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10624843-DS-5
| 10,624,843 | 21,037,340 |
DS
| 5 |
2181-01-20 00:00:00
|
2181-01-23 14:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues / Iodine / Tamiflu / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Left pleural effusion
Major Surgical or Invasive Procedure:
L chest tube placement
History of Present Illness:
Patient was admitted today from ___ clinic after a chest tube
placement and drainage. She was referred to IP for persistent
parapneumonic pleural effusion due to a post-influenza PNA first
diagnosed on ___.
In ___, Ms ___ presented to her PCP with fevers,
myalgias, cough and fatigue. She tested positive for flu and
was prescribed Tamiflu, which she quickly d/ced after developing
hives. She developed new L flank pain and presented to the
___ ED on ___, where she was diagnosed with LLL and
lingual PNA on CXR without any clear pleural effusion. She was
prescribed a 7 day course of levoflox and d/c from the ED. On
___ she represented to the ___ ED with worsening L sided
pain, and pain with deep inhalation. Repeat CXR showed
persistent left lower lobe pneumonia with new small bilateral
pleural effusions. She was advised to take ibprofen.
Her fevers and cough resolved within a week, but not the L-sided
pain. Ms. ___ presented to her PCP ___ ___ with persistent
and worsening L sided pain, aggravated by deep inhalation and
lying flat, and worsening fatigue. She was set for a outpt
repeat CXR which showed resolution of her right pleural effusion
and LLL consolidation but a loculated left pleural collection,
concerning for empyema. Outpt chest CT on ___ showed
persistent left pleural collection with complex exudative fluid.
She was then referred urgently to ___.
In ___ clinic today she reported noticable decreased in exercise
capacity and dyspnea on exertion, and occassional night sweats,
but no fevers, chills, cough. IP placed a ___ chest tube in
left ___ intercostal space set to suction and drained 20ml of
serosanguinous fluids. Repeat chest imaging after draining
showed residual fluid, concerning for emphyema. DNA ATPase was
considered but not used due to concern for bleeding. Pt was
referred for admission to monitor her status, and thoracic
surgery was consulted for possible VATS procedure.
Patient does report 15lb weight loss during the past month.
ED Course:
--------------
initial vitals: 98.5 86 95/53 16 100% RA
Labs/Studies notable for: Neg UA, WBC 5.6 HCT 38.3
Imaging notable for small left pleural fluid and gas containing
collection with pigtail chest tube in place, and stable left
lower lobe consolidation.
Patient had sharp pains at chest tube site. She 5mg IV morphine
and started on 1g IV vancomycin, 500mg IV metronidazole for PNA.
Vitals prior to transfer: Today 15:50 3 98.4 72 98/59 20 97% RA
Currently, patient continues to have sharp pain at the chest
tube site at rest, worsen w/movement of torso and arms. She also
reports developing a migraine at this time behind her right eye
c/w prior migraines. + photophobia. No N/V.
Past Medical History:
Herpes
Social History:
___
Family History:
Father: non-hodgkins lymphoma
Sister: multiple sclerosis
Physical Exam:
EXAM on ADMISSION:
Vitals: Temp 98.3 HR 70 BP 120/45 RR 20 O2SAT 100%RA
General: AAOx3, comfortable appearing, in NAD
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
MMM. OP clear.
Neck: supple, able to place chin to chest easily, no LAD, no JVP
elevation
Lungs: Chest tube to suction extending from posterior left.
Scattered wheezing bilaterally. Decreased breath sounds at left
base.
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
GU: no foley
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. MAEE. ___ strength in UE and BE
bilaterally. Sensation to light touch intact.
EXAM ON DISCHARGE:
Vitals: Temp 98.3 HR 74 BP 97/62 RR 16 O2SAT 97%RA
General: AAOx3, mildly uncomfortable, in NAD
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
MMM. OP clear.
Neck: supple, no JVP elevation
Lungs: Chest tube to suction extending from posterior left.
Scattered wheezing on right. Decreased breath sounds at left
base. Chest tube insertion site is clean, dry.
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
GU: no foley
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. MAEE. No focal neurologic deficits
Pertinent Results:
LABS on Admission:
___ 12:45PM BLOOD WBC-5.4 RBC-4.48 Hgb-13.1 Hct-38.3 MCV-85
MCH-29.3 MCHC-34.4 RDW-14.0 Plt ___
___ 12:45PM BLOOD Neuts-62.1 ___ Monos-4.6 Eos-1.6
Baso-0.4
___ 12:45PM BLOOD Glucose-90 UreaN-13 Creat-0.6 Na-138
K-5.6* Cl-102 HCO3-25 AnGap-17
___ 12:48PM BLOOD Lactate-1.4 K-4.4
Labs on Discharge:
___ 06:11AM BLOOD WBC-7.1 RBC-4.11* Hgb-12.5 Hct-34.7*
MCV-84 MCH-30.3 MCHC-36.0* RDW-14.1 Plt ___
___ 06:11AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
___ 06:11AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
Plueral Fluid Stuides:
___ 10:45AM PLEURAL WBC-2925* Hct,Fl-17.0* Polys-35*
Lymphs-61* Monos-1* Eos-3*
___ 10:45AM PLEURAL TotProt-5.9 Glucose-67 LD(LDH)-4130
Albumin-3.0 ___ Misc-PRO BNP =
MICROBIOLOGY:
Pleural Fluid prelim ___: NGTD
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.
