.7 RDW-13.0 Plt ___ ___ 06:50AM BLOOD Glucose-103* UreaN-11 Creat-0.6 Na-143 K-4.2 Cl-105 HCO3-27 AnGap-15 ___ 06:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.0 IMAGING: #CXR (___): No evidence of acute disease. #Cardiac Catheterization & Endovascular Procedure Report (___) Patient Name ___, ___ MR___ ___ Study Date ___ Study Number ___ Date of Birth ___ Age ___ Years Gender Female Race Height 157 cm (5'2'') Weight 59.40 kg (131 lbs) BSA 1.59 M2 Procedures: Catheter placement, Coronary Angiography; Left heart catheterization; LV angiogram Indications: Abnormal ECG with anterior ST elevations suspicious for STEMI Staff Diagnostic Physician ___, MD Nurse ___, RN, MBA Technologist ___, EMT,RCIS Fellow ___, MD, MSc Fellow ___, MD ___ ___, MD, PhD Technical Anesthesia: Local Specimens: None Catheter placement via right femoral artery, 6 ___ Coronary angiography using 5 ___ JR4, ___ Fr XBLAD 3.5 guide. Initial unsuccessful attempt via R radial artery due to vessel spasm Hemodynamic Measurements (mmHg) Baseline Site ___ ___ End Mean A Wave V Wave HR ___ Post LV Gram Site ___ ___ End Mean A Wave V Wave HR LV___ Contrast Summary Contrast Total (ml): Optiray (ioversol 320 mg/ml)90 Radiology Summary Total Runs Total Fluoro Time (minutes) 9.4 Effective Equivalent Dose Index (mGy) 227.172 Medication Log Start-StopMedicationAmountComment 05:36 ___ Heparin in NS 2 units/ml (IA) IA0 ml 06:00 ___ Versed IV1 mg 06:00 ___ Fentanyl IV25 mcg 06:00 ___ Versed IV0.5 mg 06:05 ___ Lidocaine 1% Subcut3 ml 06:13 ___ Lidocaine 1% Subcut8 mlright groin 06:16 ___ Fentanyl IV25 mcg 06:16 ___ Versed IV0.5 mg ___ ManufacturerItem Name ___ BAND (LARG) ___ MEDICALLEFT HEART KIT TERUMOGLIDESHEATH SLENDER5Fr COOKJ WIRE 260cm.035in ___ SCIENTIFICMAGIC TORQUE .035 180cm.035in ___ MEDICAL PROD & sCUSTOM STERILE KIT(STERILE PACK) TYCO ___ 320200ml ___ SCIENTIFICFR 4 DIAGNOSTIC5fr NAVILYSTPRESSURE MONITORING LINE 12" COOKMICROPUNCTURE INTRODUCER SET5fr CORDISXBLAD 3.56fr ST JUDEANGIOSEAL VIP 6FR6fr TYCO ___ 320100ml ___ SCIENTIFICPIGTAIL ANGLED DIAGNOSTIC5fr COOKJ WIRE 180cm.035in NAVILYSTINJECTION TUBING KIT MEDRADINJECTOR SYRINGE150ml ___ BAND (LARG) Findings ESTIMATED blood loss: <20 cc Hemodynamics (see above): Coronary angiography: right dominant LMCA: normal LAD: minimal mid plaquing LCX: normal RCA: normal LV angiography shows marked apical ballooning Femoral angiography shows stick high in femoral artery at site of inferior epigastric artery. Closed successfully with Angioseal. Assessment & Recommendations 1. LV angiogram consistent with Takotsuba cardiomyopathy 2. No significant CAD 3. Medical management 4. Careful observation for any evidence retroperitoneal bleed # ECG (___): Sinus rhythm with slowing of the rate as compared to the previous tracing of ___ there is further evolution of acute anterolateral and apical myocardial infarction with persistent ST segment elevation and deepening of T wave inversion as well as Q-T interval prolongation. Followup and clinical correlation are suggested. # Transthoracic Echocardiogram (___): The left atrium and right atrium are normal in cavity size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. There is mild regional left ventricular systolic dysfunction with distal septal hypokinesis and focal apical akinesis suggested.Overall LV systolic funciton is preserved. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal (although the apical RV appears slightly hypokinetic). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. Brief Hospital Course: Ms. ___ ___ yo female with hx hypertension, hyperlipidemia, COPD, and active ___ smoker referred from her PCP's office for hypotension and new TWI on ECG, currently s/p catheterization without significant coronary artery disease and findings consistent with stress-induced cardiomyopathy. ACTIVE ISSUES # Stress-induced Cardiomyopathy s/p catheterization: Pt presented to her PCP's office with hypotension and was found to have ECG changes with inferior Q waves and new TWI concerning for STEMI. She was referred to the ED. CXR was clear and troponins were elevated to 0.23. She went for catheterization through right femoral approach on ___, where she was noted to have no evidence of CAD, however LV angiogram was consistent with Takotsubo cardiomyopathy. No clear trigger for cardiomyopathy. Pt tolerated the catheterization well without complications. She was started on metoprolol 12.5mg q8h, and on ___ she was started on lisinopril 2.5 mg. Echo on ___ demonstrated resolved cardiomyopathy with preserved EF 55%. Her pressures improved with SBP 110s, and she was discharged home on metoprolol and lisinopril. # COPD: Pt has known history of COPD. Wheezing on lung exam, although no chest pain or shortness of breath. She was monitored on beta-blockers without interactions. Her nebulizers and home inhalers were continued through admission. CHRONIC ISSUES # Tobacco Use: Pt smokes ___ since age ___. Counseling was provided, although pt has no plan for quitting at this time. Given 2 nicotine patches while inpatient. # Alcohol use: Pt has increased alcohol use with about 15 drinks/week. No evidence of withdrawal during admission. # Hypertension: HCTZ and trandolapril discontinued during admission. Initially held in the setting of hypotension. Pt started on regimen of metoprolol and lisinopril as above. # Anxiety: Stable during admission. Continued home alprazolam. *TRANSITIONAL ISSUES* - Pt will need to have repeat Chem10 next week with BP check to evaluate BUN/Cre and electrolytes on lisinopril - Smoking cessation counseling for heavy tobacco use and counseling on alcohol use - ___ with cardiology clinic - CODE: FULL Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO TID:PRN anxiety 2. Hydrochlorothiazide 25 mg PO 3X/WEEK (___) 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN wheeze 5. lansoprazole 30 mg oral daily 6. Potassium Chloride 20 mEq PO DAILY 7. Trandolapril 4 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. ALPRAZolam 0.25 mg PO TID:PRN anxiety 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN wheeze 4. Multivitamins 1 TAB PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. lansoprazole 30 mg oral daily 7. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Stress-induced cardiomyopathy Secondary Diagnosis: Nausea, chronic obstructive pulmonary disease, tobacco use, alcohol use, hypertension, anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ after you were seen in your primary care physician's office and you were found to have a low blood pressure. Your EKG was checked which showed new findings concerning for a heart attack, so you were referred to the Emergency Department. On ___, you had a cardiac catheterization, which showed you did not have a heart attack, but instead had a stress-induced cardiomyopathy. Your home blood pressure medications were held and you were started on a new medication called metoprolol and another medication called lisinopril. Please take all of your medications as prescribed and ___ at the appointments listed below. It was a pleasure taking care of you, Your ___ Team Followup Instructions: ___
10070011-DS-20	10,070,011	28,156,484	DS	20	2181-09-12 00:00:00	2181-09-13 08:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: physohex Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ Year-Old Female with hx of emphysema, lung cancer s/p resection in ___, COPD, HTN here w/ one week of cough, diarrhea and weakness. Since her lung resection she gets a bad cold annually which is treated with clarithryomycin with good effect. She does not go in for X rays. She calls her thoracic surgeon at ___ and he prescribes it for her over the telephone. Pt had chest congestion/cough/subjective fevers/ starting 5 days ago w/ watery diarrhea and night sweats. Of note her diarrhea began prior to her taking the abx. Pt was started on biaxin and has not had fevers/night sweats but was hypotensive and tachycardic and continues to have large volume diarrhea. Her last episode of diarrhea was yesterday. It was post prandial. She had profuse large volume diarrhea. She was able to eat a grilled cheese sandwich today without difficulty. She does not have chest pain. She has mild worsening of shortness of breath. She felt very fatigued and took her BP which was low to the ___ and HR = 105 three days ago. She stopped taking the biaxin. She continued to feel poorly and continued to have a diarrhea. She saw her PCP today who referred her to the ED. Upon arrival to the ED she was hypotensive with SBP = 90s. Pt found to have acute kidney injury. Baseline creatinine is 1.0. Her husband had a cold before her but did not have any GI sx. Her husband was around his grandchildren who were sick. When she breathes in her lung is sore and she feels like she needs an abx. She thinks her sx are similar to the flares of bronchitis for which Dr. ___ her clarithromycin. In the ED upon presentation: 0 \|97.4 \|98 \|93/54 \|18\| 99% RA Hypotensive in the ED to 83/53 which improved with IVF. GIVEN LR X 4 L, alprazolam and advair. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Hx of lung cancer (stage I) s/p iVATS L lower lobe wedge resection on ___ COPD HTN Hyperlipidemia s/p Menopause Osteoporosis Eustachian tube dysfunction Benign positional vertigo Social History: ___ Family History: Her mother had HTN, PVD and a dissection of the aorta. Father died of lung cancer at age ___ Physical Exam: ADMISSION EXAM: VS: Temp: 98.0 PO BP: 101/64 HR: 88 RR: 18 O2 sat: 93% O2 delivery: RA GENERAL: Alert and in no apparent distress but she does look very tired 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. ? Mildly elevated JVP. RESP: Decreased breath sounds in the lower L lung field. No crackles or wheezes GI: Diminished bowel sounds throughout. Soft, non-distended, non-tender to palpation. No guarding or rebound. 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, slightly anxious . . DISCHARGE EXAM: Gen: NAD, well-appearing Cards: RR, no m/r/g Chest: CTAB with quiet/reduced breath sounds throughout; normal WOB at rest; no conversational dyspnea Abd: S, NT, ND, BS+ Neuro: AAOx3, conversant with clear speech, moving all 4s Psych: mildly anxious at times, cooperative, normal insight Pertinent Results: Admission labs: ================ ___ 01:38PM BLOOD WBC-9.5 RBC-3.05* Hgb-10.0* Hct-30.2* MCV-99* MCH-32.8* MCHC-33.1 RDW-12.3 RDWSD-44.8 Plt ___ ___ 01:38PM BLOOD Neuts-69.3 ___ Monos-6.8 Eos-2.5 Baso-0.6 Im ___ AbsNeut-6.56* AbsLymp-1.92 AbsMono-0.64 AbsEos-0.24 AbsBaso-0.06 ___ 01:38PM BLOOD Plt ___ ___ 01:38PM BLOOD Glucose-107* UreaN-38* Creat-3.7# Na-137 K-4.1 Cl-96 HCO3-22 AnGap-19 ___ 01:38PM BLOOD ALT-36 AST-35 CK(CPK)-108 AlkPhos-145* TotBili-0.3 ___ 01:38PM BLOOD Lipase-60 ___ 01:38PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 01:38PM BLOOD Albumin-4.2 Calcium-9.6 Phos-5.1* Mg-1.9 ___ 03:47PM BLOOD Lactate-1.1 ___ 04:34PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:34PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR* ___ 04:34PM URINE RBC-<1 WBC-6* Bacteri-FEW* Yeast-NONE Epi-2 ___ 04:34PM URINE CastHy-12* . . Discharge labs: =============== ___ 08:45AM BLOOD WBC-9.6 RBC-3.18* Hgb-10.3* Hct-31.2* MCV-98 MCH-32.4* MCHC-33.0 RDW-12.4 RDWSD-44.8 Plt ___ ___ 08:45AM BLOOD Glucose-109* UreaN-31* Creat-2.5# Na-144 K-3.7 Cl-103 HCO3-22 AnGap-19 ___ 08:45AM BLOOD calTIBC-259* Ferritn-563* TRF-199* . . Micro: ======= ___ URINE URINE CULTURE-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING . . Imaging: ========== ___ CXR - "FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are hyperinflated but clear. Chain sutures are seen in the left lung base. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality." ___ Renal u/s - "FINDINGS: There is no hydronephrosis, large stones, or worrisome masses bilaterally. Note is made of a right lower pole renal cyst measuring 3.1 x 3.0 x 2.6 cm. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. -Right kidney: 10.1 cm -Left kidney: 10.3 cm The bladder is only minimally distended and can not be fully assessed on the current study. IMPRESSION: Normal exam." Brief Hospital Course: # Diarrhea: resolved prior to admission; we were unable to collect stool sample to send for infectious testing; she was tolerating regular diet with no GI symptoms on day of discharge # Hypotension: resolved with holding home metoprolol, lisinopril, HCTZ; home metoprolol resumed prior to discharge # ___: markedly improved w/ IVF (4L LR given in ED), resolution of diarrhea, and holding home metoprolol, lisinopril, HCTZ. Baseline Cr is 1, peak Cr was 3.7 on ___. Renal u/s was normal & non-obstructive. Cr improved to 2.5 on ___ and patient was feeling well and urinating normally. She was counseled to follow-up with Dr. ___ in ___ days for repeat chem10 to ensure renal function has returned to normal prior to resuming home lisinopril +/- HCTZ. [] needs repeat chem10 in ___ days to ensure renal function has returned to baseline [] resume lisinopril as soon as renal function normalizes (strong indication due to her hx of systolic HF w/ recovered EF) [] resume HCTZ only if needed for BP control # COPD exacerbation: mild; she reported she felt some chest congestion that was helped by clarithromycin at home and a dose of clarithromycin was given initially on admission at her request; her exam on the day of discharge was reassuring against a severe COPD flare and she said she felt her breathing was comfortable and that she would feel comfortable going home and doing her usual activities with her current breathing status, so she was not given steroids or sent home with a nebulizer treatment taper. We suspect she may have had a viral illness that triggered both a mild COPD flare as well as her diarrhea. . . . . Time in care: >60 minutes in discharge-related activities on the day of discharge including extensive patient & family counseling. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO QID:PRN anxiety 2. Atorvastatin 20 mg PO QPM 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. GuaiFENesin 10 mL PO Q6H:PRN cough Duration: 3 Days 2. ALPRAZolam 0.25 mg PO QID:PRN anxiety 3. Atorvastatin 20 mg PO QPM 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until told to resume by Dr. ___ 8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do not restart Lisinopril until told to resume by Dr. ___ ___ Disposition: Home Discharge Diagnosis: # Diarrhea: resolved # Hypotension: resolved # ___: improving # COPD exacerbation: mild Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. ___, ___ were admitted to the hospital for acute kidney injury which we think was most likely due to severe dehydration/hypovolemia & low blood pressure in the setting of your profuse diarrhea. Your diarrhea has resolved and ___ are tolerating a regular diet. Please do not resume taking your home medications of lisinopril or hydrochlorothiazide until instructed to do so by Dr. ___. Please plan to see Dr. ___ in the next ___ days to have your labs checked to ensure that your kidney function has returned to your baseline, at which point one or both of those medications might be resumed. We wish ___ a full and speedy recovery. Sincerely, The ___ Medicine Tea Followup Instructions: ___
10070594-DS-14	10,070,594	29,430,934	DS	14	2174-01-19 00:00:00	2174-01-19 14:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: Liver biopsy ___ History of Present Illness: ___ is a ___ man with metastatic neurodendocrine tumor, unknown primary, who is admitted from the ED with a sycnopal episode. Patient has had progressive functional decline over the last several months with associated poor po intake. He denies nausea or frank abdominal pain, but does note bloating and significant dysgeusia. He reports having eaten 'very little' over the previous month. Additionally, he has developed large volume diarrhea over the last three weeks, up to ___ stools per day (worse at night). He has also had increasing weakness over this time. His son brought him to his medical oncology clinic on day of admission, but he had a syncopal episode in the parking lot. Patient stood up out of the car, and felt light headed. He did not fall right away, but eventually his legs 'gave out'. His son caught him and lowered him to the ground. He had no LOC, no headstrike, and he remembers the event clearly. No preceeding CP, palpitations or SOB. Does have occaisional word finding difficulty, but no other new neurologic issues. He was seen in oncology where he was noted to have soft BP's (90/59), was unable to stand up, have word finding difficulties, and slight left facial droop. He was transported to the ED. In the ED, initial VS were: pain 0, T 97.2, HR 86, BP 108/74, RR 16, O2 100%RA. Labs notable for Na 140, K 3.8, HCO3 20, Cr 1.2, ALT 22, AST 54, ALP 348, LDH 467, TBIli 1.8, Alb 3.3, WBC 7.6, HCT 36.6, PLT 245, INR 1.9, Uric acid 16.7. CXR showed possible subtle right lateral mid lung consolidation. CT head showed new bilateral hygroma - neurosurgery recommended no intervention. Liver US showed known metastatic disease, but no biliary obstruction. Patient received 1LNS prior to admission. On arrival to the floor, patient reports feeling better than he has in several weeks. No recent fevers or chills. He does have significant dry mouth and food tastes 'awful'. No CP or SOB. No palpitations. No N/V. No frank abdominal pain, but does have bloating. No dysuria. No new leg pain or weakness. No significant flushing. No new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid ___. He was then following up with one of our hepatologist, Dr. ___ he was found to have on ___, a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at ___ Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on ___ which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. PAST MEDICAL HISTORY: 1. NASH-induced cirrhosis complicated by portal hypertension. 2. Ascites and HCC. 3. Atrial fibrillation. 4. Hypertension. 5. Obesity. 6. BPH. 7. Gout. 8. Prediabetes mellitus. 9. Apparent CKD, which he is not aware of. 10. Baseline Bell's palsy left side. Social History: ___ Family History: His mother was diagnosed with intestinal cancer in her late ___ and died at age ___. Brother diagnosed in his ___ and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late ___. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: T 97.5 115/67 79 18 98%RA WT 185 lbs from 173 on admit - was slightly dry on admit, but looks overloaded still at this point GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI, dry MM. ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Irregular rhythm, regular rate, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. MUSKULOSKELATAL: Warm, well perfused extremities, 1+ ___ symmetric, slightly improved from yesterday RUE with PICC is swollen but neurologically intact, picc insertion site w/o erythema NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE EXAM VS: 97.5 PO 118 / 70 76 18 97 Ra WEIGHT: 83.92kg \|\| 185.01lb GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI, dry MM. ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Irregular heart sounds, no murmurs, rubs, or gallops; 2+ radial pulses. JVP is 2cm above clavicle RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. MUSKULOSKELATAL: Warm, well perfused extremities, 1+ ___ symmetric, slightly improved from yesterday RUE is swollen but neurologically intact NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Pertinent Results: ADMISSION LABS: ___ 02:20PM BLOOD WBC-7.6 RBC-4.18* Hgb-12.0* Hct-36.6* MCV-88 MCH-28.7 MCHC-32.8 RDW-17.7* RDWSD-56.5* Plt ___ ___ 02:20PM BLOOD Neuts-82.9* Lymphs-9.5* Monos-6.9 Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.29* AbsLymp-0.72* AbsMono-0.52 AbsEos-0.01* AbsBaso-0.01 ___ 02:20PM BLOOD ___ PTT-30.3 ___ ___ 02:20PM BLOOD UreaN-29* Creat-1.2 Na-140 K-3.8 Cl-99 HCO3-20* AnGap-25* ___ 02:20PM BLOOD ALT-22 AST-54* LD(LDH)-467* AlkPhos-348* TotBili-1.8* ___ 02:20PM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.1* Mg-2.2 UricAcd-16.7* DISCHARGE LABS: IMAGING: ___ Imaging CHEST (PA & LAT) Difficult to exclude a subtle lateral right mid lung consolidation. No focal consolidation seen elsewhere. Mild cardiomegaly. No pulmonary edema. ___ Imaging LIVER OR GALLBLADDER US 1. Enlarged heterogeneous liver parenchyma containing several heterogeneous masses including a 11 x 8 cm right liver lobe mass, better assessed on of ___ CT abdomen pelvis. Patent main portal vein with hepatopetal flow. 2. Cholelithiasis without evidence of acute cholecystitis. ___ Imaging CT HEAD W/O CONTRAST - Bilateral hygromas versus chronic subdural hematomas without significant midline shift. - No acute intracranial hemorrhage. Brief Hospital Course: ASSESSMENT AND PLAN: ___ is a ___ man with metastatic neurodendocrine tumor, unknown primary, who is admitted from the ED with a syncopal episode. # Syncope: Not clear he had a true syncopal episode, but most likely collapsed in parking lot getting out of the car in setting of orthostatic hypotension and hypovolemia as he was subsequently on evaluation found to by hypotensive with BP in ___. He has been having ongoing diarrhea for several weeks now, see below. Head CT showed concern for chronic subdural vs hygroma, unlikely that this would account for his symptoms. per NSGY this is not subdural and discussed w/ the NP from their service likely chronic hygroma and no need for further imaging and if anticoag needed that would be find from their standpoint. Pt was likely hypovolemic from ongoing diarrhea and very poor po intake. Doubt infectious process contributing, CXR without obvious infiltrate. See below for asymptomatic bacteruria. No leukocytosis or fever (developed elevated WBC after dex with chemotherapy). Doubt PE given was on anticoag at baseline. Cultures negative to date (see below for asx bacteruria) so DCd antibiotics early in course and pt continued to do quite well. # Afib/RVR - HR was up to ___ in setting of initially holding his metop/verapamil on admit due to syncope. He is asymptomatic. He has no prior CVA history. Uptitrated metop to 50mg q6 with excellent effect. Given hypotension/syncope on admit, will DC pt on metop 200mg XL (was on 100mg XL at home - but also with verapamil) and DC his verapamil as HR well controlled this admit on 50mg metop q6 and off verapamil, and possibly verapamil with more antihypertensive effect contributing to orthostasis. Was continued on apixaban given need for full anticoagulation due to RUE PICC associated DVT. # Elevated cardiac enzymes - mild, downtrended. per discussion w/ cardiology, most likely from demand in setting of hypovolemia. Pt has no history of prior MI. He has no chest pain and serial EKGs have had no dynamic changes (mild ST dep in lateral leads <1mm, stable, no e/o Q waves). Per discussion w/ cardiology, catheterization not indicated as wouldn't be candidate for dual platelet therapy most likely as anticipate thrombocytopenia in which case pt would be unable to come off of ASA/Plavix, posing significant challenges. TTE for baseline, but wouldn't likely be a surgical candidate even if significant valvular disease (showed mod MR, normal EF) Trended trops to peak (0.04). Cont metop on DC at higher dose. Could initiate statin but will consider any interactions there with chemotherapy. Per oncologist hold off on starting statin at this time given chemo and drug interactions. # Hyperbilirubinemia: # Hyperuricemia: Improved with chemo. Elevated bilirubin initially concerning for biliary obstruction, but RUQ showed no obvious obstruction. Given elevated uric acid, must also consider tumor lysis. Fortunately, his creatinine is at recent baseline and he has no gross electrolyte abnormalities. This may represent significant tumor burden turnover due to his large liver mass. He may have elevated uric acid at baseline given his historical problems with gout (none current). no e/o hemolysis on labs. ___ was hydrated initially as above. Initiated allopurinol. # Hygroma: Unclear significance. ___ be due to dehydration or possibly chronic subdural hematoma. No clear acute insult, and no history of falls outside of today's episode. Pt reports getting struck in the head as a child though unclear if related Per neurosurgery NTD at this point. Holding anticoagulation given concerns re anemia/anticpated thrombocytopenia, though from ___ standpoint ok to continue if needed from hygroma standpoint. # Diarrhea: Likely from his neuro-endocrine tumor. Stool cultures sent in ED and C.diff neg. Per pt improving over the course of the admission, using immodium prn. # Asymptomatic bacteruria - Ucx on admit grew citrobacter, but pt denied fever or leukocytosis, was not neutropenic, and continued to deny any urinary symptoms. He does at baseline have difficulty that when he urinates stool comes out along with it (pelvic muscle control issues?) but given this reflects asymptomatic bacteruria, held off on treating for now. # Protein calorie malnutrition. Nutrition consulted. Recommended supplements. # Neuroendocrine tumor: Metastatic to lymph nodes and presumably the liver. Unclear primary source. Based on cytology appears to be well differentiated high grade. Plan has been to start carboplatin/etoposide pending syncope workup and hyperbilirubinemia, which was given D1 on ___. PICC for access/chemo. Dr. ___ to arrange for outpatient port placement before next cycle. arranging for neulasta ___ appointment on ___ ___. Repeated liver biopsy ___ to rule out HCC and compare to neuroendocrine path from lymph node. Received D1-D3 of C1 Carboplatin/Etoposide while in-house. # Right arm swelling - picc in place, ultrasound showed PICC associated DVT. Patient was restarted on apixaban, PICC was pulled on ___. # Anemia - stable. likely inflammatory block and from malignancy, he may have marrow involvement. Drop initially likely hemodilutional as pt hemoconcentrated on admit. checked hemolysis labs (hapto 151, Tbili downtrending reassuring). # NASH-induced cirrhosis complicated by portal hypertension. # Ascites E/o volume overload after chemo and initial hydration. Got 20mg IV Lasix on ___ w some improvement on exam though weight stable. Resumed home 20mg Lasix daily subsequently. # Hypertension - borderline BPs in low 100s initially but normotensive upon discharge - Dose increased metoprolol, as above, and cont holding verapamil. Decreased doxazosin dose. # BPH: Dose reduced home doxazosin, continued finasteride # Gout: Initiated allopurinol, continue colchicine as needed # Prediabetes mellitus: On LSS/Fingersticks while in house # CKD: Stage IIIA. At most recent baseline # Bell's palsy left side: Known prior to admission TRANSITIONAL ISSUES: ==================== 1. Scheduled for Pegfilgrastim on ___ 2. Please monitor platelet count on ___ and C1D11 (___) as may require holding apixaban if platelet nadir <50 000 3. Discharged on increased dose of metoprolol XL (100 to 200mg) as verapamil being held in setting of orthostasis 4. Downtitrated doxazosin given orthostasis, no LUTS. Please monitor and titrate as needed. 5. Discharged on decreased dose of furosemide (40 to 20mg) given relatively poor PO intake. Discharge weight is 185lbs, dry weight assumed to be 181-182 lbs. Uptitrate to 40mg if weight after ___ is >185lbs. Discharge planning and coordination required >60 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Colchicine 0.6 mg PO DAILY:PRN Gout 3. Doxazosin 16 mg PO HS 4. Finasteride 5 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Verapamil SR 120 mg PO Q24H Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX allopurinol ___ mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Metoprolol Succinate XL 200 mg PO DAILY RX metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE RX pegfilgrastim [Neulasta] 6 mg/0.6 mL 6 mg subcu once Disp #1 Syringe Refills:0 4. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE Duration: 1 Dose RX pegfilgrastim [Neulasta] 6 mg/0.6 mL deliverable (0.64 mL) 6 mg subcutaneous once Refills:6 5. Senna 8.6 mg PO BID:PRN constipation 6. Doxazosin 4 mg PO HS RX doxazosin 4 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 8. Apixaban 5 mg PO BID 9. Colchicine 0.6 mg PO DAILY:PRN Gout 10. Finasteride 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Neuroendocrine carcinoma Atrial fibrillation Chronic kidney disease Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted after fainting. We felt you were dehydrated. You also received chemotherapy and had a liver biopsy. We think some of your blood pressure medicines caused low blood pressure in setting of dehydration and contributed to the fainting. We changed these around. Please STOP your verapamil. We increased the dose of your metoprolol instead. Also, we decreased the dose of your doxazosin as this can cause low blood pressure. We are discharging you on apixaban mostly due to your blood clot in the right arm. If your platelets drop significantly with your chemotherapy your oncologist may ask you to stop the apixaban for a moment. Call your oncologist if any signs of bleeding. You need to get your neulasta injection on ___, see below. We are sending you home with home ___ services. Your ___ Team Followup Instructions: ___
10070701-DS-5	10,070,701	27,693,754	DS	5	2156-10-06 00:00:00	2156-10-06 14:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hip fracture Major Surgical or Invasive Procedure: Left trochanteric femoral fracture repair with trochanteric fixation nail History of Present Illness: Ms. ___ is a ___ year old woman with a history of HTN, osteoporosis, osteoarthritis, GI bleed w/ anemia, and anxiety who presents for management of left hip fracture. She fell while getting ready for bed on ___. She reports that she remembers the whole incident, and denies any syncope. She denies hitting her head. She reports that since her fall she has had significant left leg and hip pain, that is worsened with moving in bed and walking. At baseline she uses is a walker but is able to get around well. She went to her PCP yesterday, and ___ left hip fracture was seen on X-ray. In the ED her VS were: T 97.8, HR 68, BP 132/70, RR 18, O2 sat 95%. She was evaluated by orthopedic surgery who recommended operating to relieve her significant pain. The risks, benefits and alternatives of surgery were discussed with her and her family, and they agreed to change her code status for surgery. She recieved tylenol, TDAP vaccine, lorazepam, and morphine in the ED, and is being admitted for medical management. On the floor, she is extremely pleasant, alert and oriented, and is comfortable in bed. Her only complaints are of left hip pain and anxiety. She denies any headaches, confusion, vision changes, nausea, abdominal pain, chest pain, SOB, or weakness now, or since her fall. ROS: (+) per HPI, anxiety, occasional heartburn (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - HTN - DJD - Osteoporosis - Osteoarthritis - Anxiety - Insomnia - Depression - ? TIA in ___ (in notes but her son doesn't recall this) - Breast cancer s/p R mastectomy - GI bleed anemia Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION EXAM: VS: 97.5 133/63 69 18 99/ra GENERAL: Edlerly woman, alert, oriented, no acute distress, comfortable laying in bed HEENT: NC/AT, PERRLA, dry mucus membranes, EOMI with no nystagmus, double vision or pain, sclera anicteric, OP clear with no erythema, exudates or lesions NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi, breathing comfortably CV RRR with occasional PVCs or PACs, normal S1/S2, ___ crescendo-decrescendo murmur best heard at right upper sternal border. No gallops or rubs. ABD soft NT ND normoactive bowel sounds, no r/g EXT Extremeties cool to the touch. 1+ DP and ___ pulses palpable bilaterally, no c/c/e NEURO awake, A&Ox3, CNs II-XII grossly intact, motor function grossly normal, limited by pain in left leg, and arthritis in wrists and hands bilaterally SKIN many seborrheic keratoses and solar lentigos over her arms, chest, abdomen and legs. No ulcers, or rashes. Papules on chin and nose DISCHARGE EXAM: Physical exam: VS 98.9 134/64 71 16 98RA GEN Alert, oriented, no acute distress, comfortable laying in bed HEENT NCAT, EOMI, MMM NECK supple, no JVD, no LAD PULM: CTABL on RA CV RRR with occasional PVCs or PACs, normal S1/S2, ___ crescendo-decrescendo murmur best heard at right upper sternal border. No gallops or rubs. ABD soft NT ND normoactive bowel sounds, no r/g EXT: Left hip with bandage in place. well perfused, + DP bilaterally, no LLE. NEURO CNs2-12 intact, motor function grossly normal, limited by pain in left leg, and arthritis in wrists and hands bilaterally SKIN many seborrheic keratoses and solar lentigos over her arms, chest, abdomen and legs. No ulcers, or rashes. Papules on chin and nose Pertinent Results: ADMISSION LABS: ___ 04:10PM BLOOD WBC-10.5 RBC-2.40* Hgb-8.1* Hct-24.1* MCV-100* MCH-33.9* MCHC-33.8 RDW-13.5 Plt ___ ___ 04:10PM BLOOD Neuts-72.4* ___ Monos-8.0 Eos-0.6 Baso-0.1 ___ 04:10PM BLOOD ___ PTT-30.5 ___ ___ 04:10PM BLOOD Glucose-125* UreaN-49* Creat-1.7* Na-129* K-4.8 Cl-97 HCO3-22 AnGap-15 ___ 04:10PM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1 PRE-OP LABS: ___ 06:40AM BLOOD WBC-10.3 RBC-2.68* Hgb-9.0* Hct-26.8* MCV-100* MCH-33.6* MCHC-33.5 RDW-14.1 Plt ___ ___ 06:40AM BLOOD ___ PTT-28.5 ___ ___ 06:40AM BLOOD Glucose-104* UreaN-53* Creat-1.7* Na-133 K-4.6 Cl-101 HCO3-23 AnGap-14 ___ 06:40AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.1 POST-OP LABS: ___:20AM BLOOD WBC-11.8* RBC-3.49# Hgb-11.5# Hct-36.0# MCV-103* MCH-33.1* MCHC-32.0 RDW-15.2 Plt ___ ___ 11:20AM BLOOD Glucose-119* UreaN-49* Creat-1.5* Na-132* K-4.6 Cl-102 HCO3-17* AnGap-18 ___ 11:20AM BLOOD Calcium-8.3* Phos-4.4 Mg-2.0 DISCHARGE LABS: ___ 07:10AM BLOOD WBC-9.2 RBC-2.91* Hgb-9.5* Hct-28.6* MCV-98 MCH-32.8* MCHC-33.3 RDW-14.3 Plt ___ ___ 07:10AM BLOOD Glucose-110* UreaN-40* Creat-1.3* Na-132* K-5.0 Cl-102 HCO3-22 AnGap-13 ___ 07:10AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9 ___ 06:30AM BLOOD VitB12-326 Folate-8.5 IMAGING: ___: CT C-SPINE W/O CONTRAST IMPRESSION: 1. Mild compression deformity of the T3 vertebral body, partially visualized, and likely chronic. No evidence of acute cervical spine fracture, malalignment, or prevertebral soft tissue swelling. 2. Multinodular thyroid goiter. ___: CT HEAD NON-CONTRAST IMPRESSION: No acute intracranial injury. ___: CXR IMPRESSION: No acute cardiopulmonary process. Possible hiatal hernia versus pronounced left atrium. Two-view chest x-ray may help further characterize if desired. ___: FEMUR, HIP, PELVIS (LEFT) PLAIN FILM IMPRESSION: Acute, comminuted, angulated intertrochanteric fracture of the left femur. ___: HIP NAILING IN OR WITH PLAIN FILMS AND FLUORO FINDINGS: Images from the operating suite show placement of a gamma nail across the previous fracture of the proximal femur. Further information can be gathered from the operative report. ___: PELVIS AND LEFT HIP, POSTOPERATIVE CONTROL The patient is after ORIF of the left hip. The ORIF components are in correct position. Known small bony fragment at the level of the minor trochanter on the left. Extensive vascular calcifications. No other abnormalities. The study and the report were reviewed by the staff radiologist. Speech and Swallow Recs: Ms. ___ did not present with any overt s/sx of aspiration with observed consistencies on today's exam. Recommend PO diet of thin liquids, ground solids, and meds crushed in applesauce. Suggest 1:1 to assist with meal set-up and maintain aspiration precautions. We will f/u early next week to monitor diet tolerance and to consider changes as necessary. This swallowing pattern correlates to a Functional Oral Intake Scale (FOIS) rating of ___. RECOMMENDATIONS: 1. PO diet: thin liquids, moist ground solids. 2. Meds crushed in applesauce. 3. Suggest 1:1 to assist with meal set-up and maintain aspiration precautions. 4. TID oral care. 5. We will f/u early next week to monitor diet tolerance and to consider changes as necessary. ___ FINAL RECS ASSESSMENT: Pt is a ___ yo F presenting after a fall at home getting into bed resulting in an acute, comminuted, angulated intertrochanteric fracture of the L femur s/p L Hip ORIF. Pt continues to present below baseline mobility limited by pain, weakness, motor control and fear of falling. Pt will continue to benefit from rehab to maximize functional mobility. It is expected that pt will return to independent level of mobility c good rehab potential ___ strong motivation, progression of mobility c ___ f/u and strong social support. Anticipated Discharge: (X) rehab ( ) home: _______________ PLAN: Plan to continue to f/u c M-F acute ___. Recommendations for Nursing: OOB to chair c golvo 3x per day to minimize deconditioning. Brief Hospital Course: Ms. ___ is a ___ year old woman with a history HTN, osteoporosis, osteoarthritis, GI bleed w/ anemia, and anxiety, who presents with left hip fracture and ___ for pre-operative management. ACTIVE ISSUES: # Left intertrochanteric femoral fracture Patient had a mechanical fall at home and hip fracture is seen on plain film. She was evaluated by orthopedics who recommend surgery. The risks, benefits and alternatives were discussed with the patient and her family and they decided to proceed with surgery and change her code status (from DNR/DNI) for the operation. She went for a left hip ORIF with trochanteric fixation (cephalomedullary nail) and received 2units PRBCs. She recovered well post-operatively. Pain was controlled with OxycoDONE ___ mg PO Q4H:PRN pain. She was started on calcium and vitamin D supplements. She was also started on Lovenox for post-surgical DVT prophylaxis for 1 month's duration, ending ___. She worked with physical therapy daily who recommended transfer to rehab for further therapy. She is weight bearing as tolerated on the left lower extremity. We anticipate that she remain in rehab for less than 30 days. # Pre-operative risk evaluation: She had no known cardiac or pulmonary disease. Good functional status ___ METS). Pre-op EKG and CXR were within normal limits. On physical exam she had a ___ systolic murmur most likely consistent with AS; however, she has no symptoms of AS, therefore an ECHO was not indicated as would not change management. Given her low risk of cardiac event, Cr < 2.0, and no history or findings of pulmonary disease, she was a good candidate for surgery. Initial HCT was 24 so she was transfused 1 unit prbc prior to surgery. She was continued on beta blockers in ___ period. # Swallowing risk/Aspiration: On intubation, a small pill was found in her throat. This was successfully removed before intubation. She was seen by speech and swallow who recommended thin liquids with moist, ground solids. Meds crushed in applesauce. She was monitored during mealtimes with 1:1 assist and aspiration precautions. # ___ - acute on chronic She had elevated creatinine on presentation to 1.7, an increase from her baseline of 1.3. With fluid resuscitation, her creatinine resolved back to her baseline. #Hyperkalemia: During her admission, K elevated to 5.5 in the setting of poor GFR and diet with significant potassium intake (mashed potatoes). EKG without peaked T waves or other concerning changes. We discussed the need for dietary limitation of potatoes. Her potassium improved gradually and was 5.0 on discharge. # Anemia Her HCT on presenation was 24, borderline macrocytic. She received 2 units PRBC HCT on discharge was 28.6. Vit B12 and folate were normal levels. Also no evidence of BI bleeding (she does have a history of GIB). INACTIVE ISSUES: # Influenza prophylaxis Patient had no symptoms of flu on admission or discharge. She was started on prophylactic tamiflu ___ due to exposure at her assisted living facility, and was continued on prophylactic tamiflu to complete her 5 day course. # HTN Patient was continued on home amlodipine, valsartan and HTZ. No issues on this hospitalization. # Anxiety Patient was continued on home lorazepam and zolpidem. TRANSITIONAL ISSUES: -DNR/DNI (her code status was reversed ___ only) -Weight bearing as tolerated -Anticipated duration of rehabilitation is less than 30 days. -Swallow precautions: liquids and ground solids, meds in ___. ___: (Daughter/HCP) ___ (home, call first) ___ (cell) ___: ___ ___: (Son-in-law) ___ (cell) ___ (work) ___: (Granddaughter) ___ (cell) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Valsartan 160 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Zolpidem Tartrate 5 mg PO HS 6. Lorazepam 0.5 mg PO TID anxiety 7. Acetaminophen 1000 mg PO Q8H 8. Docusate Sodium 100 mg PO BID 9. Oseltamivir 75 mg PO Q24H started ___. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amlodipine 10 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lorazepam 0.5 mg PO TID anxiety 5. Senna 1 TAB PO BID:PRN constipation 6. Hydrochlorothiazide 25 mg PO DAILY 7. Valsartan 160 mg PO BID 8. Zolpidem Tartrate 5 mg PO HS 9. Metoprolol Succinate XL 100 mg PO DAILY 10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #120 Tablet Refills:0 11. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #30 Packet Refills:0 12. Enoxaparin Sodium 30 mg SC Q24H Duration: 30 Days RX enoxaparin 30 mg/0.3 mL Inject into subcutaneous fat over belly daily Disp #30 Syringe Refills:0 13. Calcium Carbonate 500 mg PO TID RX calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 14. Vitamin D 800 UNIT PO DAILY RX ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #60 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left intertronchanteric femoral fracture Surgical repair: Left hip open reduction internal fixation Discharge Condition: Mental Status: Clear and coherent. Limited only by hearing. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Weight bearing as tolerated Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you while you were admitted to ___. You were admitted after falling and fracturing your left hip. You had surgery to repair this hip with pins and you tolerated this well. There were no complications of surgery. For the next month, you will continue on a blood thinner called Lovenox to prevent blood clots. You will inject this medication at the same time each day until ___. You will be transfered to a rehab facility where you will have intensive rehabilitation to restore your physical mobility. We anticipate your length of stay at rehab to be less than 30 days. Followup Instructions: ___
10070932-DS-14	10,070,932	28,249,049	DS	14	2145-12-03 00:00:00	2145-12-03 17:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: PICC removal PICC placement ___ History of Present Illness: Ms. ___ is a ___ female with a PMH of a possible mitochondrial disorder, POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since ___, who presents to the ED with fever. On review of previous records, patient was hospitalized at ___ from ___ as a transfer from ___ ___. At that time, she was initially admitted to the MICU with septic shock and Enterobacter bacteremia thought to be secondary to a PICC line. She was initially on pressors, but improved with antibiotic therapy. Her PICC line was removed. She was ultimately narrowed to cefepime. A new PICC line was placed prior to discharge. Patient states that she was feeling well for the first week following discharge. She completed a course of cefepime on ___. However, she then began to experience chills during the first hour of her TPN infusions overnight. She began to have low-grade fevers which have slowly climbed. She only gets these fevers during the first hour of TPN infusions. They are also associated with headache and neck stiffness, as well as right ear pain. All of the symptoms are gone after the fever resolves. Patient was seen in ___ clinic for follow-up on the ___, after having completed antibiotics. She was doing well at that time. However she left a phone message on the ___ regarding her fevers. On the ___ it was recommended she present to the ED. Of note, patient performs intermittent bladder caths due to neurogenic bladder dysfuction. Denies any recent changes in her urine. She remains on p.o. vancomycin every 6 hours for treatment for C. difficile. She states that this was going to continue for 2 weeks following her antibiotic completion. Per review of records and discussion with patient, it appears that ultimate plan was for PICC line to be removed with placement of a port for TPN administration. Patient states that she uses TPN nightly, with ultimate plan to transition back to enteral feeding. She works closely with her GI doctor. In the ED, initial vitals: T 98.8, HR 74, BP 114/69, RR 16, 100% RA Labs were significant for - CBC: WBC 5.6, Hgb 10.4, Plt 132 - Lytes: 139 / 103 / 13 -------------- 83 3.7 \ 24 \ 0.6 - Lactate:1.0 Imaging was significant for: CXR with no acute cardiopulmonary abnormalities. Left upper extremity PICC tip projecting over the right atrium. Consider retraction by 3 cm. In the ED, pt received PO Tylenol and IV Zofran. Vitals prior to transfer: T 101.4, HR 100, BP 132/76, 18, 100% RA Currently, recounts history as above. States that she is currently feeling unwell, with some chills. ROS: Positive as noted above. Negative for: No weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria (though of note patient straight caths). No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE ___, has family history of clots. Hypercoagulable workup at ___ reportedly negative - ? mitochondrial disease Social History: ___ Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages ___ and ___. Physical Exam: ================================ EXAM ON ADMISSION ================================ VITALS: 103.0, HR 102, BP 93/49, RR 18, 96% RA GENERAL: Slightly shivering, ill-appearing EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart tachycardic and regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored BACK: nontender on palpation of spinal processes GI: Abdomen thin, soft, non-distended, mildy tender to palpation in center and left lower quadrant. 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 ================================ EXAM ON DISCHARGE ================================ Afebrile, aVSS Pain Scale: ___ GHEENT: eyes anicteric, normal hearing, nose unremarkable, dry MM without exudate CV: RRR no mrg, JVP 8cm, previous ___ site cdi Resp: crackles at bilateral bases GI: sntnd, NABS GU: no foley, neg CVAT MSK: no obvious synovitis Ext: wwp, neg edema in BLEs Skin: L dorsum foot with v small area of blanchable maculopapular erythema (unchanged from yesterday), not warm, not tender, no rash grossly visible, L pinky toe with onychomycosis Neuro: A&O grossly, MAEE, no facial droop, DOWB intact Psych: normal affect, pleasant Pertinent Results: ================================ LABS ON ADMISSION ================================ ___ 08:52PM BLOOD WBC-5.6 RBC-3.50* Hgb-10.4* Hct-31.4* MCV-90 MCH-29.7 MCHC-33.1 RDW-13.0 RDWSD-42.0 Plt ___ ___ 08:52PM BLOOD Neuts-51 Bands-5 ___ Monos-0 Eos-10* Baso-1 ___ Metas-2* Myelos-0 AbsNeut-3.14 AbsLymp-1.74 AbsMono-0.00* AbsEos-0.56* AbsBaso-0.06 ___ 08:52PM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-139 K-3.7 Cl-103 HCO3-24 AnGap-12 ___ 09:00PM BLOOD Lactate-1.0 ================================ MICROBIOLOGY ================================ BCx and Central Line Tip Cx: Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ================================ IMAGING ================================ ___ Chest Pa and Lat No acute cardiopulmonary abnormalities. Left upper extremity PICC tip projecting over the right atrium. Consider retraction by 3 cm. CXR post PICC placement ___ Left-sided PICC terminates in the distal SVC. No pneumothorax. Brief Hospital Course: ___ woman w possible mitochondrial d/o, POTS, chronic abd pain, severe endometriosis s/p TAH/BSO, neurogenic bladder s/p stimulator, recurrent c diff, malnutrition on TPN, recent TPN line infection p/w sepsis ___ GNR bacteremia from TPN line infection. ACUTE/ACTIVE PROBLEMS: # Sepsis: fever, hypotension, tachycardia, rigors. Secondary to # Central Line associated blood stream infection: TPN line Line infection found on admission, occurred prior to arrival, PICC discontinued on admission ___. Started on vancomycin (___) and cefepime on presentation (___). She was given a line holiday and PICC replaced ___. BCx and PICC tip cx grew pan-sensitive Klebsiella so antiibotics narrowed to IV Ceftriaxone 2gm daily which will continue for 14 days from line removal, last day ___. She will have outpatient follow up with ID within 3 weeks of discharge. # Thrombocytopenia: presented with thrombocytopenia, similar to previous infection episode, likely ___ sepsis. Low 4T score, no e/o DIC. Improved with sepsis treatment # Severe malnutrition: # Malabsorptive syndrome Continued home pyrodstigmine, thiamine, folate. Held TPN while line pulled. Started MVI. Will continue TPN per home regimen. Should consider placement of tunneled Hickman 2 weeks after completion of antibiotics. # Chronic stable anemia: monitored, stable throughout admission # Eosinophilia: mild on presentation. Unclear cause, has come down with treatment of infection but timing does not fit with medication effect. Resolved with treatment of above, though it is possible that this reduction was related to bacterial infection and so patient may have underlying eosinophilia. # Dorsal foot rash: noted to have a mild pruritic erythematous macular/papular lesion on dorsal foot, treated for tinea pedis. # h/o PE. Chronic, stable, continued home LMWH # Neurogenic bladder s/p stimulator # Chronic abd pain # Endometriosis s/p TAH/BSO Continued dronabinol, ondansetron per home regimen # Anxiety: continued home buspirone # neuropathy: continued home gabapentin ========= TRANSITIONAL ISSUES - recommend repeat CBC/diff to assess if eosinophilia persists - IV Ceftriaxone to continue until ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 5 mg PO DAILY 2. Dronabinol 5 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. ondansetron 4 mg oral Q8H 5. Promethazine 25 mg PR Q6H nausea 6. Thiamine 100 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. vancomycin 125 mg oral Q6H 9. Pyridostigmine Bromide Syrup 60 mg PO TID 10. Enoxaparin Sodium 50 mg SC Q12H Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H 2 weeks total from ___ RX ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV QDaily Disp #11 Intravenous Bag Refills:0 2. Clotrimazole Cream 1 Appl TP BID RX clotrimazole 1 % Apply to skin twice a day Refills:0 3. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:0 4. Vancomycin Oral Liquid ___ mg PO BID Please take for 1 week after completion of IV antibiotics RX vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp #36 Capsule Refills:*0 5. BusPIRone 5 mg PO DAILY 6. Dronabinol 5 mg PO BID 7. Enoxaparin Sodium 50 mg SC Q12H 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. ondansetron 4 mg oral Q8H 11. Promethazine 25 mg PR Q6H nausea 12. Pyridostigmine Bromide Syrup 60 mg PO TID 13. Thiamine 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Sepsis Line infection Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure caring for you. You were admitted for fever and were found to have a line infection. You got better with antibiotics and removal of your line. Please complete your antibiotic course as prescribed which will end on ___. You should continue oral Vancomycin twice daily for 1 week after completion of IV antibiotics. We wish you the best in your recovery. Followup Instructions: ___