Pleural Fluid ___: NGTD, final pending
Blood Cultures ___: NGTD, final pending
Urine ___: < 10,000 organisms
IMAGING:
CXR ___: Small left pleural effusion loculated posteriorly,
is smaller compared to ___ and the adjacent atelectasis
has improved. An oblique band of atelectasis in the left lower
lobe is simulating hydro pneumothorax. Lungs are otherwise
clear. Cardiomediastinal silhouette is normal.
CT Chest ___:
Small left pleural fluid and gas containing collection with
pigtail chest tube in place. Stable left lower lobe
consolidation.
CXR ___:
Left pigtail catheter is in unchanged overall position.
Loculated posterior pleural effusion is better appreciated on
the lateral view, small to moderate. No pneumothorax is seen.
Heart size and mediastinal contours are unremarkable. Lungs are
clear except for linear opacity in the left lower lobe,
unchanged since the prior study.
Brief Hospital Course:
Ms. ___ was seen in interventional pulmonary clinic on ___.
Imaging showed persistent left sided pleural effusion. 20ml of
fluid was drained and a chest tube was placed in clinic.
Post-procedure imaging showed some residual fluid in the left
pleural space that was concerning for loculated effusion or
empyema, so she was admitted for further observation. Thoracic
surgery was consulted for a possible VATS procedure, and she was
started on broad-spectrum antibiotics and pain control. Her
vital signs were stable during this admission. Her chest tube
drained only 10ml of serosanginous fluid. Analysis of her
pleural fluid showed protein 5.9, chol 123, WBC 2925, LDH 4130
and pH 7.77. Consistent with exudative confusion and not likely
to be empyema. Pleurel fluid culture were NGTD, final pending.
She was reassessed in the morning, and both interventional
pulmonology and thoracic surgery felt that the residual fluid
was unlikely due to empyema and was more consistent with a
complicated parapneumonic pleural effusion with residual
pneumonia. She was discharged on a 4 week course of levofloxacin
and flagyl, and will follow-up with interventional pulmonology
clinic and thoracic surgery clinic.
TRANSITIONAL ISSUES:
-follow up chest CT and then follow up in ___ clinic
-completion of 4 weeks of antibiotics on ___
-Urine culture pending at discharge
-Blood cultures pending at discharge, NGTD
-Pleurel fluid cultures pending at discharge, NGTD
-ESR pending at discharge - per pulm for trending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Vitamin D 5000 UNIT PO DAILY
4. DiphenhydrAMINE 50 mg PO Q6H:PRN allergies/hives
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Vitamin D 5000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H
4. Levofloxacin 750 mg PO DAILY
Last dose ___
RX *levofloxacin 750 mg one tablet(s) by mouth daily Disp #*27
Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Last dose ___
RX *metronidazole 500 mg one tablet(s) by mouth three times a
day Disp #*80 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg one tablet(s) by mouth every ___ hours Disp
#*20 Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
8. DiphenhydrAMINE 50 mg PO Q6H:PRN allergies/hives
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated parapneumonic pleural effusion
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure caring for you during your brief
admission to ___ for pleural effusion (fluid around your
lung). You were admitted after chest tube placement in
Interventional Pulmonology clinic for observation. There was
initially some concern that the residual fluid in your pleural
space after drainage may represent an enclosed area of infected
fluid, or an empyema. Thoracic surgery was consulted for a
possible surgical procedure to clear that area, and you were
started on broad-spectrum antibiotics. Additionally you were
given oxycodone for pain. Your vitals signs, including your
blood oxygenation, were monitored.
On reassessment it was felt that your lung findings were likely
an area of residual pneumonia rather than empyema. Your chest
tube was not draining a lot of fluid and therefore was removed.
You will go home on 4 weeks of antibiotics to treat any
lingering infection in your lungs. You will follow-up with
interventional pulmonary clinic after a repeat CT scan to review
your progress, these appointments have been made for you. You
should also follow up with the thoracic surgeons with Dr. ___.
Again it was a pleasure caring for you during your stay at
___,
Best of wishes,
Your medicine team.
Followup Instructions:
___
|
10625410-DS-9
| 10,625,410 | 21,882,318 |
DS
| 9 |
2201-02-20 00:00:00
|
2201-02-20 16:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female hx. of eating disorder (BMI 12) presenting
with c/o weakness.
Patient reports several days of difficulty walking and 'double
vision' when she stands up. Says for last several days has had
difficulty walking and unsteadiness on her feet. Has had to used
a two handed walker where she lives. Denies falls over this
time. She lives by herself. She does endorse increased urinary
frequency as well. Denies dysuria/flank pain. She has
longstanding issues with anorexia, follows with a psychiatrist.
Was recently started on a nutritional supplement. She denies
chest pain, fevers/chills, denies diarrhea, constipation. Says
her sister was concerned for her so called EMS.
Patient presented on ___ to PCP with similar complaints. Had
labs checked including TSH which was normal. Patient at that
time was noted to be losing weight but refused hospitalization
for anorexia.
In the ED initial vitals were: 98 69 197/111 14 98%
- Labs were significant for CBC with WBC 3, H/H ___,
chemistries with bicarb 34, P 2.4, alb 4.6. As patient's BMI was
12 and she is significantly below IBW, she was admitted for
medically unstable eating disorder.
- Patient was given 1L D5NS with potassium.
On the floor, patient says she is feeling better and is
wondering when she can go home.
Past Medical History:
Anorexia nervosa, purging type
Osteopenia
Peripheral vascular disease: seen by Dr. ___ in (Cardiology)
for chronic lower extremity edema. She has had a noninvasive
lower extremity arterial testing in the past that showed SFA
disease and underwent invasive angiography with Dr. ___ in
___, which demonstrated pain in SFAs bilaterally with occlusion
of the posterior tibial vessels. There was no intervention.
Macrocytic Anemia
HYPERPARATHYROIDISM
GASTROESOPHAGEAL REFLUX
HYPOTHYROIDISM
HEPATITIS B
Anxiety/depression
Social History:
___
Family History:
Her parents are in their ___. Her mother has diabetes and her
father has no significant medical problems. She has a sister in
her ___ that has some kidney problems potentially related to
horseshoe kidney. There were no other cancers, bleeding
problems, or other significant medical problems in her family.
Physical Exam:
Admission Exam:
==================
Vitals - 153/90 hr 53 12 100% RA weight 26.5 kg
GENERAL: awake, alert, NAD, appears emaciated
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
SKIN: some bruising on ___ b/l
Discharge Exam:
===================
Vitals: 97.8 153/91 70 16 100% RA
Weight: 32.5 <-- 30.9 <--30.2 < --30.0 <--31.2<--30.6 <-- 29.9
<--30.8<--32.7 <--33.4<--33.8 <---33.7 <-- 34.4kg <-34.8
<--35.1 <-- 34.8 <--- 34.5 <-- 34.3 <-- 34.1 <-33.7 <-32.5 <-
26.5 kg (admission)
General: cachetic, chatting on the phone
HEENT: Severe temporal wasting, sunken globes, EOMs intact,
moist mucous membranes
CV: soft heart sounds, RRR
Lungs: CTA in anterior and posterior fields
Abdomen: emaciated, soft, minimal abdominal tenderness, no
guarding/rebound. faint bs
GU: no Foley.
Ext: warm well perfused, tender to palpation, chronic overlaying
erythematous macular skin rash, with sloughing.
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS:
=====================
___ 08:15PM BLOOD WBC-3.0* RBC-3.38* Hgb-11.8* Hct-33.3*
MCV-98# MCH-34.9* MCHC-35.5* RDW-13.4 Plt ___
___ 08:15PM BLOOD Neuts-50.0 Lymphs-44.2* Monos-5.1 Eos-0.3
Baso-0.3
___ 08:15PM BLOOD Plt ___
___ 08:15PM BLOOD Glucose-85 UreaN-28* Creat-0.9 Na-139
K-3.3 Cl-96 HCO3-34* AnGap-12
___ 08:15PM BLOOD Albumin-4.6 Calcium-9.7 Phos-2.4* Mg-1.7
PERTINENT LABS:
=====================
___ 04:43AM URINE Color-Straw Appear-Clear Sp ___
___ 04:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
DISCHARGE LABS:
=====================
IMAGING:
=====================
CT Head (___):
No acute intracranial hemorrhage or mass effect. Correlate
clinically to decide on the need for further workup with mri if
not contraindicated.
ECG (___):
Sinus rhythm and sinus arrhythmia. Q-T interval prolongation.
Compared to the previous tracing of ___ the voltage has
returned. The Q-T interval is prolonged. The T wave flattening
is no longer recorded. Clinical correlation is suggested.
___ Left ___ US: FINDINGS: There is normal compressibility, flow
and augmentation of the left common femoral, superficial
femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and
peroneal veins. There is normal respiratory variation in the
common femoral veins bilaterally. Note is made of ___ cyst
in the left popliteal fossa. IMPRESSION: No evidence of deep
venous thrombosis in the left lower extremity veins. ___ cyst
in the left popliteal fossa.
Abdomen supine and errect ___
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
IMPRESSION: Extensive amount of stool is demonstrated
throughout the colon. No evidence of small bowel dilatation or
small bowel. Air is present. No free air is demonstrated on the
decubitus view
___ EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old
woman with anorexia, left foot swelling, prolonged
hospitalization // r/o DVT TECHNIQUE: Grey scale, color, and
spectral Doppler evaluation was performed on the left lower
extremity veins. COMPARISON: Bilateral lower extremity
ultrasound on ___. FINDINGS: There is normal
compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color
flow and compressibility are demonstrated in the posterior
tibial and peroneal veins. There is normal respiratory variation
in the common femoral veins bilaterally. Note is made of ___
cyst in the left popliteal fossa. IMPRESSION: No evidence of
deep venous thrombosis in the left lower extremity veins. ___
cyst in the left popliteal fossa. ___ EXAMINATION: ABDOMEN
(SUPINE AND ERECT) INDICATION: ___ year old female hx of anorexia
nervosa, purging subtype (BMI 12) presenting weakness now having
increased abdominal distension // evidence of constipation/free
air? TECHNIQUE: ABDOMEN (SUPINE AND ERECT) IMPRESSION: Extensive
amount of stool is demonstrated throughout the colon. No
evidence of small bowel dilatation or small bowel. Air is
present. No free air is demonstrated on the decubitus view
___ The left atrium is normal in size. The estimated right
atrial pressure is ___ mmHg. 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 diameters of aorta at the sinus, ascending and
arch levels are normal. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The septal insertion of the
tricuspid valve is apically displaced, consistent with Ebstein's
anomaly. There is a small pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade. Compared with the prior study (images reviewed) of
___, the small pericardial effusion is new. Apical RV
hypokinesis is no longer appreciated. Other findings are
similar.