10070932-DS-16	10,070,932	24,727,163	DS	16	2146-05-16 00:00:00	2146-06-13 12:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Attending: ___. Chief Complaint: fever, L flank pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a history of chronic abdominal pain/nausea/constipation, ileus and SBO, recurrent C diff colitis s/p FMT transplant on ___, multiple line infections on TPN, endometriosis s/p total hysterectomy, bilateral PE (___) on lovenox, neurogenic bladder s/p sacral nerve stimulator (___), suspected mitochondrial disease, POTS, now presenting with 1 day of fevers and L flank pain. Of note, she was admitted in ___ with E. coli urinary tract infection and sepsis, and C. diff colitis. Yesterday during the day, she noted cloudy urine on straight cath, and reduced urine output. She began to have fevers. Last night she began feeling severe left flank pain, which occasionally radiates to left side when lying down. Endorses fevers, chills, rigors, Tmax at home 103. She felt so weak that she was unable to set up her TPN before bed. She typically drinks clear liquids, anything more makes her feel too full. Came in today because of persistent symptoms. Denies URI symptoms, chest pain, SOB. Has chronic abdominal pain and nausea not worse than baseline (is on anti-nausea home meds). Has not had many BMs or any diarrhea since FMT transplant on ___. Has chronic lymphedema of both legs, at baseline. In the ED, - Initial Vitals: Pain 10 T 100.8 HR 100 BP 101/66 RR 18 SpO2 99% RA - Exam: Gen: chronically ill-appearing middle-aged woman lying in bed in NAD HEENT: NC/AT, PERRL, oropharynx clear Lungs: CTAB Chest: RRR, no m/r/g, ___ site c/d/i without erythema or swelling Abd: +BS, soft, non-distended, diffusely mildly tender to palpation, no rebound or guarding Back: L CVA tenderness, no rashes or ecchymoses Extremities: warm and well perfused, 2+ pitting edema bilateral lower extremities - Labs: WBC 7.1 Hb 11.2 Plt 114 135 \| 103 \| ___ Gap 11 3.6 \| 21 \| 0.8\ ALT 10 AST 16 AP 53 Tbili 0.5 Alb 3.8 Lactate 0.8 Flu negative UA large leuks, pos nitrates, 46 WBC, sm blood, 6 rbc UA, BCx x2 pending - Imaging: CT A/P w/o contrast 1. No nephrolithiasis or hydronephrosis. 2. No acute abnormality within the imaged abdomen and pelvis within the limitations of this noncontrast enhanced study. - Consults: none - Interventions: 15 mg IV ketorolac 1g Tylenol 1L NS 1g IV cefepime 1L NS Levophed via ___ catheter 1g vanc On arrival to the FICU, pt endorses above history. Reports rigors are most bothersome to her, reminiscent of her last line infection. ROS: Positives as per HPI; otherwise negative. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE ___, has family history of clots. Hypercoagulable workup at ___ reportedly negative - ? mitochondrial disease Social History: ___ Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages ___ and ___. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 101.9 HR 62 BP 132/82 RR 11 99% on RA GEN: ill appearing middle aged woman covered in blankets, rigoring weak voice, in pain NEURO: AAOx3, face symmetric, moves all 4 w purpose EYES: sclerae anicteric, PERRL, EOMI HENNT: oropharynx clear CV: nl rate, reg rhythm, ___ systolic murmur RESP: CTAB GI: hypoactive BS, non-distended, soft, diffusely mildly tender to palpation, no rebound or guarding BACK: +L CVA tenderness SKIN: R upper chest port c/d/i DISCHARGE PHYSICAL EXAM VS: Reviewed in EMR Gen: young woman, appears uncomfortable but NAD Eyes: anicteric, non-injected ENT: MMM, grossly nl OP Abd: soft, non-distend. midly TTP diffusely but improved from prior. NABS. No r/g/rigidity. Ext: WWP, trace b/l symmetric nonpitting edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI, speech fluent PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS ___ 12:14PM BLOOD WBC-7.1 RBC-3.64* Hgb-11.2 Hct-32.8* MCV-90 MCH-30.8 MCHC-34.1 RDW-12.5 RDWSD-41.1 Plt ___ ___ 12:14PM BLOOD Neuts-78.8* Lymphs-10.8* Monos-9.4 Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.56 AbsLymp-0.76* AbsMono-0.66 AbsEos-0.02* AbsBaso-0.02 ___ 03:22AM BLOOD ___ PTT-35.7 ___ ___:14PM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-135 K-3.6 Cl-103 HCO3-21* AnGap-11 ___ 03:22AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.5* ___ 12:14PM BLOOD Albumin-3.8 ___ 12:14PM BLOOD ALT-10 AST-16 AlkPhos-53 TotBili-0.5 ___ 12:14PM BLOOD Lipase-16 ___ 12:22PM BLOOD Lactate-0.8 ___ 03:27PM BLOOD freeCa-1.03* MICRO - CDI PCR+, but toxin negative - likely reflecting collection after tx initiation. - Blood Cultures: no growth - Urine culture: E. coli / Klebsiella KLEBSIELLA PNEUMONIAE \| ESCHERICHIA COLI \| \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 128 R <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=___BDOMEN PELVIS ___ 1. No nephrolithiasis or hydronephrosis. 2. No acute abnormality within the imaged abdomen and pelvis within the limitations of this noncontrast enhanced study. 3. Status post cholecystectomy. TTE ___ The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 66 %. Left ventricular cardiac index is high (>4.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure.No 2D echocardiographic evidence for endocarditis. Brief Hospital Course: ___ hx chronic abdominal issues (SBO, ileus), multiple CDI (s/p FMT ___, chronic TPN with multiple line infections, endometriosis s/p TAH, b/l PE (___) on lovenox, neurogenic bladder s/p sacral nerve stimulator (___), POTS, and suspected mitochondrial disorder originally admitted to ICU with septic shock with urinary source, with subsequent development of severe recurrent CDI and sepsis vs abx induced neutropenia. # Septic Shock # E coli / Klebsiella UTI: Patient was admitted with fever and left flank pain in the setting of several past episodes of urinary tract infections, mostly from pansensitive organisms, in the last 6 months PTA. In the ED she had an acute drop in blood pressure requiring norepinephrine, which were given through her ___ catheter through which she receives chronic TPN. In the ICU, she was continued on vancomycin and cefepime. Norepinephrine was weaned and with IVF administration her pressures improved; subsequently she was transferred to the floor. Blood cultures were negative. TTE ordered for cardiac murmur heard in ICU, but no evidence of vegetations. Urine culture now growing Klebsiella and E. Coli that are near pan-sensitive. Infectious disease was consulted and recommended de-escalation to CTX given micro sensitivities. She rec'd additional days of treatment on the floor and was later discharged home to receive CTX home infusions for an additional 2 days (per ID - shorter course for c/f beta-lactam induced neutropenia) # Recurrent severe CDI: s/p FMT 2 weeks PTA, but after initiation of antibiotics in the ICU she developmed abdominal pain, cramping and frequent diarrhea consistent with her typical CDI. She was empirically started on vancomycin 125mg QID and IV flagyl, and her stool sample was collected 1 day later. CDI test was PCR+ but toxin negative, which per ID consult was likely because sample collected after 2 days treatment. She was discharged to complete a vancomycin taper of 4x/d through ___ then 3x/day through ___, then twice a day until can be seen in ID follow up. ID ___ was moved closer to ___. Please note that discharge worksheet lists patient as taking QID 4x/day for two weeks, however, patient was contacted by phone on ___ and instructed to take vancomycin taper as per ID recommendations listed above. By day of discharge, her abdominal pain and BM frequency was improved # Leukopenia # Neutropenia: Patient developed worsening leukopenia throughout hospitalization. She had no fevers. This was felt to be related to either sepsis, her flagyl, or beta-lactam exposure. Per ID recommendations, flagyl was stopped and CTX to be continued only for 2 additional days after discharge. Patient remained neutropenic on day of discharge, but her clinical course was improving, she was afebrile, and she expressed a strong desire to leave the hospital. She was instructed to seek medical attention for any development of fever, and to have her blood drawn at PCP ___ on ___, the monitor course of neutropenia. Patient education provdided regarding this issues and warning signs discussed. She has good support at home to monitor her for symptoms. # Severe malnutrition: # Malabsorptive syndrome: Pt has Hickman for TPN. Per outpatient GI note, plan was to transition to ___ enteral feeding + po intake vs just po intake. Nutrition was consulted and TPN was continued. # History of unprovoked PE (___): continued home lovenox SC BID # Thrombocytopenia: Likely due to sepsis.. No bleeding sx # QT prolonging medicines: EKG here w QTc 420 # POTS/dysautonomia: consider outpatient f/u neurology # Peripheral neuropathy: continued home gabapentin # ? Mitochondrial disorder: f/u w/ genetics outpatient # Chronic constipation (currently has diarrhea): BM regimen held. Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 10 mg PO QAM 2. BusPIRone 5 mg PO QPM 3. Clotrimazole Cream 1 Appl TP BID 4. Dronabinol 10 mg PO QAM 5. Enoxaparin Sodium 50 mg SC Q12H 6. FoLIC Acid 1 mg PO DAILY 7. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. ondansetron 4 mg oral Q8H 10. Promethazine 25 mg PR Q6H nausea 11. Pyridostigmine Bromide Syrup 60 mg PO TID 12. Thiamine 100 mg PO DAILY 13. Dronabinol 5 mg PO QPM Discharge Medications: 1. CefTRIAXone 1 gm IV Q24H RX ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 g IV DAILY Disp #2 Intravenous Bag Refills:0 2. Vancomycin Oral Liquid ___ mg PO/NG QID RX vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #84 Capsule Refills:0 3. BusPIRone 10 mg PO QAM 4. BusPIRone 5 mg PO QPM 5. Clotrimazole Cream 1 Appl TP BID 6. Dronabinol 5 mg PO QPM 7. Dronabinol 10 mg PO QAM 8. Enoxaparin Sodium 50 mg SC Q12H 9. FoLIC Acid 1 mg PO DAILY 10. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. ondansetron 4 mg oral Q8H 13. Promethazine 25 mg PR Q6H nausea 14. Pyridostigmine Bromide Syrup 60 mg PO TID 15. Thiamine 100 mg PO DAILY 16.TPN Resume home TPN as written by usual outpatient providers ___: Home With Service Facility: ___ Discharge Diagnosis: Acute Recurrent Cdiff Colitis Pyelonephritis Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fever and flank pain, you were found to have an infection in your urinary tract. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - In the hospital, it was determined that you likely had a urinary tract infection causing your symptoms. Due to low blood pressures you were originally in the ICU. Your infection was treated with IV antibiotics. However, you unfortunately developed a recurrence of C. diff and required treatment with IV and oral antibiotics. Dr ___ formulate an antibiotic plan for you while hospitalized. WHAT SHOULD I DO WHEN I GO HOME? - You will have to have your blood drawn by your PCP at your ___ appointment on ___ to make sure that your blood counts have recovered. - Seek immediate medical attention if you develop a fever > 100.4 as your blood counts (neutrophils) are low. - Please take all medications as prescribed and keep all scheduled doctor's appointments. Seek medical attention if you develop a worsening or recurrence of the same symptoms that originally brought you to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern you. It was a pleasure taking care of you! Your ___ Care Team Followup Instructions: ___
10071766-DS-12	10,071,766	25,291,316	DS	12	2163-06-05 00:00:00	2163-06-07 09:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Presyncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old ___ speaking) man with DMII (last A1c 6.9%), HTN, PVD w/claudication who presents s/p a episode of shaking and stiffness (per family) while shopping in ___. Patient was feeling well and had the sudden sensation of feeling shaky, nauseous, and like he was going to pass out. He was ___ up by his family members, did not fall (neg headstrike) and had no LOC. This lasting ROS positive for similar episode ___ years ago but otherwise negative for CP, SOB, palpitations, confusion/change in sensation before/after event. Upon arrival to ___, patient was stable with VS notable for tachycardia to HR100s, sBP 150s. Labs notable for WBC 19 (70% PMNs), HCT 38.0, Cr 1.3, normal LFTs, lipase. Serum tox was negative. CXR showed expansile lesion of the right third posterior rib, CTA neck was negative for high grade lesion. Patient was evaluated by Neurology and recommended admission to medicine for syncope work-up. Vitals on transfer: T98.1 ___ BP132/74 RR19 O2 sat 100% RA On the floor, T98.2 BP 153/78 P99 RR20 O2 sat 100%RA. Patient's family is at bedside and corroborates above story. On ROS, he reports increased urinary frequency over the past few days. He also has had worsening HA in the mornings and snores heavily. Currently, he has no pain. Past Medical History: DIABETES MELLITUS HYPERTENSION GOUT ARM PAIN HEADACHE PERIPHERAL VASCULAR DISEASE ABDOMINAL BRUIT HEART MURMUR CLAUDICATION Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM ================== 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- RRR, III/VI SEM LSB, normal S1 + S2, no rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley, no CVA tenderness Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, ___ LUE strength, 4+/5 RUE strength, ___ over b/l ___ DISCHARGE PHYSICAL EXAM ================== Vitals- T98.2 BP 153/78 P99 RR20 O2 sat 100%RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- RRR, III/VI SEM LSB, normal S1 + S2, no rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley, no CVA tenderness Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, ___ LUE strength, 4+/5 RUE strength, ___ over b/l ___ Pertinent Results: ADMISSION LABS =========== ___ 02:36PM BLOOD WBC-19.2* RBC-4.37* Hgb-11.9* Hct-38.0* MCV-87 MCH-27.4 MCHC-31.4 RDW-13.7 Plt ___ ___ 02:36PM BLOOD Neuts-70.5* ___ Monos-4.2 Eos-2.5 Baso-0.5 ___ 02:43PM BLOOD ___ PTT-29.4 ___ ___ 02:36PM BLOOD Glucose-181* UreaN-29* Creat-1.3* Na-137 K-4.5 Cl-101 HCO3-25 AnGap-16 ___ 02:36PM BLOOD ALT-11 AST-13 AlkPhos-75 TotBili-0.2 ___ 10:52PM BLOOD CK(CPK)-53 ___ 02:36PM BLOOD Lipase-35 ___ 02:36PM BLOOD Albumin-3.9 ___ 10:52PM BLOOD TotProt-6.8 Calcium-9.2 Phos-3.8 Mg-1.4* Iron-30* ___ 10:52PM BLOOD calTIBC-309 Ferritn-72 TRF-238 ___ 10:52PM BLOOD TSH-2.0 ___ 02:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:33PM BLOOD Lactate-1.9 DISCHARGE LABS =========== ___ 06:40AM BLOOD WBC-11.9* RBC-3.96* Hgb-11.2* Hct-34.0* MCV-86 MCH-28.2 MCHC-32.9 RDW-13.6 Plt ___ ___ 06:40AM BLOOD Glucose-144* UreaN-20 Creat-0.8 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-14 ___ 06:40AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.1 CARDIAC BIOMARKERS =============== ___ 02:36PM BLOOD cTropnT-<0.01 ___ 10:52PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:52PM BLOOD cTropnT-<0.01 REPORTS ====== CTA Head & Neck ___ 1. Head CT shows moderate brain atrophy, which is out of proportion to sulci. No hemorrhage. 2. CT angiography of the neck shows 50% stenosis with calcification of the right proximal internal carotid artery with mild calcification and atherosclerotic disease without calcification at the left carotid carotid bifurcation. 3. Patent vertebral arteries. 4. Likely hypoplastic distal right vertebral artery, predominantly ending in posterior inferior cerebellar artery. Otherwise, the intracranial arteries are patent without stenosis, occlusion, or aneurysm greater than 3 mm in size. 5. Soft tissue changes in the maxillary, sphenoid, ethmoid and frontal sinuses with high-density material in the right maxillary sinus suggestive of inspissated secretions and chronic sinusitis. CT Head ___ 1. No acute intracranial process. 2. Paranasal sinus inflammatory disease and bilateral mastoid air cell opacification. CXR ___ 1. No acute cardiopulmonary process. 2. Expansile lesion of the right third posterior rib of indeterminate etiology. Recommend clinical correlation for any history of osseous malignancy (i.e. multiple myeloma) and comparison with prior imaging to assess stability. Brief Hospital Course: ___ ___ speaking-male with PMH DMII (last A1c 6.9%), HTN, HLD, PVD who presenting with presyncope. # Presyncope: CT Head was conducted and negative for intracranial process, Chest X-ray negative for cardiopulmonary process. CT Neck notable for 50-60% stenosis of R carotid artery, 30% stenosis of L carotid, but patent vertebral, basilar, and posterior communicating arteries. Patient had serial cardiac biomarkers sent that were negative and he was monitored on telemetry which was negative for arrhythmia. His blood sugar was monitored and were well-controlled. He was without any symptoms/signs of stroke or seizure. As such, the etiology of his presyncope was thought to be due to hypovolemia. He was also found to have a systolic ejection murmur suggestive of aortic stenosis, which could make the patient more fluid-balance sensitive. He will need an ECHO as an outpatient to further evaluate this. # Acute Kidney Injury: The patient was found to have acute kidney injury with creatinine elevated to 1.3 (baseline 1.0). This improved base to baseline with IV fluids, suggesting a pre-renal etiology. # Leukocytosis: WBC 19 on admission, decreased down to 11 at the time of discharge. Infection was thought to be unlikely given resolution without antibiotics, lack of fever, CBC with normal diff, and CXR and UA without evidence of infection. # Anemia: The patient was found to have mild normocytic anemia of unclear etiology. This will require follow-up as an outpatient. # Hypertension: The patient was monitored and remained stable with sBP 120-150s throughout this admission. His ACEi was held in the setting of acute kidney injury and restarted at the time of discharge after renal function returned to baseline. # DM: The patient's home metformin was held and he was placed on a basic insulin sliding scale during this admission. Metformin was restarted at home dose at the time of discharge. # Peripheral Vascular Disease: Patient was without symptoms of claudication throught this admission. He was started on aspirin 81mg at the time of discharge. ========================================== TRANSITIONAL ISSUES ========================================== - No medications changes made - Found to have a ___ systolic ejection murmur suggestive of aortic stenosis. Given that this may have contributed to his pre-syncopal episode, the patient will need an outpatient ECHO to further evaluate this. - Found to have sinusitis on CT Head/Neck. Please consider ENT evaluation as this may be contributing to his chronic headache. - Found to have CT Neck notable for 50-60% stenosis of R carotid artery, 30% stenosis of L carotid, but patent vertebral, ___, and posterior communicating arteries. Recommend Carotid U/S as outpatient. - Please re-evaluate need for TID metformin (usual dosing is BID) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO TID 2. Enalapril Maleate 20 mg PO DAILY 3. Allopurinol ___ mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Enalapril Maleate 20 mg PO DAILY 3. MetFORMIN (Glucophage) 1000 mg PO TID 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Pre-syncope Acute kidney injury SECONDARY DIAGNOSIS Type 2 Diabetes Mellitus 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 take care of you during this hospitalization. You were admitted to ___ ___ for an episode where you were dizzy and felt like you were going to pass out. We conducted scans of your head that did now show any stroke, bleed, or other concerning findings. A scan of your neck did show some narrowing of your neck vessels that are not currently dangerous but should be further assessed by your PCP. We also conducted blood tests that were negative for a heart attack and showed that your blood sugar levels were normal. You were placed on a heart monitor that did not show any abnormal rhythms. You were found to be dehydrated with some abnormal kidney function. This improved with intravenous fluids. Therefore, we think that the most likely reason for you dizziness episode was dehydration. You were also found have a new heart murmur that may be due to narrowing of one of your heart valves. For this, you will need an ultrasound of your heart. It is VERY important that you call to schedule an appointment with your primary care doctor after you leave the hospital. Please take all your medications as prescribed. Followup Instructions: ___
10071795-DS-14	10,071,795	24,331,732	DS	14	2173-04-23 00:00:00	2173-04-27 13:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid Attending: ___. Chief Complaint: abdominal pain, fever Major Surgical or Invasive Procedure: ___ aspiration of tubo-ovarian abscess History of Present Illness: ___ ___ presenting with 10 day history of abdominal pain as well as fever at home to 101 a week ago. She states she first noted left-sided cramping about 10 days ago, and then developed a sharper right-sided pain a week ago. She feels pain has been constant. She was evaluated by her PCP and diagnosed with a UTI based on U/A, and was treated with course of Bactrim. She also reports increased vaginal discharge recently. She had a PUS done with her OBGYN which was suspicious for a right-sided ___, and was instructed to present to ___ for IV antibiotic treatment. However, she preferred to be treated her and was transferred to our ED. Here, she reports feeling intermittent nausea but has not vomited today or in past week. She denies urinary symptoms. Having regular BMs. No current fevers or chills. No CP, SOB. Continues to feel she is having increased vaginal discharge. She has had recent unprotected sex with a new male partner. Past Medical History: OB History: - ___&C at age ___ GYN History: Menarche age ___. LMP ___, regular menses every 21 days with 8 days of very heavy flow, significant pelvic pain.Denies a history of abnormal Pap smears. Uses condoms for birth control, no hormonal methods. Reports history of self-aborting fibroid at age ___ and history of ovarian cysts. Has genital herpes diagnosed at age ___, infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. Medical Problems: - Asthma, denies intubations or hospitalizations - Liver injury s/p laparoscopic cholecystectomy Surgical History: 1. ___, tonsillectomy. 2. ___, left knee arthroscopy. 3. ___ TAB with D&C 4. In ___, laparoscopic cholecystectomy at ___. 5. In ___, repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. ___ at ___. 6. ___, Operative HSC and myomectomy Social History: ___ Family History: Non-contributory Physical Exam: On day of discharge: T 98.8 PO 101 / 64 70 16 98 `BP `HR `RR`O2 UOP: multiple voids, not measured PE: General: NAD, A&Ox3 Lungs: No respiratory distress, normal work of breathing Abd: soft, nontender, minimally distended, improved from last exam. no rebound or guarding. +BS Extremities: no calf tenderness Pertinent Results: ___ 07:10AM HIV Ab-NEG ___ 07:10AM WBC-8.5 RBC-3.61* HGB-10.5* HCT-31.7* MCV-88 MCH-29.1 MCHC-33.1 RDW-14.4 RDWSD-46.0 ___ 07:10AM NEUTS-65.4 ___ MONOS-7.4 EOS-2.6 BASOS-0.5 IM ___ AbsNeut-5.56 AbsLymp-2.01 AbsMono-0.63 AbsEos-0.22 AbsBaso-0.04 ___ 07:10AM PLT COUNT-305 ___ 07:10AM ___ PTT-32.0 ___ ___ 07:10AM ___ ___ 04:59AM OTHER BODY FLUID CT-NEG NG-NEG ___ 12:20AM URINE HOURS-RANDOM ___ 12:20AM URINE UCG-NEG ___ 12:20AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR* ___ 12:20AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 10:46PM LACTATE-1.0 ___ 10:30PM GLUCOSE-83 UREA N-9 CREAT-1.0 SODIUM-138 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15 ___ 10:30PM estGFR-Using this ___ 10:30PM ALT(SGPT)-18 AST(SGOT)-23 ALK PHOS-99 TOT BILI-0.2 ___ 10:30PM LIPASE-25 ___ 10:30PM ALBUMIN-3.6 ___ 10:30PM WBC-9.7 RBC-3.61* HGB-10.6* HCT-32.0* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.2 RDWSD-46.0 ___ 10:30PM NEUTS-67.6 ___ MONOS-6.2 EOS-1.9 BASOS-0.4 IM ___ AbsNeut-6.52* AbsLymp-2.28 AbsMono-0.60 AbsEos-0.18 AbsBaso-0.04 ___ 10:30PM PLT COUNT-300 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after presenting to the ED with fever and abdominal pain, found to have right-sided ___. On admission, she was started on IV gentamicin and clindamycin. Her post-operative course was uncomplicated. On hospital day 1 she had ultrasound guided pelvic aspiration of the pelvic collection with drainage of 17 mL of complex fluid. Her diet was advanced without difficulty and her pain was controlled with PO dilaudid/Tylenol/ibuprofen. On hospital day2, she was transitioned to PO doxycycline and flagyl. By hospital day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, afebrile and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: 1. Zyrtec p.r.n. 2. Albuterol inhaler p.r.n., asthma attacks. 3. Concerta Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not exceed 4gm per day. RX acetaminophen 500 mg ___ capsule(s) by mouth every six (6) hours Disp #30 Capsule Refills:1 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 12 Days RX doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #24 Capsule Refills:0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity take with food RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:1 4. Metoclopramide 10 mg PO Q8H:PRN nausea RX metoclopramide HCl 10 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 5. MetroNIDAZOLE 500 mg PO BID do not drink alcohol while on this medication RX metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #24 Tablet Refills:0 6. Cetirizine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: tubo-ovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the gynecology service for your abdominal pain and fever and was found to have a tubo-ovarian abscess. You were started on antibiotics and had ___ drainage of the abscess with improvement in your symptoms. Please complete the 2 week course of antibiotics to ensure that the infection completely resolves. Please call the office at ___ with any questions or concerns. Please follow the instructions below. General instructions: Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks until your follow-up appointment * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10072214-DS-7	10,072,214	29,071,979	DS	7	2156-11-22 00:00:00	2156-11-22 16:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: left arm/leg numbness and weakness on awakening Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ left-handed female with a PMHx of DM, HTN, and prior stroke (right-sided numbness and weakness ___ years ago) who presents with left arm/leg numbness and weakness on awakening today. She was in her USOH until she awoke this morning (___) at 6 AM. At that time, she noticed that her left arm and leg were numb. She denies any symptoms yesterday. There were no paresthesias. She did not notice any facial numbness. She tried to get up, and she fell to the floor. She was unable to get up. She scooted on her rear to the bathroom, and she pulled herself up via the vanity to get to the toilet. She notes that she had more movement initially than she does now. She denies any headache, facial droop, or slurred speech. The patient, and her daughter who is at the bedside, denies any changes in her speech including paraphasic errors, inappropriate speech, or difficulty with comprehension. She presented to be ___, where a non-contrast head CT was negative. A CTA head and neck was done which demonstrated left ICA stenosis at the origin with calcified and non-calcified plaques resulting in high-grade >75% stenosis. She was then transferred to ___. Of note, the patient says she had a stroke ___ years ago. At that time she awoke with malaise and "did not want to breathe." She was told that she had depression. Subsequently, she developed right arm numbness. She also had trouble walking, and became weak on her right side. She saw Dr. ___ at ___ and she was told she had a stroke. She is currently on aspirin 81 mg daily, and she denies missing any doses. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus, and hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Diabetes Stroke Hypertension Obesity Hyperlipidemia Social History: ___ Family History: No family history of strokes or other neurological disorders Physical Exam: Vitals: T: ___ P: 70 RR: 20 BP: 150/75 SaO2: 98% on room air General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple No nuchal rigidity. Pulmonary: Lungs CTA bilaterally Cardiac: RRR on monitor Abdomen: Non-distended Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: Please see top of note for NIHSS. -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was 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. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: Mild anisocoria, left 4-->3 mm, right 3-->2 mm. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Left facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and tone. No pronation on right, unable to test on left. No adventitious movements, such as tremor, noted. [___] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 2 3 3 0 0 0 2 3 2 0 0 0 R 5 5 5 5 5 5 5 5 5 5 5 5 Left thumb abduction ___ *Does not sustain All: Represents maximum effort obtained from patient -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: reflexes more brisk on left than right, +crossed abductors and suprapatellar on left, no pectoralis jerks, left toe equivocal, right withdrawal -Coordination: No intention tremor in RUE. No dysmetria on FNF or HKS bilaterally on right. Could not test on left. -Gait: Unable to test. DISCHARGE PHYSICAL EXAM: Neurologic Exam: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was mildly dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: pupils equally reactive to light, 2.5mm->1.5mm. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Mild left facial droop, left eye closure slightly weaker than right IX, X: Palate elevates symmetrically. XII: Tongue protrudes slightly to the left -Motor: Normal bulk and tone. No pronation on right, unable to test on left. No adventitious movements, such as tremor, noted. [Delt][Bic][Tri][ECR][FExt][FFlex][IO][IP][Quad][Ham] L 3 3 0 2 1 2 0 3 3 2 R 5 5 5 5 5 5 5 5 5 5 of note, pt seen to move L hemibody more spontaneously and briskly when not tested on confrontational exam -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS. No agraphesthesia or stereoagnosis. -DTRs: Bi Tri ___ Pat Ach PecJerk CrossAbd L 3 3 3 2 2 - + R 2+ 2+ 2+ 2 1 - - Plantar response was equivocal on left and withdrawal on right -Coordination: No intention tremor in RUE. No dysmetria on FNF or HKS bilaterally on right. Could not test on left. -Gait: Unable to test. Pertinent Results: ___ 04:08PM BLOOD WBC-10.6 RBC-4.63 Hgb-14.0 Hct-41.5 MCV-90 MCH-30.2 MCHC-33.7 RDW-13.1 RDWSD-42.7 Plt ___ ___ 10:05AM BLOOD WBC-7.3 RBC-4.37 Hgb-13.2 Hct-39.8 MCV-91 MCH-30.2 MCHC-33.2 RDW-13.2 RDWSD-43.2 Plt ___ ___ 04:08PM BLOOD Neuts-72.6* ___ Monos-6.0 Eos-0.4* Baso-0.3 Im ___ AbsNeut-7.72* AbsLymp-2.15 AbsMono-0.64 AbsEos-0.04 AbsBaso-0.03 ___ 10:05AM BLOOD Neuts-60.1 ___ Monos-7.2 Eos-1.5 Baso-0.6 Im ___ AbsNeut-4.38 AbsLymp-2.18 AbsMono-0.52 AbsEos-0.11 AbsBaso-0.04 ___ 10:05AM BLOOD ___ PTT-28.2 ___ ___ 10:05AM BLOOD Glucose-308* UreaN-13 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-25 AnGap-17 ___ 10:05AM BLOOD ALT-22 AST-21 LD(LDH)-122 CK(CPK)-49 AlkPhos-94 TotBili-0.3 ___ 10:05AM BLOOD TotProt-6.5 Albumin-3.6 Globuln-2.9 Cholest-243* ___ 10:05AM BLOOD %HbA1c-11.4* eAG-280* ___ 10:05AM BLOOD Triglyc-177* HDL-49 CHOL/HD-5.0 LDLcalc-159* ___ 10:05AM BLOOD TSH-1.4 ___ 06:50AM BLOOD WBC-8.2 RBC-4.68 Hgb-13.8 Hct-42.1 MCV-90 MCH-29.5 MCHC-32.8 RDW-13.2 RDWSD-42.9 Plt ___ ___ 06:50AM BLOOD Glucose-175* UreaN-15 Creat-0.7 Na-135 K-4.3 Cl-100 HCO3-24 AnGap-15 ___ 06:50AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8 ___ Head w/o There is a focus of slow diffusion in the right thalamus extending into the right cerebral peduncle. There is no associated hemorrhage. This region is faintly hyperintense on the FLAIR images suggesting a subacute infarction. Images of the remainder of the brain appear normal. No other areas of infarction are detected. There is no evidence of hemorrhage, edema or masses. The ventricles and sulci are normal in caliber and configuration. ___ No cardiac source of embolism identified. No evidence of right-to-left shunting at the atrial level, assessed by injection of agitated saline contrast at rest and following cough and Valsalva maneuver. Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. Brief Hospital Course: Patient initially presented to ___ with L sided weakness and was seen to have a negative CT/CTA. She was transferred to ___ ED and admitted to the neurology stroke service, where she received screening labs, telemetry monitoring, MRI/MRA, and ___ consultation. U/A revealed likely urinary tract infection, which was promptly treated with IV ceftriaxone for 3 days. Screening labs were significant for elevated HbA1c, elevted total cholesterol, elevated LDL, and elevated triglycerides. MRI/MRA revealed subacute right cerebral peduncle infarction consistent with history and exam findings. Echocardiogram w/ bubble study was negative. For future stroke prophylaxis, pt was started on dual antiplatelet and statin therapies. Pt was discharged to rehabilitation center, with follow up scheduled with Dr. ___ in outpatient stroke clinic for ___. Transition Issues: -Pt will need to continue taking Aspirin and Plavix for 90 days, and then switch to monotherapy with Plavix -Pt will need to continue taking Atorvastatin and Fluoxetine -Pt will need to follow up with Neurology in the 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? () Yes - () No 4. LDL documented? (X) Yes (LDL = 159) - () 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: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Glargine 28 Units Breakfast Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. FLUoxetine 20 mg PO DAILY 4. Glargine 28 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Aspirin 81 mg PO DAILY 6. Lisinopril 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subacute ischemic stroke of the right thalamus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of left arm/leg numbness and weakness on awakening 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: Diabetes Hypertension Hyperlipidemia Previous stroke We are changing your medications as follows: Clopidogrel 75mg DAILY Atorastatin 40mg DAILY Insulin Humalog 6 units with each meal in addition to preexisting Glargine 28 units in morning Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
10072264-DS-18	10,072,264	28,943,956	DS	18	2157-05-16 00:00:00	2157-05-17 19:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: ___ Large Volume Paracentesis History of Present Illness: Ms. ___ is a ___ woman with a history of Child B, MELD 20 cirrhosis of unclear etiology (cholestatic injury, dx'd ___ c/b portal hypertension and refractory ascites requiring weekly paracenteses, insulin-dependent type 2 diabetes, ESRD on HD (___), hypertension, and diastolic heart failure who presents after a fall yesterday ___ lower extremity weakness. No head strike or LOC. She missed HD today as she was too weak to ambulate or travel to appointment. She is scheduled for a therapeutic paracentesis tomorrow. Per daughter, she has had chronic intermittent episodes of emesis and diarrhea over the past several months. Reports decreased appetite and PO intake. Denies fevers but reports chronic chills without rigors. She also reports chronic lower abdominal pain and lower back pain in the setting of ascites. No urinary/bowel retention or incontinence. In the ED, initial vitals were: T 96.9, HR 87, BP 160/96, RR 16, SaO2 100% RA. Labs were HEMOLYZED but notable for: WBC 3.0, H/H 9.9/30.7, plts 146, Na 125, K 5.3, Cl 89, HCO3, AG 15, BUN 58, Cr 6.1, glucose 526, ALT 28, AST 81, AP 211, LDH 697, troponin 0.17. Flu negative. Repeat whole blood K 5, lactate 1.6. Imaging notable for: Negative NCHCT, RUQ ultrasound with Dopplers showed patent vasculature. Diagnostic paracentesis with WBC 28 (0% PMNs, 91% macrophages). Patient was given: 10 units lispro, metoprolol 100 mg, hydralazine 25 mg, and atorvastatin 20 mg On the floor, patient endorses the above history. She states that she has felt weak all over for the past several weeks. ROS: per HPI, denies fever, night sweats, headache, cough, shortness of breath, chest pain, dysuria, hematuria. Past Medical History: 1. Diabetes, on insulin. 2. Hypertension. 3. History of diastolic heart failure. 4. End-stage renal disease on HD. 5. Cirrhosis. 6. History of osteomyelitis. PAST SURGICAL HISTORY: 1. Left arm fistula 2. C-section 3. Right middle toe amputation Social History: ___ Family History: Her uncle passed away of complications of liver disease. He did drink alcohol. There is no other family history of autoimmune disease. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.4, HR 90, BP 158/89, RR 20, SaO2 94% RA, weight 59.4 kg General: Thin Hispanic woman, appears older than stated age, comfortable-appearing HEENT: NC/AT, PERRL, EOMI, oropharynx clear Neck: Supple, no JVD CV: RRR, no m/r/g, normal S1 and S2 Lungs: Breathing comfortably, lungs CTAB Abdomen: Distended with positive fluid wave, umbilical hernia, nontender, no rebound/guarding Ext: Warm and well-perfused, 2+ peripheral pulses, no edema, LUE fistula Neuro: AAOx3, strength normal Skin: Multiple scattered erythematous and hyperpigmented papules with excoriations, some scarring DISCHARGE PHYSICAL EXAM: ======================== VS: Tm 99.3 Tc 97.8 HR 88-101, BP 107-125/52-54, RR ___, 100 RA + orthostatics (130/72->120/64->100/64, w/ ambulation 96/60), asx FSG 222 (eating)--125-270s General: Thin Hispanic woman, pleasant comfortable-appearing HEENT: PERRL, EOMI, oropharynx clear CV: RRR, no m/r/g, normal S1 and S2 Lungs: Breathing comfortably, lungs CTAB Abdomen: appears distended again, with positive fluid wave, soft on palpation, nontender, no rebound/guarding, Ext: Warm and well-perfused, 2+ peripheral pulses, 1+ edema, LUE fistula Neuro: AAOx3, no asterixis. ___ strength bilaterally UE and ___ Skin: Multiple scattered erythematous and hyperpigmented papules with excoriations, appear improved Pertinent Results: ADMISSION LABS: =============== ___ 05:40PM BLOOD WBC-3.0* RBC-3.17* Hgb-9.9* Hct-30.7* MCV-97 MCH-31.2 MCHC-32.2 RDW-14.2 RDWSD-50.5* Plt ___ ___ 05:40PM BLOOD Glucose-601* UreaN-57* Creat-6.0* Na-123* K-6.8* Cl-88* HCO3-20* AnGap-22* ___ 05:40PM BLOOD ALT-28 AST-81* LD(LDH)-697* AlkPhos-211* TotBili-0.5 DirBili-0.1 IndBili-0.4 ___ 05:40PM BLOOD Albumin-2.9* Calcium-8.4 Phos-5.9# Mg-2.4 PERTINENT LABS: =============== Ascites Analysis: 28 ___, ___ RBC, 0 Polys, 9 Lymphs, ___ Monos HbA1c: 12.6 25 VitD: <3.20 Flu PCR negative DISCHARGE LABS: ================ ___ 09:52AM BLOOD WBC-3.7 RBC-3.03* Hgb-9.4* Hct-29.8* MCV-98 MCH-31.0 MCHC-31.5* RDW-13.9 RDWSD-49.5* Plt ___ ___ 09:52AM BLOOD Glucose-186* UreaN-35* Creat-4.0* Na-132* K-4.5 Cl-91* HCO3-30 AnGap-16 ___ 05:37AM BLOOD ALT-17 AST-34 AlkPhos-194* TotBili-0.3 ___ 09:52AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.2 MICRO: ======= ___ Blood culture: pending ___ Peritoneal Fluid: 1+ PMNs, no microorganisms, no growth (final), no growth anaerobic culture IMAGING: ======== CT Head (___): IMPRESSION: No evidence for acute intracranial process. CXR (___): IMPRESSION: No evidence for acute intracranial process. RUQ U/S with Dopplers (___): 1. Patent hepatic vasculature. 2. Persistent sequelae of portal hypertension, including large volume ascites, splenomegaly, and gallbladder wall edema. 3. Coarsened hepatic echotexture compatible with cirrhosis without focal lesion. Brief Hospital Course: Ms. ___ is a ___ woman with PMH Child B, MELD 21 (___) cyptogenic cirrhosis(dx ___ c/b refractory ascites), insulin dependent type 2 diabetes, HTN, chronic dCHF, and ESRD on HD (___), presenting for evaluation of weakness, vomiting, and increased sleepiness/confusion. #Weakness.Fall: patient presented for worsening weakness for about 2 weeks, with no acute precipitant, who now presents after sustaining a fall and missing her dialysis session. She has had a prior admission with malnutrition, at that time requiring tube feeds and overall having lost ___ lbs since her dialgnosis of cirrhosis. Pt was thin on admission with large ascites with no evidence of encephalopathy. There was no indication of a syncopal event, but patient's blood pressures were noted to be lower than average, and very tightly controlled on her current blood pressure regimen. Patient was orthostatic albeit asymptomatic when working with physical therapy. Her fall appeared to be largely mechanical given large ascites, with symptoms much improved after having a 8L paracentesis. Her weakness is also likely from poor nutrition, hyperglycemia (as adressed below), and low vitamin D (undetectable level). Infectious workup was negative. Given relative confusion reported by family (no asterixis on exam), patient was trialed on lactulose during the hospitalization, but with no new changes, this was discontinued. Patient's blood pressure regimen was also changed as below. She was started on Vitamin D 5000 u, 2/week. She also reported diarrhea with nepro supplementation, so psyllium was added to help with her stool consistency. She felt well on discharge, and was scheduled for 2/week paracentesis, to be done ___ at ___ ___. # Insulin dependent diabetes type 2 with nephropathy, retinopathy, and neuropathy: At home takes Lantus 14 qam and 18 qpm with humalog during meals. Her blood sugars were elevated to 500s-600s in the ED. Labs were not consistent with DKA (no AG acidosis). Per patient, she has been taking her insulin and blood sugars at home are in 100s. However, her home regimen was continued inpatient with relatively good sugars. Prior A1c was noted to be 8.8, on repeat testing, elevated to 12.6. Patient was educated on insulin compliance, continued on a diabetic diet. She was given insulin pen injections to ease with compliance as well as reinstating ___ care to help with medication management. # Diarrhea: Patient had frequent diarrhea, light brown in color, likely exacerbated in house with lactulose administration and also side effect of nepro. Previously, she had underwent a colonoscopy that showed no evidence of masses or visible erythema. # Cryptogenic Cirrhosis: Patient diagnosed with cirrhosis in ___, Childs class B8. MELD 20 (mostly ___ ESRD). Her liver biopsy reported to show mild lymphoplasmacytic infiltrates with focal periportal inflammation and interface hepatitis and mild lobular injury. There was evidence of early cirrhosis, focal bile duct injury with bile duct proliferation. She has no history of HE, not on lactulose or rifaximin. Grade I-II varices on last EGD, not on nadolol due to renal failure. RUQ ultrasound with Dopplers showed patent vasculature. She received paracentesis as above. She was scheduled with transplant followup. # ESRD on HD ___: Initially missed on day, was resumed on home schedule. # Hypertension: Pt had SBP up 200 on prior admission, however on current admission, SBP ranged from 100-140, with positive orthostais. Home lisinopril and hydralazine were discontinued. Patient to follow up with PCP for further medication titration. Home metoprolol was continued. CHRONIC ISSUES ---------------- # GIB/VARICES: No history of GIB in the past. Had endo/colonoscopy which was negative for varices. EGD on ___ showed grade I-II varices. She was not started on nadolol given renal failure. # Hyperlipidemia: continued atorvastatin 10mg daily TRANSITIONAL ISSUES: ==================== -Patient's daughter (___) to call ___ for 2/week paracentesis (___), prescription provided -Patient would benefit from increased supervision and diabetes education regarding insulin administration. Her insulin dosing seems adequate and sugars were well controlled in the hospital with her home regimen. -Patient noted to be vitamin D Deficient, may be contributing to her weakness, started on Vitamin D 50,000 Units oral 2 times a week (___). Please follow up vitamin D level as clinically appropriate. -Patient noted to be orthostatic (although asymptomatic) with BPs in 100s, on Hydralazine and Lisinopril. These were discontinued to assess her baseline pressure. Her discharge blood pressure regimen is: -Please continue Nepro supplementation for nutrition (3 shakes a day), added Metamucil given reported diarrhea to help bulk her stools -Full Code -Contact: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 10 mg PO DAILY 2. Metoprolol Tartrate 100 mg PO BID 3. Ursodiol 500 mg PO DAILY 4. HydrALAzine 25 mg PO TID 5. Atorvastatin 10 mg PO QPM 6. Glargine 14 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Tartrate 100 mg PO BID 3. Ursodiol 500 mg PO DAILY 4. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY 5. Outpatient Lab Work Please do paracentesis twice a week ___ and ___ ICD 9: R18 6. Sarna Lotion 1 Appl TP TID RX camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply as needed for itching Refills:0 7. Vitamin D ___ UNIT PO 2X/WEEK (MO,TH) RX ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth Two times a week Disp #20 Capsule Refills:0 8. Glargine 14 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 14 Units before BKFT; 18 Units before BED; Disp #10 Syringe Refills:3 RX insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 12 Units QID per sliding scale Disp #5 Syringe Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: -Hepatic Ascites -Hyperglycemia/Diabetes type II -Decompensated Cryptogenic Cirrhosis, Childs Class B -Nutritional Deficiency/Vitamin D Deficiency -Hypertension -End Stage Renal Disease on Hemodialysis 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 feeling worsening weakness and nausea. We think this was likely from a lot of fluid in your stomach and having high sugars from your diabetes. We took out a large amount of fluid and put you on your home insulin scale. Your sugars were better controlled in the hospital on the same doses as your home. We would recommend getting new insulin supplies and making sure you are taking your medicine correctly, as high sugars can also make you very tired. Please continue taking your Nepro shakes three times a day to make sure you get enough energy. You can use metamucil to help you with your diarrhea. It is VERY Important that you go to ___ for your paracentesis (taking fluid out from your stomach) on ___ and ___. We wish you the best Your ___ care team Followup Instructions: ___
10072799-DS-22	10,072,799	28,944,995	DS	22	2137-01-31 00:00:00	2137-01-30 19:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right arm movement, facial twitching, stuttering speech. Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a ___ year-old left-handed woman with history of migraine, gastritis, chronic constipation and recent admission to the neurology service for headache and right arm parasthesias and pain attributed to cervicogenic headache, following an extensive workup, who presents today with 2 day history of a constellation of symptoms, including worsening headache, right facial spasms, right arm tremors, and increased emotional lability. History provided by patient, husband and sister at the bedside, as well as review of records. Ms. ___ was recently hospitalized ___ on the Neurology service with a 5 day history of fluctuating headache, lightheadedness, intermittent blurry vision and right arm pain and parasthesias. She had an extensive workup. This included CTA and MRI of the brain w/ and w/o contrast which were unremarkable, with no evidence of infarct, neoplasm, or mass effect. MRI C-spine notable for mild-to-moderate canal narrowing at C5-C6, which may have contributed to headache and sensory symptoms. Lumbar puncture on ___ was unremarkable (WBC 1, RBC 0, total protein 20, glucose 57, MS profile with no oligoclonal bands, CSF gram stain and culture negative). Following the LP there was concern for post-dural puncture headache versus spontaneous intracranial hypotension, as she reported new retro-orbital headaches that were relieved while supine and exacerbated while sitting, suggestive of post-dural puncture headache. These episodes were also associated with nausea. Given that there also had been a postural component to her headaches before admission (improved with lying down), it was uncertain if she had spontaneous intracranial hypotension that coincidentally worsened after the LP, or if this was a post-LP HA (or possibly both). Patient underwent placement of an epidural blood patch by anesthesia for relief of her symptoms. By the time of discharge, her symptoms responded to management with Fioricet, and recommendations were made to use a soft cervical collar at bedtime; gabapentin was also initiated to relieve paresthesias, with plan for titration by patient's outpatient neurologist. Fioricet was prescribed for as-needed use in the interim, which patient has been taking since discharge as prescribed. Since discharge on ___, patient has had a constellation of neurologic symptoms. On ___, in the evening following discharge, she reported an ongoing headache, consistent with her semiology described during admission. It was severe, but improved after taking her gabapentin and fiorcet, and she was able to sleep through the night. On that evening, however, she did find out the unfortunate news that a family friend had passed away (her aunt's daughter), whom Ms. ___ was very close to. This family friend had been ill for some time, so the death was not unexpected. However, it was especially distressing to her because her aunt did not contact anyone about the death, and she felt like it was being concealed. When the patient woke up on ___, her headache head improved. Her husband notes that her walk was somewhat unsteady at that time but the patient denied it, and was still able to walk household distances without falling or needing to hold onto objects. In the late afternoon, she began to have several new issues: 1) episodes of right arm tremor and higher amplitude movements. Her husband recorded this on video, which I reviewed. It consisted of non-rhythmic movements of the right arm, irregular in frequency, with maintained alertness. At times it appeared more like a right arm tremor and at other times it was more like nonrhythmic shaking. Patient reports that during this event, she was fully alert and aware of her arm doing it. She could suppress the movements somewhat if she concentrated, and her sister could suppress them with touching. Duration lasted anywhere from a few minutes to 10 minutes or more. She had several episodes of this over the course of the evening. 2) episodes of right face "spasm." Also recorded on video, this consisted of twitching of the right lower face, intermixed with puckering of the lip. This appears somewhat like right hemifacial spasm versus tardative dyskinesias (though it only affects the right side of the face). As with episode #1 above, could last anywhere from a few minutes to 10 minutes or more. 3) episodes of "word finding" difficulty. Patient had periods when she seemed to have difficulty expressing herself, lasting for only a few seconds at a time (never more than this). For example, when her husband asked her if she wanted to go outside to get some fresh air, she said "Lets go oo--" and unable to finish saying "out." They cannot think of any other examples of this. She had no difficulties understanding speech and still could express a few words. Sometimes when she seemed to think of a word, her eyes would "roll back" for a second or two. She otherwise was at her baseline. She contacted her Dr. ___ who recommended that she return to the Emergency Department for further evaluation, but patient declined. As these events occurred overnight, the patient woke up today (___) with no further episodes of semiologies 1 and 2. She woke up and her headache had resumed. She went to lie down and took a nap until 1:30PM. When she woke up at 1:30PM, she reported feeling "a heavy depression." She said she felt sad, though not at any one particular thing, which her husband says is typical for her. She did not mention anything about the recent passing of the family friend. She called her husband on the phone (who works as a ___ and was at work) and appeared "emotionally labile." Husband notes that she would alternate between having a "baby voice" and seeming juvenile, to crying and shouting. She was making sense while talking, and discussed her headaches. He was concerned and soon went back home, where he found her sitting on the swing, talking to EMS. Currently, patient reports she feels back to her baseline apart from ___ headache, and is anxious to be discharged from ED to go back home. Her husband notes that she still is off from her baseline, intermittently with emotional lability and "not quite with it." Past Medical History: Cervicogenic headaches s/p recent epidural patch for ?spinal headache Gastritis Chronic constipation Social History: ___ Family History: Mother with ischemic stroke at age ___. Physical Exam: ADMISSION EXAM Vitals: T 98.6F, HR 90, BP 136/90, RR 22, O2 99% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused; regular on telemetry Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert. Intermittently becomes tearful (typically when discussing topics that are distressing for her such as the loss of her family friend, and having to return to the hospital), acts somewhat juvenille, resolves after reassurance. Oriented to self, place, time and situation. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. Reports mood is "kind of sad." Denies SI, HI. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Mild R arm postural tremor. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Discharge examination unchanged from above. Pertinent Results: ___ 07:20AM BLOOD WBC-3.3* RBC-3.94 Hgb-9.9* Hct-32.1* MCV-82 MCH-25.1* MCHC-30.8* RDW-12.7 RDWSD-37.5 Plt ___ ___ 07:20AM BLOOD ___ PTT-30.6 ___ ___ 07:20AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-143 K-4.5 Cl-109* HCO3-21* AnGap-13 ___ 07:20AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8 ___ 05:56PM URINE Color-PINK* Appear-Clear Sp ___ ___ 05:56PM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 05:56PM URINE RBC->182* WBC-2 Bacteri-NONE Yeast-NONE Epi-3 TransE-<1 ___ 05:56PM URINE UCG-NEGATIVE ___ 05:56PM URINE bnzodzp-NEG barbitr-POS* opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 11:07AM CEREBROSPINAL FLUID (CSF) PARANEOPLASTIC AUTOANTIBODY EVALUATION, CSF-PND ___ 11:07AM CEREBROSPINAL FLUID (CSF) NMDA RECEPTOR AB, CSF-PND CT HEAD W/O CONTRAST No acute intracranial abnormalities. However, please note that acute ischemic changes are better detected on MRI. Brief Hospital Course: 1. Unspecified mood disorder: Patient and her husband noted a constellation of symptoms, including suppressible, non-rhythmic movements of the right upper extremity, intermittent voluntary right-sided facial grimacing, and intermittent speech, all captured on video. These findings were not clearly stereotyped, not associated with a change in mental status, and not associated with a post-ictal state, with no clear metabolic, infectious, or ischemic processes noted on testing and imaging, together reducing suspicion for seizures. Given onset of symptoms two days prior to presentation, the absence of ischemia on non-contrast head CT also argued against new infarct as contributor to patient's symptoms, particularly in light of negative brain MRI with and without contrast less than a week prior to presentation. Given patient's recent headaches and behavioral change, an autoimmune encephalitis panel (in addition to a paraneoplastic panel) were requested from CSF obtained during the most recent admission. Given the absence of a convincing neurologic etiology for patient's symptoms, patient was evaluated by the Psychiatry service, who suspected an unspecified mood disorder or possible panic disorder; consideration was also given to underlying conversion disorder or histrionic personality disorder. Recommendations included discontinuation of gabapentin, initiation of clonazepam as bridging therapy to outpatient psychiatric care, and referral for an outpatient psychiatric provider. A referral number was provided to the patient for an outpatient psychiatry NP with intake planned for within one week of discharge. In addition to the above changes, as-needed sumatriptan was prescribed for migraine headaches, with as-needed lorazepam for severe panic episodes not responding to reassurance and redirection (which patient's husband and family have been comfortably able to provide at home). As noted above, these medications will need to be reviewed by patient's outpatient psychiatry provider on ___. Neurology ___ was maintained as scheduled, with recommendation for PCP ___ in one week. Medications on Admission: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache 2. Gabapentin 100 mg PO QHS 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 4. Bisacodyl ___ mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Psyllium Powder 1 PKT PO QHS 7. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Medications: 1. ClonazePAM 0.5 mg PO BID Duration: 7 Days Do not drive or operate heavy machinery on this medication. RX clonazepam 0.5 mg 1 (One) tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 2. LORazepam 0.5 mg PO Q8H:PRN Severe panic attacks Duration: 7 Days Do not drive or operate heavy machinery while on this medication. RX lorazepam 0.5 mg 1 (One) by mouth every eight (8) hours Disp #14 Tablet Refills:0 3. Sumatriptan Succinate 25 mg PO Q6H:PRN Migraine headache Duration: 7 Days ___ take a second dose if no relief after 2 hours. No more than 8 doses per day. RX sumatriptan succinate 25 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #28 Tablet Refills:*0 4. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache 5. Bisacodyl ___ mg PO QHS 6. Omeprazole 20 mg PO DAILY 7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 8. Psyllium Powder 1 PKT PO QHS 9. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Disposition: Home Discharge Diagnosis: Mood disorder, not otherwise specified. 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 evaluation of right arm movements, right facial twitching, and stuttering speech for two days. A CT scan of your head did not show signs of a new stroke, and your neurologic examination remained stable without new concerning findings. You were seen by the Psychiatry service, who felt that your symptoms were due to a mood disorder and possibly panic attacks. They recommended stopping one of your medications (gabapentin) and starting a new medication (clonazepam) to manage your anxiety; they also felt strongly that you would benefit from seeing a psychiatry provider outside of the hospital. You also received new prescriptions for medications for your headache (sumatriptan) and as-needed medication (lorazepam) for severe panic attacks until you are seen in ___. Please follow up with your primary care provider within one week of discharge. Please also follow up with Dr. ___ at your appointment listed below; she can follow up on tests sent from your spinal fluid obtained during your last hospital stay. Please also call Anadyne Psychotherapy at ___ to schedule an intake assessment within one week of discharge to follow up on your mood symptoms. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___