MICROBIOLOGY:
======================
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
=
=
================================================================
Difficult crossmatch and/or evaluation of irregular antibody (s)
CLINICAL/LAB DATA: Ms. ___ is a ___ year old female with a
past
medical history of anorexia and depression who was admitted to
the
hospital on ___ for severe malnutrition. A blood sample was
sent
for type and screen.
LABORATORY DATA:
Patient ABO/Rh: Group O, Rh negative
Antibody Screen: Positive
Antibody Identity: Anti-K
Antigen Phenotype: ___ negative
DAT: Negative
TRANSFUSION HISTORY:
Previous non-reactive red cell transfusions: 3
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. ___ has a
new
diagnosis of Anti-K antibody. The K antigen is a member of the
Kell
blood group system. Anti-K is clinically significant and capable
of
causing hemolytic transfusion reactions and hemolytic disease of
the
fetus and newborn. In the future, Ms. ___ should receive
___ negative products for all red cell transfusions.
Approximately
91% of ABO compatible blood will be ___ negative. A wallet
card
and a letter stating the above will be sent to the patient.
ORDERING/ATTENDING MD: ___. ___
___ BY: ___. ___
___ LABS:
___. ___
___ PHYSICIAN: ___. ___
Brief Hospital Course:
___ year old female with long history of anorexia nervosa,
purging subtype presenting with weakness and a BMI of 12,
admitted for eating disorder protocol requiring a guardian;
course complicated by gastroparesis and large fecal loading
requiring intense bowel regimen.
# Anorexia: Patient's chief complaint of weakness most likely
related to underlying anorexia nervosa and ongoing weight loss.
Patient with presentation BMI of 12.1 and placed on ___ eating
disorder protocol and cared for by a multidisciplinary team that
included the medical team, psychiatric team, nutrition and
social work. To augment the nutrition she was treated with
vitamin supplememntation. Patient had several episodes of
behavioral problems challenging her care including self inducing
emesis in the shower and not finishing meals in the alloted time
requiring close supervision in the bathroom and several episodes
requiring her to consume three consecutive meals of liquid
supplements. Due to gastroparesis reported below daily meals and
total required caloric intake was divided into four meals. At
discharge she weighs 32.4 kg. Pt's sister was legally appointed
guardian; on day of discharge she and pt requested discharge
home rather than to eating disorder unit as previously planned.
Pt was assessed by psychiatry consult service, determined not to
require ___, and therefore sister legally entitled to
discharge patient against medical advice. Pt was discharged home
into her sister's care. See psychiatry OMR note on day of
discharge for further discussion of discharge evaluation and
planning.
# Depression: Patient was started on treatment for depression
with duloxetine. Duloxetine was discontinued after patient
developed mild hyponatremia and transaminitis. Psychiatry closed
followed the patient's course and determined she did not require
a ___ at discharge, as her psychiatric disease did not
place at her immediate (within days) substantial physical risk.
# GI dysmotility: Patient complained of abdominal pain worse
after eating. KUB and CT abdomen revealed grossly distended
stomach and large amount of stool. Patient was treated with
aggressive daily bowel regimen and NGT to decompress stomach.
She reported improved abdominal pain after she had improved
stooling. To treat the gastroparesis at the request of both the
patient and her family patients meals were modified to soft diet
and she had her meals broken down into four meals a day.
Additionally, she was maintained on an aggressive bowel regimen
titrated to ___ bowel movements a day. Patient's sister brought
patient out of the hospital prior to completion of medical
treatment as patient was still on IV erythromycin for
gastroparesis.
# Diplopia: patient has been complaining of blurry vision on
admission. CT head on admission revealed no acute process.
Opthomology evaluated patient and was found to have esophoria
at near and distance and Asteroid hyalosis in the left eye and
was advised to follow up with outpatient opthalmologist
provider.
# Anemia: Patient was found to have a downtrending macrocytic
anemia on this admission to a nadir of 21.7 of unclear etiology.
This was attributed to repeated phlebotomy for lab draws (very
low total plasma volume), baseline poor nutritional state,
hypothyroidism, and poor bone marrow response to lab draws.
Workup included negative stool gauiac, no evidence of hemolysis
on labs and smear, elevated TSH, low zinc and low reticulocyte
count. She received 1 unit prbcs on this admission on ___.
Copper, MMA , B12 were found to be normal. Patient treated with
iron and zinc supplements, reduced frequency of lab draws.
# Hypertension: Patient hypertension was initially treated with
labetalol which was discontinued as she was no longer found to
be hypertensive.
# Hypothyroid: TSH found to be elevated at 7.3 with a free T4 of
47. This may be a factor contributing to macrocytic anemia.
Home levothyroxine dose increased to 75mcg daily.
# Thrombocytosis: Patient developed a thrombocytosis to peak of
837 during this admission for unclear reason, though this is a
reported finding during hospitalization in patients with eating
disorder. Most likely reactive in setting of her severe
malnutrition. Platelets were trending back to normal on
dischargeat 456.
# Hyponatremia: Na nadir of 131 during hospitalization. This was
thought to be possibly due to Cymbalta, which was discontinued.
Na at discharge was 136
# Diastolic heart failure - as seen on echo report with report
of a restrictive filling abnormality, and CT with evidence of
moderate b/l pleural effusions and found to have worsening ___
edema. Patient was treated with 20mg lasix as needed dosing to
avoid overdiuresis. Home lasix was stopped at discharge.
# Osteoporosis: Home vitamin D and calcium were continued.
Transitional issues:
- Ms. ___ has a new diagnosis of Anti-K antibody. The K
antigen is a member of the Kell blood group system. Anti-K is
clinically significant and capable of causing hemolytic
transfusion reactions and hemolytic disease of the fetus and
newborn. In the future, Ms. ___ should receive ___
negative products for all red cell transfusions.
- Patient advised to follow up with primary eye doctor Dr.
___ at ___
- Levothyroxine dose increased to 75mcg due to low TSH, will
need recheck of TSH ___ (6 weeks after uptitrating dose)
- Patients blood pressures were labile but labetalol worked to
control her hypertension when needed. She was discharged
normotensive but could consider labetalol 200mg BID if needed.
- Patient was admitted on furosemide 40mg daily, thought to be
used after previous hospitalization with anasarca. She developed
worsening ___ edema, ECHO shwoed normal ejection fraction though
the left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure which
may contribute to swelling.
- Gastroparesis treatment: patient started on aggressive bowel
regimen and should continue on PO and PR medications, titrate to
___ bowel movements a day
- Please monitor electrolytes including K, Calcium, and Phos,
which were all mildly elevated. Thought to be multifactorial
from nutrition, dehydration requiring IVF, and fecal loading
- weight at discharge: 32.5kg
- Patient's sister appointed her guardian and brought the
patient home against medical advice
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clotrimazole-betamethasone ___ % topical BID
2. Furosemide 40 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Mupirocin Ointment 2% 1 Appl TP BID
5. Boost Glucose Control (nut.tx.gluc.intol,lac-free,reg) 1
bottle oral BID
6. Omeprazole 20 mg PO BID
7. rivastigmine tartrate 6 mg oral BID
8. Calcium Citrate + (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
9. Vitamin D ___ UNIT PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Acetaminophen ___ mg PO Q12H:PRN pain
12. Ibuprofen 200 mg PO DAILY:PRN pain
13. Simethicone 80 mg PO TID:PRN bloating
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H Pain/headache
2. Ferrous Sulfate 325 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Simethicone 40-80 mg PO QID:PRN gas/bloating
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily Disp
#*14 Capsule Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*28 Capsule Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
8. Vitamin D ___ UNIT PO DAILY
9. Ibuprofen 200 mg PO DAILY:PRN pain
10. Mupirocin Ointment 2% 1 Appl TP BID
11. Omeprazole 20 mg PO BID
12. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
13. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*14
Suppository Refills:*0
14. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
15. Glycerin Supps ___AILY:PRN constipation
RX *glycerin (adult) Adult 1 suppository(s) rectally daily Disp
#*14 Suppository Refills:*0
16. Polyethylene Glycol 17 g PO TID
RX *polyethylene glycol 3350 [___] 17 gram 1 powder(s) by
mouth three times a day Disp #*42 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Anorexia Nervosa NOS
gastroparesis
Secondary diagnosis:
hypertension
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital due to significant concern
about your low body weight and the effect it will have on your
long term health. While in the hospital you were treated with
the eating disorder protocol and responded well. You have made
good progress as an inpatient and we wish you continued success
in the future.
Your sister was appointed your guardian and she understands that
leaving the hospital now is against our medical advice.
You were found to have multiple medical issues for which you
should follow-up with your primary care physician. First, you
have an anemia and should continue your home iron
supplementation. Second, you have gastroparesis, which is slowly
of the gut. Please continue your bowel regimen so that you have
___ bowel movements a day. Third, you have high blood pressure
and should follow-up with your PCP as to whether or not you
should start a blood pressure medication. Fourth, for your eye
complaints, please follow-up with Dr. ___ at ___.
Fifth, for your hypothyroidism, your levothyroxine was increased
and you should have your thryoid function checked in ___.
All the best,
Your ___ care team
Followup Instructions:
___
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2182-08-28 00:00:00
|
2182-08-29 07:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o ___ speaking male with a history
of COPD, CAD s/p BMS to RCA (___) and DES to RCA (___) and
aortic stenosis s/p AVR (___) who presented with 2 days of
increasing SOB. According to his family he has been having
worsening symptoms over the past ___ days. The most concerning
feature was that he was having shortness of breath at rest which
is what prompted the family to call ___. The patient notes that
symptoms are worse with ambulation. He denied any cough, fevers,
chills, nightsweats, travel or sick contacts.
Of notes he was recently admitted to ___
for abdominal pain was subsequently found to have PE's. The
family was unable to verify that he was taking anything for
anticoagulation.
He also notes back pain and intermittent chest pain in the last
24 hours. It was reported by the ED that his anginal equivalent
is back pain.