10072945-DS-14	10,072,945	24,421,237	DS	14	2114-02-18 00:00:00	2114-02-18 17:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHX COPD, HTN, CAD, HLD sent in from clinic with SOB and wheezing in the setting of positive influenza B swab last week. The patient began to feel poorly on ___. She was having congestion, non-productive cough, headache, malaise, shortness of breath. No fever, but had night sweats. She presented to her PCP's office on ___ at which time she tested postive for influenza B. CXR was negative. Was started on tamiflu and prednisone burst 40mg x5 days for COPD flare. She felt better for a few days after starting therapy, however, then began feeling poorly again. She says the congestion has resolved, but is having shortness of breath with exertion, headache, and persistent cough. She went to her PCP's office today, at which time her peak flow was reportedly (by ED's notes) 50. She was referred to ___ for further management. In the ED, initial vs were: 97.6 99 166/72 18 96% ra. Labs were remarkable for WBC 8.5, lactate 2.0, normal chem 7. CXR w/o acute process. Patient was given albuterol and ipratropium nebs x2, azithromycin 500mg, and 40mg prednisone. Vitals on transfer: 85 140/70 22 95% RA. Past Medical History: Hypertension, essential Coronary artery disease Hypercholesteremia COPD (chronic obstructive pulmonary disease) Depression Osteoporosis Social History: ___ Family History: Mother died of lung cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.2 BP: 149/80 P: 100 R: 20 O2: 94% RA General: Alert, oriented, no acute distress, breathing comfortably w/o accessory muscle use HEENT: PERRL, No nasal erythema, normal oropharynx w/o erythema, no LAD Lungs: Mild inspiratory and expiratory wheezing in all lung fields, prolonged expiratory phase CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, no edema Skin: No rashes Neuro: Grossly intact DISCHARGE PHYSICAL EXAM: VSS, 100% RA General: well appearing female, comfortable HEENT: PERRL, MMM CV: RRR no m/r/g Lungs: CTAB, no wheezing, good air movement Abd: soft, NTP, ND, NABS Ext: no edema Pertinent Results: ADMISSION LABS: ___ 11:50AM BLOOD WBC-8.5 RBC-4.05* Hgb-13.2 Hct-39.7 MCV-98 MCH-32.7* MCHC-33.3 RDW-12.9 Plt ___ ___ 11:50AM BLOOD Neuts-58.3 ___ Monos-5.9 Eos-0.7 Baso-0.6 ___ 11:50AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-136 K-3.4 Cl-93* HCO3-28 AnGap-18 ___ 12:04PM BLOOD Lactate-2.0 DISCHARGE LABS: ___ 08:40AM BLOOD WBC-14.3* RBC-4.01* Hgb-13.3 Hct-39.5 MCV-99* MCH-33.1* MCHC-33.6 RDW-12.6 Plt ___ ___ 08:40AM BLOOD Glucose-95 UreaN-15 Creat-0.7 Na-133 K-3.9 Cl-92* HCO3-31 AnGap-14 MICRO: Blood culture ___: NGTD Urine culture ___: no growth STUDIES: CXR ___: FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. The lungs appear clear. There is no pleural effusion or pneumothorax. The chest is hyperinflated. Mid thoracic interspaces are mildly narrowed. Very small anterior osteophytes are visible throughout the thoracic spine. IMPRESSION: No evidence of acute cardiopulmonary disease. Hyperinflation. CXR ___: As compared to the previous radiograph, the lung volumes remain high, likely reflecting overinflation. However, there is no other parenchymal abnormality, notably no evidence of pneumonia or pulmonary edema. The size of the cardiac silhouette is normal. Mild scoliosis of the thoracic spine. Causes asymmetry of the ribcage. Normal hilar and mediastinal structures. CTA chest ___: IMPRESSION: 1. No pulmonary embolism. 2. Bilateral centrilobular nodules, concerning for aspiration or multifocal pneumonia. 3. Centrilobular emphysema. Echocardiogram ___: The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF = 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Brief Hospital Course: ___ F with history of COPD, HTN, CAD, HLD and recent influenza infection presents with COPD exacerbation ACUTE ISSUES: # COPD exacerbation: Pt with ongoing SOB for about a week prior to admission, did not respond to outpatient tamiflu and prednisone course. Presented with ongoing SOB likely due to refractory COPD exacerbation given recent viral infection, wheezing on exam, and history of COPD. CTA chest negative for PE. Echocardiogram was normal. CT showed small bibasilar opacities, however there were no fevers or initial white count concerning for infection. She was treated with prednisone, azithromycin, nebulizers, and cough medications. She improved symptomatically and was discharged on a prednisone taper. She should follow up with her PCP and pulmonologist at discharge. CHRONIC ISSUES: # HTN: Patient on amlodipine and enalapril at home, continued # Depression: Continued fluoxetine # Leg spasms: Continued gabapentin qhs TRANSITIONAL ISSUES: - Continue prednisone according to taper instructions - Follow up with PCP and pulmonologist after discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluoxetine 20 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Gabapentin 300 mg PO HS 5. Amlodipine 5 mg PO DAILY 6. Enalapril Maleate 5 mg PO DAILY 7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 8. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Enalapril Maleate 5 mg PO DAILY 4. Fluoxetine 20 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 6. Gabapentin 300 mg PO HS 7. Tiotropium Bromide 1 CAP IH DAILY 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 9. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough RX codeine-guaifenesin [Guaifenesin AC] 100 mg-10 mg/5 mL 5 mL by mouth every six (6) hours Refills:0 10. PredniSONE 40 mg PO DAILY Duration: 3 Days Start: Tomorrow - ___, First Dose: First Routine Administration Time RX prednisone 10 mg Four tablet(s) by mouth daily Disp #22 Tablet Refills:*0 11. PredniSONE 20 mg PO DAILY Duration: 3 Days Start: After 40 mg tapered dose 12. PredniSONE 10 mg PO DAILY Duration: 3 Days Start: After 20 mg tapered dose Discharge Disposition: Home Discharge Diagnosis: COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay. You were admitted for shortness of breath due to a COPD flare. You were given predisone, inhalers, and antibiotics. CT chest and echocardiogram were unremarkable. You improved and by discharge were feeling much better. Please continue the prednisone according to the taper instructions. We wish you the best! Your ___ care team Taper instructions: 40mg prednisone ___, 20mg ___, 10mg ___ then stop Followup Instructions: ___
10073182-DS-6	10,073,182	23,441,084	DS	6	2134-11-02 00:00:00	2134-11-02 16:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: ___, vomiting, dehydration, fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male w/PMH of DVT on warfarin secondary to Factor V Leiden who complains of vomiting, diarrhea, fall. He reports that his symptoms began ___ or ___ of this week, just after his wife became sick with vomiting and diarrhea. He vomited for approximately one day, and had diarrhea that continued until ___. He sustained a fall on ___, but has been able to ambulate since, though his pain persists. He though his diarrhea had gotten better, but it persisted and he was unable to eat, so he presented to the ED along with his wife. No other known sick contacts. His wife has had 2d of vomiting w/out fevers or chills. She has vomited more than 20 times. Today he developed the same vomiting and multiple episodes of diarrhea. They have both been having trouble keeping food down. They have no other sick contacts. TOnight he fell out of bed and may have struck his head. He has pain in his lumbar spine at the site of a prior spine fracture. He has walked since and denies new sensory changes (has chronic tingling in LEs), urinary retention or incontinence or fecal incontinence. He denies fevers, chills, chest pain, shortness of breath or headache. In the ED, initial vitals: 98.3 101 118/67 18 100% RA - Exam notable for: midline lumbar spine tenderness without deformity - Labs notable for: BUN/Cr 35/2.1, INR 2.3, stable H/H and WBC of 10, 49 hyaline casts on U/A otherwise unremarkable - Imaging notable for: CT head w/o contrast with no acute process, CT C-spine w/o contrast with no fracture or malalignment, CT L-spine w/o contrast with chronic L2 compression fracture and stable 3 cm infrarenal aneurysm and no acute fracture - Pt given: 4L NS over 14 hrs, 1 g APAP x 2, 2 mg IV morphine x 3 then 5 mg oxycodone 6 AM, zofran 4 mg x 2 He was initially observed overnight. In the AM his Cr remained at 1.9 and he was still have significant nausea and back pain so he was admitted for further management. His wife, who has ___ and reported dementia was able to be transferred to rehab. - Vitals prior to transfer: 99.5 94 108/67 18 94% RA On arrival to the floor, pt reports that he is not feeling well. Denies current nausea, chest pain or pressure, abdominal pain, pre-syncope, loss of sensation or motor function. Endorses ongoing back pain without fecal incontinence or urinary retention. Past Medical History: GASTROESOPHAGEAL REFLUX HYPERCHOLESTEROLEMIA HYPERTENSION LEG CRAMPS LOW BACK PAIN - chronic C2 compression fracture MICROSCOPIC HEMATURIA, w/u negative PROSTATE CANCER, s/p hormones and xrt, followed by Dr. ___ ABUSE ULCER DEEP VENOUS THROMBOSIS FACTOR V LEIDEN APPENDECTOMY in ___ Social History: ___ Family History: Mother ___ ___ PANCREATIC CANCER STROKE Father ___ ___ CORONARY ARTERY DISEASE Sister CORONARY ARTERY DISEASE Brother CORONARY ARTERY DISEASE Physical Exam: ADMISSION PHYSICAL EXAM: ==================== Vitals- 98.3 139/68 108 20 98% RA General- Alert, oriented, uncomfortable HEENT- Sclerae anicteric, MM dry Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, intact pulses with no edema Neuro- motor function in lower extremity normal though limited by pain, no focal weakness, no saddle anesthesia DISCHARGE PHYSICAL EXAM: ==================== Vitals- 98.6 ___ 18 94%RA General- Alert, oriented, NAD HEENT- Sclerae anicteric, MM dry Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, intact pulses with no edema Neuro- motor function in lower extremity normal though limited by pain, no focal weakness, no saddle anesthesia Pertinent Results: ADMISSION LABS: ============== ___ 10:53PM BLOOD WBC-10.0# RBC-3.77* Hgb-11.9* Hct-35.1* MCV-93 MCH-31.6 MCHC-34.0 RDW-18.3* Plt ___ ___ 10:53PM BLOOD Neuts-88.8* Lymphs-4.8* Monos-5.9 Eos-0.2 Baso-0.3 ___ 10:53PM BLOOD ___ PTT-29.4 ___ ___ 10:53PM BLOOD Glucose-135* UreaN-35* Creat-2.1* Na-140 K-4.3 Cl-95* HCO3-27 AnGap-22* ___ 10:53PM BLOOD Calcium-9.4 Phos-4.8# Mg-1.9 PERTINENT LABS: ============== ___ 07:25AM BLOOD Glucose-85 UreaN-25 Creat-1.2 Na-135 K-3.7 Cl-102 HCO3-24 AnGap-13 ___ 07:28AM BLOOD ___ PTT-35.5 ___ DISCHARGE LABS: ============== ___ 07:13AM BLOOD WBC-3.9* RBC-2.85* Hgb-9.0* Hct-25.7* MCV-90 MCH-31.8 MCHC-35.2* RDW-18.4* Plt ___ ___ 07:13AM BLOOD ___ PTT-38.2* ___ ___ 07:13AM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-138 K-3.5 Cl-102 HCO3-26 AnGap-14 ___ 07:13AM BLOOD Calcium-7.5* Phos-2.1* Mg-2.0 IMAGING: ============== CT C-spine: No fracture or traumatic malalignment. CT head: No acute intracranial process CT L-spine: 1. Approximately 40% loss of height at the superior endplate of the L2 vertebral body, increased slightly when compared to prior CT from ___, and the lumbar spine radiographs from ___. No retropulsion into the spinal canal. 2. Stable 3 cm infrarenal abdominal aortic aneurysm. ___ portable CXR IMPRESSION: As compared to ___ radiograph, bilateral interstitial opacities affecting the left lung to a greater degree than the right have worsened, and may reflect asymmetrical edema or atypical pneumonia. Small left pleural effusion is also evident. No other relevant changes. MICROBIOLOGY: ============== ___ Urine culture: No significant bacterial growth ___ Blood culture x 2: no growth to date ___ Blood culture x 2: no growth to date Brief Hospital Course: ___ with h/o DVT due to factor V leiden on coumadin who presents with vomiting, diarrhea and dehydration likely from viral gastroenteritis and fall secondary to likely dehydration with no acute neurologic symptoms. # Viral gastroenteritis: Contracted from wife, who likely contracted it during healthcare visits the week prior to presentation. Manifested with fevers, nausea and emesis that improved quickly, and diarrhea. These symptoms led to dehydration and weakness, contributing to kidney injury and fall. Symptoms improved with nausea management and aggressive hydration, diet was advanced. No other evidence of alternative infectious process while inpatient. # Fall: Secondary to dehydration, weakness and in setting of chronic lower back pain. No neurologic deficit, CT L-spine with chronic L2 fracture and loss of height but no retropulsion into spinal cord. Patient provided with oxycodone, tylenol, diazepam and lidocaine patch. He refused to work with physical therapy. # Acute kidney injury: Pre-renal given viral gastroenteritis. Resolved with aggressive hydration. HCTZ held in setting of dehydration, and was continued to be held on day of discharge given not hypertensive and eating and drinking not back to baseline. TRANSITIONAL ISSUES: =================== - continued improvement in PO intake - needs close PCP ___ for trending symptoms - consider social work support for family as patient is caretaker for wife who has ___ - Patient had three night hospital stay for back pain and was recommended to accept rehab placement which was refused. So if returns to ED, can consider transfer to rehab if no acute medical issues - HCTZ held on discharge as patient was still normotensive - was anemic in hospital and had high INR, was given script to recheck on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 5 mg PO QHS:PRN spasm 2. Hydrochlorothiazide 25 mg PO DAILY 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Losartan Potassium 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO QPM 7. Warfarin 5 mg PO DAILY16 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID Discharge Medications: 1. Diazepam 5 mg PO QHS:PRN spasm 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Losartan Potassium 50 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 40 mg PO QPM 6. Warfarin 5 mg PO DAILY16 Please hold dose on ___. Acetaminophen 1000 mg PO Q8H:PRN pain RX acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth every 8 hours Disp #80 Tablet Refills:0 8. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #60 Tablet Refills:0 10. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth daily Disp #20 Packet Refills:0 11. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #30 Tablet Refills:*0 12. Outpatient Lab Work Please check INR, CBC on ___ ICD-9 285.0 Please fax to ___ ___, ___ ___ 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: viral gastroenteritis dehydration acute kidney injury mechanical fall musculoskeletal back 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 Mr. ___, It was a pleasure participating in your care while you were inpatient at ___. You were admitted with viral gastroenteritis and dehydration that led to a fall. Fortunately you did not suffer any new fractures or neurologic complaints. We supported you with fluids and nausea management, and your ability to eat and drink improved. You had significant back pain, which was managed with opiates, muscle relaxants. You were recommended to go to rehab which you refused against medical advice. Your INR on day of discharge was high at 4.2. Please hold your Coumadin today, and get your INR rechecked tomorrow ___. You also had low blood counts, please get your blood count checked tomorrow ___. Please stop your HCTZ until you see Dr. ___ ___ she says it is ok to restart. We wish you and your wife the best, Your ___ team Followup Instructions: ___
10073248-DS-17	10,073,248	20,220,513	DS	17	2183-07-20 00:00:00	2183-07-22 11:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: anasarca, proteinuria, hematuria Major Surgical or Invasive Procedure: None performed. History of Present Illness: HISTORY OF THE PRESENTING ILLNESS: Mr ___ is a ___ year old man with a history of prostate cancer s/p radical prostatectomy in ___ who presented to the ___ ED with leg swelling. Over the past several months, he has noticed gradual worsening bilateral lower extremity edema. Additionally, he started taking more ibuprofen, up to 8/day as he works ___. He was not entirely sure if the swelling started before or after he started taking more NSAIDs. Eventually, he was evaluated by his primary care doctor and referred to the ___ clinic at ___ and has an appointment scheduled in ___. He has been trying compressive stockings. Today his wife noticed that his arms were swollen so brought him to the ER. He also reported that he felt like his eyes were becoming puffy. He denies any fevers, chills, chest pain, dyspnea, abdominal pain, nausea, emesis, constipation, diarrhea, change in urination or dysuria. He has noticed an increase in blood pressure recently. His wife notes that he also had a "kidney scan" 2 months ago that was told was normal. Patient gets all of his care at a clinic in ___, so outside records are unavailable for comparison at time of admission. In the ED, initial vitals were: Temp: 97.8 HR: 79 BP: 193/105 Resp: 16 O2 Sat: 99% RA Exam notable for: Bilateral lower extremity pitting edema to upper thigh, bilateral hand edema; skin is absent of lesions, lacerations, rashes Labs notable for: -H/H 11.7/ 34.7 -UA: - Leuk, + Prot. and Glu, 7 RBC and 7 WBC -BUN/CR: ___ Gluc 124, and Alb 1.7, ALT, AST, AP WNL Imaging was notable for: -Prelim read of Renal U/S: Normal renal ultrasound Patient was given: -Labetalol 100mg PO Upon arrival to the floor, patient reports that he has no new symptoms since arriving to the ED. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative PAST MEDICAL HISTORY: -s/p radical prostatectomy -GERD -HLD MEDICATIONS: The Preadmission Medication list is accurate and complete 1. Atorvastatin 40 mg PO QPM 2. Cialis (tadalafil) 20 mg oral DAILY:PRN as needed 3. Omeprazole Dose is Unknown PO DAILY ALLERGIES: -NKDA Past Medical History: PAST MEDICAL HISTORY: -s/p radical prostatectomy -GERD -HLD Social History: ___ Family History: FAMILY HISTORY: No family history of kidney disease Physical Exam: EXAM ON ADMISSION =================== VITAL SIGNS: ___ Temp: 98.3 PO BP: 160/102 HR: 70 RR: 18 O2 sat: 99% O2 delivery: Ra GENERAL: Calm, sitting comfortably. Anasarca HEENT: Mild periorbital edema CARDIAC: RRR, no rub/murmurs/gallop LUNGS: CTAB, no wheezes/crackles/rhonchi ABDOMEN: Nondistended though edema noted. Soft, nontender EXTREMITIES: 2+ edema past hips NEUROLOGIC: CN2-12 intact EXAM ON DISCHARGE =================== VITAL SIGNS: Temp: 97.6 PO BP: 159/94 HR: 68 RR: 16 O2 sat: 98% O2 delivery: RA GENERAL: NAD. HEENT: No evidence of periorbital edema. CARDIAC: RRR. Normal S1 S2. No murmurs, rubs or gallops. LUNGS: CTAB. No wheezes/crackles/rhonchi. No increased work of breathing. ABDOMEN: Soft. Mild edema noted in lower quadrants. Mildly tender to palpation in RLQ. EXTREMITIES: Bilateral 2+ pitting edema to hips. Bilateral upper extremity edema. Unchanged from prior. NEUROLOGIC: CNII-XII intact. No focal neuro deficits. Pertinent Results: LABS ON ADMISSION ================= ___ 02:07PM BLOOD WBC-7.3 RBC-3.80* Hgb-11.4* Hct-34.7* MCV-91 MCH-30.0 MCHC-32.9 RDW-12.9 RDWSD-42.4 Plt ___ ___ 02:07PM BLOOD Glucose-124* UreaN-27* Creat-2.0* Na-143 K-4.2 Cl-112* HCO3-21* AnGap-10 ___ 02:07PM BLOOD Albumin-1.7* Cholest-254* ___ 02:07PM BLOOD Free T4-0.7* ___ 02:07PM BLOOD TSH-5.8* ___ 02:07PM BLOOD Triglyc-218* HDL-50 CHOL/HD-5.1 LDLcalc-160* ___ 01:15PM BLOOD %HbA1c-5.7 eAG-117 ___ 07:05AM BLOOD HCV Ab-NEG ___ 01:15PM BLOOD HIV Ab-NEG ___ 01:15PM BLOOD Trep Ab-NEG LABS ON DISCHARGE ================== ___ 06:45AM BLOOD WBC-6.8 RBC-3.71* Hgb-11.1* Hct-34.7* MCV-94 MCH-29.9 MCHC-32.0 RDW-12.9 RDWSD-44.1 Plt ___ ___ 06:45AM BLOOD Glucose-89 UreaN-24* Creat-2.2* Na-145 K-4.6 Cl-110* HCO3-22 AnGap-13 MICROBIOLOGY =============== ___ 2:23 pm URINE ___. *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGING ============= RENAL U/S IMPRESSION: Normal renal ultrasound. RUE U/S IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. ___ 06:45AM BLOOD Calcium-8.1 Phos-4.6* Mg-2.0 ___ 06:45AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.0 MRV W/O CONTRAST IMPRESSION: No evidence of cerebral venous thrombosis. Brief Hospital Course: Mr. ___ is a ___ year old with recent increase in NSAID use who presented with anasarca, found to have proteinuria, microscopic hematuria, and acute kidney injury concerning for nephrotic syndrome. Extensive work up for cause of possible nephrotic syndrome was negative (as detailed below) and the most likely etiology was thought to be secondary to NSAID use. Renal biopsy was deferred to the outpatient setting as the patient recently had taken aspirin. He was diuresed with IV Lasix and blood pressure was managed with diltiazem. TRANSITIONAL ISSUES ===================== [ ] Started furosemide 40mg PO BID for at least one month until he is able to follow up with a kidney doctor ___ pending). [ ] Discharged with a prescription of Zofran for relief of nausea/vomiting [ ] Started diltiazem 180 mg ER once per day for management of hypertension in the setting of nephrotic syndrome [ ] Please get repeat lab testing to monitor kidney function in the setting of diuresis by ___ or ___; script provided [ ] Recommend avoiding omeprazole as it can potentiate Acute Interstitial Nephritis, worsening kidney function. In place, he has been discharged on ranitidine twice per day. He can also take tums more frequently for symptoms of indigestion. [ ] Highly recommend avoiding any NSAID use to avoid further nephrotoxicity [ ] The patient will be scheduled for a renal biopsy at ___. He will be contacted by our nephrology department regarding the biopsy. [ ] The patient reported frequent headaches associated with emesis. We obtained an MRI to rule out cerebral venous thrombosis which was negative. We recommend that the patient follow up with a neurologist to further evaluate the cause of his headaches. [ ] The patient was found to have negative serology results for Hepatitis B which indicate that the patient is not currently immunized against the virus. We recommend that the patient follow up with a PCP to receive the appropriate vaccination. [ ] The patient was found to have an elevated TSH (5.8) and decreased T4 (0.7). The patient denied any symptoms consistent with hypothyroidism. We recommend that the patient follow up with a PCP to determine if the patient is a candidate for further evaluation and treatment after his renal issues are resolved. [ ] The patient had elevated blood pressure (SBPs 150-160s) and cholesterol (254), triglycerides (218) and LDL (160). We recommend that the patient follow up with a PCP to determine if he needs to adjust his current medication regimen once his renal issues are resolved. [ ] Consider GI referral for persistent N/V that seems to be related to GERD. Patient's omeprazole was stopped this hospitalization given risk of AIN, but was replaced with ranitidine. ACUTE/ACTIVE ISSUES ===================== # Anasarca # Nephrotic Syndrome # ___ Mr. ___ presented with hypertension, proteinuria, hypoalbuminemia, hypercholesterolemia, spot urine protein/Cr 11.2 and anasarca consistent with nephrotic syndrome. Creatinine on admission at 2.0, with baseline 1.6 on ___. Most likely NSAID-induced given patient reports recent increase to approximately 8 pills/day several times each week. Alternate etiologies of nephrotic syndrome, including infectious, malignancy, and inflammatory were explored and were largely negative. A1C 5.7%. SPEP/UPEP negative for ___, normal Kappa/Lambda ratio. Normal C3/C4. IgG decreased at 200. IgM, IgA normal. HIV negative. Hepatitis serology negative. Syphilis negative. He was diuresed with IV furosemide with a mild improvement in pitting edema and a slight decrease in weight. In addition, he was started on protein supplementation for his diet. Creatinine stable at 2.1 on discharge. # Headache Patient reported a several month history of headaches located above forehead which occur ___ and resolve with aspirin or ibuprofen and thus were the precipitating factor for the patient's excessive NSAID use. These were well controlled with PO Tylenol. However given the his hypercoagulable risk, an MRV was also performed to assess for cerebral vein thrombosis, which was negative. Consider outpatient neurology referral. # Hypertension Patient presented with BP 193/105. Hypertension diagnosed incidentally at dentist several months ago. Patient not actively monitoring BP or taking medication. Nephrotic syndrome likely contributor. Renal artery thrombosis unlikely given normal renal US in ED and patient does not endorse flank pain. Patient received labetalol 100mg PO in ED and was controlled with diltiazem 30mg q6h while on the medicine floor. # Hypercholesterolemia Patient presented with total cholesterol 254, LDL 160. Likely elevated secondary to nephrotic syndrome. Continued home atorvastatin 80mg PO DAILY. # GERD Home omeprazole held secondary to concern for AIN, although less likely. Started Ranitidine 75mg PO twice a day with tums as needed. CHRONIC ISSUES: =============== # Hypothyroidism: TSH elevated 5.8. Free T4 0.7. Currently asymptomatic. ===== # CODE: Full (presumed) # CONTACT: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cialis (tadalafil) 20 mg oral DAILY:PRN as needed 3. Omeprazole Dose is Unknown PO DAILY Discharge Medications: 1. Diltiazem Extended-Release 180 mg PO DAILY RX diltiazem HCl 180 mg 1 capsule(s) by mouth once daily Disp #30 Capsule Refills:0 2. Furosemide 40 mg PO BID RX furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line RX ondansetron 4 mg 1 tablet(s) by mouth up to three times a day Disp #12 Tablet Refills:0 4. Ranitidine 75 mg PO BID RX ranitidine HCl 75 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Atorvastatin 40 mg PO QPM 6. HELD- Cialis (tadalafil) 20 mg oral DAILY:PRN as needed This medication was held. Do not restart Cialis until you speak with your primary care doctor due to risk of hypertension. 7.Outpatient Lab Work LABS: CHEM 7 and CBC ICD 9: 581.9 SEND TO: ___: ___ & ___ NEPHROLOGY ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES =================== Nephrotic Syndrome Hypertension SECONDARY DIAGNOSES ==================== GERD Hypercholesteremia Hyperthyroidism 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 came to the hospital because you were having full body swelling and you were urinating protein and microscopic blood. WHAT HAPPENED TO ME IN THE HOSPITAL? After doing further urine and blood studies, we found that you may have a condition called nephrotic syndrome. This causes your kidneys to leak out protein and blood and can cause you to become fluid overloaded. You were given medicine to help get some of the fluid off of you. In addition, you underwent a scan of your head which showed that there were no blood clots in your brain. WHAT SHOULD I DO WHEN I GO HOME? When you go home, you should continue to take your new blood pressure medication and also to take the water pill. This will help to get some of the fluid off of your body. You will need to follow up with the kidney doctors to get a biopsy of your kidney. DO NOT TAKE ANY OF THE FOLLOWING MEDICATIONS: ASPIRIN, EXCEDRIN, MOTRIN, OR IBUPROFEN. If you are in pain, take only Tylenol. We wish you all the best! Sincerely, Your ___ team Followup Instructions: ___
10073646-DS-12	10,073,646	26,724,486	DS	12	2147-04-23 00:00:00	2147-04-25 20:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with history of diastolic CHF (EF 55-60%), multiple myeloma previously on revlimid, recent HCAP PNA, and no known coronary disease who presents from rehab with report of chest pain and abdominal pain. Per EMS report, staff at her living facility say she had been having chest pain since yesterday and she was given aspirin there. She had also noted that she was complaining of abdominal pain, cough, and lower extremity swelling. She was taken to ___ where she was found to have a mildly elevated troponin. CXR there was concerning for pneumonia, so she was given cefepime. BNP at ___ was 2801, troponin was 0.068. Also complained of some abdominal pain and had CT abdomen/pelvis (w/ contrast) at ___ that was negative except for expected lytic lesions given multiple myeloma. She was given cefepime, furosemide, lorazepam, morphine, heparin, and aspirin prior to transfer. In the ED at ___, intial vitals were: 97.4 90 96/56 98% 4L Nasal Cannula. In the ED here she was somnolent but roused to voice and was conversant, but was not sure why she came to the hospital. She told the ED resident she felt "ticklish" but history and exam were otherwise unchanged. Labs notable for BNP 4444 and troponin 0.06->0.06. She was given vancomycin and continued on heparin gtt. Of note, she was admitted in mid ___ to ___ for HCAP, ___, neutropenia, and multiple myeloma. She is DNR but okay to intubate per MOLST form. On the floor the patient says her pain went away when she started eating. She is a very vague historian, but she thinks she's been having the pain on and off for weeks, isn't sure what causes it or makes it better. Also some loose stools and crampy abdominal pains. Past Medical History: Atrial fibrillation Diastolic CHF - last EF 55-60% on echo in ___ Multiple myeloma - previously on revlimid Recent pneumonias -RLL tx'd as HCAP at ___ in ___ Anxiety neuropathy Small pericardial effusion CKD baseline Cr 1.1-1.3 Social History: ___ Family History: Non-contributory Physical Exam: Admission: VS: T=97.2 BP=128/81 HR=84 RR=18 O2 sat=96% RA GENERAL: frail and chronically ill appearing elderly woman in NAD. Oriented x3 but some answers are inconsistent. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK: Supple, JVP is flat CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Severe kyphosis. Inspiratory rales heard in nearly all lung fields with inspiratory squeaks and rhonchi. ABDOMEN: Soft, mildly distended, mildly tender to palpation diffusely. EXTREMITIES: Bilateral LEs with stasis dermatitis, soft 3+ pitting edema bilaterally, long scar up medial right calf SKIN: warm, dry NEURO: A&Ox3 but seems confused when answering some questions, non-focal Discharge: VS: T 98.2 BP 104/62 HR 82 RR 20 99% on 2L JVP 12 cm H20 Poor inspiration, scattered wheezes, rales bilaterally at bases 1+ edema Pertinent Results: ADMISSION LABS =============== ___ 06:30AM WBC-4.7 RBC-2.78* HGB-9.0* HCT-29.8* MCV-107* MCH-32.4* MCHC-30.2* RDW-17.5* ___ 06:30AM NEUTS-76.2* ___ MONOS-5.0 EOS-0.2 BASOS-0.2 ___ 06:30AM PLT COUNT-196 ___ 06:30AM ___ PTT-112.9* ___ ___ 06:30AM CK-MB-3 proBNP-4441* ___ 06:30AM cTropnT-0.07* ___ 04:50PM cTropnT-0.06* ___ 04:50PM CK(CPK)-37 ___ 04:50PM CK-MB-2 ___ 06:30AM GLUCOSE-194* UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-41* ANION GAP-11 ___ 06:44AM LACTATE-1.2 DISCHARGE LABS ================= ___ 07:50AM BLOOD WBC-5.4 RBC-2.78* Hgb-9.0* Hct-29.8* MCV-107* MCH-32.6* MCHC-30.3* RDW-17.2* Plt ___ ___ 07:50AM BLOOD Glucose-134* UreaN-13 Creat-0.7 Na-139 K-4.4 Cl-96 HCO3-34* AnGap-13 ___ 07:50AM BLOOD Calcium-9.7 Phos-2.1* Mg-2.0 ___ 06:06PM BLOOD Vanco-15.0 ASPERGILLUS GALACTOMANNAN ANTIGEN: Negative MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG, IGM): Negative BETA GLUCAN: Negative Blood culture: Negative Urine Legionella Antigen: Negative Respiratory viral swab: Respiratory Viral Culture (Final ___: Reported to and read back by ___ ___ 1525. INFLUENZA B VIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. 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 for further information Stool: C DIFF POSITIVE IMAGING: CT chest w/o contrast ___: Dilatation of the main pulmonary artery, up to 4 cm is consistent with pulmonary hypertension. Heart size is enlarged. There is small amount of pericardial effusion. There is bilateral pleural effusion, moderate that when compared with the CT abdomen obtained two days ago demonstrate enlargement, especially on the right. There is no definitive mediastinal, hilar or axillary lymphadenopathy. For the assessment of the upper abdomen, please review recent CT abdomen and the corresponding report and no substantial change since the prior study has been demonstrated. Airways are patent till the subsegmental level bilaterally. Assessment of the imaged portion of the skeleton demonstrates innumerable lytic lesions consistent with known history of multiple myeloma. Compression fractures of the predominantly upper thoracic vertebral bodies demonstrated, also accentuated by the presence of substantial kyphosis. Multiple rib fractures are noted bilaterally. Fractures of the sternum are noted, extensive. Right lower lobe opacity is noted, most likely consistent with infectious process as well as lingular consolidation and to a lesser extent left basal opacity that might potentially represents an area of atelectasis. Right basal consolidation is out of proportion to the amount of pleural effusion thus the whole appearance is highly concerning for multifocal infection. In the absence of prior cross-sectional imaging, assessment of the dynamic changes cannot be obtained. Overall, the appearance is similar to chest radiographs obtained two days ago. CHEST X RAY ___: IMPRESSION: As compared to the previous radiograph, the pre-existing left-sided opacity is minimally improved. The opacities at both the left and the right lung basis are constant in appearance. No new all rib fractures. Moderate cardiomegaly with minimal fluid overload persists. Unchanged minimal pleural effusions. Echo ___: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >65%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate 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 no pericardial effusion. IMPRESSION: Biatrial enlargement. Normal biventricular systolic function. Moderate to severe tricuspid regurgitation with at least moderate pulmonary hypertension. Brief Hospital Course: ___ yo F with history of diastolic CHF (EF 55-60%), multiple myeloma previously on revlimid, recent HCAP PNA, and no known coronary disease who presented from rehab with report of chest pain and abdominal pain found to be from rib and sternal fractures from MM, but with increased dyspnea found to have Influeunza B, superimposed pneumonia, as well as C diff. ACTIVE ISSUES =============== # Influenza B with possible HCAP superinfection: Culture returns positive for influenza B. Immunocompromised state places her at higher risk for ongoing shedding. As such, continued on 10 day course of tamiflu. For concern of super-infection, pt. received 8 day course of vancomycin/cefepime last day was ___. Given clinical improvement and other confirmed diagnoses, did not aggressively pursue full active TB workup as pt unable to perform induced sputum test and pulmonary did not feel as though bronch was necessary. PPD returned negative. Legionella negative. Crypto ag negative. Aspergillus, B-glucan and Mycoplasma negative. Histoplasma antibody pending. # Severe CDiff: Pt. presented with abdominal pain and loose stools. CDiff sent and returned positive. Qualifies as severe given immunosuppressed status. Vanc 125mg PO Q6H for 14 days (Day #1 ___, day of HCAP completion; last day= ___ ) # Pulmonary Hypertension: LVEF >65%, showing moderate pulm hypertesnion (41mmHg) likely underestimated with moderate to severe TR. - consider further work-up with right heart cath (may not be appropriate given goals of care) # Chest Pain: Pt. presented with 3 hours of chest pain. Pt. without EKG changes, no significant CK-MB elevations. Found to have rib and sternal fractures, which are likely cause. Improved. Continued oxycodone + oxycontin (home meds) for pain # Afib with RVR: Likely precipitated by illness and mild fluid overload. Increased metoprolol to 37.5mg BID--however still with elevated rates with any activity although mostly <120 while at rest. Will convert to 100mg Toprol. CHRONIC ISSUES ================= # Chronic diastolic CHF and pulmonary hypertension: EF 55-60% on echo ___. Elevated BNP, peripheral edema and elevated JVP on exam. Pt restarted on home lasix dosing on ___. Continue metoprolol and spironolactone as well # CHRONIC PAIN - continue oxycontin, oxycodone, and gabapentin # MULTIPLE MYELOMA: Follow up with outpt provider. # GERD: - continue omeprazole # CODE: DNR/DNI # CONTACT: Patient, ___ (son, possible phone number ___ daughter ___ ___ TRANSITIONAL ISSUES ===================== # Med Changes: Metoprolol increased to 100XL for afib with RVr. # Pulm HTN workup - possible repeat TTE versus RHC # CDiff: Pt. should continue on PO vanc for 14 day course for severe CDiff (Day #1 ___ # Tamiflu: 10 day course given pt. immunocompromised (Day #1 ___. # Repeat Non-Con CT Chest: Pulmonary recommended repeat CT chest ___ weeks to evaluate for resolution of paranchymal abnormalities. If abnormalities, would refer to pulm at that time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dexamethasone 20 mg PO 1X/WEEK (MO) 3. Gabapentin 300 mg PO HS 4. Furosemide 40 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H 7. Calcium Carbonate 500 mg PO TID 8. Vitamin D 50,000 UNIT PO ONCE A MONTH ___ 9. Multivitamins 1 TAB PO DAILY 10. Spironolactone 25 mg PO DAILY 11. Metoprolol Tartrate 25 mg PO BID 12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing 13. Antacid II Plus Simethicone (alum-mag hydroxide-simeth) 400-400-30 mg/5 mL oral every 4 hours PRN dyspepsia 14. Bisacodyl ___AILY:PRN consitpation 15. Docusate Sodium 100 mg PO BID 16. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 17. Acetaminophen 650 mg PO Q4H:PRN pain 18. DiphenhydrAMINE 25 mg PO HS:PRN insomnia Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Bisacodyl ___AILY:PRN consitpation 4. Calcium Carbonate 500 mg PO TID 5. Dexamethasone 20 mg PO 1X/WEEK (MO) 6. Docusate Sodium 100 mg PO BID 7. Furosemide 40 mg PO DAILY 8. Gabapentin 300 mg PO HS 9. Metoprolol Succinate XL 100 mg PO DAILY ___ need to increase for rate control 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 13. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H 14. Spironolactone 25 mg PO DAILY 15. Albuterol 0.083% Neb Soln 1 NEB IH QID 16. Ipratropium Bromide Neb 1 NEB IH QID 17. OSELTAMivir 75 mg PO Q12H Day #1 was ___. Please complete through ___ for ___. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose 19. Vancomycin Oral Liquid ___ mg PO Q6H Please complete 2 week course starting from ___ through ___. Vitamin D 50,000 UNIT PO ONCE A MONTH ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Hospital acquired pneumonia Influenza B Clostridium difficile Secondary: Atrial fibrillation Pulmonary hypertension Multiple Myeloma Chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. You were admitted for chest pain which was found to be due to your fractures from multiple myeloma. However, you were also found to have pneumonia, flu, and an infection in your colon called Clostridium Difficile. You completed your treatment for pneumonia, but will need to continue medications for influenza and clostridium difficile. Followup Instructions: ___
10073847-DS-25	10,073,847	27,496,246	DS	25	2135-01-23 00:00:00	2135-01-23 15:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending: ___. Chief Complaint: leg pain Major Surgical or Invasive Procedure: ___ Lumbar Puncture History of Present Illness: OMED ATTENDING ADMISSION NOTE . ADMIT DATE: ___ ADMIT TIME: 0200 . Primary: ___ . ___ YO M with h/o stage IV double-hit DLBCL s/p R-EPOCH x6 and IT MTX ppx x4 (finish ___ who is admitted for back pain and new thecal sac mass, likely disease relapse. . Patient reports four weeks of constant lower back pain radiating to bilateral calves. Also with weakness of left foot flexors. Difficulty ambulating. No bowel or bladder incontinence. No new parasthesias (residual peripheral neuropathy from chemo). Denies any recent fever or chills. No meningeal signs such as headache, visual changes or neck stiffness. No weight loss. . Patient seen by Dr. ___ on ___ for routine follow-up and found to have decreased left plantar flexion strength. He had an MRI of his ankle on ___ which showed mild edema. Patient reports back/leg pain worsened, went to ___ ___ on ___. Arranged to have MRI of lumbar spine at ___ on ___. Started on prednisone 20 daily. MRI read this am (___), showed enhancing extramedullary intradural lesion in the thecal sac at L1 concerning for leptomeningeal spread and thickening/enhancement of nerve roots of cauda equina. Patient instructed to come to the ___ at ___ for further evaluation. Had returned to ___ ___ am due to worsening leg pain, prescribed dilaudid. . Patient had achieved CR by PET on ___. CSF was never positive. He had a PET scan on ___ which revealed no FDG avid disease. . ___: 98.8 93P 160/84 20 97%RA; dilaudid 1mg iv x 2; LP performed . ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: HEMATOLOGIC HISTORY: -___ Presented to OSH with pain in R hip and groin. Plain film showed lucency in R superior ramus. CT showed multiple enlarged pericardial lymph nodes, bulky disease in abdomen and pelvis, multiple hypoattenuating masses in the liver up to 7 cm, bilateral renal masses, destructive expansile lesion in in right pubic tubercle, lytic lesion in T6. -___ CT-guided biopsy revealed aggresssive diffuse large B-cell lymphoma, with 80% proliferation rate. FISH positive for BCL6, MYC and IGH/MYC translocations. -___ PET scan showed bilateral FDG avid mediastinal and internal mammary LAD. -___ BM biopsy showed atypical lymphocytosis and eryhtroid hyperplasia, 10% small-sized monoclonal B-cells. -Echo showed EF 55-60% with evidence of diastolic dysfunction. -___ Admitted for cycle #1 EPOCH, febrile on admission. Rituximab given as outpatient. -___ Admitted for cycle #2 EPOCH. -___ Admitted for cycle #3 EPOCH. -___ Admitted for cycle #4 EPOCH. -___ Admitted for cycle #5 EPOCH. . OTHER PMH: CAD s/p angioplasty and ___ ___ to ___ Diag. Normal stress test ___ (completed ~ 12 minutes on ___. HTN. Hyperlipidemia. Vasectomy. OSA s/p uvulopalatopharngoplasty. Chronic sinus complaints. Tonsillectomy. Social History: ___ Family History: Father with hx of colon cancer. No family hx of any blood disorders or other cancers that he is aware of. Physical Exam: ADMISSION EXAM: VS: 98.3 140/90 80 16 95%RA Appearance: alert, NAD Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmm, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, nt, nd, +bs Msk: ___ strength throughout except left plantar flexors ___, + SLR bilaterally Neuro: cn ___ grossly intact, ___ plantar flexors on left, wide based gait, unable to walk on toes Skin: no rashes Psych: appropriate, pleasant Heme: no cervical ___ DISCHARGE EXAM: O: 97.1, 116/68, 62, 18, 97RA Appearance: alert, NAD Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmm, no JVD, neck supple, no lymphadenopathy Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, nt, nd, +bs Msk: ___ strength throughout except left plantar flexors ___, + SLR bilaterally Neuro: cn ___ grossly intact, ___ plantar flexors on left, wide based gait appears very unsteady, unable to walk on toes, unchanged from prior Skin: no rashes Psych: appropriate, pleasant Heme: no cervical ___ ___ Results: ADMISSION LABS: ___ 09:51PM CEREBROSPINAL FLUID (CSF) PROTEIN-1424* GLUCOSE-8 ___ 09:51PM CEREBROSPINAL FLUID (CSF) WBC-2238 RBC-100* POLYS-3 ___ MONOS-13 OTHER-52 ___ 07:35PM GLUCOSE-175* UREA N-19 CREAT-0.8 SODIUM-142 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14 ___ 07:35PM WBC-14.5# RBC-4.96 HGB-14.8 HCT-44.7 MCV-90 MCH-29.8 MCHC-33.1 RDW-14.6 ___ 07:35PM NEUTS-88.2 LYMPHS-7.3* MONOS-4.1 EOS-0.2 BASOS-0.2 ___ 07:35PM PLT COUNT-228 ___ 07:35PM ___ PTT-26.8 ___ . DISCHARGE LABS: ___ 07:35AM BLOOD WBC-8.9 RBC-4.20* Hgb-12.7* Hct-37.9* MCV-90 MCH-30.3 MCHC-33.5 RDW-14.2 Plt ___ ___ 07:35AM BLOOD Glucose-137* UreaN-25* Creat-0.8 Na-141 K-4.1 Cl-100 HCO3-30 AnGap-15 ___ 07:35AM BLOOD Calcium-8.4 Phos-4.5# Mg-2.3 ___ 01:55AM BLOOD ALT-237* AST-55* LD(LDH)-222 AlkPhos-50 TotBili-0.3 . Imgaging ___ MRI ___: 1. An enhancing extramedullary intradural lesion in the thecal sac at L1. Thickening and enhancement of nerve roots of cauda equina. These findings likely represent lymphomatous infiltration/ leptomeningeal spread of lymphoma. 2. Moderate degenerative changes in the lumbar spine most notable at L4-L5 and L5-S1 levels. . MRI Thorasic and Cervical SPINE: . Redemonstration of the lesion at the level of L1 extending caudally. Additionally, less marked leptomeningeal enhancement is seen beginning at the level of the inferior endplate of T10 extending inferiorly to the previously seen lesion, consistent with leptomeningeal involvement by lymphoma. 2. No evidence of bone marrow abnormality or paravertebral or epidural soft tissue lesion. 3. Degenerative changes of the cervical spine, most marked at C5/C6 where a disc-osteophyte complex contacts the left anterolateral aspect of the spinal cord, with no abnormality of intrinsic cord signal at that level. 4. Indeterminate left adrenal nodule, as previously noted. . MRI Brain: 1. Few nonspecific FLAIR hyperintense foci. No foci of abnormal enhancement in the brain parenchyma or in the CSF spaces, in the head to suggest leptomeningeal enhancement, assessment of the IACs is somewhat limited. Please note that even though there is no definite abnormal enhancement on the MR images, leptomeningeal involvement cannot be completely excluded, in particular given the appearance of the thecal sac and the nerves of the thecal sac on the prior MR ___ study. Correlate with CSF analysis for excluding leptomeningeal enhancement and consider close followup as clinically indicated. 2. Fluid and mucosal thickening in the left mastoid air cells, right maxillary sinus as described above. 3. Small focal prominence at the right ICA termination measuring approximately 4 mm, which needs further evaluation with MR angiogram to exclude a small aneurysm. -- ___ CT Head W/O Contrast: No acute intracranial process. Please note that MRI with contrast would be more sensitive for detection of small intracranial lesions. Brief Hospital Course: ___ YO M with h/o stage IV double-hit DLBCL s/p R-EPOCH x6 and IT MTX ppx x4 (finish ___ who is admitted for back pain and new thecal sac mass found to be diseae recurrance by LP cytology. Patient was seen and evaluated by neurosurgery as well as radiation oncology. Patinet was started on high-dose MTX which he tolerated well. . #DLBCL: Patient was admitted with new low back pain and worsening gait at home. An MRI done in the ___ showed new enhancement of the cauda equina concerning for disease recurrance and recieved dexamethasone. LP was preformed with a large amount of atypical white cells, which upon review by pathology were consistant with DLBCL. Paitent was seen by neurosurgery as well as radiation oncology for evaluaiton of worsening symptoms and gait disturbance. As patient's symptoms stabilized without further deterioration high-dose methotrexate was initiated as the treatment of choice. Upon addequate alkalinization of the urine with NaHCO3 he recieved this infusion along with leukovorin rescue without incident and discharged once his blood levels had cleared. Of note patient's ALT was elevated to 237 after treatment. . #Leukocytosis: patient was noted to have a leukocytosis after presentation felt to be related to the dexamethasone he had recieved. . #HTN, CAD s/p stent: Patient's aspirin was held during methotrexate infusion out of concern for possible thrombocytopenia. Once methotrexate levels had cleared the patient was restarted on his home aspirin dose. . #Smoking cessation: patient had quit smoking several weeks prior to admission and was given nicotine patches while in house. He did not report any symptoms of craving and was encouraged to continue to abstaine from tobacco. Patient was discharged with addtional prescriptions for nicotine patch. . #Back Pain: patinet had radiant bilateral leg pain originating in his lumbar spine. There was subtle R>L decreased motor strength appreciated on admission exam that improved over the course of his stay. ___ saw the patient and cleared him to return home. He was treated with narcotics with good effect and had his regimen titrated to 20 mg BID oxycontin and oxycodone ___ mg Q4H:PRN pain. . TRANSITIONAL ISSUES: -Patient is a full code -Patient is a former smoker will need continued positive reinforcement -Patient had LFTs elevated above baseline at time of discharge, will need checked as an outpatient with his next set of lab work. -Patient was found to have partially enhancing sub-centimeric left adrenal mass on MRI spine. Recommend reimaging with adrenal protocol as an outpatient -Patient was found to have a small defect of the left ICA seen on MRI brain, radiology recommends MRA neck to evaluate for anneursym. Medications on Admission: Norvasc 10mg daily Lisinopril 15mg qhs Toprol XL 200mg daily Aspirin 81 mg x 2 daily Advair bid Dilaudid 2mg q3-4h prn Prednisone 20mg daily (started ___ ___t OSH ___ concerning for cord compression) Diazepam 5mg q8h qhs Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 5. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. leucovorin calcium 5 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6 hours) for 4 doses. Disp:16 Tablet(s) Refills:0 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 10. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp:30 Tablet(s) Refills:2 11. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:60 Tablet Extended Release 12 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: PRIMARY -Recurrance of Diffuse Large B Cell Lymphoma -CAD s/p angioplasty and ___ ___ to ___ Diag. SECONDARY -Hypertension -Hyperlipidemia -Vasectomy -OSA s/p uvulopalatopharngoplasty. -Chronic sinus complaints -Tonsillectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted for evaluation of your low back pain. You underwent a lumbar puncture which showed that you have had a reoccurance of your lymphoma surrounding your spinal cord. Radiation therapy was considered, but given your stable neurologic exam you were instead treated with high-dose methotrexate. You tolerated this infusion well and were discharged once the methotrexate in your blood had cleared. You will be discharged on a medication called leukovorin which you will need to take every 6 hours for the next ___ hours. You were also started on a medication called oxycontin 20 mg every 12 hours and oxycodone ___ mg every 4 hours as needed for break through pain. You will need to call Dr. ___ at ___ to schedule your next follow up appointment as well as your next methotrexate infusion. We are very glad to know you have quit smoking and encourage you to keep up the good work. You have been prescribed additional nicotine patches to help in these efforts! The following changes have been made to your medications: -START Leukovorin 20 mg every 6 hours for 4 doses -START Oxycontin 20 mg every 12 hours -START Oxycodone ___ mg every 4 hours as needed for pain -START Nicotine patch 21 mg every 24 hours -START Docusate 100 mg twice a day -START Senna 8.6 mg twice a day -CONTINUE all other medications Followup Instructions: ___