In the ED, initial VS were: 98.1 95 143/69 26 100% r/a. Patient
was given duonebx3 and solumedrol 125mg x1. He notably had a
troponin of 0.05.
On arrival to the floor, he stated that he was feeling better
from a shortness of breath stand point. He also noted some
persistnet back pain.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Coronary Artery Disease
- Myocardial infraction twice
- Aortic Stenosis s/p AVR (___)
- PERCUTANEOUS CORONARY INTERVENTIONS:
RCA stent ___ Bare metal), ___ Drug Eluting), also gives h/o
3 other PTCAs in the past.
3. OTHER PAST MEDICAL HISTORY:
Emphysema
COPD - on oxygen therapy off and on
h.o. GI Bleed(aspirin associated)
BPH
GERD (+ for H. Pylori)
Anemia
Infrarenal AAA
Vertigo - ? Viral tinitus
Diverticulosis
Osteoporosis
Appendectomy
Right inguinal hernia repair
Bilateral cataract surgery
Social History:
___
Family History:
Father with MI at age ___
Physical Exam:
VS - Temp F 98.2, BP 138/70, HR 101, 98% O2-sat RA
GENERAL - elderly male in NAD
HEENT - MMM, OP clear
NECK - supple, no thyromegaly, no JVD appreciated
LUNGS - crackles noted at the bases, wheezing bilaterally
HEART - RRR, -m/r/g appreciated S1/S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
CTA Chest ___
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Severe emphysema and chronic small airway disease.
3. Multiple new left lower lobe pulmonary nodules, the largest
measuring 7
mm. Recommend a repeat CT in six months to evaluate for
stability.
4. Thyroid nodule. Recommend non-emergent evaluation with a
thyroid
ultrasound, if clinically indicated.
5. Moderate atherosclerotic disease in the coronary arteries,
aorta, and
along the aortic valve.
6. Multiple mid thoracic vertebral compression deformities,
slightly
progressed from ___.
Bilateral Lower Extremity Ultrasound ___
IMPRESSION:
No evidence of DVT in either lower extremity.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of COPD, CAD s/p
BMS to ___ (___) and DES to RCA (___) and aortic stenosis s/p
AVR (___) who presented with 2 days of increasing SOB now
considerbaly improved.
# Shortness of Breath, most c/w COPD flare: Patient has a
history of COPD, coronary disease and was recently diagnosed
with PE. CTA negative for PE yesterday and LENIs negative for
DVTs. IVC filter placement was advised but family and patient
elected to defer this decision to patient's cardiologsit Dr.
___. Given that acute PE is no longer seen on CTA, this is
reasonable.
Presentation was most consistent with COPD exacerbation,
patient was started on a steroid taper and advised home
nebulized therapy. All home COPD medications were continued and
refills were provided.
# CAD: Patient has a signficant history of coronary disease with
multiple interventions and reported history of MI's. Continued
aspirin 81mg and simvastatin 20mg daily.
# BPH: Continued tamsulosin qhs
# Hypertension: Continued beta-blocker thearpy.
Transitional Issues:
Patient and Family were instructed to discuss IVC filter
placement with his cardiologist Dr. ___ the a history PEs
increases future risk of PEs. Will also need to consider
hypercoagulable and malignancy w/u given the unprovoked nature
of his VTE.
Incedental findings on CTA Chest that need continued monitoring
and follow-up:
1. Multiple new left lower lobe pulmonary nodules, the largest
measuring 7
mm. Recommend a repeat CT in six months to evaluate for
stability.
2. Thyroid nodule. Recommend non-emergent evaluation with a
thyroid ultrasound, if clinically indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Acetaminophen 325-650 mg PO Q6H:PRN Pain
8. Mag-Al Plus *NF* (alum-mag hydroxide-simeth) 200-200-20 mg/5
mL Oral BID:PRN Upset Stomach
9. Calcium Carbonate 500 mg PO BID
10. Hydrocortisone Cream 1% 1 Appl TP BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Quetiapine Fumarate 25 mg PO QHS
13. Docusate Sodium 100 mg PO DAILY:PRN Constipation
14. Senna 1 TAB PO BID:PRN Constipation
15. Ferrous Sulfate 325 mg PO DAILY
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
17. Pantoprazole 40 mg PO Q12H
18. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
19. Theophylline SR 200 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY:PRN Constipation
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
inh(s) ih twice a day Disp #*1 Unit Refills:*2
5. Furosemide 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Simvastatin 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB(s) IH every
six (6) hours Disp #*120 Unit Refills:*2
10. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 NEB(s) IH every
six (6) hours Disp #*120 Unit Refills:*2
11. PredniSONE 60 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 inh IH
daily Disp #*1 Unit Refills:*2
13. Lisinopril 30 mg PO DAILY
14. Senna 1 TAB PO BID:PRN Constipation
15. Amiodarone 200 mg PO DAILY
16. Calcium Carbonate 500 mg PO BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Hydrocortisone Cream 1% 1 Appl TP BID
19. Quetiapine Fumarate 25 mg PO QHS
20. Theophylline SR 200 mg PO BID
RX *theophylline [___] 200 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*2
21. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
22. Mag-Al Plus *NF* (alum-mag hydroxide-simeth) 200 mg/5 mL
ORAL BID:PRN Upset Stomach
Discharge Disposition:
Home
Discharge Diagnosis:
COPD Exacerbation
CAD
chronic systolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for shortness of breath. You were
evaluated and treated by the medicine service. You shortess of
breath was caused by worsening of your emphysema which improved
with steroid medications and breathing treatments. You will need
to continue these treatments at home.