10074282-DS-3	10,074,282	29,469,637	DS	3	2159-10-28 00:00:00	2159-10-28 19:17:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of delusions, HTN, HLD, diabetes, blindness presents with FTT. Pt was recently admitted to the ___ overnight for ILI and since the discharge she has had incresed weakness and inability to care for herself. Per patient's daughter ___, Ms. ___ was able to ambulate on her own, walking to the bathroom, until last ___ when she was too weak to get out of bed or walk. She was also febrile to ___. She was then taken to ___ where she was diagnosed with an ILI and discharged with Tamiflu. Unfortunately the patient was unable to tolerate Tamiflu and did not complete treatment. Patient has also had decreased PO intake over the last few days. She has had recent sick contacts at home. No complaints of cough, SOB, sore throat, or diarrhea. The patient has had 3 episodes of emesis s/p eating recently. Family has ___ every other day, and reports more difficulty caring for her. In the ED, initial vitals were: 98.0 51 103/50 16 96% RA. Labs were significant for WBC of 23, 90% PMNs, BUN 85, creatinine 2.5 (baseline 0.7). CXR was w/o evidence of pneumonia, and UA w/o evidence of infection. Received 1L IVF in the ED. On the floor, initial vitals were: 98.5 112/40 76 16 95% RA. She denies pain but does not want her abdomen palpated. ROS: (+) Per HPI Past Medical History: Diabetes mellitus type II Hypertension Hyperlipidemia Delusional disorder Blindness from glaucoma Social History: ___ Family History: Hypertension Physical Exam: Initial Physical Exam ==================== VS: T: 98.5 BP: 112/40 P: 76 R: 16 O2: 95%RA GENERAL: sleeping, arousable to voice, answers some questions appropriately, no acute distress HEENT: Sclera anicteric, dry mucous membrane NEURO: moves all extremities CV: distant heart sounds, Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops REST: Decreased breath sounds, clear to auscultation, no wheezes, rales, or rhonchi ABD: soft, no rebound, rigidity, or guarding though patient does resist abdominal exam, TTP @ LLQ EXT: Warm, well perfused, no clubbing, cyanosis or edema SKIN: no rash or lesion Discharge Physical Exam ==================== Vitals: Tm-98.3 Tc-98.0 108-130/50-60 ___ 18 98%RA GENERAL: NAD, Alert HEENT: MMM NECK: supple, no neck LAD, NEURO: Tongue protrudes down midline, moves all extremities CV: RRR. No murmurs, rubs, or gallops LUNGS: Decreased breath sounds secondary to poor inspiratory effort but CTAB ABD: +bs, soft, ND, denies tenderness to palpation but grimaces with exam, stable from before. EXT: Warm, well perfused, no clubbing, cyanosis or edema SKIN: no rash or lesion Pertinent Results: Initial Labs ========================= ___ 12:40PM BLOOD WBC-23.8# RBC-3.75 Hgb-10.6* Hct-32.2* MCV-86 MCH-28.2 MCHC-32.8 RDW-13.6 Plt ___ ___ 12:40PM BLOOD Glucose-104* UreaN-85* Creat-2.5# Na-133 K-4.0 Cl-91 HCO3-28 AnGap-18 ___ 12:40PM BLOOD ALT-115* AST-77* AlkPhos-218* TotBili-0.6 ___ 08:25AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.6 ___ 01:45PM BLOOD CRP-90.2* ___ 08:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE ___ 07:15AM BLOOD calTIBC-190* Hapto-298* Ferritn-404* TRF-146* ___ 07:00AM BLOOD Lipase-100* ___ 12:40PM BLOOD Lipase-78* ___ 08:25AM BLOOD GGT-415* ___ 01:45PM BLOOD ESR-109* Imaging ======================= ___ CXR FINDINGS: Frontal and lateral views of the chest. Relatively low lung volumes are seen; however, the lungs are clear without focal consolidation or effusion. The cardiomediastinal silhouette is within normal limits. Severe degenerative changes noted at the right shoulder. No acute osseous abnormality is identified. IMPRESSION: No definite acute cardiopulmonary process. ___ Abdominal U/S IMPRESSION: 1. Mild central intrahepatic biliary ductal dilatation and enlarged common bile duct. No stones are visualized within the CBD. 2. Cholelithiasis 3. Two hyperechoic lesions within the liver consistent with hemangiomas. ___ Abdominal CT IMPRESSION: 1. Stranding surrounding diverticula at the splenic flexure has slightly increased from ___. Stranding at the pancreatic head and within the mesentery is unchanged. It is unclear from imaging if this represents diverticulosis with reactive stranding in the mesentery or pancreatitis with reactive stranding in the left hemiabdomen, or two concurrent processes. No abscess. 2. Lipoma in the left rectus femoris muscles with areas of stranding. Low grade liposarcoma cannot be excluded. Discharge Labs ====================== ___ 06:00AM BLOOD WBC-16.5* RBC-3.31* Hgb-9.5* Hct-28.2* MCV-85 MCH-28.8 MCHC-33.8 RDW-14.4 Plt ___ ___ 06:00AM BLOOD Glucose-121* UreaN-9 Creat-0.5 Na-136 K-3.8 Cl-100 HCO3-29 AnGap-11 ___ 06:00AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1 Brief Hospital Course: Ms. ___ is an ___ legally blind female with history of untreated latent TB, delusions, HTN, HLD, diabetes, who presented with 10 days of fatigue and ___, found to have a leukocytosis to 22k, positive Influenza A, and elevated LFTs and lipase. ACUTE ISSUES # Leukocytosis Patient presented with leukocytosis to 23 which continued to rise during admission without a clear cause. CXR, Urinalysis, and blood cultures were negative. No nuchal rigidity on exam and no fevers, or neurologic signs concerning for meningitis. No rashes or ulcerations. She did not meet SIRS criteria. Abdominal discomfort was the only localizing sign on admission. She was started on cipro/flagyl for possible abdominal infection such as diverticulitis. CT A/P showed stranding around diverticular near the splenic flexure and stranding at the pancreatic head, but no overt signs of infection. Additionally, the patient's abdominal exam improved, she tolerated POs without N/V, and her C. Diff was negative. The infectious disease team was consulted and recommended a repeat CXR and mycolytic blood cultures which were pending at discharge but negative to date. They did not think she needed continued antibiotics so she received a 6 day course of antibiotics. She did have an elevated ESR and CRP concerning for an inflammatory process. The hematology team was consulted and determined that given her wbc was wnl at ___ one week ago, her current leukocytosis was unlikely to be due to a primary malignant process. # Influenza A The patient tested positive for Influenza A. Given that her symptoms developed >1 week ago, she was outside the window for treatment. She remained hemodynamically stable and was afebrile throughout her admission. # FTT: On admission, the patient was initially somewhat difficult to arouse and communicate with. A few days into her hospital stay she was conversing normally. Physical therapy evaluated the patient and recommended disposition to rehab. A social work consult was also placed given that the patient stated that family members were stealing money from her. # Transaminitis The patient presented with a mild transaminitis on admission with a normal T bili. She had some initial tenderness on abdominal exam which soon resolved, and a negative ___ sign. An abdominal ultrasound showed mild biliary ductal dilatation, and enlargement of the common bile duct without stones. A lipase was also mildly elevated to 100 during admission. Her transaminitis resolved during admission. Given that her abdominal exam improved, and she experienced no further N/V during admission, these laboratory abnormalities may have been secondary to passage of a gallstone which resolved. # Acute Kidney Injury The patient presented with an acute kidney injury with a Cr of 2.5. This was most likely pre-renal in nature. She received IV fluid hydration and by discharge her Cr had returned to a baseline of 0.4. CHRONIC ISSUES # Anemia of chronic disease: The patient presented with a hct of 32 near her baseline of 35. There were no signs of active bleeding throughout her admission and her Hct remained stable. # HTN: The patient's home BP medications were intially held due to acute kidney injury. As her acute kidney injury resolved, her home medications including Amlodipine, HCTZ, and Losartan were restarted. # Diabetes: The patient's home metformin and glipizide were held during admission. Her blood sugars were managed with an insulin sliding scale. # HLD: The patient's was continued on her home pravastatin # Delusional disorder: The patient's Risperidone and Depakote were held as she was initially somnolent. They were restarted on discharge. # Glaucoma: The patient's home eye drops including travatan were continued during admission. TRANSITIONAL ISSUES The patient has hyperpigmented macules on her palate that should be monitored as an out-patient for change in morphology or pigmentation FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO DAILY 2. Acetaminophen 1300 mg PO Q12H pain 3. Amlodipine 10 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO DAILY 5. GlipiZIDE 2.5 mg PO DAILY 6. Travatan Z (travoprost) 0.004 % ophthalmic Daily 7. Hydrochlorothiazide 25 mg PO DAILY 8. Divalproex (DELayed Release) 250 mg PO DAILY 9. RISperidone 2 mg PO DAILY 10. Losartan Potassium 100 mg PO DAILY 11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. Pravastatin 40 mg PO DAILY 4. Acetaminophen 325 mg PO Q8H:PRN pain 5. Divalproex (DELayed Release) 250 mg PO DAILY 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 7. Travatan Z (travoprost) 0.004 % ophthalmic Daily 8. RISperidone 2 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Losartan Potassium 100 mg PO DAILY 11. Hydrochlorothiazide 25 mg PO DAILY 12. GlipiZIDE 2.5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS 1. Leukocytosis, reactive 2. Failure to Thrive 3. Acute Kidney Injury SECONDARY DIAGNOSIS 1. Anemia of chronic disease 2. Glaucoma 3. Diabetes mellitus type II 4. Hypertension 5. Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___: It was a pleasure caring for you at ___ ___. You were admitted because you were very weak. You were found to have the flu, which did not require further treatment. Your white blood cell count was high, which was concerning for an infection. The Infectious Disease doctor evaluated you and felt that you were recovering from an infection. The hematologists evaluated you and determined that you had no blood problem. You continued to demonstrate improvement. We wish you the very best. Sincerely, Your ___ Team Followup Instructions: ___
10074474-DS-21	10,074,474	26,500,750	DS	21	2165-11-06 00:00:00	2165-11-06 19:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine / Sulfa (Sulfonamide Antibiotics) / naproxen Attending: ___. Chief Complaint: fatigue, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with PMH significant for indolent non-Hodgkin B cell lymphoma that transformed into DLBCL for which he is on R-CHOP as recently as 3 days ago, chronic left plantar ulcer, chronic hepatitis C, cirrhosis, anemia, polysubstance abuse, tobacco dependence, and latent TB presented from nursing home with AMS and fatigue. Per notes from nursing home, the patient had an acute change in mental status today and slept all day at his nursing home. He was satting 84-88% on RA, for which he was put on 2L and went up to 96%. In ED, patient was found to be hypotensive to as low as ___ and was started on levophed through his right chest port. He was also given cefepime 2g IV and vancomycin 1g IV, as well as 3L NS for sepsis. A CXR showed a right hilar opacity concerning for pneumonia. He was also given 2u pRBCs for a Hgb of 5.7. Notable labs from the ED include WBC 0.3 with absolute neutrophil count 0.10, hemoglobin 5.7, platelets 27, INR 1.5, AST 145 ALT 31. A non-contrast head CT was negative for acute intracranial process. Patient endorses pain in his left foot which he attributes to a chronic wound. Of note, a cast was placed last month by podiatry over the foot and is still in place. Cultures of the wound form ___ grew MRSA. Patient denies nausea, vomiting, chest pain, shortness of breath, cough, abdominal pain, diarrhea. Past Medical History: DLBCL on R-CHOP (last treatment ___ Ulcer of left foot with MRSA on culture from ___ Chronic hepatitis C Cirrhosis Anemia Polysubstance abuse Tobacco dependence disorder Social History: ___ Family History: N/A Physical Exam: ADMISSION PHYSICAL EXAM VITALS: T 98.7 HR 90 BP 115/76 RR 16 SpO2 97% on 3L GENERAL: Laying in bed. Appears restless. Somnolent but arousable. Drifting off to sleep intermittently. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Crackles in the right mid and lower lung fields. No wheezes or rhonci. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, no edema. LLE in hard cast below the knee. SKIN: No lesions or rashes noted. Exam of LLE limited by cast. NEURO: CNII-XII grossly intact. Moving all 4 extremities. No focal deficits. Oriented to place, knew it was ___. DISCHARGE PHYSICAL EXAM: VITALS: 98.4 99/46 84 98% RA GENERAL: Sitting up in bed eating a cheeseburger, well appearing. Cachectic. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Decreased breath sounds bilaterally, no appreciable rales or rhonchi. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, no edema. left foot in gauze dressing. NEURO: CNII-XII grossly intact. Moving all 4 extremities. No focal deficits. AOx3. Pertinent Results: Admission labs =============== ___ 05:40PM BLOOD WBC-0.3* RBC-2.03* Hgb-5.7* Hct-17.8* MCV-88 MCH-28.1 MCHC-32.0 RDW-15.2 RDWSD-48.7* Plt Ct-27* ___ 05:40PM BLOOD Neuts-19* Bands-13* ___ Monos-41* Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.10* AbsLymp-0.08* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 05:40PM BLOOD ___ PTT-30.4 ___ ___ 06:40PM BLOOD ___ ___ 05:40PM BLOOD Glucose-136* UreaN-9 Creat-0.6 Na-135 K-3.6 Cl-100 HCO3-23 AnGap-12 ___ 05:40PM BLOOD ALT-31 AST-145* LD(LDH)-320* AlkPhos-113 TotBili-1.6* ___ 05:40PM BLOOD Lipase-8 ___ 05:40PM BLOOD Albumin-3.3* Calcium-8.1* Phos-1.6* Mg-1.8 UricAcd-1.6* ___ 05:40PM BLOOD Hapto-215* ___ 11:10PM BLOOD ___ pO2-41* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 ___ 06:27PM BLOOD Lactate-2.5* ___ 11:10PM BLOOD freeCa-1.02* ___ 08:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:10PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 Pertinent labs =============== ___ 10:48PM BLOOD WBC-1.0# RBC-2.87# Hgb-8.2# Hct-24.9# MCV-87 MCH-28.6 MCHC-32.9 RDW-14.6 RDWSD-46.0 Plt Ct-52# ___ 05:45AM BLOOD WBC-0.4# RBC-2.49* Hgb-7.2* Hct-21.4* MCV-86 MCH-28.9 MCHC-33.6 RDW-14.7 RDWSD-45.6 Plt Ct-36* ___ 10:48PM BLOOD Neuts-50 Bands-4 Lymphs-12* Monos-29* Eos-0 Baso-0 Atyps-4* Metas-1* Myelos-0 AbsNeut-0.54* AbsLymp-0.16* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00* ___ 05:45AM BLOOD Neuts-46 Bands-5 Lymphs-18* Monos-31* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.20* AbsLymp-0.07* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 05:45AM BLOOD Neuts-46 Bands-5 Lymphs-18* Monos-31* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.20* AbsLymp-0.07* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 10:48PM BLOOD ___ PTT-34.9 ___ ___ 05:45AM BLOOD ___ PTT-34.3 ___ ___ 10:48PM BLOOD Glucose-156* UreaN-9 Creat-0.5 Na-141 K-3.0* Cl-106 HCO3-19* AnGap-16 ___ 05:45AM BLOOD Glucose-123* UreaN-8 Creat-0.4* Na-137 K-3.1* Cl-105 HCO3-21* AnGap-11 ___ 02:30PM BLOOD Glucose-172* UreaN-8 Creat-0.4* Na-139 K-3.1* Cl-105 HCO3-22 AnGap-12 ___ 10:48PM BLOOD ALT-28 AST-117* LD(___)-321* AlkPhos-99 TotBili-2.8* ___ 05:45AM BLOOD DirBili-1.1* ___ 10:48PM BLOOD Albumin-2.9* Calcium-7.1* Phos-2.0* Mg-1.7 UricAcd-1.3* Discharge labs =============== ___ 06:01AM BLOOD Glucose-107* UreaN-8 Creat-0.5 Na-139 K-4.4 Cl-98 HCO3-23 AnGap-18* ___ 02:08AM BLOOD ALT-27 AST-69* AlkPhos-85 TotBili-0.9 ___ 06:01AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7 Studies =============== CXR ___: Right suprahilar opacity. Given patient's port, question of underlying malignancy in this location. Alternatively, infection would be possible. Correlation with prior imaging sh would be of use. Followup will be necessary. CT head w/o contrast (___): IMPRESSION: 1. Moderately limited study due to patient motion. 2. No large intracranial hemorrhage, mass effect or acute large territorial infarction. FOOT AP,LAT & OBL LEFT (___): IMPRESSION: There is soft tissue swelling about the first MTP joint. There is soft tissue calcification lateral to the first metatarsal head. There is slight bony irregularity along the first metatarsal head medially and at the first proximal phalangeal base. This is equivocal for osteomyelitis.Comparison two old films if available would be helpful. Alternatively, MRI could also be performed. Calcaneal spur is seen. There are mild degenerative changes of the talonavicular joint and spurring of the talar head. CT CHEST W/O CONTRAST ___: Large, partially necrotic mass like lesion, anterior segment right upper lobe has features which suggest treated primary tumorand needs to be compared with pretreatment imaging to assess the real change. If this is not the primary lymphoma, or the lymphoma involuted substantially, then the lung lesion is a necrotizing pneumonia. Right hilar and right lower paratracheal lymph nodes are enlarged. Several other mediastinal lymph nodes are top-normal size. =============== Microbiology =============== Blood culture (___) (x3): no growth to date Urine culture (___): no growth MRSA screen (___): positive swab Respiratory viral panel (___): negative urine legionella antigen (___): negative Brief Hospital Course: Mr. ___ is a ___ year old man diffuse large B cell lymphoma (C2 of R-CHOP), chronic left plantar ulcer, HCV cirrhosis (unclear decompensation history), history of polysubstance abuse, and history of latent TB who presented from his nursing home with neutropenic fever in septic shock. #Neutropenic fever: #Septic shock: Patient presented with septic shock, requiring levophed after IV fluid resuscitation. He was started on vancomycin, cefepime and azithromycin as concern that source was pneumonia. A CT chest was done that showed a mass consistent with his known DLBCL, but there is concern that this may have led to development of pneumonia. Although his ANC improved to 960 prior to discharge and he remained afebrile, antibiotics were continued to complete an ___ecause there was concern that this was a true pneumonia. Vancomycin was included in the final antibiotic regimen as he had a positive MRSA screen. Last day of vancomycin and cefepime is ___, and last day for azithromycin is ___. #Diffuse large B cell lymphoma: The patient is currently under the care of Dr. ___ at ___. He is now on cycle 2 of R-CHOP, with cycle 2 day 1 on ___. Per Dr. ___ had a good response to the first round of chemotherapy. It is unclear if he received filgastrim or neuopogen at rehab; he did not receive any while inpatient. Home allopurinol was continued. #Pancytopenia: Likely secondary to chemotherapy, but there is likely a component of bone marrow suppression from cirrhosis and HCV (although do not know the extent of his disease). Patient received 2 units of pRBCs in ED with appropriate response. #Chronic left foot plantar ulcer: The patient came in with a hard cast on the left lower extremity. This cast was removed so that the ulcer could be exonerated as a source of infection. Podiatry evaluated his foot and deemed it to be chronic ulceration with no signs of infection at this time. Thus, surgical intervention not warranted. He will follow up with his outpatient podiatrist at ___. #Coagulopathy: INR 1.5 during hospitalization despite no anticoagulation. Likely secondary to chronic liver disease and malnutrition, with potential worsening for antibiotics. #Malnutrition: albumin 2.9 in setting of known malignancy. Nutrition was consulted who recommended regular diet without neutropenic restriction. They sent chocolate Ensure frappe TID, and encouraged intake Agree with MVI, x5 days thiamine/folate as well. #Hx of latent TB: Per outside notes, patient has been treated with INH and rifampin in the past. No signs of acute TB at this time. #HCV/HBV cirrhosis: Unknown decompensation history. Patient had no ascites or signs of hepatic encephalopathy. His variceal status is unknown to us as he does not receive care here, but had no signs of GI bleeding. Patient was continued on tenofovir for HBV. #HTN: Patient's home amlodipine was held in setting of hypotension at admission. His blood pressures were in the low 100s throughout the rest of his hospitalization, and therefore amlodipine was not continued at discharge. #Chronic pain: Patient continued on home regimen of oxycontin 20mg BID and oxycodone 10mg q4hrs for breakthrough pain. #Anxiety: Continued home alprazolam 1mg TID at home once initial encephalopathy resolved. TRANSITIONAL ISSUES: #Follow up final blood cultures #Antibiotic plan at discharge: vancomycin and cefepime last day = ___, last day azithromycin ___ #Repeat CBC with differential on ___, review with MD at rehab #Vancomycin trough to be drawn before morning dose on ___, please confirm with pharmacy safe to give dose after this #Followed by Dr. ___ at ___ for oncologic care #Cycle 2 Day 1 of R-CHOP = ___ #Patient should follow up with outpatient podiatrist in 3 weeks #Patient is weight bearing on left heel, should wear surgical boot #Amlodipine discontinued for SBPs in 100s #Recommend evaluation by nutrition at rehab for optimization of malnutrition and supplementation in the setting of cirrhosis and malignancy #If patient does not have a hepatologist, recommend referral for management of HCV cirrhosis #Code status: DNR/DNI #Contact: ___, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 5. protein 40 mL oral QID 6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 7. Ondansetron 4 mg PO Q8H:PRN Nausea, vomiting 8. ALPRAZolam 1 mg PO TID 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH PAIN 10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 11. Bisacodyl 10 mg PR QHS:PRN Constipation 12. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation 13. Milk of Magnesia 30 mL PO DAILY:PRN Constipation Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 1 Day Last day ___ 2. CefePIME 2 g IV Q8H Last day ___. 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Nicotine Patch 14 mg TD DAILY 6. Thiamine 100 mg PO DAILY 7. Vancomycin 1250 mg IV Q 12H Last day ___. 8. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 9. Allopurinol ___ mg PO DAILY 10. ALPRAZolam 1 mg PO TID 11. Bisacodyl 10 mg PR QHS:PRN Constipation 12. Docusate Sodium 100 mg PO DAILY 13. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation 14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation 15. Ondansetron 4 mg PO Q8H:PRN Nausea, vomiting 16. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH PAIN 17. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 18. protein 40 mL oral QID 19. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Septic shock Neutropenic fever SECONDARY DIAGNOSES Diffuse large B cell lymphoma HCV cirrhosis Chronic pain Chronic left plantar ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at the ___. You were admitted to the hospital because you had a fever and low white blood cell counts, and we were concerned you had an infection. You required admission to the intensive care unit. Your infection is most likely in your lungs, this is also called pneumonia. You were given IV antibiotics, and will continue to get these for 4 more days once you go back to rehab. You should continue to follow up with your oncologist, Dr. ___ your podiatry (foot doctor) team. If you have fevers, chills, problems breathing, or anything symptoms that concerns you, please seek medical attention. We wish you the best of luck in your health. Warmly, Your ___ Care Team Followup Instructions: ___
10074556-DS-21	10,074,556	24,049,696	DS	21	2128-10-09 00:00:00	2128-10-10 07:11:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Mediastinal Mass Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old male, with past history of acute pancreatitis c/b necrosis requiring necrosectomy in ___, GERD, who is presenting today for expedited workup of a chest mass. Patient was recently seen by the GI department for ___ on ___ because of progressive weight and skin lesions, given history of necrotic pancreatitis. This was notable for a partially visualized heterogeneously enhancing necrotic soft tissue masses within the anterior mediastinum, with the largest masses measuring up to 8.1 cm in the right cardiophrenic space, causing mass effect on the right atrium with possible invasion of the underlying heart. There is also invasion of the chest wall anteriorly with abnormal enhancement within the lower aspect of the sternum suggestive of bony invasion, concerning for an aggressive neoplastic disease. Because of this on MRCP, patient then underwent a CT chest on ___ (delay due to insurance issues), which was remarkable for large necrotic, multi lobulated anterior mediastinal mass/masses with suspected pericardial invasion, with associated chest wall, hilar, axillary and supraclavicular lymphadenopathy. Patient therefore presents to the ED for expedited oncology workup. Patient reports that he started to feel unwell about ___ months prior. He was started to about 15 lb weight loss (unintentionally, ___ lb weight loss per month), with significant night sweats and also pruritis. Notably because of pruritis, patient was evaluated by dermatology and started on some course of prednisone which resulted improvement in the pruritis. He denies any chest pains, palpitations. He does report the dyspnea on exertion with specifically weight lifting. He denies any abdominal pains, nausea/vomiting, diarrhea. Notably, patient was also seen by cardiology on ___ for evaluation of sinus tachycardia. Also noted on that note that patient had been having ongoing weight loss and pruritis. At that time, patient had been recommended endocrinology evaluation and a TTE was ordered. In the ED, initial vitals: 0 98.4 119 149/96 18 100% RA - Labs were significant for: WBC 5.5 (PMN 74%), Hgb 13.2, Hct 40.9, Platelet 319. MCV 83. Sodium 139, K 5.2, Chloride 98, Bicarb 27, BUN 12, Cr 1.2. Glucose 95. - ALT 26, AST 54, AP 98, LDH 636, T-bili 0.5. Uric Acid: 6.5 - Urinalysis: Cloudy, 1.016, pH 7, Trace Protein, RBC 1. - Imaging: None new. - In the ED, s/he received: No medications - Vitals prior to transfer: 0 112 142/72 15 100% RA Upon arrival to the floor, ##### REVIEW OF SYSTEMS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: >> Admission Physical Exam: Vital Signs: 99.5 153/86 118 18 97%RA Pulsus - 6 mmHg 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 rganomegaly, 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: Pertinent Results: >> Admission Labs: ___ 01:30PM BLOOD WBC-5.5 RBC-4.95 Hgb-13.2# Hct-40.9 MCV-83 MCH-26.7 MCHC-32.3 RDW-12.7 RDWSD-37.9 Plt ___ ___ 01:30PM BLOOD Neuts-74.4 Lymphs-9.0* Monos-15.2* Eos-0.6* Baso-0.4 Im ___ AbsNeut-4.06 AbsLymp-0.49* AbsMono-0.83* AbsEos-0.03* AbsBaso-0.02 ___ 07:15AM BLOOD ___ PTT-29.5 ___ ___ 01:30PM BLOOD Glucose-95 UreaN-12 Creat-1.2 Na-139 K-5.2* Cl-98 HCO3-27 AnGap-19 ___ 01:30PM BLOOD ALT-26 AST-54* LD(LDH)-636* AlkPhos-98 TotBili-0.5 ___ 01:30PM BLOOD b2micro-3.6* ___ 01:30PM BLOOD HCV Ab-Negative ___ 09:28PM BLOOD HIV Ab-Negative . >> Discharge Labs: . >> Pertinent Reports: ___ Cardiovascular ECHO; The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Diastolic function could not be assessed. 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. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Normal global biventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Small to moderate circumferential pericardial effusion without echocardiographic signs of tamponade. . ___HEST W/CONTRAST: Large necrotic, multilobulated anterior mediastinal mass/masses with suspected pericardial invasion. Associated chest wall, hilar, axillary and supraclavicular lymphadenopathy. The nodule in the left upper lobe is concerning for pulmonary involvement of this neoplastic process. At the top of my differential diagnosis consider lymphoma, other diagnostic considerations include thymic carcinoma and less likely an immature germ cell tumor or sarcomatous lesion. After review of the MR images, there is apparent loss of the fascial plane between the right pericardial mass and the right atrium which is concerning for myocardial infiltration. Correlation with histology advised. Left axillary lymph nodes would be amenable to biopsy. In the differential diagnosis for the pulmonary nodule consider a primary lung malignancy (would be unlikely though) and infection. Brief Hospital Course: Mr. ___ is a ___ year old male, with past history of pancreatic necrosis s/p necresectomy in ___, now with imaging concerning for large mediastinal mass found to have DLBCL. # Mediastinal Mass, DLBCL: Patient is having now invasion of a large mediastinal mass/masses with necrosis, with suspected pericardial and chest wall invasion. There is significant lymphadenopathy as well that is associated with this. Given location and size, as well as B-symptoms, this would be concerning most likely for a lymphoma process type process at top of differential for malignancy. Most notable at this time is potentially compression of the SVC as well invasion into the pericardium, however at this time clinically stable without pulsus. Pt had axillary lymph node biopsies given that an MRCP for routine pancreatitis incidentally found a mediastinal mass concerning for lymphoma. Pt later transferred from medicine to ___ given concerns of active lymphoma. Biopsies showed DLBCL. Decision was made to pursue EPOCH treatment, rituxan was deferred for cycle 1 given tumor burden. Pt tolerated EPOCH without complications, some bowel concerns with alternating constipation and diarrhea but resolved at discharge. Pt also taught neupogen injections which he will continue outpatient. No concerns with tumor lysis syndrome given labs and ECHO, hepatitis non-concerning. Patient will follow up with oncology within the next week. Pt will receive a phone call to make this appointment. #Sinus tachycardia: Patient found to be tachycardic HR 120s for past 6 months, unclear etiology initially and saw cardiologist outpatient who started beta-blocker which was later discontinued by another cardiologist. Pt's ECHO was unrevealing although CT showed involvement of the SVC and RA. Tachycardia improved at discharge with HR in 80-100s. # History of Acute Pancreatitis now s/p necresectomy: patient has been tolerating well, with increased weight loss now likely ___ to underlying process. Continued creon, colesevelam, nortriptyline. Hyocyamine held in setting of diarrhea. # GERD Continued pantoprazole. TRANSITIONAL ====================== -Pt is to continue neupogen and pick this up outpatient. He has been informed regarding this and how to self-inject. -Pt will follow up with oncology now that his cycle 1 of EPOCH is complete. He will receive a phone call regarding the appointment time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 2 CAP PO TID W/MEALS 2. colesevelam 625 mg oral BID 3. Nortriptyline 10 mg PO QHS 4. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO TID:PRN constipation RX docusate sodium 100 mg 1 capsule(s) by mouth up to three times a day as needed Disp #30 Capsule Refills:0 2. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting RX lorazepam [Ativan] 0.5 mg ___ tabs by mouth every 12 hours as needed Disp #30 Tablet Refills:0 3. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth every 8 hrs as needed for nausea Disp #30 Tablet Refills:0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth as needed daily Refills:0 5. Senna 17.2 mg PO BID constipation RX sennosides [senna] 8.8 mg/5 mL 1 syrup by mouth ___ tablespoon Refills:*0 6. WelChol (colesevelam) 625 mg PO BID 7. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 8. colesevelam 625 mg oral BID 9. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID 10. Nortriptyline 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== DLBCL SECONDARY DIAGNOSIS ==================== pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted for your lymphoma which was classified as diffuse large B-cell lymphoma. You were treated with chemotherapy called EPOCH and you tolerated the chemotherapy well without severe symptoms. You will continue neupogen injections at home, and this has been explained to you. If you have worsening symptoms of nausea, fever, chills, shortness of breath, please return for further evaluation. It was a pleasure taking care of you at ___! Your ___ Team Followup Instructions: ___
10074556-DS-29	10,074,556	23,864,934	DS	29	2129-04-09 00:00:00	2129-04-09 22:02:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Chills Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with primary mediastinal lymphoma s/p 6 cycles of dose adjusted R-EPOCH in ___ with residual disease (CHL) now s/p ICE who is admitted from the ED with chills, low grade temperatures and nasal congestion. Patient reports about 3 days of nasal congestion and rhinitis with clear discharge. He was seen in ___ clinic on ___, and was otherwise feeling well. However, after getting home at 3pm, he noted chills. He checked his temperature and it was 99.7. Chills continued and his temperature fluctuated from mid- 99's up to 100.2. He has a mild ___ headache. No visual changes. No ST. No CP, SOB, or cough. He remains quite active. No N/V. Mild constipation, last BM this am. No dysuria. No new rashes. No new joint pains or leg swelling. He reports some close contacts with cold symptoms. In the ED, initial VS were pain 0, T 98.6, HR 125, BP 135/99, RR 17, O2 100%RA. Initial labs were notable for WBC 7.2 (ANC 4390), HCT 40.8, PLT 112, NA 139, K 3.8, HCO3 28, Cr 1.0, UA negative, rapid flu swab negative. CXR showed no acute process. No interventions were performed. VS prior to transfer were pain 4, T 97.9, HR 76, BP 132/84, RR 18, O2 99%RA. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 ___ - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) ___ - DA-R-EPOCH dose level 3 ___ - DA-R-EPOCH dose level 4 ___ - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg - ___ PET-CT shows residual FDG-avid disease - ___: Right video assisted thoroscopy mediastinal lymph node biopsy which ultimately came back positive for classical hodgkin's lymphoma with no residual evidence for viable DLBCL. - ___: C1D1 ICE Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis - Arrhythmia Social History: ___ Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regularly irregular rate, tachycardic, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: ================================== VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, EOMI ENT: Oropharynx clear without lesion CARDIOVASCULAR: Tachycardic, regular rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Pertinent Results: ADMISSION LABS: ======================= ___ 10:30AM BLOOD WBC-7.3# RBC-4.42* Hgb-13.1* Hct-38.5* MCV-87 MCH-29.6 MCHC-34.0 RDW-12.3 RDWSD-38.7 Plt ___ ___ 10:30AM BLOOD Neuts-64 Bands-2 Lymphs-13* Monos-9 Eos-0 Baso-0 ___ Metas-10* Myelos-2* AbsNeut-4.82 AbsLymp-0.95* AbsMono-0.66 AbsEos-0.00* AbsBaso-0.00* ___ 10:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL ___ 10:30AM BLOOD Plt Smr-LOW* Plt ___ ___ 10:30AM BLOOD UreaN-10 Creat-0.9 Na-140 K-4.3 ___ 10:30AM BLOOD Glucose-98 ___ 10:30AM BLOOD ALT-44* AST-36 LD(LDH)-241 AlkPhos-129 TotBili-0.2 ___ 10:30AM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.4 Mg-2.2 UricAcd-5.2 DISCHARGE LABS: ======================= ___ 04:34AM BLOOD WBC-7.7 RBC-4.08* Hgb-12.1* Hct-35.7* MCV-88 MCH-29.7 MCHC-33.9 RDW-12.3 RDWSD-39.0 Plt Ct-88* ___ 04:34AM BLOOD Neuts-80* Bands-0 Lymphs-5* Monos-14* Eos-0 Baso-0 ___ Myelos-1* AbsNeut-6.16* AbsLymp-0.39* AbsMono-1.08* AbsEos-0.00* AbsBaso-0.00* ___ 04:34AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* Macrocy-NORMAL Microcy-1+* Polychr-1+* Spheroc-1+* Ovalocy-1+* Tear Dr-OCCASIONAL ___ 04:34AM BLOOD Glucose-149* UreaN-7 Creat-1.0 Na-137 K-4.1 Cl-97 HCO3-27 AnGap-13 ___ 04:34AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 MICROBIOLOGY: ======================= BLOOD/URINE CX NEGATIVE, RESPIRATORY PANEL NEGATIVE, FLU PCR NEGATIVE IMAGING: ======================= ___ CXR: FINDINGS: Lungs are fully expanded and clear. No pleural abnormalities. Heart size is normal. Cardiomediastinal and hilar silhouettes are unremarkable - extensive mediastinal lymphadenopathy previously seen on CT is not appreciated. A dual lumen right IJ central venous Port-A-Cath tip projects over the right atrium. IMPRESSION: No evidence of an acute cardiopulmonary abnormality. Brief Hospital Course: Mr. ___ is a ___ with Hodgkin's lymphoma and primary mediastinal lymphoma who presented with 1 day of low grade fever (max 100.2F) and chills consistent with an upper respiratory infection, likely viral in nature. # Low-grade temperatures # Chills # Nasal congestion/rhinitis: No documented fever but chills, low grade temps, and nasal congestion/rhinitis c/f acute URTI. No other clear infectious symptoms. Young children at home with cold-like symptoms. Flu swab negative, additional respiratory viral panel pending. He likely has as viral process. He had no fevers while inpatient and was able to be discharged with follow-up. # Primary mediastinal lymphoma # Classical Hodgkin's lymphoma: SP 6 cycles EPOCH for mediastinal DLBCL. Now with residual classical Hodgkin's lymphoma. SP C1 ICE with plan for second cycle followed by auto-SCT consolidation. He has recovered his counts from prior ICE cycle and is no longer on neupogen or levoflox ppx. He was continued on home Bactrim and acyclovir ppx. # Tachycardia: Patient has history of bigeminal PVC's and sinus tachycardia. EKG in ED showed sinus tach with PVC's. He is asymptomatic. Appears similar to outpatient rates. Pt states that this is his baseline. Home metoprolol was continued. # History of pancreatitis: Continued home creon. # Biopsychocial - Cont home nortyptiline - Cont home ativan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Creon ___ CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 4. Nortriptyline 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 6. Acyclovir 400 mg PO Q8H 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Ondansetron ODT 4 mg PO Q8H:PRN nausea 10. Filgrastim 480 mcg SC ASDIR 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Filgrastim 480 mcg SC ASDIR 2. Acyclovir 400 mg PO Q8H 3. colesevelam 625 mg oral BID 4. Creon ___ CAP PO QID PRN meals and snacks 5. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nortriptyline 10 mg PO QHS 8. Ondansetron ODT 4 mg PO Q8H:PRN nausea 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary: Viral Sinusitis Primary mediastina lymphoma 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 having low grade fevers, chills and nasal congestion. We checked you for the flu which was negative. We also did a chest x-ray which did not show any pneumonia. You did not have any fevers while you were here. You likely have a virus which is causing nasal congestion. Please keep your follow-up appointments and take your medications as listed below. It was a pleasure taking care of you, -Your ___ Team Followup Instructions: ___
10074908-DS-5	10,074,908	29,170,411	DS	5	2165-01-17 00:00:00	2165-01-18 17:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: seafood Attending: ___. Chief Complaint: Weakness, Jaw Pain Major Surgical or Invasive Procedure: ___: Extraoral L parapharyngeal abscess I&D with ___ drain placement; Extraction of teeth 3, 9, 12, 18 Endotracheal Intubation History of Present Illness: ___ year old ___ speaking female with DMII, dementia, ___, with 2 days of left submandibular swelling and pain, decreased PO intake. Family reports she complained of pain in the throat yesterday, and today complained of pain in the left jaw. She also had a subjective fever today, and was referred to ED by her PCP. Of note, patient was last hospitalized ___ for elective placement of VP shunt for NPH. In the ED, initial vitals: T99.2 HR89 BP180/152 RR16 O297% RA - Her exam was notable for somnolence, asymmetric tense swelling to the left mandibular angle tender to palpation, trismus with 3-4cm of opening, poor dentition apparent, foul smelling breath. Pulmonary exam notable for coarse breath sounds radiating through bilateral lung fields. - Examination by OMFS showed: "OC/OP shows floor of mouth soft + pus along sulcus/duct. Left neck swelling. FOE shows moderate epiglottis edema. VC visualized and without edema." - Labs were notable for: WBC 9.1 (80% PMNs), Hbg 13.9, Plts 300, lactate 1.4,with normal chem10. - ENT and Anesthesia were requested. - CT neck with contrast showed a 1.4 x 1.0 cm hypodense lesion with internal foci of air is identified in the left parapharyngeal space (02:37, 602b:38), concerning for phlegmon/ early abscess. - Patient was given cefepime 2g and dexamethasone 10mg. Patient was taken to OR and is now s/p extraoral I&D left submandibular space with associated extraction of 4 teeth (3 maxillary, 1 mandibular). 1 ___ was placed (extra-oral to intra-oral) with 4x4 gauze dressing placed. Procedure was otherwise uncomplicated and lasted 13 minutes. Patient was intubated and paralyzed during procedure. On arrival to the MICU, patient was intubated and sedated, inability to follow commands. He was noted to have 6.5ETT with no cuff leak. ENT recommended keeping intubated overnight with plans for extubation in the morning after scope and with backup from anesthesia/ENT. Anesthesia also note that intubation was not difficult but they did use glidescope for intubation. Past Medical History: DEMENTIA H/O CEREBELLAR MENINGIOMA, calcified, q6 mo MRI; with residual right sided weakness HYDROCEPHALUS S/P VP SHUNT DIABETES TYPE II ___ DISEASE FRONTAL CORTEX DEMENTIA, OVER THE LAST ___ YEARS Social History: ___ Family History: Adopted in ___ Physical Exam: Admission Physical Exam: ========================== Vitals: T97.5 HR80 BP128/79 RR29 100% Vent: 40%FiO2 Peep5 CMV 400 RR14 GENERAL: intubated, sedated, pinpoint pupils HEENT: bite block in place NECK: bandaging left side of neck with overlying dressing, c/d/i LUNGS: ctab, mechanical breath sounds CV: rrr, no m/r/g ABD: soft, nondistended, nontender, normoactive bs EXT: no ___ edema NEURO: not following commands ACCESS: 18g, 20g Discharge Physical Exam: ======================== Vitals: T 98 HR 79 BP 107/66 RR 20 SpO2 99% on RA General: Alert, making good eye contact and smiling in response to my smile, no acute distress HEENT: L jaw without palpable fluctuance, crepitus, or tension. L jaw operative site is clean/dry/intact. No purulent drainage or surrounding erythema. Lungs: Poor inspiratory effort, but clear to auscultation anteriorly/laterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/gallops Abdomen: Soft, non-tender to palpation, non-distended, bowel sounds normoactive, no guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: No new rashes or lesions Neuro: Moving all four extremities spontaneously. CN II-XII grossly intact. Pertinent Results: >> Admission Labs: ==================== ___ 02:47PM BLOOD WBC-9.1 RBC-4.49 Hgb-13.9 Hct-39.4 MCV-88 MCH-31.0 MCHC-35.3 RDW-12.0 RDWSD-38.5 Plt ___ ___ 02:47PM BLOOD Neuts-80.1* Lymphs-12.2* Monos-7.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-7.30# AbsLymp-1.11 AbsMono-0.64 AbsEos-0.01* AbsBaso-0.03 ___ 02:47PM BLOOD ___ PTT-28.9 ___ ___ 02:47PM BLOOD Glucose-144* UreaN-7 Creat-0.6 Na-137 K-5.0 Cl-99 HCO3-23 AnGap-20 ___ 02:47PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 ___ 11:07PM BLOOD Type-ART Temp-36.5 FiO2-40 pO2-193* pCO2-28* pH-7.47* calTCO2-21 Base XS--1 Intubat-INTUBATED ___ 03:00PM BLOOD Lactate-1.4 >> Discharge Labs: ================== ___ 07:00AM BLOOD WBC-3.6* RBC-4.37 Hgb-13.2 Hct-38.6 MCV-88 MCH-30.2 MCHC-34.2 RDW-12.0 RDWSD-38.9 Plt ___ ___ 07:00AM BLOOD Glucose-169* UreaN-10 Creat-0.5 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 >> Pertinent Reports: ===================== ___ Imaging CHEST (PORTABLE AP) Compared to chest radiographs since ___, most recently ___ at 01:18. Endotracheal tube has been repositioned, now in standard placement. Lungs clear. Cardiomediastinal and hilar silhouettes and pleural surfaces normal. Transesophageal drainage tube passes into the nondistended stomach and out of view. ___ Imaging CHEST (PORTABLE AP) ET tube indwelling he ET tube tip less than a cm from carina should be withdrawn 2 or 3 cm. Lungs fully expanded and clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. Nasogastric tube passes into the stomach and out of view. ___ Imaging CHEST (PORTABLE AP) Lungs grossly clear. Heart size normal. Esophageal drainage catheter passes into the stomach and out of view. An identified catheter, perhaps a ventriculoperitoneal shunt, traverses the right neck chest and upper abdomen, also passing of view. ___ Imaging CT NECK W/CONTRAST 1. 1.4 x 1.0 x 0.9 cm hypodense area within the left parapharyngeal space at the level of the angle of the mandible containing foci of gas with peripheral enhancement and extensive adjacent inflammatory changes most compatible with phlegmon and early abscess formation. 2. Re- demonstration of extensive periapical lucencies within maxillary and mandibular teeth bilaterally, likely reflective of periodontal disease, but these are not adjacent to the area of phlegmon/ early abscess. 3. 3.2 cm calcified right posterior fossa mass is unchanged, consistent with a meningioma. Brief Hospital Course: ___ year old female with DMII, dementia, ___ presented with 2 days of left submandibular swelling and pain, decreased PO intake, found to have parapharyngeal space abscess, s/p drainage and antibiotics. ACTIVE ISSUES ============== # Left submandibular space/odontogenic infection: CT neck demonstrating a 1.4 x 1.0 cm hypodense lesion with internal foci of air identified in the left parapharyngeal space concerning for phlegmon/early abscess. On ___, patient underwent extraoral I&D left submandibular space with associated extraction of 4 teeth (3 maxillary, 1 mandibular) with placement of ___. Patient was given 4 doses of Decadron for concern of airway swelling. She was extubated within 24 hours. She was maintained on peridex mouthrinse BID and Unasyn from ___, whereupon she was switched to clindamycin for a 7 day course (ending ___. ___ was discontinued on ___ per OMFS. CHRONIC ISSUES ================ # NPH s/p VP Shunt/frontotemporal dementia: Baseline dementia. # Hypertension: Home lisinopril was held in the setting of soft pressures on admission. # Diabetes: Home metformin was held and patient was started on ISS while hospitalized. # ___ Disease: Patient was maintained on home carbidopa-levodopa. TRANSITIONAL ISSUES ================== # PARAPHARYNGYEAL SPACE ABSCESS: antibiotics (clindamycin) to continue until ___ # LEUKOPENIA: noted on labs at discharge. Would recommend repeat CBC in 1 week after completing antibiotics and work up as necessary. # Communication: Husband ___ ___ # Code: FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Lisinopril 5 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Carbidopa-Levodopa (___) 1 TAB PO TID 6. Alendronate Sodium 70 mg PO QSUN 7. Cyclobenzaprine 5 mg PO TID:PRN pain 8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QSUN 2. Atorvastatin 80 mg PO QPM 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 5. Cyclobenzaprine 5 mg PO TID:PRN pain 6. Lisinopril 5 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Clindamycin 300 mg PO Q6H Duration: 7 Days Final day of antibiotics: ___. 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Parapharyngeal abscess 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. ___, You were admitted to the ___ because you had two days of decreased appetite and jaw/throat pain. You were found to have an infection in an area around your left jaw. Our oral/ maxillofacial surgeons were able to drain this abscess, as well as remove four teeth that may have been a source of this infection. We treated you with antibiotics and monitored your blood for signs of infection. We are sending you home with clindamycin pills to help get rid of this infection. You will be completing a 7-day course, with the last day of your antibiotics to complete on ___. Warm regards, Your ___ Team Followup Instructions: ___
10075053-DS-2	10,075,053	26,259,455	DS	2	2177-06-21 00:00:00	2177-06-25 11:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: generalized pain s/p MVC with rollover Major Surgical or Invasive Procedure: none History of Present Illness: ___ with no PMHx presents to the ED intoxicated (EtOH) and s/p MVC. The patient was the unrestrained passenger involved in an MVC with rollover at unknown speed-- Estimated to be high by EMS, as the vehicle rolled over on ___, found significantly deformed about 100 feet away from the street. Patient entrapped in vehicle, which took ___ minutes to extract. Past Medical History: none Social History: ___ Family History: non-contributory Physical Exam: SUBJECTIVE: Patient endorsing full body pain. Denies chest pain, SOB, fever, chills, N/V. OBJECTIVE: Vitals: Temp: 98.1 BP: 100/65 HR: 58, RR: 18, O2 sat: 95%, O2 delivery: Ra Gen: A&Ox3 ___: RRR assessed peripherally Pulm: non-labored breathing on room air MSK: RUE: diffuse soreness/pain limits fulls strength ___ motor intact to shoulder abduction/shrug ___ elbow flexion/extension; wrist flexion/extension but limited secondary to pain; r/u/m nerve distributions intact about hand Sensation diffusely intact to RUE including ax/r/m/u nerve distributions Tenderness to palpation diffusely RUE, especially about Right ulnar styloid, no significant pain to snuff box DRUJ assessed and comparable to contralateral (left) side palpable radial pulse w/brisk cap refill distally LUE: diffuse soreness/pain limits fulls strength ___ motor intact to shoulder abduction/shrug ___ elbow flexion/extension; wrist flexion/extension but limited secondary to pain; r/u/m nerve distributions intact about hand Sensation diffusely intact to RUE including ax/r/m/u nerve distributions Tenderness to palpation diffusely RUE Palpable radial pulse w/brisk cap refill distally RLE: Scattered superficial abrasions about thigh and leg Minor knee effusion, no obvious deformities Motor intact to thigh ext/flexion; knee extension and flexion and ___ intact Sensation diffusely intact about thigh, leg, foot (SPN and DPN) Brisk cap refill distally LLE: Scattered superficial abrasions about thigh and leg Minor knee effusion, no obvious deformities Motor intact to thigh ext/flexion; knee extension and flexion and ___ intact Sensation diffusely intact about thigh, leg, foot (SPN and DPN) Brisk cap refill distally Pertinent Results: ___ 02:20AM BLOOD WBC-8.0 RBC-4.07* Hgb-12.4* Hct-38.1* MCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.5 Plt ___ ___ 02:20AM BLOOD Plt ___ ___ 04:23AM BLOOD ___ PTT-26.2 ___ ___ 02:20AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-141 K-4.2 Cl-104 HCO3-27 AnGap-10 ___ 02:15AM BLOOD ALT-183* AST-225* AlkPhos-50 TotBili-0.2 ___ 02:15AM BLOOD Albumin-4.4 Calcium-9.2 Phos-4.0 Mg-2.0 ___ 02:15AM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG RIGHT WRIST: There is a mildly displaced fracture through the ulnar styloid. Deformity of the fourth metacarpal most likely represents a healed fracture. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. Diffuse soft tissue swelling is seen around the wrist. There is an intravenous line along the dorsal aspect of the wrist. Brief Hospital Course: Mr ___ presented to ___ Department early in the morning on ___ s/p MCV accident with EtOH intoxication. Upon arrival to ED the patient was assessed and managed via trauma protocols. The patient was found to be hemodynamically stable and not in respiratory distress. He was assessed with an EFAST US scan, trauma X-rays of the chest and pelvis, and pan scanned with CT which showed evidence of possible pulmonary contusions, but no injuries that warranted immediate surgery. Given findings, the patient was taken not to the operating room but instead managed conservatively with pain management and close monitoring. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV medications and then quickly transitioned to oral tylenol, ibuprofen, and oxycodone once tolerating oral diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. MSK: Due to generalized pain and superficial injuries, after initial X-rays and CT pan scan, patinet recived additional xrays of his R elbow, hand, wrist, ankle, bilateral knees, L tib/fib. All of which were noncerning for acute processes of fxs with the notable exception of the R wrist: There is a mildly displaced fracture through the ulnar styloid. Deformity of the fourth metacarpal most likely represents a healed fracture. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. Diffuse soft tissue swelling is seen around the wrist. There is an intravenous line along the dorsal aspect of the wrist. During his stay, Mr. ___ was seen by OT, Social work, as well as Spiritual Care given the traumatic nature of the mechanism of his injuries. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Patient agreed to follow-up with the ortho hand clinic for further assessment and management of his wrist fracture and well as follow-up with ACS. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Do not exceed 3000 mg in 24 hours. Do not take with alcohol 2. Ibuprofen 600 mg PO Q6H 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe Duration: 3 Days Take only the minimum amount needed for severe pain RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #15 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bilateral pulmonary contusions right ulnar styloid 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 the hospital because you were involved in a car accident. Upon assessment here at ___, you were noted to have sustained bruising (contusions) to both your lungs. It will resolve on its own and requires no medical intervention. You have been seen by social work and occupational therapy because you do not remember the accident. You have been cleared to go home to continue your recovery. Please follow the discharge instructions below: 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 driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10075925-DS-11	10,075,925	24,184,489	DS	11	2132-12-26 00:00:00	2132-12-26 16:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: SOB Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo F with h/o HTN, dCHF, DM2, s/p renal transplant, admitted on ___ with a several day h/o dyspnea with exertion, progressive, called EMS and found to have hypoxemia to the 50's. Pt with mild CP on admission (resolved). She reports 9 lb weight gain over six months (wt 209 lbs on admission). In the ED, started on BiPAP. She was treated with empiric abx (for possible PNA) and bid furosemide (for possible pulm edema), with marked improvement. She is now sitting in bed, conversant, on 5L O2, with her husband and daughter at the bedside. She is being transferred to the medical service from the ICU for further care. She currently has no SOB (on O2). She has no HA, f/c, N/V, CP, abd pain. [X] 10 point review of symptoms negative except as noted above. Past Medical History: HTN/dCHF DM2 Living donor renal transplant from her husband (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: HMED ADMISSION EXAM: Afeb 83 160/74 RR 12 SaO2 95% (5L NC) NAD RRR Scattered wheezes/rhonchi +BS, soft, NT, ND No ___ edema A+Ox3 . . HMED DISCHARGE EXAM: VS: 24 HR Data (last updated ___ @ 1457) Temp: 98.0 (Tm 98.5), BP: 132/84 (112-159/58-84), HR: 74 (74-88), RR: 18 (___), O2 sat: 95% (93-98), O2 delivery: RA Wt: 90 kg (198.4 lbs) on standing scale Gen: NAD, disheveled, +cushingoid appearance HEENT: EOMI, MMM Neck: obese, unable to visualize any JVP/JVD Cards: RR Chest: trace LLL crackles, no wheezing, normal WOB Abd: obese, S, NT, ND, BS+ Skin: acanthosis nigricans in various places on the back, thickening of skin Ext: no ___ edema, grossly normal strength in arms/legs Neuro: awake, alert, conversant Psych: calm, cooperative Pertinent Results: ADMISSION LABS: ================= ___ 07:08AM BLOOD WBC-10.4* RBC-4.87 Hgb-14.3 Hct-47.8* MCV-98 MCH-29.4 MCHC-29.9* RDW-18.4* RDWSD-61.6* Plt ___ ___ 07:08AM BLOOD Neuts-81.3* Lymphs-9.1* Monos-8.2 Eos-0.5* Baso-0.2 NRBC-0.5* Im ___ AbsNeut-8.48* AbsLymp-0.95* AbsMono-0.85* AbsEos-0.05 AbsBaso-0.02 ___ 07:08AM BLOOD ___ PTT-27.7 ___ ___ 07:08AM BLOOD Glucose-106* UreaN-31* Creat-1.1 Na-135 K-8.6* Cl-94* HCO3-25 AnGap-16 ___ 07:08AM BLOOD ALT-<5 AST-58* CK(CPK)-182 AlkPhos-70 TotBili-0.6 ___ 07:08AM BLOOD CK-MB-7 proBNP-1020* ___ 07:08AM BLOOD cTropnT-0.05* ___ 07:08AM BLOOD Albumin-4.4 ___ 05:02PM BLOOD Calcium-10.0 Phos-3.8 Mg-2.0 ___ 07:15AM BLOOD ___ pO2-51* pCO2-53* pH-7.32* calTCO2-29 Base XS-0 Intubat-NOT INTUBA Comment-ADDED TO A ___ 07:15AM BLOOD K-5.0 . . NOTABLE LABS WHILE INPATIENT: ============================= ___ 07:08AM BLOOD CK-MB-7 proBNP-1020* ___ 07:08AM BLOOD cTropnT-0.05* ___ 05:02PM BLOOD CK-MB-9 cTropnT-0.06* ___ 06:17AM BLOOD CK-MB-5 cTropnT-0.08* ___ 09:00AM BLOOD tacroFK-5.2 ___ 10:35AM BLOOD tacroFK-7.4 . . DISCHARGE LABS: ================ ___ 07:10AM BLOOD WBC-9.0 RBC-4.91 Hgb-14.4 Hct-46.9* MCV-96 MCH-29.3 MCHC-30.7* RDW-16.4* RDWSD-56.7* Plt ___ ___ 07:10AM BLOOD Glucose-248* UreaN-41* Creat-1.1 Na-136 K-4.9 Cl-90* HCO3-31 AnGap-15 ___ 07:10AM BLOOD Calcium-9.7 Phos-2.4* Mg-2.5 . . MICRO: ======= Flu - negative Resp viral screen - negative Resp viral Cx - pending ___ Blood culture x2 - pending . . IMAGING: ======== ___ CXR: IMPRESSION: Hypoinflated lungs with moderate pulmonary edema and probable small bilateral pleural effusions. Retrocardiac opacities may represent atelectasis, however, superimposed pneumonia cannot be excluded in the appropriate clinical setting. . ___ CXR: IMPRESSION: In comparison with study of ___, there again are low lung volumes with substantial enlargement of the cardiac silhouette and moderate pulmonary edema. Increased opacity at the right base with silhouetting of the hemidiaphragm is consistent with pleural effusion and volume loss in the left lower lobe. The left hemidiaphragm is better seen, suggesting some improvement in atelectatic changes and pleural effusion. In the appropriate clinical setting, it would be impossible to exclude superimposed pneumonia/aspiration, given the findings described above in the absence of a lateral view. . ___ TTE: EF 66%; Small-moderate circumferential pericardial effusion without evidence for hemodynamic compromise. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Brief Hospital Course: Active Problem list: ===================== # Acute hypoxic respiratory failure # Possible community-acquired pneumonia # Acute HFpEF exacerbation # Type II NSTEMI (demand ischemia i/s/o CKD) # Small-to-moderate circumferential pericardial effusion # Mechanical fall while hospitalized # ___ on CKD # Hx of renal transplant on chronic immunosuppression # HTN # IDDM # OSA - untreated . . Hospital Course: ================= # Acute hypoxic respiratory failure # Acute on chronic HFpEF # Possible CAP -Presented with acute hypoxic respiratory failure from HFpEF +/- CAP -SOB and hypoxia responded well to BIPAP and IV Lasix initially in ED and ICU, was over 7 L net negative in ICU. -On transfer to the floor, her O2 sats remained low (w/ 4 L O2 requirement) despite developing signs of contraction alkalosis and intravascular hypovolemia, so she was continued on CAP treatment w/ cefepime and given gentle IVF with resolution of the contraction alkalosis, intravascular hypovolemia and gradual resolution of her hypoxia. -Received total course of 5 days of cefepime for CAP, last dose on ___ . # HFpEF w/ acute exacerbation -TTE on ___ showing normal LVEF, significant LVH, ___ ___ - suggestive of hypertensive heart disease and consistent with chronic HFpEF; presentation with severe hypoxia that responded to BIPAP plus IV Lasix with large volume UOP -Being discharged on her prior home dose of Lasix (10 mg daily), this may ultimately need to be increased to keep her weights stable -She was counseled on the importance of daily weights, sodium restriction, and fluid restriction for CHF management and instructed to notify her MD if increasing daily weights or developing signs/symptoms of volume overload/CHF -Discharge weight: 90 kg (198.4 lbs) . # Small-to-medium pericardial effusion w/o evidence for tamponade: unclear etiology; she resolved clinically back to her baseline with diuresis and abx for possible CAP. [] Consider outpatient cardiology referral or interval cardiac imaging for assessment of small-to-moderate pericardial effusion noted on ___ TTE. . # Hx of renal transplant -Renal transplant service actively followed the patient while she was hospitalized. Her home tacro/MMF doses were not changed during this hospitalization. . # Fall: mechanical fall while hospitalized, tripped on roommate's luggage. No clinical sequelae of fall. ___ evaluated patient and found her to be independent in all activities. . # HTN: on 5-drug regimen for BP control at home. Possible that untreated OSA may be contributing to her recalcitrant hypertension; could also be related to renovascular causes I/s/o renal transplant. Discussed with ___ fellow, no changes to her home regiment made while inpatient. . # DM2, uncontrolled with complications - continued insulin . # OSA: endorses prior Dx, says she wasn't able to wear the CPAP/BIPAP mask due to claustrophobia "a long time ago." [] consider outpatient sleep study to evaluate other/new mask types . . Transitional issues: ======================= -Discharge standing weight: 90 kg -Advised patient to call to schedule PCP ___ within ___ days to follow-up on this hospitalization. [] Consider outpatient cardiology referral or interval cardiac imaging for assessment of small-to-moderate pericardial effusion noted on ___ TTE. [] Consider outpatient sleep study to evaluate other/new mask types so that she might be started on treatment for OSA. . . . Time in care: Greater than 45 minutes in patient care, patient counseling, care coordination and other discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Chlorthalidone 25 mg PO DAILY 4. Furosemide 10 mg PO DAILY 5. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Labetalol 300 mg PO BID 7. Mycophenolate Mofetil 500 mg PO BID 8. Tacrolimus 1.5 mg PO Q12H 9. Valsartan 160 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY Discharge Medications: 1. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Chlorthalidone 25 mg PO DAILY 6. Furosemide 10 mg PO DAILY 7. Labetalol 300 mg PO BID 8. Mycophenolate Mofetil 500 mg PO BID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 10. Tacrolimus 1.5 mg PO Q12H 11. Valsartan 160 mg PO BID Discharge Disposition: Home Discharge Diagnosis: # Acute hypoxic respiratory failure # Possible community-acquired pneumonia # Acute HFpEF exacerbation # Type II NSTEMI (demand ischemia i/s/o CKD) # Small-to-moderate circumferential pericardial effusion # Mechanical fall while hospitalized # ___ on CKD # Hx of renal transplant on chronic immunosuppression # HTN # IDDM # OSA - untreated Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms ___, You were admitted to the hospital with shortness of breath and very low oxygen levels (hypoxia). You were treated initially with BIPAP, diuretics to help you pee out excess fluid, and IV antibiotics for possible pneumonia. With these interventions your shortness of breath improved rapidly and your oxygen levels improved more gradually, but have now returned to normal levels. You have completed a 5 day course of antibiotics for possible pneumonia and are doing well. However, if in the next ___ days you develop fevers or shaking chills, worsening shortness of breath, cough, or sputum production, please return to the ___ emergency department immediately, as you may need more antibiotics. You are being discharged back on your regular diuretic regimen (Furosemide 10 mg daily). It is VERY IMPORTANT that you weigh yourself each day, at approximately the same time of day, and notify your doctor if your weight is increases by more than 3 lbs from your current weight. If your weight is increasing, you may need to take more of the furosemide (Lasix). It was a pleasure caring for you while you were in the hospital, and we wish you a full and speedy recovery. Sincerely, The ___ Medicine Team Followup Instructions: ___
10075925-DS-12	10,075,925	21,574,077	DS	12	2133-03-31 00:00:00	2133-03-31 21:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with h/o HTN, HFpEF, DM2, s/p Living donor renal transplant ___, who presented with one week of worsening dyspnea and leg edema, found to be hypoxemic to 70% on RA in ED. Patient notes she was caring for her father who also has a bronchitis or PNA. She has been progressively dyspneic with rest and ambulation. She denies orthopnea, however does endorse PND. Endorses weight gain and leg edema and abdominal bloating. Per our records she has gained 24lbs since ___. She has only been taking 10mg Lasix at home and reportedly her nephrologist asked her to increase, but patient was worried it would hurt her kidneys so she did not increase. Denies chest pain/pressure, palpitations, syncope, presyncope, sputum production, fevers, chills, sweats. Denies n/v, abdominal pain. Denies recent surgery or immobilization, or hemoptysis. In ED initial VS: ___ 70 122/54 20 70% RA Labs significant for: whole K 7.4, Cr 1.3 (baseline ___, Normal WBC. Lactate 3.3 Patient was given: Vanc/Cefepime. Dextrose, insulin, calcium gluconate. NO FLUIDS. Imaging notable for: CXR with known cardiomegaly and diffuse interstitial edema with right pleural effusion. Difficult to r/o focal infiltrate. Consults: Nephrology transplant VS prior to transfer: ___ 80 133/79 20 95% 5L NC On arrival to the MICU, patient notes her breathing is somewhat better. However still dyspneic, especially with activity. Denies chest pain, palpitations, pre-syncope. REVIEW OF SYSTEMS: Otherwise negative review. Past Medical History: HTN HFpEF DM2 Living donor renal transplant from her husband (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION EXAM GENERAL: Alert, oriented, in NAD. Pleasant. Obese. Cushingoid features. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVD elevated to earlobe at 90 degrees LUNGS: Bilateral crackles in lower to mid lung fields. No wheezing, rhonchi. CV: Tachycardic, Regular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Obese, soft, non-tender, bowel sounds present, no rebound tenderness or guarding EXT: WARM, WELL perfused in upper and lower extremities. 1+ pitting edema bilaterally. Some edema in arms. SKIN: No rashes. Bronze skin. NEURO: AAx0x3. Moves all extremities with purpose. DISCHARGE EXAM ___ 1132 Temp: 98.0 PO BP: 117/75 HR: 80 RR: 18 O2 sat: 100% O2 delivery: neb FSBG: 205 GENERAL: Comfortable, in NAD HEENT: NC/AT, PERRLA, EOMI NECK: Supple, no lymphadenopathy, unable to assess JVD given neck pannus CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: Decreased breath sounds throughout. No wheezes, rales, rhonchi ABDOMEN: Soft, NT/ND. Normoactive bowel sounds. No evidence of organomegaly EXTREMITIES: No lower extremity edema. NEUROLOGIC: CN II-XII intact. No focal neurological deficits SKIN: No obvious skin rashes, ulceration, or skin breakdown. Pertinent Results: ADMISSION LABS ___ 05:50PM BLOOD WBC-9.1 RBC-4.70 Hgb-14.0 Hct-46.0* MCV-98 MCH-29.8 MCHC-30.4* RDW-20.1* RDWSD-69.6* Plt ___ ___ 05:50PM BLOOD ___ PTT-28.7 ___ ___ 05:50PM BLOOD Glucose-197* UreaN-42* Creat-1.3* Na-133* K->10.0* Cl-93* HCO3-25 AnGap-15 ___ 07:52PM BLOOD proBNP-708* ___ 12:05AM BLOOD CK-MB-9 cTropnT-0.03* ___ 05:50PM BLOOD Calcium-9.4 Phos-5.6* ___ 05:59PM BLOOD ___ pO2-87 pCO2-55* pH-7.30* calTCO2-28 Base XS-0 ___ 05:59PM BLOOD Lactate-3.3* K-7.4* INTERVAL LABS ___ 12:05AM BLOOD ALT-24 AST-16 CK(CPK)-191 AlkPhos-80 TotBili-0.6 ___ 02:56AM BLOOD %HbA1c-6.4* eAG-137* ___ 12:17AM BLOOD ___ pO2-48* pCO2-55* pH-7.30* calTCO2-28 Base XS-0 ___ 04:02PM BLOOD ___ pO2-47* pCO2-75* pH-7.31* calTCO2-40* Base XS-7 ___ 04:02PM BLOOD Glucose-302* Lactate-2.0 K-4.6 DISCHARGE LABS ___ 06:26AM BLOOD WBC-7.9 RBC-4.96 Hgb-14.6 Hct-47.2* MCV-95 MCH-29.4 MCHC-30.9* RDW-17.4* RDWSD-59.9* Plt ___ ___ 06:26AM BLOOD Glucose-235* UreaN-35* Creat-1.1 Na-137 K-4.5 Cl-90* HCO3-29 AnGap-18 ___ 06:26AM BLOOD Calcium-10.5* Phos-3.7 Mg-2.0 ___ 06:26AM BLOOD PTH-PND ___ 03:05AM BLOOD 25VitD-PND ___ 06:26AM BLOOD tacroFK-6.7 MICROBIOLOGY Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: NO GROWTH. IMAGING CHEST X-RAY ___: Severe cardiomegaly with vascular congestion and moderate interstitial edema and a trace right-sided effusion. Superimposed infection would be difficult to exclude in the appropriate clinical context. TTE ___: Small to moderate pericardial effusion without echocardiographic evidence of tamponade. Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Compared with the prior study (images reviewed) of ___, the size of the pericardial effusion is likely similar (suboptimal apical images on the prior study preclude definitive comparison). CXR ___: Cardiac silhouette is enlarged. There is again seen diffuse interstitial opacities bilaterally. There is worsening of opacities at the right base. Again, findings can be seen with pulmonary edema; however, given the diuresis, infection should also be considered. CXR ___: Mild to moderate pulmonary edema has improved since ___, particularly at the base of the right lung. Small pleural effusions, moderate cardiomegaly and dilatation of the pulmonary arteries have improved as well. No pneumothorax. Indentation of the trachea from the left at the thoracic inlet is long-standing, usually due to an enlarged thyroid. Clinical evaluation recommended. Brief Hospital Course: Ms. ___ is a ___ female with history of hypertension, HFpEF, DM2, ESRD ___ DM s/p LURT (___) maintained on cellcept and tacrolimus, who presented with dyspnea, lower extremity edema and weight gain, found to be hypoxemic on admission with O2 70% on RA in the ED, admitted for acute on chronic HFpEF exacerbation to the ICU, requiring BiPAP, diuresed with IV Lasix, subsequently weaned to room air and transitioned to PO Lasix 30mg daily, likely with central and obstructive sleep apnea. # Mixed Hypoxemic Respiratory Failure # Acute on chronic HFpEF - Patient initially presented with a one-week history of worsening dyspnea on exertion and at rest, also with 20 pound weight gain since ___ and worsening abdominal distention, on admission was hypoxic to 70%, with BNP 700. CXR showed pulmonary edema, requiring ICU admission for BiPAP. She initially received vancomycin and cefepime to cover possible PNA, continued on ceftriaxone and azithromycin in the ICU, however antibiotics were subsequently discontinued given the low suspicion for pneumonia. She was diuresed with IV lasix 80mg boluses, subsequently transitioned to PO Lasix 30 mg daily, increased from her home dose 10 mg. Trigger for acute on chronic HFpEF exacerbation was unclear, given no obvious underlying infection, troponin 0.03 on admission with flat CK-MB within her baseline the setting of ESRD status post LURT. Reported adherence to home PO Lasix, possibly dietary discretion. Discharge weight 91.2 kg, 201.06 lbs. # Apnea # Acute on chronic respiratory acidosis - Of note, with chronic respiratory acidosis and observed to have apneic episodes overnight with desaturations to the ___. She likely has underlying obstructive sleep apnea and probable central apnea. When awakened, she recovers her tidal volume and oxygenation. Her CO2 improved with high settings on the Trilogy mask. She had intermittent apnea episodes while sleeping, but easily recovers. She was counseled on the need for sleep medicine followup and consideration of different options for her apnea, given that she would like to avoid CPAP. On the floor, she was weaned to room air. With ambulation she maintained O2 sats of 90-96%. # ESRD s/p LURT - History of ESRD ___ DM s/p LURT (___). She was continued on home cellcept 500mg BID and tacrolimus 1.5mg BID with goal trough ___. # HTN - Was continued on home amlodipine 10mg daily, home valsartan 160 mg PO BID, home labetalol 300 BID, and home chlorthalidone 25mg. Furosemide was increased from 10 mg daily to 30 mg daily. # DM2 - Home glargine was increased from 30 units to 34 units given hyperglycemia. # CAD primary prevention - Continued home Aspirin 81 mg PO DAILY and atorvastatin 20 mg PO QPM # UTI prophylaxis - Continued home macrobid ___ daily TRANSITIONAL ISSUES [ ] New/Changed Medications: - Lasix increased from 10 to 30 mg daily - Glargine increased from 30 units to 34 units [ ] Discharge diuretic: 30 mg furosemide daily [ ] Discharge weight: Discharge weight 91.2 kg, 201.06 lbs. [ ] Please ensure that patient goes to outpatient pulmonary appointment that has been scheduled. [ ] Please check CHEM 10 at hospital discharge follow up appointment. Please monitor weight and volume status at outpatient follow up. Please titrate furosemide as needed. [ ] Calcium was slightly elevated upon discharge. Please follow up PTH and Vitamin D level, which are pending at discharge. [ ] Please ensure follow up with outpatient endocrinologist. We have emailed to assist with follow up appointment. # CODE: Full, CONFIRMED # CONTACT: ___ (Husband/HCP): ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Chlorthalidone 25 mg PO DAILY 5. Labetalol 300 mg PO BID 6. Mycophenolate Mofetil 500 mg PO BID 7. Tacrolimus 1.5 mg PO Q12H 8. Valsartan 160 mg PO BID 9. Furosemide 10 mg PO DAILY 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 11. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 13. Docusate Sodium 100 mg PO BID 14. Fish Oil (Omega 3) 1000 mg PO DAILY 15. Vitamin D 1400 UNIT PO DAILY Discharge Medications: 1. Furosemide 30 mg PO DAILY RX furosemide 20 mg 1.5 tablet(s) by mouth daily Disp #45 Tablet Refills:*0 2. Glargine 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Chlorthalidone 25 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Labetalol 300 mg PO BID 11. Mycophenolate Mofetil 500 mg PO BID 12. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 13. Tacrolimus 1.5 mg PO Q12H 14. Valsartan 160 mg PO BID 15. Vitamin D 1400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on Chronic HFpEF - Apnea - Acute on chronic respiratory acidosis SECONDARY DIAGNOSIS - ESRD s/p LURT - HTN - DM - Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. Why did you come to the hospital? - You initially came to the hospital because of difficulty breathing What happened during your hospitalization? - You were initially admitted to the ICU for assistance breathing with a BIPAP mask - You received medications through your IV to help from extra fluid from your lungs - Your oxygen levels decreased at night and you also had low oxygen levels during the day WHEN YOU GO HOME: - Your medications and follow up appointmets are below. - You will need a sleep study and we have scheduled you to see a pulmonologist. - Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. -Please make sure to make your appointment at Healthcare Associates on ___ at 2:55 pm. It was a pleasure taking care of you. -Your ___ Team Followup Instructions: ___
10075925-DS-16	10,075,925	25,211,602	DS	16	2133-11-15 00:00:00	2133-11-15 20:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Attending: ___. Chief Complaint: R arm fracture, respiratory failure, metastatic cancer Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with a past medical history pertinent for HTN, HFpEF, IDDM, ESRD due to DM s/p LURT ___ (living donor: husband), widely metastatic adenocarcinoma of the lung (bones, liver) who was recently discharged to home hospice ___ with home nursing, including tri- or bi-weekly drainage of R chest Pleurex, who now presented ___t home from bed leading to a left midshaft humerus fracture. Ortho saw patient and placed her arm in a coaptation splint. She was subsequently triaged for admission to hospital medicine to facilitate inpatient hospice arrangement. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Metastic Lung Cancer Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband (___) Pericardial effusion (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Chronically ill woman lying in bed with rebreather mask on, right arm splinted and wrapped, husband at bedside, in no apparent distress. EYES: PERRL. EOMI. Anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No murmur. No JVD. PULM: Breathing comfortably with rebreather mask on. Bilateral crackles and wheezes, right chest Pleurex in place with site c/d/i. GI: Bowel sounds reduced. Abdomen non-distended, soft, non-tender to palpation. GU: No suprapubic fullness or tenderness to palpation. EXTR: Right arm in splint and wrapped extensively. No lower extremity edema. Distal extremity pulses palpable throughout. SKIN: No rashes, ulcerations, scars noted. NEURO: Lethargic but arousable to voice. Oriented to self and husband, not clear on place or details of situation. Face symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all limbs spontaneously. No tremors, asterixis, or other involuntary movements observed. PSYCH: Very lethargic. Denies pain or distress. Answers simple questions appropriately. Appropriate affect. DISCHARGE: T97.7 BP 126/75 HR84 RR20 90% on 6L NC Gen: lethargic woman resting in bed with NC, NAD. HEENT: anicteric sclera, EOMI, OP clear Lungs: Bilateral crackles R > L. Right pleurex in place. Cards: RRR no m/r/g Abd: soft, NTND Ext: well perfused, no edema Neuro: very lethargic, responsive to voice but not following commands nor answering questions appropriately. Pertinent Results: IMAGING: ======= HUMERUS (AP & LAT) ___ There is an oblique fracture through the midshaft of the right humerus with lateral displacement and apparent apex dorsal angulation of the distal fracture fragment. Evaluation of alignment is limited on this single projection. There is prominent surrounding soft tissue swelling. Limited view of the elbow joint is unremarkable. There is no definite displaced rib fracture in the right chest cage on limited assessment. IMPRESSION: Oblique fracture through the midshaft of the right humerus with displacement and probable angulation as described. Brief Hospital Course: Ms. ___ is a ___ woman with a past medical history pertinent for HTN, HFpEF, IDDM, ESRD due to DM s/p LURT ___ (living donor: husband), widely metastatic adenocarcinoma of the lung (bones, liver) who was recently discharged to home hospice ___ with home nursing, including tri- or bi-weekly drainage of R chest Pleurex, who now presented ___t home from bed leading to a left midshaft humerus fracture. Ortho saw patient and placed her arm in a coaptation splint. She was subsequently triaged for admission to hospital medicine to facilitate inpatient hospice arrangement. # Widely metastatic lung adenocarcinoma # Home to inpatient hospice transition Discharged to home hospice last admission. Unfortunately, experienced fall with resultant humerus fracture. After discussion with family/HCP, felt that inpatient hospice would provide optimal care. She has a right pleurex catheter that has been getting drained bi- to tri-weekly, last drained ___ for 550cc. # Right humerus fracture: Presented with right arm pain after fall and found to have an oblique fracture through the midshaft of the right humerus on x-ray. Her injury was deemed inoperable and she was placed in a coaptation splint. She is to be nonweightbearing on the right side. She would need follow up in ___ clinic in ___ weeks but expect her life expectancy to be more limited. # ESRD s/p LURT. Patient unable to take home tacrolimus 2.5 mg BID, so this was discontinued. # DM1: Previously on 22u lantus qHS, has been cut back drastically by husband in setting of poor to no PO intake. Received 8u lantus + 2u correction insulin ___ and was hypoglycemic morning of ___ with FSBG of 50. Discharging on 5u lantus to maintain basal insulin level and prevent precipitation of DKA. # TRANSITIONAL ISSUES: ===================== [] Please continue draining R. pleurex catheter as needed for comfort (previously getting drained ___ per week. [] Recommend continuing some level of basal insulin to prevent DKA. [] If patient again able to take PO meds, would consider restarting tacrolimus to prevent rejection of kidney transplant (which would cause avoidable discomfort). [] As above, right humerus to be kept in coaptation splint and she is non-weoghtbearing on that extremity. Greater than 30 minutes spent coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Labetalol 200 mg PO BID 3. Glargine 22 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Docusate Sodium 100 mg PO BID 5. Tacrolimus 2.5 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever 2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions 3. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q15MIN:PRN moderate-severe pain or respiratory distress 4. LORazepam 0.5-2 mg IV Q2H:PRN anxiety This is a new medication for comfort. 5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN pain 6. Glargine 5 Units Bedtime Discharge Disposition: Extended Care Discharge Diagnosis: # Stage IV Lung Cancer: # End of life care: Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, It was a privilege to care for you at the ___ ___. You were admitted to the hospital after a fall at home. You are now ready for discharge to an ___ facility for ongoing care. Sincerely, Your ___ team Followup Instructions: ___
10076144-DS-13	10,076,144	24,347,474	DS	13	2203-07-07 00:00:00	2203-07-07 14:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit / cats Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None TTE - The left atrium is mildly dilated. The left atrial volume index is moderately increased. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. IMPRESSION: Low normal LV function with beat to beat variability in the LVEF. Moderately thicked aortic valve leaflets with mild AS and trace AI. Mild MR ___ TR. ___ is mild pulmonary artery systolic hypertension. Abdominal US IMPRESSION: The patient ate recently in the gallbladder is not distended however there is no gross evidence of gallbladder wall thickening. There is no ascites. History of Present Illness: HPI: ___ with h/o COPD, HTN, ?CHF. here with fever of ___ and 5 days of worsening shortness of breath. He reports being in usual health till 5 days ago when he started having cold like symptoms including cough/mucus, sore throat. Next day he started having low grade temps. His symptoms slowly progressed and he presented today to his PCP who sent him here after a negative flu test. He reports yellow sputum with cough. His dyspnea had progressed to even at rest. He had sick contact in office about a week ago. Has known COPD for at least ___ but no h/o exacerbation. In ED he was noted to be wheezing, received nebs, solumedrol, Lasix 20mg IV and azithromycin for COPD exacerbation. His symptoms have now resolved and he feels back to baseline. He was also noted to have afib in ED, which is a new diagnosis to him. he reports h/o CHF and takes Lasix 20 QOD but does not remember having fluid build up in past. No chest pain, abdominal pain, diarrhea, dysuria or leg swelling or rashes. ROS: negative for 10 systems except as mentioned above Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX ___ ABSCESS Social History: ___ Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: Admission Exam Vitals:98.5PO 125 / 68L Sitting ___ RA General: well build gentleman in no distress HEENT: no pallor. no icterus, moist mucosa Chest: b/l CTA ___ normal. irregular rhythm, tachyacrdic ___: soft, nt, nd, nabs Ext: no c/c/e Skin: no rash Neuro: non focal. normal speech Psych: mood appropriate Pertinent Results: Admission labs ___ 12:26PM BLOOD WBC-7.6 RBC-4.42* Hgb-12.2* Hct-37.9* MCV-86 MCH-27.6 MCHC-32.2 RDW-14.0 RDWSD-43.9 Plt ___ ___ 12:26PM BLOOD Glucose-128* UreaN-30* Creat-1.5* Na-137 K-4.8 Cl-99 HCO3-21* AnGap-17 ___ 12:26PM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1 ___ 12:47PM BLOOD Lactate-1.4 Imaging: CxR: ___: no acute cardio-pulmonary process Ekg: afib with HR 108bpm ___ 06:56AM BLOOD Glucose-117* UreaN-44* Creat-1.6* Na-144 K-4.7 Cl-103 HCO3-26 AnGap-15 ___ 06:30AM BLOOD WBC-9.5 RBC-4.28* Hgb-11.9* Hct-36.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.9 RDWSD-43.0 Plt ___ Brief Hospital Course: Impression/plan: ___ with h/o COPD, HTN, ?CHF, presenting with a fever and shortness of breath c/w viral illness and COPD exacerbation found to have new atrial fibrillation. #COPD Exacerbation in the setting of #Pneumonia Was flu negative. Repeat CXR with possible pneumonia. Will place on levofloxacin today -Prednsione 40 mg x5 day -Levofloxacin for 5 day course - Standing Duonebs today and wean as able - Tylenol as needed for fever -recheck ambulatory sats #Atrial fibrillation New diagnosis. Could be in the setting of above exacerbation but could also be new process. His TSH was normal. His echo is with low normal EF and with dilated LA and increased PCWP>18mmHg . His BNP was elevated, wonder if component of CHF is also contributing. -Increase metoprolol 37.5mg po bid for rate control - Apixiban #Acute diastolic HFpEF with echo showing dilated LA and increased PCWP>18mmHg with increased shortness of breath will trial a dose of IV Lasix. Lasix 20 mg IV metoprolol as above Daily weights #Elevated troponin could be NSTEMI type II in the setting of COPD exacerbation. He denies chest pain. He will likely need a stress test once recovered from this acute illness. repeat trop was negative. ___ Update - patient stabilized on current regimen, dc on steroid taper without levaquin, PCP and cardiology follow up, continue apixaban, abdominal US performed without ascites or other findings, patient had elevated troponins which were believed to be due to cardiac stress. Recommend outpatient stress test >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Furosemide 20 mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. amLODIPine 7.5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY:PRN gastritis 6. Ascorbic Acid ___ mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO DAILY constipation Discharge Medications: 1. Apixaban 2.5 mg PO BID RX apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID copd RX fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 inhalation orally twice a day Disp #1 Disk Refills:1 3. Metoprolol Tartrate 37.5 mg PO BID RX metoprolol tartrate 37.5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 4. PredniSONE 40 mg PO DAILY copd Duration: 2 Doses Start: Tomorrow - ___, First Dose: First Routine Administration Time This is dose # 1 of 3 tapered doses RX prednisone 10 mg 1 (One) tablet(s) by mouth daily Disp #14 Tablet Refills:0 RX prednisone 10 mg 4 tablet(s) by mouth daily Disp #8 Tablet Refills:0 5. PredniSONE 20 mg PO DAILY copd Duration: 2 Doses Start: After 40 mg DAILY tapered dose This is dose # 2 of 3 tapered doses RX prednisone 10 mg 2 tablet(s) by mouth daily Disp #4 Tablet Refills:0 6. PredniSONE 10 mg PO DAILY copd Duration: 2 Doses Start: After 20 mg DAILY tapered dose This is dose # 3 of 3 tapered doses RX prednisone 10 mg 1 tablet(s) by mouth daily Disp #2 Tablet Refills:0 7. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Ascorbic Acid ___ mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO DAILY constipation 11. Omeprazole 20 mg PO DAILY:PRN gastritis 12. Tiotropium Bromide 1 CAP IH DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. HELD- amLODIPine 7.5 mg PO DAILY This medication was held. Do not restart amLODIPine until follow up with PCP. Blood pressure controlled without. Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: COPD Exacerbation Heart failure exacerbation Pneumonia Type II NSTEMI w/ troponin leak due to CHF exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Why You were admitted You were admitted after you began to have severe shortness of breath. What we did for you? You were found to be in a COPD exacerbation for this you were treated with prednisone, azithromycin, and new inhalers. You were also found to have a possible pneumonia and were started on an antibiotics called levofloxacin. You were noted to be in a new heart rhythm called atrial fibrillation for this you were started on two new medications one called metoprolol and one called apixiban. You had COPD exacerbation and pneumonia. You received antibiotics and steroids. You improved. You had congestive heart failure, you received Lasix for diuresis, and you improved. Please follow up with PCP ___ ___ weeks Please monitor your weight Please take medications as prescribed We wish you the best Your ___ Team Followup Instructions: ___
10076263-DS-23	10,076,263	26,818,240	DS	23	2193-02-20 00:00:00	2193-02-20 21:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ======================================================= ___ ADMISSION NOTE Date of admission: ___. Seen/examined at 1620. ======================================================= PCP: Dr. ___ HC) CC: abdominal pain HISTORY OF PRESENT ILLNESS: ___ yo F with hx of EtOH abuse, c/b EtOH pancreatitis, also HTN, asthma and depression, p/w acute onset abdominal pain x 4 days, in setting of heavy daily EtOH use. Per pt, pain is diffuse, radiates to the back, severe, pressure-like, "achey," ___, with associated nausea and non-bloody emesis, inability to tolerate PO. Also had some loose, non-bloody stool today. Per pt, all symptoms are consistent with prior pancreatitis flares. Last EtOH this AM. Denies hx of withdrawl seizures / DT's. Denies F/C. . In the ED, initial vs were: T 98.1 P ___ BP 144/101 R 18 O2 sat 100% on RA. Labs were remarkable for lipase 136, AST/ALT 141/47. AlkPhos 110, but Tbili WNL. CBC and electrolytes WNL. Patient was given Morphine 5mg IV x 3 doses, zofran 4mg IV x 1. Vitals on Transfer: T 98.3, HR 95, BP 171/110, RR 16, O2 sat 99% on RA. . Currently still c/o severe abdominal pain, improved with IV morphine in ED. Otherwise has no other complaints. . Review of sytems: (+) 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 constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: ___ Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.2, AVSS Pain: ___ General: NAD, uncomfortable, able to speak in full sentences HEENT: Dry MM, anicteric Lungs: no crackles, mild wheeze, good air movement CV: RRR, no murmurs Abdomen: soft, ND, NABS, moderate TTP diffusely, no rebound/guarding Ext: no edema, WWP Skin: no rashes Neuro: AAOx3, fluent speech . . DISCHARGE PHYSICAL EXAM: Pain: ___ Abd: soft, mild TTP on deep palpation in epigastrium. No rebound or guarding. Exam otherwise similar to above. . Pertinent Results: Admitting Labs: ==================== CBC and Chem 7 - WNL AST/ALT 141/47 Alk Phos 110 T.Bili - WNL Lipase 135 Albumin - WNL Lactate 2.8 UA - unremarkable U-HCG - NEGATIVE . . Additional Labs ==================== ___ 06:40AM BLOOD WBC-7.6 RBC-3.45* Hgb-12.0 Hct-38.3 MCV-111* MCH-34.9* MCHC-31.4 RDW-15.0 Plt ___ ___ 04:10PM BLOOD Na-138 K-3.5 Cl-99 ___ 10:43AM BLOOD Glucose-102* UreaN-3* Creat-0.4 Na-137 K-3.8 Cl-101 HCO3-28 AnGap-12 ___ 06:40AM BLOOD ALT-33 AST-73* AlkPhos-94 TotBili-1.1 ___ 10:43AM BLOOD Calcium-8.8 Phos-2.0* Mg-1.6 . . IMAGING: ==================== ___ PA/Lat CXR FINDINGS: Upright PA and lateral radiographs of the chest. The lungs are normally expanded and clear. The cardiomediastinal silhouette and hilar contours are normal. There is no pleural effusion or pneumothorax. IMPRESSION: Unremarkable radiographs of the chest. . . ___ CT Abd/Pelvis IMPRESSION: 1. Interval collapse of left lower lobe with tubular branching hypodensities, and surrounding the pleural fluid compatible with inspissated secretions. In sum, this picture suggestive of mucus plugging versus obstructive lesions which is less likely given the relative normal appearance 3 days prior. . 2. Mild amount of peripancreatic stranding, without evidence of focal fluid collections or other sequela of acute pancreatitis. . 3. The stomach is quite distended relative to the rest of the GI tract, which may suggest gastroparesis. Recommend gastric emptying study for additional evaluation. . 4. Trace perihepatic and pelvic free fluid. . . ___ PA/Lat CXR Comparison is made with prior study, ___. . Cardiomediastinal contours are normal. Bibasilar opacities are a combination of pleural effusions and atelectasis, larger on the left side. The collapse of the left lower lobe is grossly unchanged. There is no pneumothorax. There are low lung volumes. Residual contrast is seen in the colon. . . Brief Hospital Course: ___ yo F with PMH EtOH dependence, c/b EtOH pancreatitis, p/w abdominal pain and elevated lipase, c/w recurrent EtOH pancreatitis. . # EtOH pancreatitis - although mildly elevated lipase only, given her symptoms c/w prior episodes, treated for acute EtOH pancreatitis with IVF, supportive care and bowel rest. Her symptoms improved, although did her abdominal pain did not improve completely. She was able to tolerate PO and did not have any nausea or vomiting. Since her abdominal pain did not completely resolve, a CT Abd/Pelvis was obtained, which was notable for peripancreatic stranding c/w pancreatitis, as well as gastric distention and LLL collapse. E-mycin was tried for possible gastroparesis, but did not provide any improvement in residual abdominal pain. Reglan could not be tried due to her use of Seroquel. Gastric emptying study, as gastroparesis was felt to be unlikely given her ability to tolerate PO and absence of N/V. EtOH gastritis may also be contributing, so pt had her PPI dose increased. . # Transaminitis - ratio of AST: ALT c/w EtOH intake, downtrended after admission. . # EtOH dependence - she was placed on CIWA protocol, but did not require any BZD's. She was counseled on the importance of EtOH cessation to avoid recurrent pancreatitis and long-term complications of EtOH abuse. She was placed on MVI/thiamine/folate. She was offered but declined S/W consult. . # LLL collapse - incidental finding on imaging (see Radiology Reports above in RESULTS section). Pt did not have any respiratory symptoms, so it is unclear what this finding may represent. Ddx includes mucus plugging as well as obstructive lesion. Pt will need repeat imaging in a few weeks with Chest CT or at least CXR. Letter sent to PCP to communicate findings. Findings and need for f/u imaging also communicated to patient. . # HTN, benign - pt p/w elevated BP, but had not taken her home BP med on day of admission. She was restarted on her home Verapamil and her BP was largely normotensive to slight hypertensive. . # Depression - stable mood. continue home psych meds . # Asthma - chronic stable. Currently no evidence of flare. Albuterol nebs PRN. . # Tobacco dependence - nicotine patch daily while inpatient. . . TRANSITIONAL ISSUES: 1. f/u with PCP to assess for complete resolution of her GI symptoms, if still persistent, consider referral to GI for possible EGD 2. repeat chest imaging, optimally chest CT to assess for resolution of LLL collapse 3. PENDING STUDIES AT TIME OF DISCHARGE: NONE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Verapamil SR 240 mg PO Q24H 3. QUEtiapine Fumarate 100 mg PO BID anxiety 4. Sertraline 100 mg PO DAILY 5. TraZODone 100 mg PO HS 6. Gabapentin 600 mg PO TID 7. Thiamine 100 mg PO DAILY Discharge Medications: 1. Gabapentin 600 mg PO TID RX gabapentin 600 mg 1 tablet(s) by mouth three times daily Disp #21 Capsule Refills:0 2. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule,delayed ___ by mouth daily Disp #7 Capsule Refills:0 3. QUEtiapine Fumarate 100 mg PO BID anxiety RX quetiapine 100 mg 1 tablet(s) by mouth twice daily Disp #14 Tablet Refills:0 4. Sertraline 100 mg PO DAILY RX sertraline 100 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 5. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 6. TraZODone 100 mg PO HS RX trazodone 100 mg 1 tablet(s) by mouth every night Disp #7 Tablet Refills:0 7. Verapamil SR 240 mg PO Q24H RX verapamil 240 mg 1 tablet extended release(s) by mouth daily Disp #7 Tablet Refills:0 8. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #14 Capsule Refills:0 9. Senna 1 TAB PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #14 Tablet Refills:0 10. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 11. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain RX morphine 15 mg 1 tablet(s) by mouth every six hours Disp #20 Tablet Refills:0 12. Multivitamins 1 TAB PO DAILY RX multivitamin 1 tablet(s) by mouth daily Disp #7 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: EtOH Pancreatitis EtOH depdendence Left Lower Lobe Collapse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for abdominal pain, most likely related to your alcohol use and consistent with alcoholic pancreatitis. Your pain improved with bowel rest and supportive care, but has not resolved completely. Your symptoms should continue to improve and we strongly encourage you to stop / abstain as much as possible from alcohol use. Also, your CXR and CT scan did show some abnormalities in your left lower lung, but you did not have symptoms of pneumonia. We recommend that you have a repeat CT scan or at least a CXR in a few weeks time. . Please follow-up with your physician as listed. . Please take your medications as listed. . Followup Instructions: ___