We also discovered that you were recently found to have blood
clots in you lung at a ___ in ___ and had GI bleeding
when blood thinning medication were used. With this knowldge,
you were advised to have an IVC filter placed to protect your
lungs from large clots going to your lungs in the future. You
and your family decided that you did not want a filter placed
now and would prefer to have your cardiologist Dr. ___
this filter at a later time.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
___
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2183-01-03 00:00:00
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2183-01-07 22:56:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year-old right-handed ___ speaking male with a history of
COPD, CAD s/p MIx2 with BMS to RCA (___) and DES to ___ (___)
and aortic stenosis s/p AVR (___), aspirin-associated GI-bleed,
PE, presenting with dizziness, which when asked to described
further, reports as lightheadedness, "about to pass out."
Translation is provided by his daughter who is at bedside. It
comes on only when moving from a supine to seated or standing
position. It is not triggered by head turn. It last for
approximately 30 seconds before resolving. This has been
occurring for the past 4 weeks. He also notes he has a
"whooshing" sensation in the middle of his head that is
constant. He only told his daughter about this sensation 4 days
ago. She took him to the ___ (or possibly
___ ___ evening. There they evaluated
him, did a head CT, and checked labs. They told him that his
blood counts were low (numbers not known) and that he would
likely need a blood transfusion soon, but since it was not an
emergency, they told him to call his PCP. He has had a history
of GI bleed in the past, but reportedly there was no blood when
they performed a rectal exam. His daughter called the PCP but
due to him being out of town for the next week, has not heard
from him or the covering doctor.
She brought him in to see his ENT, Dr. ___ saw him
today. By his daughter's report, he thought that the
lightheadedness was related to the anemia, as well the head
whooshing, and instructed him to seek further work up for the
anemia. ENT thought that dizziness was not related to ENT
pathology.
Since the onset of these symptoms, he has had no difficulties
with diplopia, dysarthria, incoordination. No nausea or
vomiting. He has been using a walker at home to hold onto while
first getting up. No difficulties walking otherwise. He does
have chronic left ear hearing loss that has not worsened
recently. He complains of increased tremulousness and increase
generalized fatigue for the past month. He also notes LLE edema
earlier in the day, which has since resolved.
In the ED, initial vitals were 98.4 55 143/51 16 96%. Neurology
was consulted in the ED, and noted that his heart rates were in
the 100s, BP 70/40s while they were in the room. Pale skin, very
dry MM. Neurological exam is normal, mild tremulousness in the
hands. Able to stand at bedside unassisted, however paused and
endorses lightheadedness. Able to walk normally after
lightheadedness ended. Rectal exam in the ED was guaiac
negative. Labs were notable for Hgb 7.3, Hct 26.9, MCV 63.
(Previously Hgb closer to 9, Hct ___, MCV 75.) UA with few
bacteria and small leukocytes. Lactate 4.6. EKG shows bigeminy @
104, rbb sinus beats unchanged from ___, ventricular beats
new. CXR was done and showed patchy bibasilar airspace
opacities, likely atelectasis, and also emphysema. Per neurology
consult, overall presentation was thought to be consistent with
symptomatic anemia, with possible concern for GI bleed given
history and antiplatelet therapy. CT head was performed prior to
transfer. He was given 1L IV NS and 1unit PRBC.
Vitals prior to transfer were: 97.8 95 141/72 20 97% RA
On the floor, patient is alert, orientated, conversant, in no
acute distress. History was obtained with the help of his
daughter, who translated for him. He confirmed the above, in
addition he mentioned that his vision has been blurry and he has
been seeing floater, also reports runny eyes. He states that
these problems are new over the past 4 weeks, starting around
the same time as his dizziness. He also reports that he had a
runny nose for the past few days, and feels like there is
something in his throat. He has been self-administering an
antibiotic starting three days ago, which he has been taking 3
times a day, last taken this morning. He also states that he had
left sided leg swelling over the last week, but started taking
tamsulosin and urinating up to 15 times daily, with resolution
of his left leg swelling today. He denies any fevers, chills,
weight loss, buring or pain with urination, present cough, runny
nose. He denies any redness or irritation in his eyes.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss, but
may have gained some weight recently with leg swelling. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath - he usually sleeps on a couple of
pillows at night and this has not changed recently. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No dark or bloody
stools. No recent change in bowel or bladder habits. No dysuria.
He does have chronic arthritis and has pain in his right
shoulder and right side, worse when he sleeps on that side.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Coronary Artery Disease
- Myocardial infraction twice
- Aortic Stenosis s/p AVR (___)
- PERCUTANEOUS CORONARY INTERVENTIONS:
RCA stent ___ Bare metal), ___ Drug Eluting), also gives h/o
3 other PTCAs in the past.