10076616-DS-4	10,076,616	21,934,451	DS	4	2118-01-28 00:00:00	2118-01-31 12:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with hx. HTN, mild developmental delay who presented from group home to OSH with c/o dizzines/near syncope, was found to have NSVT (5 beats, asymptomatic) and transferred to ___ for further w/u Patient felt lightheaded this AM and fell, unwitnessed. Denied headstrike, denies LOC. Went to ___ where CT head, neck/bilateral shoulder and CXR's were negative. EKG as per report showed first degree AV block. chem-7 and trop were also negative x1. He was noted to have 5 beats of vtach on tele, asymptomatic, started on a lidocaine drip and transferred to ___. In the ___, initial VS: 98 95 120/78 16 100%. Patient's lidocaine drip was stopped, remained relatively asymptomatic and was admitted to ___ for syncope workup. On arrival to the floor, patient is a poor historian due to developmental delay and therefore the following has been obtained from his contact, ___: Pt complained of feeling tired over last 2 weeks, had several incontinent episodes of diarrhea on ___. However, he has been drinking and eating well. He complained of swollen painful R hand, had negative XR and was started on ibuprofen 600mg prn pain. His BPs at home have been well controlled, and his lasix dose is currently 60mg daily. Mr. ___ did not witness the fall but does report that patient was conscious throughout and had felt dizzy beforehand. REVIEW OF SYSTEMS Pt unable to provide due to developmental delay. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: none -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Developmental Delay HTN Cellulitis ___ edema Abdominal hernia repair as child Ventricular ectopy noted during hospitalization for cellulitis in ___. Social History: ___ Family History: Unable to obtain Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.3, 152/72, 99, 20, 98% on RA General: AAOx1, NAD, pleasant HEENT: MMM, EOMI, PERRL, wearing glasses Neck: unable to assess JVD due to excess neck fat CV: sinus with multiple skipped beats, normal rate. no m/g/r. Lungs: CTAB but limited by pt unwilling to sit up ___ shoulder pain Abdomen: obese, s, nd, nt, normal bs GU: no foley Ext: 2+ ___ edema to mid shins bilaterally. b/l shoulder tenderness, unable to raise arms above head Neuro: CNs grossly intact, no focal deficits. neuro exam limited by shoulder pain Skin: venous stasis changes on shins bilaterally Pulses: 2+ radial and DP pulses b/l DISCHARGE PHYSICAL EXAM: VS: 98 (98.3), 132/78, 88, 22, 92%RA desat to 86% overnight) TELE: Frequent ectopy; ___ runs of NSVT General: A+Ox2; NAD HEENT: MMM, EOMI, PERRL, no oral lesions Neck: JVD not elevated CV: RRR, no MRG, PMI non-displaced Lungs: LCTA-bl, no w/r/r Abdomen: Obese, +distended, no HSM, +NABS Ext: ___ wrapped in compressive stockings changes. + RUE hand mild ttp Neuro: CNII-XII intact, no focal deficits Pulses: 2+ radial and DP pulses b/l Pertinent Results: ADMISSION LABS: ___ 02:50PM BLOOD WBC-9.5 RBC-4.89 Hgb-14.3 Hct-41.7 MCV-85 MCH-29.2 MCHC-34.2 RDW-12.9 Plt ___ ___ 02:50PM BLOOD Neuts-72.0 Lymphs-15.6* Monos-11.3* Eos-0.5 Baso-0.6 ___ 02:50PM BLOOD Glucose-128* UreaN-14 Creat-1.0 Na-136 K-3.9 Cl-101 HCO3-25 AnGap-14 ___ 02:50PM BLOOD cTropnT-<0.01 ___ 02:50PM BLOOD Calcium-8.6 Phos-2.7 Mg-2.2 OTHER RELEVANT LABS: ___ 02:15PM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-NEG ___ 12:14PM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:14PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 12:14PM URINE RBC-8* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 12:14PM URINE Hours-RANDOM TotProt-34 ___ 12:14PM URINE U-PEP-NO PROTEIN DISCHARGE LABS: ___ 06:40AM BLOOD WBC-10.2 RBC-4.41* Hgb-13.1* Hct-37.5* MCV-85 MCH-29.8 MCHC-35.0 RDW-13.2 Plt ___ ___ 03:00PM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-133 K-4.8 Cl-100 HCO3-26 AnGap-12 ___ 06:40AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.1 MICRO: URINE CULTURE ___: NEGATIVE BLOOD CULTURE ___: PENDING C. DIFFICILE ANTIBODY (STOOL) ___: NEGATIVE IMAGING: TTE ___: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality due to body habitus. No structural cardiac cause of syncope identified. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen.. No structural valvular abnormality. No resting LVOT obstruction. CXR ___: FINDINGS: Widening of the upper mediastinum is shown to be due to increased mediastinal fat (mediastinal lipomatosis) and tortuous vessels on recent neck CT ___. Heart size is normal. Hazy opacity in left cardiophrenic angle region probably represents an enlarged cardiac fat pad in the setting of mediastinal lipomatosis. Adjacent linear opacity at the left lung base favors atelectasis. Consider a standard PA and lateral chest x-ray to exclude the possibility of a small left pleural effusion when the patient's condition permits. Right lung and pleural surfaces are clear. OSH IMAGING: ___ ___: 1. Age related involution, minimal small vessel ischemic white matter change. Otherwise normal noncontrast CT scan of the head. 2. No acute hemorrhage, acute infarction, edema, mass, mass effect, or fracture. L shoulder XR ___: Bones are intact and well aligned. The glenohumeral relationship is anatomical. Glenohumeral and acromioclavicular joint spaces appear preserved. There is no fracture, deformity, unusual calcification or other focal bony abnormality. Acromiohumeral distance is preserved. There is limited difference between the 2 views. Conclusion: Unremarkable appearance of the left shoulder. Limited motion/ rotation between the 2 views. CXR ___: Lite radiographs achieved. Arms in the field on lateral view. Cardiac, mediastinal, hilar, pleural outlines are normal. No abnormality of pulmonary vasculature. Lung parenchyma is clear. No adenopathy or pneumothorax. Chest wall skeletal structures visualized appear unremarkable. No change seen from radiograph(s) ___. Conclusion: Normal chest. No active/acute chest disease. R hand XR ___: no fracture or dislocation Brief Hospital Course: Mr. ___ is a ___ with a PMHx of HTN, developmental delay, who presented from his group home with c/o dizziness and unwitnessed fall and was found to have wide-complex NSVT on telemetry. He was started on lidocaine drip, and transferred to ___ for further management. # Fall/Ectopy: SP unwitnessed fall without LOC and no notable injuries. DDx included orthostatic hypotension, vasovagal event, and cardiogenic pre-syncope (i.e. VT given ectopy suggesting scar). Pt was noted to be asymptomatic with ectopic episodes of NSVT during this admission so it is likely that ectopy was unrelated to fall. Troponins were negative x 2. TTE continued to show mild LVH and preserved EF. SPEP/UPEP were negative. Pt underwent Cardiac MRI but was unable to tolerate the test due to physical discomfort. Pt was noted to have night-time O2 desaturation (~86%). It is likely that ectopy is, at least in part due to pulm HTN (possibly from undiagnosed OSA). # Hyponatremia: Likely hypovolemic in setting of recent diarrhea. He received IVF and his sodium improved. # Hypotension on ___: Pt developed hypotension to 70mmHg systolic. This was in the setting of diarrhea/hypovolemia. There was no increase in the frequency of ectopy, and no evidence of hemorrhage or cardiogenic causes. He received 500cc NS and BP improved. Lisinopril and lasix were discontinued. # Emesis - Resolved: Likely viral gastroenteritis. No evidence of GIB or c. difficile. # Fever/Leukocytosis Pt presented with a leukocytosis, likely ___ viral GI illness. UA/UCx were negative. C. difficile antibody negative. CXR not compelling for PNA. # Diarrhea: Pt had 5d of diarrhea with intermittent nausea/vomiting. This was likely ___ viral gastroenteritis. He received immodium with improvement of symptoms. # ___ edema with venous stasis changes: Patient had no crackles or JVD elevation. On presentation, pt's lasix dose was 60mg daily. Abumin was wnl. Lasix 60mg po daily was held, given diarrhea/hypotension noted on this admission. Compression stockings were placed. # HTN: BP was well controlled (with exception of one epiosde of hypotension on ___. Lisinopril 10mg daily and Furosemide 60mg daily were held. Metoprolol was fractionated to tartrate 12.5mg po bid. # HLD: Continued simvastatin 20mg daily. TRANSITIONAL ISSUES: # EMERGENCY CONTACT: ___ at ___ - Please follow up final blood cultures from this admission (___) - Please consider re-starting lasix and lisinopril (held, given episode of hypotension) - Please follow up repeat Na to ensure improvement of hyponatremia - Please follow up final results of Cardiac MRI on ___ - Please follow up ACE level - Please obtain sleep study, considering high likelihood of OSA (which may be, in part, leading to frequent ectopy), given night-time oxygen falls - PLEASE NOTE: Lidocaine drip has been initiated on two occasions for short runs of asymptomatic NSVT. In absence of symptoms or evidence of persistent VT, there is no clear indication for IV lidocaine. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Furosemide 60 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Ibuprofen 600 mg PO Q8H:PRN pain 5. nystatin NF 100,000 unit/gram Topical daily apply on both lower legs Discharge Medications: 1. Simvastatin 20 mg PO DAILY 2. Ibuprofen 600 mg PO Q8H:PRN pain 3. nystatin NF 100,000 unit/gram Topical daily 4. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Mechanical fall Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure to participate in your care at ___. You were admitted to ___ after a fall for further evaluation of extra heart beats. These extra heart beats are benign. Please follow up with your primary care doctor for ___ management of all of your other medical issues. Best Regards, Your ___ Medicine Team Followup Instructions: ___
10076617-DS-12	10,076,617	26,439,893	DS	12	2164-09-29 00:00:00	2164-10-21 18:47:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Clindamycin Attending: ___ Chief Complaint: Left facial droop Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ F w PMHx of DM, HTN, and HLD who presents to ___ with almost 24hrs of left facial droop. Ms. ___ reports that she noticed her deficits yesterday (___) at around 3PM when they were pointed out by a relative. She is certain that her mouth and eye were working normally earlier in the day when she looked in the mirror to put on her make up. Her relative is a physician and while she told Ms. ___ that she thought she had Bell's Palsy, she did recommend that she go to the ED. Ms. ___ did not seek medical attention until this morning when she went to her primary care clinic. They recommended that she go to the ED to get a CT scan. Ms. ___ does report a dull L sided headache that began yesterday, she does not usually suffer from headaches. She also complains of tenderness to palpation over the L mandibular angle, and a new L ear ache. Ms. ___ denies any recent illnesses including URI or diarrhea. She denies any associated weakness or sensory changes. She denies new bowel and bladder difficulties. She denies any difficulties comprehending speech, though thinks she might be mildly dysarthric due to her facial droop. She denies confusion. She denies dizziness. She denies new auditory symptoms including hyperaccusis. She denies food tasting odd. No history suggestive of possible tick bite. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VS T98.1 HR72 BP112/67 RR16 Sat98%RA GEN - elderly W, talkative, pleasant HEENT - NC/AT, dry mouth, difficulty closing L eye; L TM clear, no vesicles or rash noted NECK - full ROM, does complain of some L sided pain on L rotation CV - RRR RESP - on supplemental O2, normal WOB ABD - obese, soft, NT, ND EXTR - healing sore on R heel, WWP NEUROLOGICAL EXAMINATION MS - Awake, alert, oriented x3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards, but misses ___. Recalls a coherent history. Speech is fluent with normal prosody and no paraphasias. Naming, repetition, comprehension, and reading are all intact. No apraxia. No evidence of hemineglect. No left-right agnosia. CN - [II] PERRL 3->2 brisk. VF full to number counting. [III, IV, VI] ?Incomplete abduction of R eye on R gaze and L eye on L gaze. Denies diplopia. Per patient, long-standing ?lateral gaze limitations. [V] V1-V3 without deficits to light touch or pin-prick bilaterally. [VII] L NLFF at rest with decreased activation of L lower face. Weak L eye closure. Frontalis muscle activation is symmetric. Lower face weakness persists with emotional smile. [VIII] Hearing intact to voice. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline with full ROM. MOTOR - Normal bulk and tone. No pronation, no drift. No orbiting with arm roll. No tremor or asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 4+ 5 5 5 5 5 R 5 5 5 5 5 4+ 5 5 5 5 5 SENSORY - No deficits to light touch or pin-prick throughout. Proprioception intact at B/L great toes. REFLEXES - =[Bic] [Tri] [___] [Quad] [Gastroc] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response flexor on the left, equivocal on the R. COORD - No dysmetria with finger to nose. Good speed and intact cadence with rapid alternating movements. GAIT - Normal initiation. Narrow base. Slightly antalgic and mildly unsteady, ?limping on the LLE. Patient does endorse being slightly unsteady, denies limp. . =========================== DISCHARGE PHYSICAL EXAM =========================== VS 98.1, 107-119/67-73, HR 73-88, RR 18, 96% on RA MS - Alert Cranial nerve - Incomplete L eyelid closure, left facial weakness, left facial droop with NLFF, Asymmetric blink on the left with + Bell's phenomenon. 3mm ___, EOMI, VFF, sensation symmetric, tongue symmetric, palate symmetric, shoulder shrug symmetric strength. Motor - ___ in Deltoid, biceps, triceps, IP, quad, TA No drift. Reflexes - 2+ bic, tric, ___, Quad Pertinent Results: ================ ADMISSION LABS ================ ___ 10:50AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.0* Hct-31.4* MCV-94 MCH-29.8 MCHC-31.8* RDW-14.2 RDWSD-48.4* Plt ___ ___ 10:50AM BLOOD Neuts-64.8 ___ Monos-8.6 Eos-2.5 Baso-1.2* Im ___ AbsNeut-4.16 AbsLymp-1.45 AbsMono-0.55 AbsEos-0.16 AbsBaso-0.08 ___ 10:50AM BLOOD Plt ___ ___ 12:45PM BLOOD ___ PTT-31.0 ___ ___ 10:50AM BLOOD Glucose-153* UreaN-41* Creat-1.4* Na-137 K-4.5 Cl-100 HCO3-23 AnGap-19 ___ 10:50AM BLOOD ALT-27 AST-24 AlkPhos-110* TotBili-0.5 ___ 10:50AM BLOOD Lipase-67* ___ 04:56AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1 Cholest-185 ___ 10:50AM BLOOD Albumin-4.0 ___ 12:45PM BLOOD %HbA1c-5.9 eAG-123 ___ 04:56AM BLOOD Triglyc-90 HDL-55 CHOL/HD-3.4 LDLcalc-112 ___ 12:45PM BLOOD TSH-1.1 ___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:35PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:35PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 12:35PM URINE RBC-35* WBC->182* Bacteri-MANY Yeast-NONE Epi-6 TransE-2 ___ 12:35PM URINE CastHy-6* ___ 12:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG . URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. INTERPRET RESULTS WITH CAUTION. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL MORPHOLOGIES. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. . . ==================== STUDIES ==================== EKG ___ Sinus rhythm with atrial premature beats. Otherwise, within normal limits. Compared to the previous tracing of ___ wave abnormalities have resolved. . CXR ___ No acute cardiopulmonary process. . CTA HEAD AND NECK ___ 1. No acute intracranial abnormality. 2. No flow limiting stenosis within the vessels of the head and neck. . MRI BRAIN ___ No acute infarct or mass effect. A few small scattered cerebral white matter changes, can relate to small vessel ischemic changes, etc. Mild to moderate diffuse parenchymal volume loss Brief Hospital Course: Ms. ___ is a ___ F w PMHx of DM, HTN, and HLD who presents to ___ with new left facial droop. . By the morning after admission, she had developed significant left facial weakness, both upper and lower face involving eyelid closure which was consistent with peripheral ___ nerve palsy. There were no other concerning findings on neurologic exam. . Her CTA head and neck did not show any significant vessel narrowing and her MRI Brain was negative for acute stroke. Her stroke risk factors were checked and HbA1C and thyroid studies were within normal limits. However, lipid panel was pending on discharge and will need follow up by primary care. . She was incidentally found to have a urinary tract infection on this admission and was treated with Nitrofurantoin for 7 days total. . She was treated for Bell's Palsy with a course of Prednisone 60mg daily and Valacyclovir 1000mg TID for 7 days total on discharge. . She should follow up with primary care - no neurology outpatient follow up is required. . No changes were made to her home medications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Vesicare (solifenacin) 5 mg oral DAILY 4. Dapsone 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Lisinopril 2.5 mg PO DAILY 7. Sertraline 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. GlipiZIDE 5 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Vesicare (solifenacin) 5 mg oral DAILY 8. PredniSONE 60 mg PO DAILY Duration: 7 Days RX prednisone 20 mg 3 tablet(s) by mouth DAILY Disp #21 Tablet Refills:0 9. ValACYclovir 1000 mg PO TID Duration: 7 Days RX valacyclovir 1,000 mg 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7 Days RX nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #12 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1.) Left Bell's Palsy/Left peripheral ___ nerve palsy 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 left facial droop which we feel is clinically consistent with Bell's Palsy. You had a CT of the vessels going to your brain that do not have any narrowing. You had a Brain MRI that was negative for stroke. You had no other abnormalities on your exam that are suspicious for any other process. We have started treatment for you Bell's Palsy with steroids and an antiviral medication that you should take for 7 days total. You were also found to have a urinary tract infection and will need antibiotics for 6 more days as prescribed. Please take as prescribed. Followup Instructions: ___
10076617-DS-14	10,076,617	21,474,221	DS	14	2165-09-28 00:00:00	2165-10-02 20:06:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin Attending: ___. Chief Complaint: fever, weakness, UTI Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ yo F with history of Sweets Syndrome, Type 2 DM, pulmonary hypertension on home oxygen, who presented to the ED on ___ with urinary tract infection and was discharged from the ED who then represented later in the day after she almost collapsed at ___. In the ED, initial vitals: - Exam notable for: 100.4 86 149/110 16 96% on 2 L - Labs notable for: U/a with lg leuks, moderate blood, trace ketones, WBC 10.7 (N predominance), Hb 9.2, Hct 28.7 BUN 32, Cr 1.3, Glc 208, lactate 1.5, flu negative - Imaging notable for: CXR with Re- demonstrated moderate pulmonary edema without definite focal consolidation. Atypical infection is not excluded in the appropriate clinical setting. - Patient given: Tylenol ___ mg PO x1, ibuprofen 400 mg po x1, ceftriazone IV 1 gram, 1000 ml NS at 100 cc/hr - Vitals prior to transfer: 99 80 136/72 20 97% nasal cannula On arrival to the floor, pt reports 1.5 weeks of chills. Says went to urgent care yesterday (___) after she felt dizzy. She received IVF and got a CXR. She returned home and continued to feel poorly. Said she has felt week and very fatigued. She came to the ED today (___) and was diagnosed with UTI. She was then discharged and went to pharmacy to pick up Rx. At pharmacy she felt so weak that she was unable to walk to the car. EMS was called and she was brought back to the ED. Notes that she has been having chills, fatigue and fever. Endorses runny nose, congestion, and mild h/a. No cough. Also reports increased urinary frequency. No dysuria. No abdominal pain, diarrhea, back pain, shortness of breath, chest pain, changes in vision, changes in her skin or skin rash. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION EXAM: Vitals:98.0 107 / 51 80 20 92 ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mouth appears dry Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at ___ Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Neuro: ___ strength is ___ bilaterally, sensation to touch is intact DISCHARGE EXAM: Vitals:99.4 PO 147 / 81 L Lying 81 20 95 2 L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mouth appears dry Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at ___ Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Neuro: BLE strength intact, no TTP of knees Skin: hemorrhagic vesicle on left ___ MCP with surrounding erythema. R MCPs mildly erythematous. Faint erythematous papules over extensoral surface of elbows bilaterally. Pertinent Results: ADMISSION LABS: ___ 12:30PM BLOOD WBC-10.7* RBC-3.09* Hgb-9.2* Hct-28.7* MCV-93 MCH-29.8 MCHC-32.1 RDW-13.3 RDWSD-45.8 Plt ___ ___ 12:30PM BLOOD Neuts-82.2* Lymphs-6.9* Monos-10.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.77# AbsLymp-0.74 AbsMono-1.07* AbsEos-0.01* AbsBaso-0.03 ___ 04:00PM BLOOD ___ PTT-27.5 ___ ___ 12:30PM BLOOD Glucose-208* UreaN-32* Creat-1.3* Na-133 K-4.3 Cl-95* HCO3-23 AnGap-19 ___ 06:08AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9 UricAcd-6.7* Iron-25* ___ 06:08AM BLOOD calTIBC-225* ___ Ferritn-348* TRF-173* ___ 06:08AM BLOOD LD(LDH)-195 ___ 12:50PM BLOOD Lactate-1.5 ___ 01:40PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 01:40PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 01:40PM URINE RBC-17* WBC->182* Bacteri-MANY Yeast-NONE Epi-1 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 \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ BLOOD CULTURES X2: NO GROWTH TO DATE STUDIES: ___ CXR: Re- demonstrated moderate pulmonary edema without definite focal consolidation. Atypical infection is not excluded in the appropriate clinical setting. ___ KNEE FILMS, BILATERAL: IMPRESSION: Diffuse osteopenia. Moderate to moderately severe osteoarthritis in both knees. No obvious fracture or dislocation identified on these views. No gross effusion detected in either knee. A small joint effusion might not be apparent on the cross-table lateral views. No bone erosion, periostitis, or chondrocalcinosis detected in either knee. DISCHARGE LABS: ___ 07:23AM BLOOD WBC-6.6 RBC-2.61* Hgb-7.6* Hct-24.4* MCV-94 MCH-29.1 MCHC-31.1* RDW-14.1 RDWSD-47.8* Plt ___ ___ 07:23AM BLOOD Glucose-132* UreaN-23* Creat-1.1 Na-138 K-3.6 Cl-103 HCO3-24 AnGap-15 ___ 07:23AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Brief Hospital Course: Ms ___ is a ___ yo F with history of Sweets Syndrome, Type 2 DM, pulmonary hypertension on home oxygen, who presented to the ED on ___ with symptoms of URI found to have UTI, also with bilateral knee pain that may have been due to manifestation of Sweet's syndrome. #Complicated cystitis: Initially treated with CTX, then bactrim. She will continue bactrim 1 DS BID (total 7d, ___. #Acute bilateral medial knee pain: Resolved by day of discharge. ___ have been due to Sweet's flare, exacerbated by infection. Knee films with moderate-severe osteoarthritis. Evaluated by rheumatology - no effusion to be tapped. She initially was unable to walk due to the pain, but was cleared by ___ on day of discharge. #___ SYNDROME: With apparent flare, precipitated by UTI. She developed characteristic skin lesions on bilateral MCP/elbows. She continued dapsone. #URI : No evidence of PNA on CXR. No cough. Mild symptoms. Treated with supportive care #Acute on chronic kidney disease: Stage ___ CKD at baseline. S/p IVF in the ED. Suspect that this is pre renal in setting of recent illness and decreased PO intake. Cr downtrended to normal. #Acute on chronic anemia: Hgb last 11 in ___. She did have hemolysis during her last admission. Hemolysis labs negative. Transferrin sat 14%, but iron studies suggestive of anemia of chronic disease. #DEPRESSION Continued sertraline TRANSITIONAL ISSUES: ===================== -Knee XRAYS showed diffuse osteopenia; consider DEXA -Last day ABx ___ # CODE STATUS: Full code with limited trial # CONTACT: Name of health care proxy: ___ Relationship: ___ Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Vesicare (solifenacin) 5 mg oral DAILY 2. GlipiZIDE 5 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #7 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: complicated urinary tract infection acute viral syndrome acute tendonitis acute on chronic Sweet's syndrome secondary chronic kidney disease type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Why were you here: -You were very weak and almost collapsed -You had a urinary tract infection -You had knee pain likely from a Sweet's flare What was done: -We gave you fluids in your IV and antibiotics. You improved. What to do next: -Take all your medications as prescribed and follow-up at the appointments below. We wish you all the best, Your ___ team Followup Instructions: ___
10076617-DS-16	10,076,617	25,575,063	DS	16	2167-09-09 00:00:00	2167-09-10 15:37:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin Attending: ___. Chief Complaint: Dyspnea, leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman CKD stage III, hypertension, anxiety, type 2 diabetes, anemia, mild moderate pulmonary hypertension on home oxygen, and a history of Sweet's syndrome who presented to the ED as a transfer from ___ with worsening dyspnea and leg swelling. Notably, patient was seen in CDAC in ___ for moderate pulmonary effusion which was new compared to her prior echo about six months prior. No evidence of tamponade physiology, hemodynamically stable with a normal pulsus paradoxus in the clinic. Follow up TTE showed spontaneous resolution. Three days prior to this admission the patient noticed her right leg becoming more swollen. She has also been feeling increased shortness of breath as well as dizziness. She noted the last day or two that her left leg was starting to swell as well. She denies any headache, chest pain, visual changes, abdominal symptoms. She has a history of Sweet's syndrome and and apparently thought she was having a flare. Regarding the dizziness, pt reports the comes/goes. Has had periods without dizziness. No clear exacerbating factors - denies worsening with standing from seated, head turning, or association with sob. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: 98.9 126/54 80 18 95ra GENERAL: Well developed, well nourished HEENT: Normocephalic atraumatic. CARDIAC: RRR, ___ systolic murmur at RUSB LUNGS: CTAB with no accessory muscle use. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused, trace edema in ankless SKIN: 1cm punched out appearing lesion on right ankle, no drainage or surrounding erythema or warmth DISCHARGE PHYSICAL EXAM: ======================= VITALS: T 98.9 PO BP 118 / 65 HR 84 RR 16 O2 95% RA GENERAL: Obese, well-developed woman NAD HEENT: Normocephalic atraumatic. CARDIAC: RRR, ___ systolic murmur at ___ LUNGS: Course crackles in lower lung fields posteriorly; no wheezes ABDOMEN: Soft, non-tender, non-distended. BS+ EXTREMITIES: Warm, well perfused, non-pitting edema up to knees bilaterally NEURO: no focal neurological deficits; moves all extremities with purpose Pertinent Results: ADMISSION LABS: ====================== ___ 12:45PM BLOOD WBC-6.2 RBC-2.83* Hgb-8.6* Hct-28.4* MCV-100* MCH-30.4 MCHC-30.3* RDW-14.4 RDWSD-53.4* Plt ___ ___ 12:45PM BLOOD Neuts-67.3 ___ Monos-7.7 Eos-2.3 Baso-1.1* Im ___ AbsNeut-4.17 AbsLymp-1.32 AbsMono-0.48 AbsEos-0.14 AbsBaso-0.07 ___ 12:45PM BLOOD ___ PTT-28.3 ___ ___ 12:05PM BLOOD Glucose-119* UreaN-21* Creat-1.0 Na-144 K-4.7 Cl-103 HCO3-25 AnGap-16 ___ 12:05PM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0 ___ 12:45PM BLOOD calTIBC-317 VitB12-709 Folate->20 Hapto-<10* Ferritn-277* TRF-244 DISCHARGE LABS: ================== ___ 08:02AM BLOOD WBC-4.7 RBC-2.58* Hgb-8.0* Hct-26.4* MCV-102* MCH-31.0 MCHC-30.3* RDW-14.6 RDWSD-54.3* Plt ___ ___ 08:02AM BLOOD Glucose-124* UreaN-16 Creat-1.0 Na-145 K-5.0 Cl-105 HCO3-28 AnGap-12 ___ 08:02AM BLOOD ALT-21 AST-24 LD(LDH)-223 AlkPhos-83 TotBili-0.8 ___ 07:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0 IMAGING: =============== CHEST CT ___: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Small vessel airway disease and multifocal patchy airspace opacities. Differential considerations include multifocal pneumonia as well as aspiration pneumonitis. Follow-up CT chest in ___ weeks after resolution of symptoms is recommended. 3. Multiple pulmonary nodules as described above. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules bigger than 8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. TTE ___: FINDINGS: LEFT ATRIUM (LA)/PULMONARY VEINS: SEVERELY increased LA volume index. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Mildly dilated RA. Dilated IVC with normal inspiratory collapse==>RA pressure ___ mmHg. LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity size. Normal regional/global systolic function. The visually estimated left ventricular ejection fraction is 55-60%. Normal cardiac index (>2.5 L/min/m2). No resting outflow tract gradient. Tissue Doppler suggests elevated PCWP. RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall motion. AORTA: Normal sinus diameter for gender. Normal ascending diameter for gender. Normal arch diameter. Normal descending aorta. No coarctation. Focal calcifications in aortic sinus. No coarctation. AORTIC VALVE (AV): Mildly thickend (3) leaflets. Mild stenosis (area 1.5-1.9 cm2). Peak gradient obtained from right parasternal orientation. Trace regurgitation. MITRAL VALVE (MV): Mildly thickened leaflets. No systolic prolapse. Mild MAC. Papillary muscle fibrosis/ calcification. Mild-moderate [___] regurgitation. Central regurgitant jet. Regurgitation severity could be UNDERestimated due to acoustic shadowing. PULMONIC VALVE (PV): Normal leaflets. No stenosis. Physiologic regurgitation. TRICUSPID VALVE (TV): Mildly thickened leaflets. Mild [1+] regurgitation. Mild-moderate pulmonary artery systolic hypertension. PERICARDIUM: No effusion. Anterior fat pad RIGHT LOWER EXTREMITY ULTRASOUND ___: ====================================== IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Brief Hospital Course: PATIENT SUMMARY: ================= ___ with hx of CKD III, DM2, endometrial cancer, mild-moderate AS, presumed Sweet's syndrome, pulmonary HTN presenting with bilateral ___ pain, non-pitting edema, and dyspnea on exertion. ACUTE ISSUES: ================== # ___ discomfort, non-pitting edema: # DOE: Pt reports edema, with minimal pitting on exam, arguing against significant lower extremity interstitial edema. Difficult to assess objective change compared to baseline. TTE essentially unchanged compared to prior. Suspect her DOE is driven primarily by her underlying ILD, for which she is followed by Dr. ___. The constellation of her symptoms - Sweet syndrome, ILD, pyoderma gangrenosum - does point towards some underlying, unifying, systemic process. There are case reports of pulmonary involvement of Sweet syndrome, which would require BAL +/- transbronchial biopsy for diagnosis. Patient was able to ambulate comfortably on 2L of oxygen prior to discharge, which is her baseline. She will need close follow-up with pulmonology. # Hemolytic anemia: Patient has chronic, longstanding, with evidence of low grade anemia for at least ___ years per ___ records. G6PD checked and greater than upper limit of normal. Coombs test negative. Dapsone (without G6PD deficiency) can still cause hemolytic anemia. Per last hematology visit at ___, thought that anemia was in setting of dapsone. Would advise outpatient hematology evaluation, given stability and chronicity of this process. ================ CHRONIC ISSUES: ================ # HLD: Continued Aspirin 81 # Sweet's Syndrome: Continued Dapsone 100 mg, will need age appropriate cancer screening as outpatient given associations with Sweet's Syndrome. Will also need dermatology and hematology followup. # Depression: Continue Sertraline 100 mg. # T2DM: Held GlipiZIDE 5 mg. ISS while inpatient. # Overactive bladder: Vesicare (solifenacin) 5 mg oral DAILY (not formulary) held. TRANSITIONAL ISSUES: ===================== Discharge Hemoglobin: 8.0 Discharge Platelets: 127 Absolute Retic 0.11 Haptoglobin <10 []Patient needs up to date screening for malignancy, especially in setting of presumed Sweet's Syndrome diagnosis. [] Patient needs follow-up with heme in setting of Sweet's syndrome and hemolytic anemia. [] Last biopsy of skin suggestive of Sweet's versus vasculitis. Should follow-up with dermatology. [] CT chest ___ showing multifocal patchy airspace opacities. Recommended follow-up in ___ weeks to check for resolution. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Sertraline 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. GlipiZIDE 5 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Sertraline 100 mg PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: # ___ discomfort # Dyspnea on exertion # Pulmonary Hypertension # Hemolytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you had worsening swelling in your legs and shortness of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - We did imaging of your lungs to look for blood clots, imaging of your leg, and imaging of your heart. We also did blood tests to better understand your low red blood cell counts. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - It is extremely important that you call to get your BiPAP setup, and that you use it every day. Your lung pressures are already elevated, and we don't want this to continue to get worse. - Please make sure you go to all of your appointments (listed below). - Please call to get a dermatology appointment. -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10076617-DS-17	10,076,617	20,598,574	DS	17	2167-11-25 00:00:00	2167-11-25 14:44:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ___ Allergies: Clindamycin / dapsone Attending: ___ Chief Complaint: Dizziness, hyperglycemia, sweets syndrome worsening Major Surgical or Invasive Procedure: Bedside debridement of sweets lesions over fingers by dermatology History of Present Illness: As per HPI in H&P by Dr. ___ ___: ___ female with history of sweet syndrome, non-insulin-dependent diabetes, frequent urinary tract infections, pulmonary hypertension on home O2, who presents with at least 2 weeks of increasing weakness and dizziness, poor glucose control, and recently diagnosed urinary tract infection. Patient states she has been in and out of ___ with blood sugars over 500, and multiple episodes of DKA. She does not typically use insulin at home. She was recently diagnosed with a urinary tract infection and started on Keflex, last dose was yesterday. She feels that she is also having a sweets flare. On ___, she was taken off of dapsone due to bone marrow suppression, and was started on prednisone. Patient also had a fall about 1 week ago, for which she refused to be seen at the hospital. She sustained a large bruise to the right side of the chest, but feels her symptoms have been improving does not feel that she injured anything else. In the ED, initial vital signs were 98.7 87 ___ 99% on room air. CBC with normal WBC and platelets of 106. MP notable for BUN of 23 and creatinine 1.2. UA grossly positive with large leuk esterase, positive nitrites, however with 4 epis. CXR showed pulmonary vascular congestion without focal consolidation ___ she received 10 units subcu insulin x2, IV ceftriaxone, aspirin, sertraline. She was admitted further for treatment of UTI. Upon arrival to the floor, the patient confirms the story as above. She reports that in ___, she was taken off of dapsone due to hemolytic anemia. She had taken dapsone for many years and feel that it was very effective in treating her sweet syndrome. She was then started on prednisone and colchicine through the works for ___ who is at ___. When she started taking prednisone, she knows her sugars, which she checks twice a day, increased a lot. She began to experience feeling dizzy and unwell. She reports she went to urgent care approximately twice per week to get insulin, although she is never been on insulin before. Because of this, her prednisone was decreased to half a pill per day. In this setting, she has noticed new lesions developing on her hands, as well as a lesion on her nose. She also reports painful lesions on her buttocks. She states in general she was not feeling well. She did experience some urinary symptoms, typically urinary frequency and dysuria. She went to a clinic, where she was given a full course of Macrobid which she completed. She returned to that clinic, she was reportedly told that she still had a urinary tract infection and was prescribed Keflex which she began to take yesterday. She continues to feel unwell, with worsening lightheadedness and mild headache. She otherwise denies abdominal pain. Of note, she did have a mechanical fall in ___, during which time she bruised her right chest. She denies lightheadedness at that time. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. " Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Mucous membranes dry CV: Heart regular, no murmur Chest: Large bruise on right breast RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, non-tender to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: + dark ulcer on L middle finger, on right bridge of nose, pinpoint lesions developing on fingertips NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect DISCHARGE EXAM: Vitals reviewed and unremarkable, sugars ranging 132183. Inputs and outputs reviewed and unremarkable. Obese older woman seated in a chair next to the bed, standing and ambulating without difficulty in the room. 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. Skin with rashes consistent with healing sweet syndrome, no significant new lesions. She has some red skin on her bilateral middle fingertips, and some scabbed areas on her elbows and a few on her lower extremities. Please see ___ dermatology note for more details. Pertinent Results: ADMISSION LABS: ___ 09:30AM BLOOD WBC-6.3 RBC-4.13 Hgb-11.8 Hct-36.5 MCV-88 MCH-28.6 MCHC-32.3 RDW-12.5 RDWSD-40.2 Plt ___ ___ 09:30AM BLOOD Neuts-75.1* Lymphs-15.3* Monos-6.7 Eos-1.9 Baso-0.5 Im ___ AbsNeut-4.70 AbsLymp-0.96* AbsMono-0.42 AbsEos-0.12 AbsBaso-0.03 ___ 09:30AM BLOOD Glucose-627* UreaN-23* Creat-1.2* Na-137 K-4.8 Cl-98 HCO3-23 AnGap-16 ___ 09:30AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8 ___ 06:29AM BLOOD ALT-20 AST-13 AlkPhos-67 TotBili-0.3 ___ 09:58AM BLOOD ___ pO2-35* pCO2-44 pH-7.40 calTCO2-28 Base XS-1 ___ 09:58AM BLOOD Glucose-600* Lactate-1.8 K-4.1 PERTINENT LABS: ___ 06:36AM BLOOD %HbA1c-10.8* eAG-263* ___ 06:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 06:29AM BLOOD HCV Ab-NEG ___ 06:29AM BLOOD HCV VL-NOT DETECT ___ 09:00AM BLOOD Cyclspr-32* ___ 08:50AM BLOOD Cyclspr-75* ___ 09:35AM BLOOD Cyclspr-84* MICRO: Stool C.diff PCR (___): negative Wound swab culture (___): MSSA (resistant to clindamycin) BCx (___): No growth x2 UCx (___): Pan-sensitive E.coli IMAGING: CXR PA/Lat (___): IMPRESSION: Pulmonary vascular congestion without focal consolidation. XR bilateral hands (___): IMPRESSION: Mild diffuse soft tissue edema about the bilateral hands and questionable chronic erosions at the right hand long finger DIP and proximal triquetrum and left ulnar styloid process tip. Recommend clinical correlation for inflammatory arthropathy. MR right wrist without contrast (___) - incomplete study: IMPRESSION: 1. Evaluation for synovitis is limited due to motion degradation and lack of IV contrast. 2. Chronic changes related to a combination of likely inflammatory arthritis and osteoarthritis in the carpal bones and at the wrist joints. 3. Small loculated joint effusion in the ulnocarpal joint, fluid in the distal radioulnar joint and nonspecific mild soft tissue edema in the dorsal intercarpal ligament and at the ulnar aspect of the wrist likely relates to chronic synovitis with mild acute inflammatory component not excluded. This could be further evaluated with Doppler ultrasound if MRI contrast is not feasible. 4. Mild tendinosis of the extensor carpi ulnaris with intrasubstance tearing. 5. Mild peritendinitis of the extensor digitorum tendons at the hand, and trace fluid in the ECU, second and third extensor compartment and trace edema about the flexor tendon sheaths in the carpal tunnel, nonspecific but may relate to mild tenosynovitis. This could be further evaluated with Doppler ultrasound if MRI contrast is not feasible. 6. Degenerative tearing of the TFCC. MR right hand without contrast (___) - incomplete study: IMPRESSION: 1. Evaluation for synovitis is limited by lack of IV contrast 2. Chronic cortical changes likely related osteoarthritis with possible superimposed chronic erosive changes. 3. Small joint effusions at the third metacarpophalangeal joint and fifth proximal interphalangeal joints, with mild associated soft tissue no particular at the fifth PIP may represent mild synovitis. Recommend clinical correlation. If clinically warranted, further evaluation with Doppler ultrasound can be performed if contrast-enhanced MRI is not feasible. 4. Mild peritendinitis around the extensor digitorum tendons, similar to prior MRI. Trace fluid in multiple extensor compartment tendon sheaths, trace edema about the flexor tendons in the carpal tunnel, as well as loculated fluid in the ulnar carpal joint space and associated soft tissue edema is nonspecific but mild acute on chronic inflammation is not excluded. Note that overall the soft tissue edema has decreased from prior study of ___ however. 5. Trace nonspecific fluid surrounding the fourth and fifth digit flexor tendons. 6. Please see MRI wrist of same day for additional Findings. DISCHARGE LABS: ___ 04:30AM BLOOD WBC-6.3 RBC-4.09 Hgb-11.5 Hct-36.9 MCV-90 MCH-28.1 MCHC-31.2* RDW-13.3 RDWSD-43.0 Plt ___ ___ 04:30AM BLOOD Glucose-96 UreaN-26* Creat-1.2* Na-139 K-6.4* Cl-106 HCO3-20* AnGap-13 ___ 07:40AM BLOOD ALT-42* AST-29 AlkPhos-85 TotBili-0.4 ___ 07:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.6 Brief Hospital Course: SUMMARY: ___ female with history of sweet syndrome, non-insulin-dependent diabetes, frequent urinary tract infections, pulmonary hypertension on home O2, who presented with at least 2 weeks of increasing weakness and dizziness, poor glucose control, and recently diagnosed urinary tract infection & worsening of her Sweets syndrome lesions with course complicated by hyperglycemia in the setting of diabetes mellitus type II requiring initiation of insulin. Seen on the day of discharge, the patient was doing well, no new concerns or issues. The nurses had worked extensively to help her understand her follow-up appointments including once a day, as well as helping arrange her medications and supplies for her transport home with a chair car. She had no questions for me and was looking forward to leaving. HOSPITAL COURSE BY PROBLEM: # Hyperglycemia # Diabetes mellitus, type II Severe hyperglycemia on admission, occurring in the setting of steroids for her Sweet syndrome. FSBG as high as 600, but no other evidence of hyperglycemic-hyperosmolar nonketotic syndrome. Initially, due to worsened joint pain and swelling (related to her Sweet syndrome), prednisone was resumed with plans for a more prolonged taper. However, because of the patient's joint pain/swelling, she does not have enough dexterity to self-administer insulin. On ___, her prednisone was stopped (after cyclosporine had been initiated on ___ with hopes that she would not require insulin to go home. However, her joint pain/swelling worsened dramatically after the prednisone was discontinued and a lower dose was resumed later that night. Because of this she was placed on insulin NPH. Occupational therapy and ___ were consulted to teach the patient strategies for insulin self-administration, especially given that her Hgb A1c is 10.8%. She unfortunately had some hypoglycemia so her glipizide was stopped. Case management arranged for her to have a ___ visit once a day for insulin administration and a morning sugar check. She was discharged on NPH 28 units once daily in the morning. This should be titrated as she tapers down on prednisone. For every 5 mg the prednisone goes down, ___ estimated that the NPH should be decreased 6 units. As a result for a decrease in prednisone from 20 mg daily to 15 mg daily the NPH would go from ___ units. She will follow-up with her primary care doctor regarding her diabetes, and can be referred to ___ if needed by her PCP. Given that the patient could not self administer her insulin nor could she work the glucometer herself, we recommended that she try to find someone who could help her check her sugar once a day after 12 ___. The ___ will help with the morning blood sugar check. She was instructed to bring her fingerstick values to her follow-up appointment. # Sweet Syndrome Patient has a history of Sweet syndrome which has been treated by a dermatologist at ___ (she wants to transfer her care to ___. Her Sweet syndrome was well controlled on dapsone, however she developed hemolysis as a side effect so this was discontinued by hematology. Since discontinuation of dapsone, the patient has noted the appearance of several new painful lesions as well as worsened joint pain and swelling. For workup for possible alternative therapies, QuantGOLD was negative, hepatitis serologies negative, and LFTs wnl. Dermatology was consulted. They recommended starting cyclosporine which was done on ___. Her hospital course was prolonged waiting for a prior authorization for cyclosporine to go through. As above she was also treated with a prolonged prednisone taper. Derm recommended that she use betamethasone ointment for new skin lesions and they will consider intralesional steroid injections as an outpatient. Unfortunately her insurance denied to provide prior authorization for cyclosporine so the plan was made to titrate this off, and go up slightly on her prednisone (from 15 mg to 20 mg, and to continue using the topical steroid as needed. She was provided with a short/quick taper of cyclosporine which will finish on ___. # Likely inflammatory arthritis Dermatology did not think that her arthritis is a manifestation of her Sweet syndrome. Rheumatology was consulted; they will see her in clinic. In the meantime, they recommend a prolonged steroid taper to control her symptoms. MRI was attempted but not able to be completed due to patient discomfort. # E.coli Urinary Tract Infection Patient reported urinary frequency on admission. She was treated with a complete course of Bactrim. # Vertigo - chronic issue, reinitiated meclizine, which has worked for her in the past with improvement in her symptoms. She indicated an interest in following up with ENT as an outpatient, and was provided with their contact information RESOLVED # ___: Admission creatinine of 1.2, improved to baseline 1 after IV fluids and PO hydration. CHRONIC/STABLE PROBLEMS: # Hx of Hemolytic anemia in the setting of dapsone: Patient has a history of low grade anemia for at least ___ years per ___ records. G6PD checked and greater than upper limit of normal. Coombs test negative. Dapsone recently discontinued with improvement in hemolysis parameters. Given inability to tolerate prednisone and appearance of new lesions while taking colcichine, the risk of hemolysis with future use of dapsone was discussed with heme/onc. They recommended against any future use of dapsone in this patient. Interestingly since the improvement in her chronic anemia with discontinuation of dapsone she no longer requires supplemental O2 (she was on home O2 prior to admission). She will follow-up with hematology as an outpatient. # HLD, Primary prevention of coronary artery disease: - Continued Aspirin 81 mg daily - atorvastatin was held while she was on cyclosporine (given a drug drug interaction) and will be restarted once that medication has washed out of her system # Depression: - Continued Sertraline 100 mg daily # Overactive bladder: Vesicare (solifenacin) 5 mg oral DAILY (not formulary) held. TRANSITIONAL ISSUES: [ ] Insulin will need to be adjusted as she tapers down on prednisone. [x] The patient is safe to discharge 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. Aspirin 81 mg PO DAILY 2. PredniSONE 10 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. GlipiZIDE 10 mg PO QAM 5. GlipiZIDE 2.5 mg PO QPM 6. Multivitamins 1 TAB PO DAILY 7. Sertraline 100 mg PO DAILY 8. Vesicare (solifenacin) 5 mg oral DAILY 9. Atorvastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen 325 mg 2 tablet(s) by mouth Q6H:PRN Disp #50 Tablet Refills:0 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX betamethasone dipropionate 0.05 % 1 Appl twice a day Refills:1 3. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat RX benzocaine-menthol [Cepacol Sore Throat ___ 15 mg-3.6 mg ___ lozenges q2h Disp #48 Lozenge Refills:0 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H Take 1 dose on ___ evening, then one dose ___ morning, and 1 dose ___ evening, then stop 5. NPH 28 Units Breakfast RX blood sugar diagnostic [OneTouch Verio] AS DIR AS DIR Disp #50 Strip Refills:0 RX lancets [Ultra Thin Lancets] 31 gauge AS DIR AS DIR Disp #100 Each Refills:0 RX insulin NPH isoph U-100 human [Humulin N NPH U-100 Insulin] 100 unit/mL AS DIR units SC 28 Units before BKFT; Disp #1 Vial Refills:1 RX insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine] 31 gauge X ___ AS DIR AS DIR Disp #90 Syringe Refills:0 6. PredniSONE 20 mg PO DAILY RX prednisone 5 mg 4 tablet(s) by mouth DAILY in the morning Disp #100 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Colchicine 0.6 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Sertraline 100 mg PO DAILY 11. Vesicare (solifenacin) 5 mg oral DAILY 12. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until ___ (4 days after you finish the cyclosporine) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Sweets syndrome, Hyperglycemia 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 because your blood sugars were too high, causing dizziness, you had a urinary tract infection, and your Sweet syndrome had worsened on the decreasing dose of steroids. Since we did not feel dapsone is safe for you, our dermatologists recommended cyclosporine. Unfortunately, your insurance refused to pay for cyclosporine, so we began to taper you off this ___, increased your prednisone dose, and encouraged you to use the topical steroid and follow-up with Dermatology for intra-lesional steroid injections. You should follow-up with Rheumatology about your joint pains (inflammatory arthritis). For your diabetes you were started on NPH insulin once daily in the morning, which will be administered by a visiting nurse. You should follow-up with your primary care doctor about your diabetes and insulin. Call them -- or your PCP -- with any questions about your sugars. They can refer you to ___ if needed. It is important that your sugars be checked at least twice a day. The ___ can help in the morning. Please try to ask a friend, neighbor, or family member to help you check your sugar sometime between 12pm and 10pm each day. Please write down the times you check your sugars, and the values, and bring that information to your follow-up appointment with your PCP. It is important that Dermatology, Rheumatology, and your PCP coordinate your prednisone dose and your insulin dose. As the prednisone goes down, the insulin must go down. For every 5mg the prednisone is decreased, the insulin should go down 6 units, for instance when the prednisone goes from 20 to 15mg, the insulin should go from 28 to 22 units. Please do not restart your atorvastatin until 4 days after finishing cyclosporine. Your other follow-up appointments are listed below. Followup Instructions: ___
10076617-DS-18	10,076,617	20,459,993	DS	18	2168-02-01 00:00:00	2168-02-01 15:58:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin / dapsone Attending: ___. Chief Complaint: Right ___ toe pain Major Surgical or Invasive Procedure: I&D of R ___ toe abscess (___) History of Present Illness: CC: Right ___ ___ Swelling HISTORY OF PRESENT ILLNESS: Mrs ___ is ___ year old woman with a history of IDDM2, pHTN, Sweet syndrome and inflammatory arthritis on prednisone, pHTN admitted with right ___ toe SSTI. Patient reports being in her USOH until approximately 2 weeks ago when she developed a corn on her right ___ toe. This developed into a blister and then became increasingly swollen and painful. Denies any antecedent trauma. She endorsed continued irritation with shoes, requiring padding, and had to rely more on her walker. The pain and swelling have increasingly affected her walking, and she presented to the hospital today at the prompting of her friend. She also has pain to a lesser extent in the left forefoot, although to much less extent than her right. She does not have any systemic symptoms, deniy f/c/n/c. Not lightheaded or dizzy, with normal cardiopulmonary function. She continues to eat well and have normal bowel/urinary function. Patient originally was seen in ___ where she received 1 dose of CTX and subsequently transferred to ___. In the emergency department, she was seen by podiatry who performed a bedside I&D, unroofing a purulent fluid collection was drained. The underlying area probed deeply to bone. Patient was started on antibiotics and a wound culture sent from the aspirate. To note, patient was recently hospitalized with UTI, worsening Sweet syndrome, and inflammatory arthritis 1 month ago. Since discharge, her prednisone was decreased to 15mg and she is close to transitioning to methotrexate. ROS: Positive per above, otherwise comprehensive ROS negative. Past Medical History: - IDDM2 - CKD, stage III - HTN - HLD - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on CPAP (setting unknown) - Sweet's syndrome (dx in 1990s, previously on dapsone, now colchicine/prednisone) - Likely serongative inflammatory arthritis - COPD, PRN supplemental O2 with ambulation (2L NC) - Pulmonary HTN Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION: ========== VS: 98.1 144/83 65 18 98/RA GEN: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: MMM, grossly nl OP CV: RRR nl S1/S2 no g/r/m RESP: CTAB no w/r/r EWOB SIFS GI: soft, NT/ND NABS no r/g/rigidity. GU: No IUC, no suprapubic tenderness/fullness EXT: WWP, no trace ___ edema MSK: MSK: MCP of b/l hands enlarged R>L, DIP/PIP also slightly swollen, thought without erythema, warmth, or tenderness. R ___ toe swollen, erythematous, TTP (recently I&D this AM). No discharge or exudate. Left foot bandage DSD CDI. TTP along ball of foot, but banadage not removed per pt. Capillary fill time ___. SKIN: several nodules, scattered mostly on b/l arms ~1cm slightly erythematous, slighty tender (chronic x weeks per pt) NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs. Strenght ___ in b/l ___ major felxors and extensors, sensation in b/l ___ grossly preserved to fine touch PSYCH: pleasant, appropriate affect DISCHARGE: ========== GENERAL: NAD, sitting comfortably in bed EYES: PERRL, anicteric sclerae ENT: OP clear CV: RRR, nl S1, S2, II/VI SEM, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM MSK: mild synovitis of the MCPs and wrists b/l, R>L with soft tissue fullness of the hands b/l; no e/o synovitis or effusions of the knees b/l; lower ext warm without edema NEURO: AOx3, CN II-XII intact, ___ strength in all extremities, sensation grossly intact throughout, gait testing deferred PSYCH: pleasant but anxious SKIN: R ___ pulses palpable; ulcer on lateral R ___ toe s/p I&D without residual purulence/erythema/TTP; superficial blisters on plantar surface LLE w/o erythema or TTP; violacious papule on periungual surface of L index finger with new, painful papules on multiple fingertips and the R olecranon process Pertinent Results: ADMISSION: =========== ___ 07:53PM BLOOD WBC-7.8 RBC-3.85* Hgb-10.8* Hct-34.6 MCV-90 MCH-28.1 MCHC-31.2* RDW-15.9* RDWSD-51.9* Plt ___ ___ 07:53PM BLOOD Plt ___ ___ 06:50AM BLOOD ___ 07:53PM BLOOD Glucose-181* UreaN-17 Creat-1.0 Na-142 K-4.1 Cl-106 HCO3-26 AnGap-10 ___ 07:42AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 ___ 08:03AM BLOOD %HbA1c-10.6* eAG-258* ___ 07:53PM BLOOD CRP-4.6 ___ 07:53PM BLOOD Lactate-0.7 DISCHARGE: ========== ___ 07:00AM BLOOD WBC-7.9 RBC-3.78* Hgb-10.7* Hct-34.2 MCV-91 MCH-28.3 MCHC-31.3* RDW-15.8* RDWSD-52.2* Plt ___ ___ 07:00AM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-146 K-3.8 Cl-106 HCO3-29 AnGap-11 ___ 06:57AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 CRP 38.9 (from 4.6) Prior: ------ INR ___ Fibrinogen 310 A1c 10.6% UA: neg bld, neg nit, lg ___, tr prot, 1000 gluc, 122 WBCs, few bact BCX (___): pending x 2 R ___ toe swab (___): 2+ PMNs, no organisms; sparse growth Grp B strep and rare growth of CoNS; mixed flora UCx (___): >100K yeast IMAGING: ======== US L hand (___): No wrist or MCP joint effusion is identified. Trace tenosynovitis of flexor tendons are noted. No focal fluid collection is identified. No significant synovitis is demonstrated in the wrist or MCP joints. US R hand (___): No joint effusion is identified. Soft tissues surrounding the extensor tendons and small finger MCP and PIP joints are suggestive of tenosynovitis/synovitis. MRI R foot w/w/o cont (___): 1. No MRI signs for acute osteomyelitis or soft tissue abscess. There is dorsal forefoot and fifth toe soft tissue swelling. 2. Degenerative changes of PIP joints of the second through fifth toes. ABIs b/l (___): No evidence of arterial insufficiency to the lower extremities bilaterally. R foot plain films (___): 1. No definite destructive lesion. If there is continued clinical concern, MRI would be more sensitive for the detection of osteomyelitis. 2. Swelling of the right fifth digit without evidence of acute bony abnormality. 3. Degenerative changes as described above. Brief Hospital Course: ___ with hx Sweet's syndrome (on prednisone/colchicine), seronegative inflammatory arthritis, IDDM, CKD stage III, HTN, HLD, OSA, pHTN/COPD (intermittent 2L NC) presenting with R ___ toe abscess s/p I&D and likely flare of Sweet's syndrome and inflammatory arthritis. # R ___ toe abscess/cellulitis: Patient p/w R ___ toe abscess with cellulitis, s/p I&D in ED by podiatry, with culture growing Grp B strep, rare CoNS, and mixed flora. Per podiatry, ulcer probed to bone, but plain films without e/o osteomyelitis, CRP initially nl (subsequently rose, attributed to arthritis as below), and MRI foot without radiographic evidence of osteomyelitis. ABIs nl. She was treated with Unasyn initially with significant improvement in her R ___ toe pain and erythema. She was transitioned to Augmentin to complete a 10d course through ___ (was not covered for MRSA given improvement on Unasyn). Wound was treated with betadine dressings daily and a surgical boot for ambulation. She will f/u with outpatient podiatry. # Sweet's Syndrome: Diagnosed in ___, previously followed at ___ and maintained on dapsone (d/c'd for hemolytic anemia). Recently admitted ___ with Sweet's flare, started on cyclosporine (which was d/c'd for insurance reasons), and discharged on increased prednisone dose with plan for taper. Recently tapered from pred 20mg -> 15mg per outpatient dermatologist, Dr. ___, with plan for MTX initiation in near future in conjunction with rheumatology; continues on colchicine. Presents this admission with a flare of her Sweet's, with new lesions on her fingertips and R olecranon. Dermatology was consulted and injected a L index periungual lesion. Prednisone was increased by rheum for her inflammatory arthritis as below, which should also treat Sweet's, and betamethasone ointment to the hands was initiated, with plan for a 2 week course (through ___. She was discharged on prednisone 20mg PO daily and topical steroids with plan for dermatology f/u with Dr. ___ ___ consideration of MTX initiation (appointment requested, pending at discharge). # Likely seronegative inflammatory arthritis: Worked up last admission and seen by rheumatology as outpatient; thought to have seronegative inflammatory arthritis. Per dermatology last admission, arthritis not thought to be attributable to Sweet's, although interestingly flares of the two seem to co-occur. Complained of worsening joint pain ___ with rising CRP, for which rheumatology was consulted. U/S performed at rheum's requests showed evidence of synovitis/tenosynovitis of the R MCP/PIP joints without effusions. Rheum recommended increasing prednisone to 30mg x 3d followed by taper to 20mg daily and outpatient f/u for consideration of DMARD. She will take prednisone 20mg PO daily, with plan for outpatient f/u with Dr. ___ on ___ for consideration of MTX. Pain was improving at discharge. # IDDM2: Hyperglycemic in setting of prednisone for Sweet's. Initiated on NPH qAM last admission ___. A1c 10.6%. Continued home NPH 28u qAM with addition of ISS. # Diarrhea: Likely attributable to antibx. C.diff was negative. # L plantar foot blister: Blister on plantar L foot evaluated by podiatry in ED, s/p I&D without signs of infection. Treated with betadine dressings and surgical boot. She will f/u with outpatient podiatry on ___. # Thrombocytopenia: Plt 138 on ___. Was noted to be thrombocytopenic during recent hospitalization in ___. No e/o bleeding or DIC. Stable at 147 on discharge. # CKD stage III: B/l appears to be 1.0-1.2. F/u with Dr. ___ on ___. # OSA # pHTN: Patient one home O2 (2L) intermittently with exertion. Previously on CPAP at home but has not been using; declined while inpatient. # HLD: Continued home aspirin, statin # Depression: Continued home sertraline # Overactive bladder: Home Vesicare NF, will substituted tolterodine while inpatient. TRANSITIONAL [ ] prednisone 20mg daily through rheumatology f/u [ ] f/u with rheumatology and dermatology consideration of methotrextate initiation [ ] adjust insulin for improved glycemic control Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Colchicine 0.6 mg PO BID 3. Vesicare (solifenacin) 5 mg oral DAILY 4. Acetaminophen 650 mg PO Q6H 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. PredniSONE 15 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. NPH 28 Units Breakfast 10. triamcinolone acetonide 0.5 % topical daily 11. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL oral daily Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth every twelve (12) hours Disp #10 Tablet Refills:0 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX betamethasone dipropionate 0.05 % Apply a small amount to affected areas twice a day Refills:0 3. PredniSONE 20 mg PO DAILY RX prednisone 20 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL oral daily 8. Colchicine 0.6 mg PO BID 9. NPH 28 Units Breakfast 10. Multivitamins 1 TAB PO DAILY 11. Sertraline 100 mg PO DAILY 12. triamcinolone acetonide 0.5 % topical daily vaginal application 13. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right ___ toe abscess/cellulitis Sweet's syndrome Seronegative inflammatory arthritis Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with an abscess on your right ___ toe. The abscess was drained by the podiatry team and you were treated with antibiotics. An MRI of your foot showed no evidence of bone infection. You are being discharged on an antibiotic called Augmentin, which you should continue through ___ (10 days total). While here, you were noted to have a flare of your Sweet's syndrome and your arthritis. You were seen by the dermatology and rheumatology teams, and your prednisone dose was increased. Please continue prednisone 20mg PO daily until you see your rheumatology team on ___. Please take your medications as prescribed and follow-up with your outpatient doctors as below. With best wishes, ___ Medicine Followup Instructions: ___
10077370-DS-20	10,077,370	21,019,625	DS	20	2112-11-18 00:00:00	2112-11-26 14:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Mintezol / codeine Attending: ___. Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: ___: ESOPHAGOGASTRODUODENOSCOPY ___: ENDOBRONCHIAL ULTRASOUND, BIOPSY OF HILAR LYMPH NODES History of Present Illness: Mrs. ___ is a ___ year old female with past medical history of pre-diabetes and dyslipidemia, who presents for evaluation of dysphagia. She reports that she started experiencing difficulty swallowing food approximately 3 days ago. The dysphagia was initially to solids, then also involved liquids. She tried to eat crushed food but was unable to finish her meals. On the day prior to admission, she woke up with a sensation of food stuck and choking her. She also reports that it is starting to become difficult to swallow secretions. She ___ "it feels my throat is smaller". She went to ___, where a CT scan showed abnormal thickening of the mid to distal esophagus question esophagitis or mass. She came to ___ for further evaluation. In the ED, initial vitals: 98.6 103 161/81 20 98% RA Exam: managing secretions, comfortable, breathing comfdortbaly, no acute distress Imaging at ___ (see report below) Patient was given pantoprazole IV GI was consulted and recommended NPO, protonix BID 40 mg IVadmit to medicine, scope ___. Vitals prior to transfer: 98.1 97 148/90 16 100% RA On arrival to the floor, patient was overall comfortable but tired looking. She confirmed history above. In addition, she reports numbness in the right forehead, left groin, left hip, and left axilla a few weeks ago after returning from ___. She also reports intermittent left scapular pain for a few weeks, relieved with Tylenol. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: GERD Leiomyoma of uterus Glaucoma suspect with open angle OHT (ocular hypertension) Cataract, nuclear sclerotic senile Optic atrophy Benign neoplasm of eyelid Hypercholesteremia Prediabetes Social History: ___ Family History: - Father ___ at age ___ Alzheimer's; Diabetes; Hypertension; Stroke - Mother ___ at age ___ Alzheimer's; Diabetes; Hyperlipidemia; Hypertension; Inflammatory Bowel Disease; Glaucoma - Sister ___ at age ___ Alzheimer's; Anemia - Hereditary; Breast cancer; Diabetes - Sister with breast cancer - Brother Alive; ___ at age ___ Diabetes; Hyperlipidemia; Hypertension; Stroke - Daughter Alive - Son Alive Physical ___: ADMISSION PHYSICAL EXAM: ======================== VS: 98.1 PO 168 / 83 95 18 99 RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal, decreased sensation in right forehead, left groin, left hip, and left axilla. DISCHARGE PHYSICAL EXAM: ======================== VS: 99.6 148/88 97 97%RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple, no masses palpated in thyroid, no tenderness to palpation PULM: CTA b/l without wheeze or rhonchi COR: RRR nml S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: AAOx3 - PERRLA, EOM intact, facial sensation as below, facial muscles strong and equal bilaterally, decreased palatal elevation on L, SCM ___ b/l, tongue protrudes midline with equal L and R movement. - Decreased sensation to light touch in right forehead (V1 distribution), L mandible (V3 distribution), left groin to hip in dermatomal fashion (T11-L1), and left axilla. - ___ strength upper and lower extremities. Finger to nose with mostly smooth pursuit, increasingly fatigued as test goes on with slight tremble. No pronator drift. Gait deferred. Pertinent Results: ADMISSION LABS: ============== ___ 08:10PM BLOOD WBC-3.6* RBC-4.37 Hgb-11.9 Hct-37.4 MCV-86 MCH-27.2 MCHC-31.8* RDW-13.1 RDWSD-40.7 Plt ___ ___ 08:10PM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-27 AnGap-15 ___ 08:10PM BLOOD ALT-22 AST-21 LD(LDH)-227 AlkPhos-85 TotBili-0.4 ___ 08:10PM BLOOD Albumin-3.8 Calcium-9.6 Phos-3.2 Mg-2.0 OTHER PERTINENT LABS: ==================== ___ 07:37AM BLOOD TotProt-6.8 Calcium-9.6 Phos-2.8 Mg-2.1 ___ 05:10AM BLOOD VitB12-577 ___ 05:15AM BLOOD TSH-1.6 ___ 07:37AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* ___ 07:37AM BLOOD RheuFac-<10 ___ CRP-83.0* ___ 07:37AM BLOOD PEP-NO SPECIFI ___ 07:37AM BLOOD HCV Ab-Negative DISCHARGE LABS: ============== ___ 06:18AM BLOOD HBV VL-NOT DETECT ___ 06:18AM BLOOD WBC-3.6* RBC-4.19 Hgb-11.3 Hct-35.8 MCV-85 MCH-27.0 MCHC-31.6* RDW-13.3 RDWSD-41.7 Plt ___ ___ 06:18AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-141 K-3.9 Cl-102 HCO3-27 AnGap-16 ___ 06:18AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.0 URINE STUDIES: ============= ___ 05:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 05:40PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 05:40PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-2 MICROBIOLOGY: ============= ___ 5:40 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 5:10 am Blood (LYME) Lyme IgG (Preliminary): Sent to ___ for Lyme Western Blot testing. Lyme IgM (Preliminary): Sent to ___ for Lyme Western Blot testing. ___ 5:10 am SEROLOGY/BLOOD FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. Time Taken Not Noted Log-In Date/Time: ___ 5:47 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: 10,000-100,000 CFU/mL Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). IMAGING/STUDIES: ============== ___ Neck (___): IMPRESSION: 1. No suspicious mass in the oral pharynx or hypopharynx. 2. Incidental thyroid complex nodule. 3. Incidental tiny polyp right maxillary sinus. ___ Second Read: No oro pharyngeal or retropharyngeal mass identified. There is no narrowing of the airways. 1.6 cm enhancing thyroid nodule with surrounding hypodensity. Further evaluation is recommended with ultrasound RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up recommended. ___ College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm in patients age ___ or ___, or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___ Chest w/ Contrast (___): 1. Abnormal thickening of the mid to distal esophagus question esophagitis or mass. No obstruction as the oral contrast passes beyond this into the stomach. 2. Extensive bilateral hilar adenopathy. 3. 1.2 cm soft tissue nodule right lung base posterior medially. ___ Second Read: -Confluent mediastinal and symmetric bilateral hilar lymphadenopathy with peribronchial nodules, suspicious for sarcoidosis. -Slightly spiculated solid pulmonary nodule in the right lower lobe measuring up to 12 mm. This is likely be part of the spectrum of sarcoidosis and less likely lymphoma or small cell lung cancer. However, transbronchial biopsy and tissue diagnosis would be helpful for definitive clinical management. -Multiple enlarged lymph nodes adjacent to the esophagus, which is mildly enlarged. Gastric Biopsy (___): Stomach, mucosal biopsy: - Chemical-type gastropathy. Barium Swallow (___): 1. Mild penetration of thin liquids. Residue in the piriform sinuses with holdup of barium tablet in the left piriform sinus for around 2 minutes. Recommend dedicated formal video oropharyngeal swallow study with the speech pathology team for more detailed evaluation of the oropharynx. 2. Normal esophageal motility. 3. Small hiatal hernia. MRI Brain; MRA Head and Neck (___): 1. Images are limited by motion, pulsation, and other artifacts. 2. No evidence for an acute infarction, intracranial mass, or other intracranial abnormalities. 3. Inadequate assessment of the proximal common carotid and vertebral arteries. No evidence for internal carotid stenosis by NASCET criteria. 4. No evidence for flow-limiting intracranial arterial stenosis. 5. Approximately 1.7 cm left thyroid nodule is better seen on the ___T Mandible (___): 1. No evidence of focal mandibular lesion. 2. Incidental note of a torus ___. 3. Small right maxillary mucosal retention cyst. Bronchus Biopsy (___): TBNA: Nonspecific T cell dominant lymphoid profile; diagnostic Immunophenoptyic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical, morphologic (see separate pathology report ___-___) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. Surgical Pathology: Part 1: Endobronchial biopsy, carina: - Bronchial mucosa with focal necrotizing granulomatous inflammation, see note. Part 2: Endobronchial ultrasound guided transbronchial needle aspiration, lymph node level 7: - Non-necrotizing granulomatous inflammation, see note. - There is no evidence of malignancy. Part 3: Endobronchial ultrasound guided forceps level 7: - Scant fragments of lymphoid tissue and smooth muscle. - There is no evidence of granulomatous inflammation, nor of malignancy; multiple levels are examined. Note: AFB and GMS stains, performed on Parts 1 & 2, are negative. Fine Needle Aspiration: Lymph node, level 11R, EBUS-TBNA: NEGATIVE FOR MALIGNANT CELLS. - Non-necrotizing granulomas (see note). - Lymphocytes consistent with lymph node sampling. Lymph node, Level 7, EBUS-TBNA: NEGATIVE FOR MALIGNANT CELLS. - Rare histiocytic aggregates suggestive of non-necrotizing granulomas. - Lymphocytes consistent with lymph node sampling. Lingula Lavage: NEGATIVE FOR MALIGNANT CELLS. - Pulmonary macrophages and bronchial epithelial cells. Chest XRay (___): No pneumothorax identified Brief Hospital Course: Ms. ___ is a ___ yo F with hx of HLD who presented with ___ weeks of acute onset dysphagia with patchy numbness over forehead, chin, left arm, and left abdomen. Initially she presented to ___ where she had a CT scan that demonstrated confluent mediastinal and symmetric bilateral hilar lymphadenopathy as well as thickening of her distal esophagus. She was transferred to ___ for further evaluation of her lower esophageal thickness. Underwent an EGD on ___, which was unremarkable. Biopsy obtained demonstrated chemical-type gastropathy. Her dysphagia was further worked up during her hospitalization. She underwent additional imaging which did not demonstrate any evidence of brain stem stroke. She was evaluated by neurology who felt her presentation was most consistent with a neuropathy from a local nerve injury. A CT of her mandible did not demonstrate any mass compressing a peripheral nerve. She was evaluated by speech and swallow, who made adjustments to her diet which assisted greatly with swallowing. For her mediastinal lymphadenopathy noted on ___ chest CT, she underwent further work-up with a bronchoscopy with biopsy performed by interventional pulmonology on ___. Tolerated the procedure well. Final biopsy report pending at discharge, although preliminary read consistent with sarcoidosis. Rheumatology was consulted due to concern for possible sarcoidosis with nerve involvement leading to dysphagia. The plan at discharge was to initiate steroids as an outpatient to determine if this would aid in her dysphagia. ACTIVE ISSUES: =============== #Dysphagia: Acute dysphagia to solids and liquids over the two weeks prior to admission. Differential was broad and included possible CVA, mechanical obstruction, nerve injury, or neuropathy. Initially Mrs. ___ presented to ___, where she underwent imaging of the chest and neck. Neck without evidence of any masses. CT torso with extensive bilateral hilar adenopathy and abnormal thickening of the mid to distal esophagus concerning for esophagitis vs mass without evidence of obstruction. She was transferred to ___ for further evaluation. Due to concern for esophageal mass, GI was consulted and performed an EGD on ___. She tolerated the procedure well and a biopsy was obtained. EGD overall unremarkable and biopsy returned with findings of chemical-type gastropathy. On repeat read of CT torso, felt that this thickening may have been due to extensive lymphadenopathy. For further work-up of her dysphagia, ENT was consulted for evaluation for vocal cord dyfunction given that she also had some change in quality to her voice. Nothing remarkable was seen on examination. To work-up possible lateral medullary syndrome, an MRI brain and MRA head/neck were obtained to evaluate for stroke. These were overall unremarkable. Neurology was consulted who noticed she had subtle palate deviation to the right with chin numbness that may suggest a peripheral nerve injury. Recommended malignancy work-up and CT of her mandible to look for bony lesion. CT mandible was overall unremarkable, and the patient had recently had normal screening mammogram and colonoscopy within the past year without any concerning new symptoms. Due to concern that perhaps her sarcoid was contributing to her neurologic symptoms, she underwent a bronchoscopy to evaluate for her hilar lymphadenopathy. Underwent a bronchoscopy with biopsy on ___iopsy with preliminary findings suggestive of sarcoidosis. Other testing for infectious etiologies including Quantiferon gold, Aspergillus, and B-glucan were negative. Rheumatology was consulted and recommended initiating steroids, which the patient preferred to do as an outpatient. Noted to be hepatitis B core positive and surface antibody positive, indicating past, cleared infection. Hepatology was consulted and recommended that should she be initiated on high dose steroids, she should start entecavir 0.5mg po daily, to be continued until 6 months after completion of immunosuppresion. #Scattered numbness: On presentation described numbness in right forehead, left groin, left hip, and left axilla in dermatomal fashion (terminates midline). No other motor or sensation deficits. Unclear etiology, although had extensive work-up as above. Possibly secondary to sarcoidosis with neurologic involvement. #Leukopenia: White blood cell counts during hospitalization between 2.8K - 4.5K. Possibly due to underlying inflammatory condition. Stable throughout hospitalization without evidence of infection. # Elevated blood pressure: Noted during hospitalization intermittently up to SBP 170s. Should be followed up and treated as an outpatient if this persists. CHRONIC ISSUES: =============== #Dyslipidemia: Continued home pravastatin *TRANSITIONAL ISSUES:* ======================== - Please follow-up on final biopsy results; if sarcoid may benefit from trial of steroids - If steroids are started, the patient will need to be started on entecavir 0.5mg po daily. Will also need liver follow-up within one month if started on therapy. This therapy should continue until about 6 months after steroids are discontinued. - Dysphagia: Patient discharged on pureed liquids. Patient will benefit from continued speech and swallow therapy as an outpatient. Please continue to monitor her nutritional status as it is very difficult to take in anything PO. - Hypertension: Blood pressures inpatient ranged from 111-170/59-94. Consider starting blood pressure agents upon discharge. - Noted to have a 1.5 cm complex left thyroid nodule with calcification on CT chest at ___ Please follow-up as an outpatient - If started on steroids will need to take supplemental calcium and vitamin D if low; will also need DEXA screening - Started on pantoprazole to help with reflux and given that she will be started on steroids as an outpatient. - Contact: ___ (husband) ___ - Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 20 mg PO QPM 2. coenzyme Q10 10 mg oral DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Medications: 1. Entecavir 0.5 mg PO DAILY Only to be started if started on prednisone RX entecavir 0.5 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 (One) tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. coenzyme Q10 10 mg oral DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Multivitamins 1 TAB PO DAILY 7. Pravastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: Sarcoidosis, Oropharyngeal dysphagia Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ (___) due to difficulty with swallowing. While here, they did a CT scan which showed enlarged lymph nodes near the esophagus. An upper endoscopy with a stomach biopsy showed no evidence of cancer. Given that you were having continued difficulty with swallowing, an MRI was obtained of your brain which did not show any evidence of stroke. Neurology also evaluated you and agreed you did not have a stroke. We believe some of your swallowing difficulty could be from underlying sarcoidosis given the large lymph nodes we saw on your CT scan. An endobronchial ultrasound with biopsy of your lymph nodes was done that preliminarily showed sarcoidosis. We are awaiting the final results. You will have an appointment with Rheumatology this week to discuss further treatment options. During your admission, you were also found to have been exposed to Hepatitis B in the past and made a full recovery. However, because the treatment of sarcoidosis is steroids, there is a risk of reactivation of the Hepatitis B viral infection. Thus, if rheumatology initiates you on steroids, you will also need to take entecavir to prevent reactivation. If started on entecavir, you will also need to make an appointment with Dr. ___ (hepatology) for 1 month follow-up. Please follow up with your outpatient providers and all your scheduled appointments. Thank you for allowing us to be involved in your care. Sincerely, Your ___ Care Team Followup Instructions: ___
10077534-DS-8	10,077,534	29,345,364	DS	8	2133-06-02 00:00:00	2133-06-02 20:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Inderal / Minipress / Clonidine / Enalapril / Verapamil / Cozaar / Nifedipine / Norvasc / Bacitracin / Micardis / fluocinonide / Nizoral / nystatin / Atrovent / levofloxacin Attending: ___. Chief Complaint: cough, transient left leg weakness/burning Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ HTN, HLD, spinal stenosis, and possible TIA versus syncopal episode in the past who is presenting with an episode of transient left leg burning pain and weakness in the setting of URI. Pt reports that she has had a recent productive cough of yellow sputum since ___. Of note, she was around her 12 grandchildren and 3 greatgrandchildren for Christmas with multiple children with URI like symptoms. She was treated with amoxicillin with mild improvement so started on levaquin ___. This morning, the patient noted left leg weakness and a burning pain for 30 minutes. She reports that she was standing at the kitchen counter when it suddenly started. She had to hold onto counter so as to not fall. She denies any trauma associated with the event. No CP, SOB, lightheadedness or palpitations. The feeling resolved spontaneously. She presented to her PCP who referred her to ___ for further evaluation. In the ED, initial vitals were: 98.1 120/65 16 96RA Exam notable for ___ weakness in left arm and leg, chronic left foot drop, decreased sensation to pin over left shin following the L5 distribution. CTAB Labs showed WBC 3.5, nl coags, Na 127, BUN/Cr 34/2, lactate 1.5 Imaging showed CT head w/ no acute process; CXR w/ small b/l pleural effusions, lungs clear Received IVF Seen by neurology who thought her lightheadedness is most likely secondary to volume depletion in the setting of her URI. Left leg symptoms c/w her lumbar spinal stenosis but likely worsened by deconditioning. Neurology recommended no further inpatient neurologic work up. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports that she feels relieved that she did not have a stroke. She reports that her cough is ongoing. Denies SOB. She reports that because she was sick she was eating primarily broth but reports drinking a lot of water. No n/v/d. Patient endorses thirst. Past Medical History: - HTN - history of TIA versus syncopal event - anemia - HLD - Blepharitis - low back pain - hemorrhoids - colonic polyps - diverticulitis - GERD - allergic rhinitis - possible ocular migraine - osteoarthritis - osteoporosis - Raynaud's - stress incontiness - chronic left foot drop - nocturnal leg cramps - history of squamous cell carcinoma Social History: ___ Family History: unknown Physical Exam: ADMISSION EXAM ============== Vital Signs: 98.3 PO 133/61 84 18 93 RA 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: 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. DISCHARGE EXAM ============== Vitals: T 98, BP 110/61, HR 66, RR 18, SpO2 92/RA General: Alert, lying comfortably flat in bed, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear CV: RRR, normal S1 + S2, no M/R/G Lungs: rare expiratory ronchi, no wheezes or crackles Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: ___ strength upper/lower extremities, strength equal b/l, grossly normal sensation, gait deferred. Pertinent Results: ADMISSION LABS ============== ___ 01:20PM ___ PTT-26.2 ___ ___ 01:20PM PLT COUNT-219 ___ 01:20PM NEUTS-68.1 LYMPHS-16.1* MONOS-14.9* EOS-0.0* BASOS-0.3 IM ___ AbsNeut-2.37 AbsLymp-0.56* AbsMono-0.52 AbsEos-0.00* AbsBaso-0.01 ___ 01:20PM WBC-3.5* RBC-3.69* HGB-11.5 HCT-34.2 MCV-93 MCH-31.2 MCHC-33.6 RDW-12.5 RDWSD-42.7 ___ 01:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:20PM ALBUMIN-4.1 ___ 01:20PM cTropnT-<0.01 ___ 01:20PM LIPASE-83* ___ 01:20PM ALT(SGPT)-28 AST(SGOT)-52* ALK PHOS-66 TOT BILI-0.2 ___ 01:20PM GLUCOSE-110* UREA N-34* CREAT-2.0* SODIUM-127* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-23 ANION GAP-20 ___ 01:52PM LACTATE-1.5 ___ 11:57PM PLT COUNT-178 ___ 11:57PM WBC-3.5* RBC-3.34* HGB-10.3* HCT-30.8* MCV-92 MCH-30.8 MCHC-33.4 RDW-12.5 RDWSD-42.4 ___ 11:57PM CALCIUM-8.3* PHOSPHATE-2.9 MAGNESIUM-2.0 ___ 11:57PM GLUCOSE-123* UREA N-34* CREAT-1.5* SODIUM-129* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-21* ANION GAP-16 MICRO ===== ___ 1:20 pm BLOOD CULTURE Blood Culture, Routine (Pending): DISCHARGE LABS ============== ___ 06:55AM BLOOD WBC-2.8* RBC-3.27* Hgb-10.1* Hct-30.5* MCV-93 MCH-30.9 MCHC-33.1 RDW-12.7 RDWSD-43.3 Plt ___ ___ 06:55AM BLOOD Neuts-61.2 ___ Monos-10.7 Eos-0.7* Baso-0.3 Im ___ AbsNeut-1.78 AbsLymp-0.78* AbsMono-0.31 AbsEos-0.02* AbsBaso-0.01 ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD ___ PTT-30.7 ___ ___ 06:55AM BLOOD Glucose-86 UreaN-32* Creat-1.4* Na-132* K-4.2 Cl-97 HCO3-20* AnGap-19 ___ 06:55AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 IMAGING ======= ___ (PA & LAT) COMPARED TO THE ONLY PRIOR CHEST RADIOGRAPHS AVAILABLE, ___. MILD TO MODERATE CARDIOMEGALY INCREASED SLIGHTLY. SMALL BILATERAL PLEURAL EFFUSIONS. LUNGS CLEAR. THORACIC AORTA IS CALCIFIED BUT NOT FOCALLY ANEURYSMAL. ___ HEAD W/O CONTRAST No acute intracranial hemorrhage or mass effect. Please note that MRI is more sensitive for the detection of acute infarction. Brief Hospital Course: ___ w/ HTN, HLD, spinal stenosis, and possible TIA versus syncopal episode in the past who is presenting with an episode of transient left leg burning pain and weakness in the setting of URI. #LEFT LEG WEAKNESS AND PAIN: She was seen by Neurology in the Emergency Room. Most likely secondary to known lumbar spinal stenosis and deconditioning in setting of recent bronchitis. CT head reassuring. No further neurologic work up needed per neurology. Symptoms did not return during patient's time in the hospital. Walked with nursing while admitted; no evidence of weakness or unsteadiness. #BRONCHITIS: Recent bronchitis, now s/p course of amoxicillin with some improvement. Low suspicion for pneumonia given absent leukocytosis and CXR without obvious infiltrate. Received 1 day of levofloxacin as outpatient from PCP prior to admission. She reported that she felt palpitations later that day after taking the medication, thus did not take it the next day. The inpatient team opted to not continue any antibiotics given high suspicion for viral etiology (no fever, clear xray, patient report of improvement in her symptoms and desire to hold off on antibiotics). #AoCKD: Baseline Cr 1.3-1.4. Creatinine 2.0 on admission. Most likely secondary to pre-renal azotemia in setting of recent poor oral intake with infection. Cr back to 1.4 at time of discharge. #HYPONATREMIA: Most likely hypovolemic hyponatremia in setting of recent poor oral intake. Chronically in low 130s. Held chlorthalidone, BPs 110s-120s while admitted, will discharge patient off these medications; to be restarted at the discretion of Dr ___. CHRONIC ISSUES: ============== #HTN: held ___, spironolactone, chlorthalidone on admission for ___ BPs 110s-120s while admitted, will discharge patient off these medications; to be restarted at the discretion of Dr ___. #HLD: continued home atorvastatin #GERD: continued home omeprazole TRANSITIONAL ISSUES =================== [ ] ANTIHYPERTENSIVES: held home valsartan, spironolactone, and chlorthalidone for hyponatremia and ___ on admission [ ] HYPONATREMIA: chronically hyponatremic. Initially 127 on admission, recovered to 132 at time of discharge. Should be rechecked at next PCP ___ (within 1 week of discharge). [ ] BRONCHITIS: viral, likely the cause of cough. Treated supportively. [ ] SUPPORT AT HOME: this is a concern of daughter/HCP, ___. Pt feels safe at home in current situation. ___ need to be addressed going forward. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 160 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Chlorthalidone 25 mg PO DAILY 4. Levofloxacin 500 mg PO Q24H 5. Spironolactone 25 mg PO DAILY 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY 7. Aspirin 325 mg PO DAILY 8. Loratadine 10 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. DiphenhydrAMINE 25 mg PO QHS:PRN unknown Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. DiphenhydrAMINE 25 mg PO QHS:PRN unknown 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Loratadine 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= Viral bronchitis Spinal stenosis Acute on chronic renal failure Hyponatremia SECONDARY DIAGNOSES =================== Hypertension 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 ___ from ___ to ___ for burning pain and weakness in your left leg, as well as a cough that we suspect is due to bronchitis. You were seen by neurology (brain/nerve specialists) in the emergency department, who felt that the passing episode of leg weakness and burning that you experienced was likely the product of your spinal stenosis (narrowing of your spinal canal), as well as weakness caused by your viral bronchitis and small appetite. You were also noted to have a worsening of your kidney function. This also was likely caused by poor food/drink intake with your bronchitis. Your kidney function improved back to your baseline state prior to discharge. As we felt that your bronchitis was most likely caused by a virus, we stopped the antibiotic, levofloxacin (Levaquin). Your body should clear the virus on its own, without medication. If you have any further questions regarding your time here, please do not hesitate to call ___ ___ ___ front desk). We wish you the best with your health going forward. Your ___ Care Team Followup Instructions: ___
10077769-DS-9	10,077,769	21,673,397	DS	9	2150-02-28 00:00:00	2150-03-05 16:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___ Chief Complaint: Lower back pain, difficulty walking Major Surgical or Invasive Procedure: Interventional radiology performed a CT- guided percutaneous bone biopsy on ___. History of Present Illness: ___ yo male h/o IVDU (on suboxone, last heroin in ___ and Hepatitis C with worsening low back pain since ___ weeks ago, couch fell on him when he helped someone move. Initially fine, able to move around without sig pain. A few days later, he had pain, couldn't walk. Presented to ___ and was admitted from ___ where he was treated with toradol, dilaudid, presentation thought to be ___ herniated disc. Lumbar x-ray were negative for fracture. He was evaluated by ___ and cleared for home. After discharge, his pain worsened, resulting in multiple doctors ___. He woke up the morning of presentation unable to walk, so he was taken to ___ ED by ambulance. His MRI without contrast from the OSH revealed discitis/osteomyelitis at L5/S1 with a small mass (abscess vs hematoma) abutting the L5/S1 nerve roots, however this was done without contrast. He was transferred to ___ for further care due to possible need for Neurosurgical or Spine evaluation. In the ED, initial vitals: ___ / 126/___ / ___% RA - Exam notable for: not recorded - Labs notable for: mild ALT elevation to 43, Alb: 3.3 - Imaging notable for: none - Patient given: 4mg IV morphine x2, 4.5mg IV PipTaz, 1.5g IV vanc, - Vitals prior to transfer: ___% RA On arrival to the floor, pt reports excruciating lower back pain at rest with radiation down both legs, worse on R. The right radiating leg pain continues down to foot; left sided radiates only partially down leg. He reports worsening numbness in his R foot. He denies any fevers, abdominal pain, or bladder/bowel incontinence. Last BM several days ago. He does admit to having a history of IV drug use, but none since ___. He was on suboxone but stopped it last week since his pain was so severe (and he wanted to have pain medicine). Past Medical History: IVDU: - previously 2g heroin/day, last IVDU in ___ - sniffed fentanyl a few weeks ago Hepatitis C Opioid dependence GERD Lumbar disc herniation at L5-S1 (___): - previously treated with cortisone injections, prednisone Social History: ___ Family History: father - emphysema Physical ___: ======================== ADMISSION PHYSICAL EXAM: ======================== VITALS - 97.3 PO / 88 / 177/94 Lying / ___ RA GENERAL - Occasionally writhing in pain, otherwise very still HEENT - NC/AT, No ___ spots CARDIAC - tachycardic, regular rhythm, no murmurs PULMONARY - Clear anteriorly, did not auscultate posteriorly due to pain ABDOMEN - soft, ND, patient withdrawing to palpation, reporting back pain EXTREMITIES - WWP, no splinter hemorrhages, janeways lesions, or oslers nodes SKIN - No lesions on face, arms, or lower legs NEUROLOGIC - ___ L dorsi/plantar flexion, ___ R dorsi/plantar flexion, 4+/5 b/l toe dorsi/plantar flexion, able to lift L leg off bed, able to move R leg, 1+ patellar reflexes, sensation decreased on R foot along lateral and medial aspects as well as in the first interdorsal space ======================== DISCHARGE PHYSICAL EXAM: ======================== Vitals: 97.4-98.___-100%RA Exam: GENERAL - Lying in bed, very still HEENT - NC/AT CARDIAC - RRR, no murmurs PULMONARY - Clear anteriorly, did not auscultate posteriorly due to pain ABDOMEN - soft, NDNT EXTREMITIES - WWP SKIN - No lesions on face, arms, or lower legs NEUROLOGIC - ___ L dorsi/plantar flexion b/l Pertinent Results: ================== ADMISSION LABS ================== ___ 02:30AM BLOOD WBC-8.8 RBC-4.19* Hgb-12.1* Hct-38.9* MCV-93 MCH-28.9 MCHC-31.1* RDW-13.2 RDWSD-44.8 Plt ___ ___ 02:30AM BLOOD Neuts-65.7 Lymphs-18.2* Monos-14.4* Eos-0.9* Baso-0.2 Im ___ AbsNeut-5.76 AbsLymp-1.60 AbsMono-1.26* AbsEos-0.08 AbsBaso-0.02 ___ 02:30AM BLOOD Ret Aut-1.1 Abs Ret-0.05 ___ 02:30AM BLOOD Glucose-110* UreaN-18 Creat-1.0 Na-138 K-4.3 Cl-103 HCO3-27 AnGap-12 ___ 02:30AM BLOOD ALT-43* AST-17 AlkPhos-71 TotBili-<0.2 ___ 02:30AM BLOOD Lipase-28 ___ 02:30AM BLOOD cTropnT-<0.01 ___ 02:30AM BLOOD Albumin-3.3* Iron-39* ___ 02:30AM BLOOD calTIBC-268 Ferritn-213 TRF-206 ___ 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 02:53AM BLOOD Lactate-1.2 ================== IMAGING ================== Final Report EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE ___ INDICATION: History of IV drug use with traumatic back pain with right leg numbness and tingling with outside hospital MR concerning for epidural abscess or hematoma. COMPARISON: Outside hospital lumbar spine MR ___. IMPRESSION: 1. L5-S1 discitis osteomyelitis. 2. 5.1 x 1.3 cm anterior epidural abscess spanning the L5 and S1 vertebral bodies, extending through the left S1-S2 neural foramen with partially imaged presacral abscess/phlegmon measuring at least 3.0 x 0.8 cm. 3. Mild spondylosis at the L4-L5 level. 4. No evidence of fracture. ================== MICROBIOLOGY ================== GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: Reported to and read back by ___ (___) AT 12:15 ___ ___. ___ Susceptibility testing requested by ___ ___ ___ . ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. 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. SENSITIVE TO ___. ___ sensitivity testing performed by ___. ENTEROBACTER CLOACAE COMPLEX. RARE GROWTH. SECOND 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 after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVE TO ___. ___ sensitivity testing performed by ___. 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 PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ====================== OTHER INTERVAL LABS ====================== ___ 07:56AM BLOOD CRP-6.3* ___ 07:25AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* ___ 06:42AM BLOOD HIV Ab-Negative ___ 02:30AM BLOOD calTIBC-268 Ferritn-213 TRF-206 ================== DISCHARGE LABS ================== ___ 09:50AM BLOOD WBC-10.2* RBC-4.76 Hgb-14.2 Hct-42.5 MCV-89 MCH-29.8 MCHC-33.4 RDW-13.6 RDWSD-44.2 Plt ___ ___ 09:50AM BLOOD Glucose-103* UreaN-19 Creat-0.9 Na-139 K-4.8 Cl-102 HCO3-25 AnGap-17 ___ 09:50AM BLOOD ALT-90* AST-52* AlkPhos-80 TotBili-0.4 ___ 09:50AM BLOOD Calcium-10.3 Phos-3.6 Mg-2.2 ___ 07:56AM BLOOD SED RATE- 45 Brief Hospital Course: This is a ___ year old man with a history of polysubstance abuse (last reported IVDU ___ who presents with several weeks of traumatic back pain, found to have an epidural abscess and vertebral discitis, now being medically managed with IV ___ be discharged with plan for daily infusions at ___. #Epidural abscess/discitis: Patient presented originally to ___ with severe low back pain with radiation down both legs, worse on the right, for several weeks in duration. No evidence of cauda equina. MRI was performed there which was suspicious for epidural abscess (although performed without contrast), and thus he was transferred to ___ for further care. At ___, MRI with contrast was concerning for large L5/S1 epidural abscess (5.1 x 1.3 cm anterior epidural abscess spanning the L5 and S1 vertebral bodies, extending through the left S1-S2 neural foramen with partially imaged presacral abscess/phlegmon measuring at least 3.0 x 0.8 cm). Neurosurgery was consulted and recommended nonoperative management. Interventional radiology conducted a CT-guided bone biopsy, which grew Enterobacter cloacae when cultured. At the recommendation of Infectious Disease, he was initially treated with IV ceftriaxone before being switched to ___ on the day of discharge after sensitivities were confirmed. He remained afebrile with only a mild leukocytosis throughout the hospitalization. His inflammatory markers were only mildly elevated (ESR 45, CRP 6.3). His urine cultures and blood cultures had no growth on date of discharge. Patient refused placement at a supervised facility where he could receive IV antibiotics through a ___, and he was not otherwise eligible for a ___ or ___ services. Follow up was organized with the ___ where he will receive daily infusions of ___ through a PIV under the supervision of Dr. ___ in conjunction with his primary care nurse ___. This infection is most likely secondary to IV suboxone injection as below. # History of IVDU: Patient reports previous use of 2g/day of heroin, last injected in ___. He reports no additional heroin use since then. Earlier this year, he started taking prescribed suboxone per recommendation of his probation officer. He later disclosed that he had recently begun to solubilize and inject the suboxone. He said that he never received a "high" from it, but that he felt it was more convenient than waiting for "the terrible tasting pill to take 15 minutes to dissolve under my tongue." He also later admitted to "sniffing fentanyl" he obtained without a prescription to treat his significant pain. He believes that all of these actions are still in alignment with his recovery process. On admission to the hospital, his urine toxicology screen was positive for opioids and oxycodone, but his urine and serum toxicology screens were otherwise negative. He was disqualified from his suboxone program for misusing it, but he was provided with information about methadone programs. # Pain control: We attempted to balance worsening his addiction/dependence while adequately addressing his pain. He was placed on standing Tylenol, naproxen, cyclobenzaprine, and IV dilaudid that we quickly transitioned to PO dilaudid. Subjectively, he reported poor pain control with relief only within the first 30 minutes after receiving medications. However, objectively, he appeared somewhat relaxed and was able to converse with visitors. We added a lidocaine patch, which did not make a significant difference to his reported pain level. He was very frustrated with the team, but he was redirectable and acknowledged that the team's rationale was valid even though he remained frustrated. # Anemia, normocytic, hypochromic: Patient presented with a Hgb 12.1 on admission, no baseline available. No obvious source of bleeding. Anemia studies notable for retic of 1.1%, low iron, other iron studies wnl. Most likely related to inflammation vs phlebotomy. CHRONIC ISSUES: # Hepatitis C: No history of treatment. ALT slightly elevated here and albumin 3.3. We trended his LFTs daily given standing acetaminophen, but there were no major changes. #GERD: We continued his home omeprazole. TRANSITIONAL ISSUES [] Continue with ___ 1 gram IV q24hrs for 6 weeks. ___ consider transitioning to oral levaquin 750mg PO QD if daily PIV therapy is not possible, although this is not ideal. [] Patient needs weekly CBC with diff, BUN/Cr, AST/ALT, and ESR/CRP. [] Monitor closely for symptoms of urinary incontinence/saddle anesthesia; it remains unclear whether antibiotic therapy alone will be adequate given the size and extent of his abscess. Should symptoms worsen or if there is no improvement, he should receive an MR of his spine with contrast to assess the current abscess and discitis/osteomyelitis; we have felt that surgical decompression would have been of value but this was deferred on this admission. [] Should the patient feel like he can come to ___, or the PCP request that he be seen by ___ ID, the clinic number is ___. [] Patient expressed some interest in methadone treatment as an outpatient. We have provided him with options but this must be established as outpatient. ___ Opioid Treatment Program ___ Men's Addiction Treatment Center ___ Habit Opco at ___ ___ ___ Champion Program (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 2. Cyclobenzaprine 10 mg PO BID:PRN back pain 3. Omeprazole 20 mg PO DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Please do not take more than 3 pills in a 24 hour period. RX acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours Disp #30 Tablet Refills:0 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe Please do not take more than the prescribed dose. Make sure you have regular bowel movements. RX hydromorphone 4 mg 1 tablet(s) by mouth every four to six hours Disp #30 Tablet Refills:0 3. Naproxen 500 mg PO Q12H Please do not take more than 2 pills/day due to risk of bleeding. RX naproxen 500 mg 1 tablet(s) by mouth every twelve hours Disp #30 Tablet Refills:0 4. Cyclobenzaprine 15 mg PO TID:PRN back spasm RX cyclobenzaprine 7.5 mg 2 tablet(s) by mouth every eight hours Disp #42 Tablet Refills:0 5. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Lumbar epidural abscess Secondary Diagnosis: Anemia Chronic Hepatitis C History of opioid use disorder 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 transferred from ___ for further management of your epidural abscess that was causing you considerable pain. We started you on broad spectrum intravenous antibiotics, and you were given pain medications to help decreased your pain, although your pain level was difficult to decrease. We foresee that your pain will improve once the infection improves. We consulted the neurosurgery team, who recommended nonoperative management. We consulted interventional radiology to biopsy the area so we could choose an effective antibiotic for long term treatment. You were seen by the Infectious Disease specialists as well who recommended 6 weeks of antibiotics. Because you were opposed to IV antibiotic treatment in a supervised setting, we organized daily appointments at the ___ where you can receive a daily antibiotic. It is CRITICAL that you complete the full course of treatment, not only because worsening infection could cause increased pain, but also could spread and become a life-threatening illness and cause permanent neurological damage. During your hospitalization, you vocalized a strong commitment to your continued recovery. We want to support and encourage you to seek out additional resources, including possible treatment in a ___ clinic, which will help reinforce your efforts. We have provided you with one week of dilaudid to help you reach your next appointment, but following up with the providers listed below is very important. We have also provided you with a prescription for narcan for your safety. As you may know, these medications can be constipating, so please be sure to monitor your bowel movements as you may need increasing amount of fiber or stool softeners. Finally, you should NOT drive or operative machinery while you are on these pain medications as they can impair your balance, perception and judgment. Thank you for letting us be a part of your care team, The ___ 7 Floor Team Followup Instructions: ___
10078309-DS-17	10,078,309	27,617,852	DS	17	2174-04-13 00:00:00	2174-04-13 15:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with PMH of chiari malformation and left retro-orbital aneurysm presenting with 5 days of abdominal pain. Constant sharp epigastric and RUQ pain, he denies changes in pain with food but has had decreased PO intake. He has had nausea and non-bloody vomiting once or twice a day. Denies diarrhea, constipation or blood in stool. Took aleve and tums with mild relief of pain. Denies ever having pain like this before, denies any alcohol use in ___ years. Scheduled a visit with his PCP but missed the appointment and came to the ED. In ED lipase was elevated at 166 and all other blood work was unremarkable. Given IV fluids, morphine and zofran. He said pain improved from ___ to ___, feels hungry now and wants to eat. Ten point ROS reviewed and otherwise negative. Past Medical History: chiari malformation left retro-orbital aneurysm Neurofibroma excised from left hand Social History: ___ Family History: Parents with HTN and DM. Denies family history of pancreatic or biliary disease. Physical Exam: Admission PE: VS: T 97.6 HR 78 BP 116/67 RR 18 97% RA GEN: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, anicteric sclera CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: soft, mild epigastric tenderness, ND, +BS, no hepatosplenomegaly Ext: no c/e/e Neuro: CN II-XII intact, ___ strength throughout Skin: warm, dry no rashes Discharge exam: Gen: NAD, resting comfortably HEENT: NCAT, oropharynx clear, MMM CV: RRR, no mrg Resp: CTA ___, no wheezes, rhonchi Abd: soft, nt, nd no organomegaly, neg murphys Ext: no CCE Neuro: no focal deficits Skin: clean, dry, no rash Pertinent Results: ___ 09:00PM GLUCOSE-117* UREA N-17 CREAT-1.2 SODIUM-139 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 ___ 09:00PM ALT(SGPT)-12 AST(SGOT)-19 ALK PHOS-49 TOT BILI-0.2 ___ 09:00PM LIPASE-166* ___ 09:00PM WBC-7.8 RBC-4.40* HGB-12.9* HCT-38.6* MCV-88 MCH-29.3 MCHC-33.4 RDW-13.8 RDWSD-44.1 Discharge: ___ 05:55AM BLOOD WBC-8.0 RBC-4.29* Hgb-12.5* Hct-38.0* MCV-89 MCH-29.1 MCHC-32.9 RDW-13.8 RDWSD-44.7 Plt ___ ___ 05:55AM BLOOD Glucose-120* UreaN-15 Creat-1.1 Na-141 K-4.0 Cl-108 HCO3-26 AnGap-11 ___ 05:55AM BLOOD ALT-9 AST-17 AlkPhos-44 TotBili-0.1 ___ 05:55AM BLOOD Triglyc-142 HDL-43 CHOL/HD-3.8 LDLcalc-92 ___ 05:55AM BLOOD Cholest-163 IMAGING: RUQ U/S: PRELIMINARY: IMPRESSION: Normal abdominal ultrasound. Specifically, normal gallbladder and biliary tree. Brief Hospital Course: ___ year old male with PMH of chiari malformation and left retro-orbital aneurysm presenting with 5 days of abdominal pain. #GI: Abdominal pain, seems unlikely to be pancreatitis, however if it is pancreatitis it is quite mild. Based on exam, would favor gastritis as a cause as patient reports some burning sensation as well. Patient was able to tolerate PO and ate lunch without incident. NO red flag symptoms. Patient was started on omeprazole empirically with plan to take for 4 weeks, maalox prn, tylenol prn and f/u with PCP. Denies any alcohol use. #Tobacco use: nicotine patch while inpatient #FEN/PPX: low fat diet, ambulatory Full code [x]>30 minutes was spent in coordination of care and counseling on day of discharge ___, MD ___ Medications on Admission: Patient is on no preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain RX acetaminophen 325 mg 2 tablet(s) by mouth q6 Disp #90 Tablet Refills:0 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN upset stomach RX alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20 mg/5 mL ___ ml by mouth four times a day Refills:0 3. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Gastritis 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 evaluation of abdominal pain. While you were here, you were able to tolerate food. You had an ultrasound of your liver and gallbladder which showed no abnormalities. You had a very mild elevation of your lipase, which may be consistent with pancreas inflammation, however it seems more likely that you had inflammation of the stomach. Because of this, you were started on a medication called omeprazole, which you should take daily for the next 4 weeks. Additionally, you were given a prescription for maalox which you can take 4 times a day as needed for upset stomach. Please follow up with your PCP to discuss your abdominal pain. Followup Instructions: ___
10078480-DS-14	10,078,480	25,516,910	DS	14	2171-11-13 00:00:00	2171-11-13 13:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: opiates / clindamycin / Sulfa(Sulfonamide Antibiotics) / procaine penicillin / shellfish derived Attending: ___. Chief Complaint: ___ HMED Admission Note . CC: altered mental status . PCP: Dr ___ (___) Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with history of depression who presents with altered mental status. Pt is typically independent and lives alone. She has a history of depression and was seen by her psychiatrist on ___ where her sertraline was doubled to 100mg daily. Over the past two weeks, per her son she has been increasingly altered. About ___ days ago her speech became rambling with emotional lability. Yesterday, she was noted to have incoherent speech and was unable to move. Her son does note some rigidity as well. She was also noted to have some visual hallucinations. She was brought to the ER for evaluation. In the ER, she was initially agitated but responded to olanzapine. She had normal vital signs and largely normal labs and tox screen. Infectious workup of urine and CXR was negative. Head CT was unchanged from prior MRI. She was seen by Psychiatry who recommended medical admission and decrease in her sertraline to 50 mg. . Per her son, she was previously managing all her medications. She has not had any med changes aside from increase in sertraline. She does take Ativan and per his report she does tend to over use it at times, but it generally has a sedating effect on her when she uses it. . ROS: unable to obtain Past Medical History: Hypertension Depression GERD osteoarthritis s/p L knee replacement osteoporosis Social History: ___ Family History: mother with CAD, father died of old age Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 120/70 65 18 96%RA Gen: NAD, lying in bed HEENT: NCAT, no nuchal rigidity CV: rrr, no r/m/g Pulm: clear Abd: soft, nontender, nondistended Ext: warm, no edema Neuro: alert, attempting to communicate with gestures and occasional words; moves all extremities spontaneously; no rigidity; strength is ___ in all extremities; CN ___ is intact Psych: at times it appears she is responding to internal stimuli, not agitated . DISCHARGE PHYSICAL EXAM: VS: Tm AF, Tc 97.7, BP 139/73, HR 97, RR 18, sat 97% on RA Pain: zero out of 10 Gen: Elderly woman lying in bed, eating breakfast HEENT: anicteric, dry MM CV: RRR, ___ systolic murmur Lungs: CTAB from anterior lung fields Abd: soft, NT, ND, NABS Ext: WWP, no edema Neuro: fluent speech Mood: calm, but flight of thoughts Pertinent Results: ADMISSION LABS: ==================== ___ 06:20PM BLOOD WBC-12.1* RBC-4.96 Hgb-14.7 Hct-43.4 MCV-88 MCH-29.6 MCHC-33.8 RDW-13.8 Plt ___ ___ 06:20PM BLOOD Neuts-65.9 ___ Monos-4.4 Eos-1.1 Baso-0.6 ___ 06:20PM BLOOD Glucose-103* UreaN-16 Creat-0.8 Na-140 K-3.2* Cl-100 HCO3-29 AnGap-14 ___ 06:20PM BLOOD ALT-6 AST-16 AlkPhos-73 TotBili-0.4 ___ 06:20PM BLOOD Albumin-4.4 ___ 06:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:20PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . PERTINENT LABS: =================== ___ 01:06AM BLOOD Lactate-1.4 ___ 11:20AM BLOOD Cortsol-8.8 ___ 05:35PM BLOOD TSH-3.3 ___ 05:35PM BLOOD VitB12-1637* Folate-10.4 ___ 06:49AM BLOOD ALT-20 AST-49* AlkPhos-71 TotBili-0.7 ___ 06:25AM BLOOD ALT-24 AST-49* AlkPhos-70 TotBili-0.6 ___ 06:30AM BLOOD ALT-20 AST-64* AlkPhos-68 TotBili-0.6 ___ 06:50AM BLOOD ALT-18 AST-30 ___ 11:20AM BLOOD Glucose-163* UreaN-24* Creat-1.0 Na-135 K-4.0 Cl-101 HCO3-22 AnGap-16 ___ 06:49AM BLOOD Glucose-111* UreaN-29* Creat-1.3* Na-144 K-4.0 Cl-105 HCO3-28 AnGap-15 ___ 06:30AM BLOOD UreaN-23* Creat-1.0 ___ 06:49AM BLOOD WBC-9.2 RBC-4.82 Hgb-14.2 Hct-41.7 MCV-86 MCH-29.3 MCHC-34.0 RDW-13.5 Plt ___ ___ RPR: Non-reactive . IMAGING: ================== ___ PCXR IMPRESSION: No acute cardiopulmonary process. Leftward deviation of the trachea at the thoracic inlet as on prior suggestive right thyroid enlargement which can be further assessed by dedicated thyroid ultrasound. . ___ CT HEAD IMPRESSION: 1. No acute intracranial hemorrhage or evidence of large territorial infarction. 2. Moderate, global cerebral atrophy. Findings are similar as compared to the patient's prior MRI dated ___. 3. 8 mm linear radiopaque foreign body identified within the left maxillary sinus. . ___ EEG IMPRESSION: This is an abnormal awake and drowsy EEG because of nearly continuous focal slowing and poorly sustained and slow posterior dominant rhythm in the right posterior quadrant indicative of mild to moderate focal cerebral dysfunction in this region possibly structural in origin. There is mild diffuse slowing of the background indicative of mild diffuse cerebral dysfunction which is non-specific as to etiology. There are no epileptiform discharges or electrographic seizures. . Brief Hospital Course: ___ year old woman with depression who presents with altered mental status. Her presentation is subacute but gradually worsening in the past 2 weeks. Her altered mental state is likely related to her SSRI (sertraline) use . # Delirium, in the setting of depression, memory loss, likely progressive dementia - ___ work-up for delirium was unremarkable, as there was no evidence of infection. TSH, B12, folate all WNL. RPR was non-reactive. Head CT was stable vs recent MRI. She was seen by Neurology and underwent EEG evaluation which did not show seizure. She was seen by Psychiatry, and they suspected sertraline, with recent dose increase, as the likely culprit. Sertraline was DC'ed on ___, with subsequent improvement in her mental status, albeit slowly and without full return to her baseline. We suspect that given the long half life of sertraline (up to 104 hours) and her older age, she likely still has a few days for the sertraline to be cleared completely from her system. Psychiatry did recommend starting Seroquel, which also seemed to be correlated with improvement in her mental status. She was increased to 25mg BID, but developed mild transaminitis, so the Seroquel has been reduced back to 25mg QHS. Psychiatry had recommended ___ placement, however the family was resistant to this and preferred admisson to SNF. Of note, the patient likely has some underlying dementia, as her recent outpatient MRI did show evidence of chronic small vessel disease. The fmaily is aware that the patient is unlikely to return to her previous living situation (assisted living) and if her mental status improves, would like to have her travel with assistance back to ___, where she can live with her daughter and ___ supervision. Overall, despite her delirium, she was never significantly agitated and did not require IV/IM sedatives or antipsychotics. Most often, she was easily redirectable. . # Acute Kidney Injury - Pt noted to have decreased urine output as well as increased Cr, in setting of decreased PO intake. She received IVF with normalization of her Cr. With encouraged PO intake, her Cr and UOP remained stable. . # Transaminitis - developed mild transaminitis (AST 64), suspect from Seroquel side effect, as 1 - 6 % of patients on Seroquel develop transaminitis. After decreasing Seroquel from 25mg BID to 25mg QHS, transminitis resolved. She was asymptomatic, without any GI symptoms. . # Hypertension / #hyperlipidema - stable BP's, continue home meds: amlodipine, ASA, atorvastatin, atenolol . # GERD - continued home omeprazole. No GI symptoms. . ### Contact info: Son Dr. ___ ___. . TRANSITIONAL ISSUES: 1. D/C to SNF 2. consider dedicated thyroid ultrasound to f/u leftward deviated trachea persistently seen on CXR, including admission CXR from ___, with concern for right thyroid enlargement. Did not check acutely, as her TSH on this admission was normal. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Atorvastatin 5 mg PO DAILY 4. Lorazepam 1 mg PO DAILY:PRN anxiety 5. Omeprazole 20 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Cetirizine 10 mg PO TID Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Atorvastatin 5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. QUEtiapine Fumarate 25 mg PO QHS Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Medication induced delirium Possible underlying dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with acute confusion. You underwent thorough work-up for medical causes of your confusion, but the work-up was largely unremarkable. You were evaluated by the Neurologists and the Psychiatrists. We suspect the most likely cause of your confusion is due to side effect from your home medication Sertaline (Zoloft), with some possible underlying dementia. . Please take your medications as listed. . Please see your physicians as listed. Followup Instructions: ___
10078805-DS-20	10,078,805	25,487,374	DS	20	2173-03-01 00:00:00	2173-03-01 14:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ampicillin / indomethacin / lisinopril Attending: ___. Chief Complaint: Lower extremity swelling and erythema Major Surgical or Invasive Procedure: none History of Present Illness: ___ with Hx prostate cancer s/p resection (___), HTN, chronic ___ edema p/w ___ swelling and erythema concerning for cellulitis. He was accidentally pushed into a sharp stair about a month ago, causing a LLE laceration. This was repaired with several sutures on ___ and he was given a treatment course of Augmentin x 10 days. He completed this course ___. He did well for the following weeks, but about two days ago was noted to have worsening swelling and erythema by his acupuncturist. He was sent to urgent care, who referred him to the ED. . He denies any new injury to the leg, fevers, chills, and pain. He had not noticed any increasing swelling or redness until it was pointed out to him. At this time he denies weakness, numbness, tingling, or pain in the distal foot. Past Medical History: DM (diabetes mellitus), type 2 with renal complications Chronic renal disease, stage III (baseline Cr 1.3-1.5) Shingles (Dx ___ Proteinuria Onychomycosis Anemia (baseline Hct mid-30s) VITAMIN D DEFIC, UNSPEC OBESITY UNSPEC HYPERCHOLESTEROLEMIA GOUT, UNSPEC URINARY INCONTINENCE - MIXED CANCER - PROSTATE , s/p Brachy ___ HYPERTENSION - ESSENTIAL ANXIETY STATES, UNSPEC POSITIVE PPD (___) Social History: ___ Family History: Non-contributory Physical Exam: PHYSICAL EXAM: VS - Temp 97.7F, BP 124/76, HR 70, R 20, O2-sat 95% RA GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear LUNGS - CTAB, no r/rh/wh HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft, distended, tympanitic, no rebound/guarding EXTREMITIES - WWP, 2+ bilateral ___ edema Left ___ with erythema from the ankle to just below the knee. Area of skin breakdown in anterior mid-leg without purulence or bleeding. No erythema below ankle or above knee. Erythema receeded from marked line. Chronic edema of b/l lower legs SKIN - skin breakdown on the left shin, healed zoster rash in dermatomal distribution on left flank NEURO - awake, A&Ox3, moving all extremities Pertinent Results: Admission Labs: ___ 07:50PM BLOOD WBC-7.7 RBC-4.13* Hgb-12.5* Hct-37.2* MCV-90 MCH-30.2 MCHC-33.5 RDW-15.0 Plt ___ ___ 07:50PM BLOOD Neuts-68.5 ___ Monos-5.1 Eos-3.3 Baso-0.7 ___ 07:50PM BLOOD Glucose-85 UreaN-34* Creat-1.4* Na-142 K-3.7 Cl-103 HCO3-31 AnGap-12 ___ 07:50PM BLOOD proBNP-75 ___ 08:49PM BLOOD Lactate-1.1 . Interim Labs: ___ 07:18AM BLOOD WBC-9.9 RBC-3.96* Hgb-11.8* Hct-35.4* MCV-89 MCH-29.8 MCHC-33.3 RDW-15.0 Plt ___ ___ 07:30AM BLOOD WBC-7.0 RBC-3.92* Hgb-12.1* Hct-35.6* MCV-91 MCH-30.8 MCHC-33.9 RDW-15.1 Plt ___ ___ 07:25AM BLOOD WBC-5.7 RBC-3.87* Hgb-11.5* Hct-35.5* MCV-92 MCH-29.8 MCHC-32.6 RDW-15.1 Plt ___ ___ 06:45AM BLOOD WBC-6.6 RBC-3.86* Hgb-11.6* Hct-35.1* MCV-91 MCH-29.9 MCHC-32.9 RDW-14.8 Plt ___ ___ 07:18AM BLOOD Glucose-113* UreaN-33* Creat-1.5* Na-144 K-4.0 Cl-105 HCO3-30 AnGap-13 ___ 07:30AM BLOOD Glucose-98 UreaN-32* Creat-1.6* Na-140 K-4.1 Cl-103 HCO3-26 AnGap-15 ___ 07:25AM BLOOD Glucose-98 UreaN-33* Creat-1.6* Na-142 K-4.0 Cl-107 HCO3-26 AnGap-13 ___ 06:45AM BLOOD Glucose-107* UreaN-32* Creat-1.5* Na-140 K-3.7 Cl-105 HCO3-27 AnGap-12 ___ 07:18AM BLOOD proBNP-200 ___ 07:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4 ___ 07:25AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3 ___ 06:45AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2 . Discharge Labs: . Microbiology: Blood culture (___): NGTD . Imaging: ___ ultrasound ___ IMPRESSION: No DVT of the left lower extremity. . CXR (___): Lung volumes are low, but clear. Heart size normal. No pleural abnormality. Extensive degenerative change in the thoracic spine is consistent with loss of height, kyphosis, osteophyte formation and disc space narrowing. Brief Hospital Course: ___ with Hx prostate cancer s/p resection (___), HTN, chronic ___ edema p/w ___ swelling and erythema concerning for cellulitis. . # Cellulitis: Injury a month ago, previously treated with Augmentin, now with late exacerbation. The patient did not know of a recent injury, but it was not clear why the infection would recur (or be reinfected) after several weeks. In either case, the treatment with Augmentin is sufficiently distant that this was not considered a refractory infection. The area of infection was well demarcated and there was no lymphangitic spread. The distal foot was unaffected and there was no neurological compromise or sign of compartment syndrome. Due to the patient's diabetes, he was at risk for a broad spectrum of infections. However, this infection did not extend to the foot and appears to have originated at the original injury site. He was initially treated with IV vancomycin and ceftriaxone. The infection rapidly receded from the marked lines, and he transitioned to oral cefalexin for discharge. He had no fever during his admission. . # Chronic ___ edema: Secondary to lymphedema from prostate surgery. Review of outside records revealed no history of heart failure and a normal echo less than a year ago. BNP was not elevated. His home Lasix was continued to reduce pedal edema. . # Zoster: Recent Zoster flare this fall, now skin lesions are healing but patient has continued neuropathic pain. Continued home gabapentin, added capsaicin cream for topical relief. . Inactive issues: # Rash: fungal rash, continued miconazole cream # T2DM: Most recent HbA1c 6.4%. used ISS while an inpatient, continued glimepiride on discharge # Gout: continued home allopurinol # HTN: SBP 120-130s. continued home Diovan, Lasix as above, fish oil, statin, ASA # Health maintenance: continued MVI, Vit D . . # CODE: Full # CONTACT: ___, HCP Phone number: ___ . Transitional Issues: - Follow-up with primary care clinic to ensure resolution of infection Medications on Admission: Furosemide 40 mg Oral Tablet TAKE 1 TABLET by mouth TWICE DAILY Gabapentin 300 mg Oral Capsule take 3 capsules THREE TIMES DAILY Glimepiride 1 mg Oral Tablet Take 1 tablet daily with breakfast Allopurinol ___ mg Oral Tablet take 1 and ___ tablets DAILY Ketoconazole 2 % Topical Cream Apply to affected area twice daily DIOVAN 80 MG TAB (VALSARTAN) Take 1 tablet daily FISH OIL 1,000 MG CAP (OMEGA-3 FATTY ACIDS/VITAMIN E) Take ___ capsules daily SIMVASTATIN 10 MG TAB take 1 tablet EVERY EVENING for cholesterol VITAMIN C ORAL (ASCORBIC ACID) 1 daily MULTIVITAMINS ORAL 1 daily ASPIRIN 81 MG TAB 2 daily VITAMIN D 1,000 UNIT TAB (CHOLECALCIFEROL) 1 tablet daily NYSTATIN 100,000 UNIT/G TOPICAL POWDER apply to affected area QD Discharge Medications: 1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 9 days. Disp:36 Capsule(s) Refills:0 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours): until resolution of Zoster. 4. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day: with breakfast. 5. allopurinol ___ mg Tablet Sig: 1.5 Tablets PO once a day. 6. ketoconazole 2 % Cream Sig: One (1) thin film Topical twice a day. 7. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fish Oil 1,000 mg Capsule Sig: ___ Capsules PO once a day. 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 14. nystatin 100,000 unit/g Powder Sig: One (1) application Topical once a day. 15. capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day): Zoster rash. Disp:qs qs Refills:2 Discharge Disposition: Home Discharge Diagnosis: cellulitis 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: It was a pleasure caring for you at ___ ___. You came to the hospital with an infection on the skin of your left leg. You injured your leg several weeks ago and had been treated as an outpatient with improvement. However, it recently worsened and you were advised to seek inpatient treatment. We treated the infection with IV antibiotics with rapid improvement. You were transitioned to oral antibiotics for a total 14 day course. We did not find any signs of a deeper infection. We made the following changes to your medications: - START cefalexin. This is an antibiotic to treat your infection with a total 14 day course. You received 5 days of antibiotics in the hospital, so you will finish this drug on ___. - START capsaicin cream for your Zoster rash pain You should try to keep your left leg elevated as possible while you are home. This will reduce your chronic ankle swelling and will help the infection to continue to heal. Please follow-up at your health clinic to ensure the infection clears (see appointment below). Followup Instructions: ___
10079290-DS-14	10,079,290	25,728,335	DS	14	2143-04-01 00:00:00	2143-04-01 15:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left-sided sensory changes Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ RHM y/o with a history of IDDM, HL and HTN, who presented with several days of left hemibody paresthesias, and was found to have a right thalamic stroke on an outside MRI. He reports that he had an initial sensation of sudden onset headache, chest pain and left hemibody tingling last ___. As the chest pain had persisted on ___, he went to ___ ED, where his workup inlcuded a stress test and regular EKG which reportedly were unremarkable. The tingling sensation returned on ___, and has persisted since. No weakness. He saw his PCP yesterday, who ordered an MRI, which showed a small right thalamic lacunar stroke. His PCP subsequently started him on ASA 325mg today, and sent him to ___. His risk factors include type II diabetes, hypertension and hyperlipidemia. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies 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: - Type II diabetes w diabetic nephropathy - HLD - HTN Social History: ___ Family History: Father had heart attack at ___ yrs, GF had stroke in his ___, no clotting disorder Physical Exam: Physical Exam: General: Awake, cooperative, NAD. Obese. HEENT: NC/AT, MMM. Neck: Supple, FROM Pulmonary: Breathing comfortably Abdomen: Soft, NT/ND. Extremities: No edema or deformities Skin: No rashes or lesions noted Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact comprehension. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation with hyperesthesia on L. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No tremor, asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___- ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: Hyperesthesia and paresthesias of L hemibody. -DTRs: Bi Tri ___ Pat Ach L 1 tr 1 tr tr R 1 tr 1 tr tr Plantar response was flexor bilaterally. No clonus. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: deferred Pertinent Results: ___ 07:30PM GLUCOSE-176* UREA N-8 CREAT-0.7 SODIUM-143 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14 ___ 07:30PM WBC-5.3 RBC-5.11 HGB-13.9* HCT-42.1 MCV-83 MCH-27.3 MCHC-33.1 RDW-12.5 ___ 07:30PM NEUTS-52.0 ___ MONOS-4.6 EOS-1.9 BASOS-0.7 ___ 07:30PM PLT COUNT-277 ___ 07:30PM ___ PTT-28.9 ___ Brief Hospital Course: Mr ___ was admitted to the Stroke Service at ___ ___ after presenting with paresthesias on the left side of his body. He was found to have a small ischemic infarct in his right thalamus on an MRI done by his PCP. This was confirmed on a head CT done as an inpatient and was felt to be due to microvascular damage from his diabetes, hypertension, and hyperlipidemia. He will have an echocardiogram as an outpatient. His blood pressure medications were initially modified to allow for permissive hypertension. He resumed his home regimen on discharge. He was started on full dose aspirin. His A1c was noted to be high and should be followed up by his PCP or ___. Medications on Admission: - insulin - lisinopril 20 TID - HCTZ ___ - amlodipine 5mg qd - metformin 100mg BID - metoprolol 25mg BID - atorvastatin 80mg qd Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Glargine 80 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Metoprolol Tartrate 25 mg PO BID 7. Lisinopril 20 mg PO TID To be take in the morning and afternoon 8. Hydrochlorothiazide 12.5 mg PO BID 9. Hydrochlorothiazide 25 mg PO DAILY To be taken in the evening Discharge Disposition: Home Discharge Diagnosis: Right thalamic infarct Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted to the Stroke Service at ___ ___ after presenting with altered sensation on the left side of your body. You were found to have a small stroke on the right side of your brain in an area that controls sensation on an MRI done by your Primary Care Provider. This was confirmed on a CT scan done while you were inpatient. This was likely due to damage to the small blood vessels in your brain from your diabetes, high blood pressure, and high cholesterol. You will have an echocardiogram as an outpatient to look for a clot or hole in your heart. You were started on full dose aspirin. You will follow-up with Dr ___ as an outpatient. Your hemoglobin A1c was noted to be high, suggesting that you need improved control of your diabetes. You should discuss this with your Primary Care Provider or ___ as soon as possible. Followup Instructions: ___
10079505-DS-16	10,079,505	21,829,299	DS	16	2170-08-22 00:00:00	2170-08-26 16:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Celexa / Keflex Attending: ___. Chief Complaint: Fall, right hip fracture Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a ___ nursing home resident with PMHx dementia, HTN and recurrent falls who had an unwitnessed fall two days ago and presents from an OSH with right hip pain and inability to bear weight. She was unable to provide any history due to her dementia. She was brought to an OSH where CT head and C-spine were negative and R hip/pelvis plain films showed a R comminuted intertrochanteric fracture. She was noted to have erythema and swelling of her RLE for which LENIs were obtained; no DVT was seen. She received IV vanco x 1 for presumed cellulitis and was transferred to ___ for surgical evaluation. In the ED, initial VS 98.6 70 157/93 20 95% on RA. Exam notable for resolving ecchymosis over R knee (patient had another fall 2 weeks ago with reassuring imaging), R hip TTP and limited ROM with shortening and external rotation of the RLE. RLE also with swelling and erythema. Labs were notable for K 5.3, Cr 0.9 (baseline 0.6). CBC showed no leukocytosis and H/H 8.6/27.4 (baseline 11.5/33.1 in ___. Lactate 0.9. UA was grossly positive and blood/urine cultures were drawn. The patient refused CXR. The patient received IV cipro x 1. Past Medical History: # Peripheral Vascular Disease # Gastroesophageal Reflux Disease # Osteoarthritis # Dementia (?) # Hyperlipidemia # Hip Fx # Mu___ Social History: ___ Family History: Mother died in ___ of "old age," father died of "stomach ulcers" in his ___. . Physical Exam: Admission: Vitals: 99 144/49 66 18 96%RA General: AAO x1 (doesn't know place and thinks it's ___, in 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: large ecchymosis on R upper arm, ecchymosis on R knee (from prior fall), RLE with mild erythema and TTP, lower extremities dry, warm, well perfused, 2+ pulses Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge: Vitals: 98.1-98.8 152-178/46-53 52-67 ___ 97-100%RA General: AAO x2, in 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: large ecchymosis on R upper arm, ecchymosis on R knee (from prior fall), RLE with mild erythema and TTP, pain in R arm when raising arms, lower extremities dry, warm, well perfused, 2+ pulses Neuro: did not cooperate Pertinent Results: ___ 09:40PM WBC-7.6 RBC-2.99* HGB-8.6# HCT-27.4 MCV-92 MCH-28.8 MCHC-31.4* RDW-13.6 RDWSD-46.2 ___ 09:40PM NEUTS-70.2 LYMPHS-16.3* MONOS-9.6 EOS-3.0 BASOS-0.4 IM ___ AbsNeut-5.32 AbsLymp-1.24 AbsMono-0.73 AbsEos-0.23 AbsBaso-0.03 ___ 09:40PM GLUCOSE-83 UREA N-23* CREAT-0.9 SODIUM-134 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-24 ANION GAP-13 ___ 09:40PM PLT COUNT-221 ___ 09:40PM ___ PTT-26.7 ___ ___ 09:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 09:40PM URINE RBC-10* WBC-85* BACTERIA-FEW YEAST-NONE EPI-0 ___ 09:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___ Relevant Labs: Imaging studies: OSH XR Hip: Right hip arthroplasty is again seen. There is an acute comminuted fracture through the intertrochanteric regionm with a free fragment involving the greater trochanter. However, the femoral component of the prosthesis remain centered within the bone. Allowing for loss of bone mineralization, the native periacetabular region appears unremarkable. An ossification near the anterior superior iliac spine likely relates to calcific tendinopathy. OSH PELVIS: The patient is rotated, with limited evaluation of the right superior and inferior pubic rami, though these appear intact on the AP view of the hip. The right ischial appears grossly intact. Aside from the immediate right periacetabular region, the remainder of the right ilium, as well as the sacrum and coccyx, are obscured by bowel gas and not adequately evaluated. Right sacroiliac joint is als obscured. Left sacroiliac joint and pubic symphysis do not appear widened. The left hemipelvis is unremarkable. Left hip joint appears grossly aligned in the single projection provided. There are degenerative changes in the visualized lower lumbar spine. ___ CXray: Unchanged appearance of the right rib fractures. Moderate cardiomegaly persists. Mild pulmonary edema is unchanged. No new focal parenchymal opacities, in particular no pneumonia. No pleural effusions. ___ ShoulderXray: There are no signs for glenohumeral joint dislocation on this single axillary view. There is overall demineralization. No displaced fractures are seen. Brief Hospital Course: ___ resident with PMHx dementia, HTN and recurrent falls who had an unwitnessed fall two days ago and presents from an OSH with right hip fracture # R intertrochanteric fracture: Comminuted fracture, prosthesis well seated in acetabulum. Ortho evaluated pt and felt that because the prostheses appeared stable to continued closed/non-operative treatment. She is weight bearing as tolerated. She was seen by ___ and dishcarged to rehab. Her pain was managed with APAP and low dose oxycodone. She should follow up with Dr ___ (ortho NP) in 2 weeks for repeat xrays of her hip. She will receive 6 weeks of enoxaparin for DVT ppx. # s/p fall: Per son ___, she undid her wheelchair restrains and bent over to pick something up from the floor. It was at this time that she fell. Fall is likely mechanical. Workup for infection, MI, hypovolemia all negative. #Delirium: She has waxing and waning levels of alertness. Per son she is like this at baseline. ___ also be component of confusion given change in environment. #Dementia: Per son she is currently at baseline. He says her speech started being difficult to understand starting a few months ago when she was prescribed an antidepressant. Speech/swallow eval ok'd her to take po. She was maintained on BID oral care, aspiration precautions. Her buproprion was stopped # HTN: Continue home meds # PVD: No signs of ischemia, distal pulses palpable - Aspirin 81mg # HLD: holding home simvastatin, as contraindicated with amlodipine # CODE STATUS: DNR/DNI (confirmed, MOLST paperwork) # CONTACT: Son (___?) ___ ___: Follow up with ___ in 2 weeks for repeat xrays of her hip. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Docusate Sodium 100 mg PO BID 5. Cyanocobalamin 1000 mcg IM/SC ONCE 6. Multivitamins 1 TAB PO DAILY 7. Amlodipine 10 mg PO DAILY 8. Sodium Chloride 1 gm PO DAILY 9. Acetaminophen 325 mg PO BID 10. diclofenac sodium 1 % topical Q8H:PRN 11. Simvastatin 20 mg PO QPM 12. melatonin 3 mg oral QHS 13. Furosemide 20 mg PO DAILY 14. clotrimazole-betamethasone ___ % topical 5X/DAY 15. TraZODone 25 mg PO QHS:PRN sleep 16. saccharomyces boulardii 250 mg oral BID Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Furosemide 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Simvastatin 20 mg PO QPM 9. TraZODone 25 mg PO QHS:PRN sleep 10. Enoxaparin Sodium 40 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 12. Sarna Lotion 1 Appl TP TID 13. clotrimazole-betamethasone ___ % topical 5X/DAY 14. Cyanocobalamin 1000 mcg IM/SC ONCE 15. diclofenac sodium 1 % TOPICAL Q8H:PRN pain 16. melatonin 3 mg oral QHS 17. saccharomyces boulardii 250 mg oral BID 18. Sodium Chloride 1 gm PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R hip fracture R shoulder fracture Dementia Hypertension Anemia Discharge Condition: Mental Status: Confused - always, AxoX1 Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital here at ___ because you had a right hip fracture after a fall. It sounds as if you leaned forward and fell out of your wheelchair. We did not find any other medical cause of your fall, however as you were recently started on bupropion this medication was discontinued at discharge . X-rays of your hip did not show a dislocation. You were evaluated by orthopedic surgery who recommended non surgical intervention. You will continue to work with physical therapy and bear weight on your leg as tolerated. You also noted pain in your right shoulder while trying to lift your arms. Imaging of your shoulder showed that there was an old fracture and no dislocation. You will work with physical therapy to help to improve your mobility. You were started on medication (lovenox) to help prevent blood clot after your fall. Please continue this for 6 weeks. It was a pleasure taking care of you! Your ___ Care Team Followup Instructions: ___
10079632-DS-15	10,079,632	26,559,290	DS	15	2119-09-20 00:00:00	2119-09-24 16:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: vaginal bleeding Major Surgical or Invasive Procedure: D&C History of Present Illness: CC: bleeding, abdominal pain HPI: ___ yo F G1P0010 presenting with vaginal bleeding, abdominal pain S/p med AB ___ at PP, did well initially. Yesterday started having heavy vaginal bleeding soaking 10 ___ pads. Feeling a little light-headed. Also passed a couple baseball size clots. Mild abdominal pain. Vomited once yesterday. No other N/V. No issues with urination. No fevers, chills. ROS: negative except as above Past Medical History: PMH: denies PSH: denies OBHx: G1 - med AB GYNHx: - LMP currently having bleeding s/p med ab - denies h/o STIs MEDS: none ALL: NKDA Social History: ___ Family History: Noncontributory Physical Exam: Discharge physical exam Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, no rebound/guarding Ext: no tenderness to palpation Pertinent Results: ___ 12:24AM BLOOD WBC-21.6* RBC-3.81* Hgb-11.2 Hct-31.6* MCV-83 MCH-29.4 MCHC-35.4 RDW-12.9 RDWSD-38.6 Plt ___ ___ 12:24AM BLOOD Neuts-80.5* Lymphs-13.9* Monos-4.8* Eos-0.1* Baso-0.2 Im ___ AbsNeut-17.39* AbsLymp-3.01 AbsMono-1.04* AbsEos-0.03* AbsBaso-0.05 ___ 06:52AM BLOOD WBC-6.7 RBC-2.86* Hgb-8.3* Hct-25.1* MCV-88 MCH-29.0 MCHC-33.1 RDW-13.4 RDWSD-42.6 Plt ___ ___ 06:52AM BLOOD Neuts-48.6 ___ Monos-6.1 Eos-1.0 Baso-0.4 Im ___ AbsNeut-3.27 AbsLymp-2.95 AbsMono-0.41 AbsEos-0.07 AbsBaso-0.03 ___ 12:24AM BLOOD Glucose-149* UreaN-10 Creat-0.7 Na-141 K-3.2* Cl-102 HCO3-24 AnGap-15 ___ 06:52AM BLOOD Glucose-110* UreaN-7 Creat-0.5 Na-142 K-4.0 Cl-108 HCO3-27 AnGap-7* ___ 06:52AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.9 ___ 12:55PM BLOOD HIV Ab-NEG ___ 02:25AM URINE Color-Amber* Appear-Hazy* Sp ___ ___ 02:25AM URINE Blood-LG* Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD* ___ 02:25AM URINE RBC->182* WBC-28* Bacteri-FEW* Yeast-NONE Epi-<1 ___ 02:25AM URINE AmorphX-RARE* ___ 02:25AM URINE Mucous-OCC* ___ 10:05AM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing ultrasound-guided D&C for retained products of conception. Please see the operative report for full details. )retained products of conception s/p D&C Her post-operative course was uncomplicated. Her pre-procedure Hct was 31.6 and stabilized at 25.1 post-procedure. She was started on PO iron supplementation for management of her anemia. As her blood type was Rh positive, Rhogam was not indicated. ) Endometritis She presented with fundal tenderness and a leukocytosis to 21.6 with left shift. She was treated with IV ampicillin/gentamicin/clindamycin for 24 hours ___ for empiric coverage of endometritis. Her leukocytosis resolved, and her WBC count wsa 6.1 on day of discharge. Patient was transitioned to PO antibiotics (Doxycycline and Flagyl). Her workup for vaginal infections was negative. ) Hypokalemia Her labs were notable for asymptomatic hypokalemia with K 3.2. Her potassium was repleted with appropriate rise to normal level. She clinically improved after her D&C and antibiotic treatment and was then discharged home in stable condition with outpatient follow-up arranged. Medications on Admission: none Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in a day RX acetaminophen 500 mg ___ tablet(s) by mouth Q6H PRN Disp #50 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID constipation Please take while taking iron supplements to prevent constipation. RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #50 Capsule Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #18 Capsule Refills:0 4. Ferrous Sulfate 325 mg PO DAILY anemia Please do not take at the same time as antibiotics. RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth Daily Disp #50 Tablet Refills:0 5. Ibuprofen 600 mg PO Q6H:PRN Pain Take with food. Do not exceed 2400mg in a day. RX ibuprofen 600 mg 1 tablet(s) by mouth Q6H PRN Disp #50 Tablet Refills:0 6. MetroNIDAZOLE 500 mg PO BID Duration: 9 Days RX metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #18 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: retained products of conception endometritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service for medical care. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ ___ with any questions or concerns. Please follow the instructions below. General instructions: Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your follow up appointment. * Nothing in the vagina (no tampons, no douching, no intercourse) for 2 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower * No tub baths for 2 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring more than 1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10080421-DS-3	10,080,421	27,045,826	DS	3	2183-05-26 00:00:00	2183-05-26 14:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: aspirin / phenobarbital Attending: ___ Chief Complaint: Left intertrochanteric femur fracture Major Surgical or Invasive Procedure: ___: L TFN History of Present Illness: Mrs. ___ is a ___ with history of paroxysmal SVT, remote GI bleed ___ peptic ulcer s/p surgical repair, an Alzheimer dementia who presents after a mechanical fall. She denies head strike or LOC. She presented to ___, where a CT-C Spine was obtained, which demonstrated likely a chronic C1-C2 mild lateral subluxation. She was placed in a C-Collar despite any neck pain and was transferred to ___ for further evaluation. She was seen by the ACS service, and the C-Collar was cleared. She does endorse left hip pain. Past Medical History: - Paroxysmal SVT, ___ and ___ documented. - Upper GI bleed secondary to aspirin use in the 1950s. - Glaucoma. - Macular degeneration. - Peptic ulcer disease, status post surgery in ___. Social History: ___ Family History: NC Physical Exam: Discharge Exam: Gen: NAD/AOx3 CV: RRR Resp: CTAB Abd: Soft, NT/ND Extrem: LLE: Incision c/d/I SILT s/s/sp/dp/t nerve distributions Firing ___ 2+ ___ pulses Foot wwp, good cap refill Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left intertrochanteric fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L TFN 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 weight bearing as tolerated in the left 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. Escitalopram Oxalate 5 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. rivastigmine tartrate 3 mg oral DAILY 5. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY 6. Lisinopril 5 mg PO DAILY:PRN hypertension 7. Aspirin 81 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Ferrous GLUCONATE 325 mg PO DAILY 10. Psyllium Powder 1 PKT PO DAILY 11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Escitalopram Oxalate 5 mg PO DAILY 7. Ferrous GLUCONATE 325 mg PO DAILY 8. Lisinopril 5 mg PO DAILY:PRN hypertension 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral DAILY 11. Omeprazole 20 mg PO DAILY 12. Psyllium Powder 1 PKT PO DAILY 13. rivastigmine tartrate 3 mg oral DAILY 14. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left intertrochanteric femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 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. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. 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 Orthopaedic Surgeon, Dr. ___. You will follow up with ___ in ___ 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: Weight bearing as tolerated left lower extremity Treatments Frequency: Primary dressings were changed, dressing changes as needed by nursing. Followup Instructions: ___
10080443-DS-6	10,080,443	24,427,299	DS	6	2126-04-20 00:00:00	2126-04-20 11:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R flank pain Major Surgical or Invasive Procedure: cystoscopy, Right ureteral stent placement History of Present Illness: Ms. ___ is a ___ female with a history of nephrolithiasis who has been treated by Dr. ___ in the past who began to experience some right flank pain on ___ afternoon. This progressively got worse and she presented to the emergency room today for evaluation. She has had subjective fevers and chills at home. No nausea, vomiting. Past Medical History: PAST MEDICAL HISTORY: 1. Hypertension. 2. Nephrolithiasis. 3. Osteoporosis of the lower back. 4. Depression. PAST SURGICAL HISTORY: 1. C-section x3. 2. Lap band. 3. ESWL. 4. Multiple cystoscopies and ureteroscopies in the past. Social History: ___ Family History: NC Physical Exam: AVSS NAD no resp distress abd soft obese ntnd no CVAT Brief Hospital Course: The patient was admitted to Dr. ___ service from the ___ ED for for cystocopy and left ureteral stent placement. Please see dictated operative note for details. She spiked a fever to 103.7 following the procedure but remained hemodynamically stable. She was treated with ceftriaxone and ampicillin with resolution of her fevers. Her urine cultures did not grow any organisms, and blood culture were pending from ___ at time of discharge. She passed a voiding trial prior to discharge. She will be discharged home on cefpodoxime for a 10 day course. On the day of discharge she had remained afebrile for >24h without abnormal vital signs. Her pain was well controlled with oral pain medications, she was tolerating regular diet, ambulating without assistance, and voiding without difficulty. He is given explicit instructions to call Dr. ___ ___ follow-up. Medications on Admission: BUPROPION HCL [WELLBUTRIN SR] - (Prescribed by Other Provider) - 100 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once daily LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day POTASSIUM CITRATE - (Prescribed by Other Provider) - 10 mEq (1,080 mg) Tablet Extended Release - 2 Tablet(s) by mouth RALOXIFENE [EVISTA] - (Prescribed by Other Provider) - 60 mg Tablet - one Tablet(s) by mouth per day SERTRALINE - (Prescribed by Other Provider) - 100 mg Tablet - 2 Tablet(s) by mouth per day SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 2. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking narcotics. Disp:60 Capsule(s) Refills:2 6. raloxifene 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: ___ to 1 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO ONCE (Once) for 1 doses. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. Disp:45 Tablet(s) Refills:2 10. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for burning with urination for 1 days. Disp:3 Tablet(s) Refills:0 11. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 12. potassium citrate 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. 13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Obstructing right stone Discharge Condition: stable Discharge Instructions: -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequecy over the next month. - You may experience some pain associated with spasm of your ureter. This is normal. Take Motrin as directed and take the narcotic pain medication as prescribed if additional pain relief is needed. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -You may shower and bathe normally. -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, unless otherwise noted. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: ___
10080443-DS-8	10,080,443	28,790,420	DS	8	2130-05-27 00:00:00	2130-05-27 10:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: chills/nausea Major Surgical or Invasive Procedure: none History of Present Illness: Ms ___ is a pleasant ___ with history of DM2, nephrolithiasis and urosepsis who presents today with chills/nausea/dysuria. The patient has undergone treatment for UTI twice in the last 1 month as an outpatient with Macrobid and Cipro (completed the Cipro 10 days ago). The day after she completed the course of Macrobid her sxs returned and she re-presented to her PCP who started her on ciprofloxacin. Urine culture ___ grew pansensitive E. Coli. Today, she continued to have chills so she went to urgent care and was found to have persistent bacturia. She was referred to the ED for further evaluation as she says this is similar to when she had an infected stone in the past. On arrival to the ED, she denies abdominal pain, vomiting, back pain, chest pain, shortness of breath. Has had a cough for the last several months which has been nonproductive. In the ED, initial vitals were: 98, 103, 153/85, 15, 98. Labs were notable for WBC 10.5, UA with lg leus, sm blood, nitrite neg, lipase 83. CTU showed 5x6x10 mm non-obstructing stone in L renal pelvis as well as a nonobstructing stone in the lower part of the R kidney. She was given ceftriaxone and 1 l NS. Flu swab NEGATIVE On the floor, pt states that she feels warm but has no other sxs currently. Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Denies arthralgias or myalgias. Past Medical History: (per OMR, confirmed with pt): S/P ADJ LAP GASTRIC BAND-10CM DEPRESSION DIABETES TYPE II HYPERLIPIDEMIA NEPHROLITHIASIS OSTEOPOROSIS HYPERTENSION CONTACT DERMATITIS H/O BASAL CELL CARCINOMA H/O COLONIC POLYPS Social History: ___ Family History: (per chart, confirmed with pt): Mother -ALCOHOL ABUSE -DEPRESSION -HYPERTENSION -HYPERCHOLESTEROLEMIA -OSTEOPOROSIS Father -DIABETES ___ -HYPERLIPIDEMIA -HYPERTENSION -KIDNEY STONES MGM RECTAL CANCER at ___, lived to ___ GLAUCOMA Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 137/62 100.1 89 18 97%02 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No Foley Ext: Warm, well perfused, no CCE Neuro: aaox3 CNII-XII and strength grossly intact Skin: no rashes or lesions PSYCH: appropriate, not depressed Discharge Physical Exam: VS: 98.1, 128/85, 69, 18, 96% RA Pain: zero out of 10. Gen: NAD, comfortable in bed HEENT: anicteric CV: RRR, no murmur Pulm: CTAB, no crackles or wheeze Abd: soft, NT, ND, NABS, no flank pain or CVAT Ext: no edema Skin: warm, dry Neuro: AAOx3 Psych: stable, appropriate Pertinent Results: Admission Labs: ___ BLOOD WBC-11.1* RBC-5.22* Hgb-15.5 Hct-44.5 Plt ___ ___ 08:40PM BLOOD Neuts-82.9* Lymphs-8.4* Monos-5.0 Eos-2.9 Baso-0.4 ___ BLOOD Glucose-158* UreaN-26* Creat-1.1 Na-140 K-3.4 Cl-98 HCO3-28 AnGap-17 ___ BLOOD ALT-18 AST-22 AlkPhos-55 TotBili-0.8 Lipase-83* ___ BLOOD Albumin-4.6 ___ OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ URINE Color-Yellow Appear-SlHazy Sp ___ ___ URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.5 Leuks-MOD ___ URINE ___ Bacteri-MANY Yeast-NONE ___ Microbiology: ___ Urine Culture # 1 - URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ___ Urine Culture # 2 -URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Imaging: ___ PA/LAT CXR IMPRESSION: No acute cardiopulmonary process. . ___ CTU A/P IMPRESSION: 1. 5 x 6 x 10 mm nonobstructing stone in the left renal pelvis. Punctate nonobstructing stone in the lower pole of the right kidney. No fluid collection to suggest abscess. 2. Cholelithiasis. Brief Hospital Course: ___ yo F with hx of DM, nephrolithiasis, recently failed outpt treatment of UTI, now presenting with chills and persistently positive UA. # UTI, complicated: sxs have returned twice after completion of 5 d of abx. Complicated given DM2. She has failed two out abx regimens and concern that she may have had a partly treated infection that has recurred. No e/o obstruction on CTU, but does have large stone in the left renal pelvis, which could explain the persistent UTI, as her urine culture had grown pan-sensitive E. coli, which should have responded to both Macrobid and Cipro. She was put on ceftriaxone and her symptoms and leukocytosis entirely resolved. -Transitioned to PO ciprofloxacin for 10 more days. -outpatient Urology follow-up. # Cough: She has had a chronic non-productive cough for greater than 3 months. CXR reassuring, flu negative. Recommend outpatient follow-up. # Depression: cont sertraline # HTN: cont HCTZ, losartan # Osteoporosis: cont raloxifene # HLD: cont statin. Last lipid panel ___, LDL 79, HDL 79, TC 180, ___ 109 # DM2: diet controlled, A1C 6.4 (___) -cont ASA -Was placed on ISS while in house in setting of infection. # FEN: No IVF, replete electrolytes, regular diet # PPX: Subcutaneous heparin, senna/colace, pain meds # ACCESS: peripherals # CODE: presumed full # CONTACT: husband, ___ ___ # DISPO: Home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg calcium -250 unit oral DAILY 3. Evista (raloxifene) 60 mg oral DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Losartan Potassium 50 mg PO DAILY 8. potassium citrate 10 mEq (1,080 mg) oral DAILY 9. Sertraline 100 mg PO DAILY 10. Simvastatin 20 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Evista (raloxifene) 60 mg oral DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Sertraline 100 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. potassium citrate 10 mEq (1,080 mg) ORAL DAILY 10. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg calcium -250 unit oral DAILY 11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: UTI, complicated Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after presenting to Urgent Care and the ED with nausea and the chills. You were recently treated for UTI with 2 courses of oral antibiotics. You were ruled out for the flu. You were placed on IV antibiotics initially. Your urine sample was concerning for persistent UTI and your urine cultures are pending. You had a CT scan of your abdomen which shows kidney stones, including a stone measuring up to 1cm in the left kidney. This stone is not causing an obstruction in your kidney, but may be contributing to your UTI, and should be evaluated by your urologist Dr. ___ in the future in the outpatient setting. You are being discharged on 10 more days of ciprofloxacin. Followup Instructions: ___
10080640-DS-12	10,080,640	21,161,576	DS	12	2169-07-01 00:00:00	2169-07-01 14:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: morphine Attending: ___. Chief Complaint: L tentorial meningioma vs. dural thickening Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female visiting from ___ who presents today with persistent headaches. The patient states that she has been experiencing headaches since ___ and she was diagnosed with a left tentorial SDH in ___. She has had several head CTs and MRIs in ___ which revealed a stable SDH vs meningeal lesion. She also had an LP for the same symptoms that was negative. She followed by a neurologist as well, and in the past she has been treated with Prednisone taper for the headaches. Her last prednisone treatment was back in ___. The patient states that over the last couple of days her headaches returned, she called her PCP in ___ who advised her to go to the ED for evaluation. Per the patient she fell 2 days ago when placing her left foot (baseline left foot drop) on the curb and fell with no head strike. She endorses constant frontal headache and blurred vision, she denies dizziness, nausea, vomiting, nuchal rigidity or photophobia. Past Medical History: HTN, HLD, Hypothyroidism, and chronic headaches. Social History: ___ Family History: Patient was unsure about family history with regard to cancer Physical Exam: On admission O: T: 98.1 BP: 162/54 HR: 84 R: 18 O2Sats: 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. Left eye watery and tearing. 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, for the exception of baseline left foot drop ___ ___. No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Handedness Left or Right On discharge Gen: WD/WN, comfortable, NAD. HEENT: Pupils: EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. Left eye watery and tearing. 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, for the exception of baseline left foot drop ___ ___. No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Handedness Left or Right Pertinent Results: ___ non contrast head CT Acute subdural hematoma layering along the left tentorium cerebelli measuring approximately 3 mm in depth. ___ brain MRI with and without contrast Linear enhancement along the lateral aspect of the left tentorium, contiguous with the patent left transverse sinus, with corresponding hyperdensity on the preceding CT. The enhancement is compatible with either chronic dural thickening secondary to prior hematoma or with a meningioma. The hyperdensity may be seen in a meningioma, but acute blood products cannot be excluded without comparison to prior CTs. Brief Hospital Course: On ___, the patient was admitted to ___ for further workup of suspected SDH vs. meningioma. She was stable neurologically and was doing well clinically. On ___, the patient was stable and there were no events over night. A MRI of the brain with and without contrast was performed which showed the area in question may be a meningioma vs. dural thickening. She still complained of headaches. She worked with ___. On ___, the patient was stable and there were no events over night. It was decided that there was no need for neurosurgical intervention. The patient was discharged to home with follow up instructions for neuro-oncology and neurosurgery PRN. Medications on Admission: Simvastatin, Topamax, enalapril-HCTZ, and levothyroxine. Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headaches RX butalbital-acetaminophen-caff 50 mg-300 mg-40 mg ___ capsule(s) by mouth Every 6 hours as needed Disp #45 Capsule Refills:0 2. Enalapril Maleate 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Simvastatin 10 mg PO QPM 6. Topiramate (Topamax) 50 mg PO BID 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN HA RX oxycodone 5 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left tentorial meningioma vs. dural thickening Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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. 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. Followup Instructions: ___

Subsets and Splits