3. OTHER PAST MEDICAL HISTORY:
Pulmonary embolism
Emphysema
COPD - on oxygen therapy off and on
h.o. GI Bleed(aspirin associated)
BPH
GERD (+ for H. Pylori)
Anemia
Infrarenal AAA
Vertigo - ? Viral tinitus
Diverticulosis
Osteoporosis
Appendectomy
Right inguinal hernia repair
Bilateral cataract surgery
Social History:
___
Family History:
Father with MI at age ___.
Physical Exam:
ADMISSION Physical Exam:
Vitals: 99.5, 147/51, 48, 16, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. No conjunctival
injection//erythema/discharge.
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE Physical Exam:
Vitals: 97. 9 -121/75 - 102 - 16 - 99ra
i/o 693 in, yest 1350/br.
weight yest 58.1 kg
General: Alert, oriented, no acute distress, sitting in bed
HEENT: Sclera anicteric, MMM, oropharynx clear. No conjunctival
injection//erythema/discharge. EOMi.
Neck: supple, prominent v waves, no LAD
Lungs: crackles to mid lung bases bilaterally, no wheezes,
rales, rhonchi
CV: irregular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no edema
Neuro: cn ___ intact. gait slow, but otherwise wnl.
Pertinent Results:
ADMISSION LABS
===============
___ 06:27PM BLOOD WBC-9.8 RBC-4.30* Hgb-7.3* Hct-26.9*
MCV-63*# MCH-17.0*# MCHC-27.1* RDW-19.0* Plt ___
___ 06:27PM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-5 Eos-0
Baso-0 ___ Myelos-0
___ 06:27PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Target-1+
Pencil-OCCASIONAL Tear Dr-1+ Fragmen-OCCASIONAL Ellipto-1+
___ 06:27PM BLOOD ___ PTT-27.7 ___
___ 06:27PM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-145
K-3.8 Cl-103 HCO3-26 AnGap-20
___ 06:27PM BLOOD ALT-37 AST-19 AlkPhos-63 TotBili-0.4
___ 06:27PM BLOOD Albumin-4.4 Calcium-9.2 Phos-4.2 Mg-1.9
___ 06:37PM BLOOD Lactate-4.6*
___ 06:37PM BLOOD Hgb-8.0* calcHCT-24
___ 06:27PM BLOOD Lipase-17
OTHER PERTINENT LABS
=====================
___ 08:38AM BLOOD freeCa-1.11*
___ 08:38AM BLOOD Lactate-2.0
___ 07:30AM BLOOD calTIBC-337 VitB12-511 Folate-GREATER TH
Hapto-222* Ferritn-5.0* TRF-259
___ 07:30AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 Iron-17*
___ 07:10AM BLOOD Mg-2.1
___ 07:30AM BLOOD LD(LDH)-218
___ 07:10AM BLOOD Glucose-86 UreaN-18 Creat-0.9 Na-142
K-3.9 Cl-104 HCO3-23 AnGap-19
___ 07:30AM BLOOD Ret Man-2.3*
___ 07:10AM BLOOD WBC-9.3 RBC-4.60 Hgb-8.3* Hct-30.7*
MCV-67* MCH-18.2* MCHC-27.2* RDW-21.5* Plt ___
___ 06:27PM URINE Color-Straw Appear-Clear Sp ___
___ 06:27PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 06:27PM URINE RBC-0 WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1
CARDIAC ENZYMES
___ 06:27PM BLOOD cTropnT-0.03*
___ 02:01AM BLOOD CK-MB-4 cTropnT-0.03*
___ 07:30AM BLOOD proBNP-1261*
___ 01:15PM BLOOD CK-MB-4 cTropnT-0.05*
___ 02:01AM BLOOD CK(CPK)-34*
MICROBIOLOGY
============
___ URINE URINE CULTURE-FINAL
INITIAL EKG Normal sinus rhythm with intra-atrial conduction
abnormality and ventricular bigeminy. Incomplete right
bundle-branch block. Suspect inferior myocardial infarction of
indeterminate age. Diffuse non-specific ST-T wave abnormalities.
Compared to the previous tracing of ___ the ventricular
premature complexes are new. The ST segment abnormalities are
new in comparison to previous tracing of ___.
Rate PR QRS QT/QTc P QRS T
___ 372/449 66 5 -2
REPEAT EKG
Sinus rhythm. Occasional ventricular premature beats. Possible
old myocardial infarction. Anterior ST-T wave changes are
non-specific. Compared to the previous tracing of ___
ventricular ectopy is less frequent.
Rate PR QRS QT/QTc P QRS T
88 ___ 74 -3 -38
CXR FINDINGS:
The patient is status post median sternotomy and CABG. Heart
size remains borderline enlarged, and unchanged. The aorta is
tortuous. Lungs remain hyperinflated with attenuation of the
pulmonary vascular markings towards the apices compatible with
underlying emphysema. There is no pulmonary vascular
congestion. Patchy bibasilar airspace opacities could reflect
atelectasis. No pleural effusion or pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION: Mild bibasilar atelectasis. Emphysema.
CT HEAD
FINDINGS: There is no evidence of acute intracranial
hemorrhage, edema, mass, mass effect, or vascular territorial
infarction. The ventricles and sulci are normal in size and
configuration. There is a small right basal ganglial
hypodensity, likely prominent perivascular space or old lacunar
infarct. Periventricular and subcortical white matter
hypodensities are suggestive of chronic small vessel ischemic
disease. There are calcifications in the bilateral distal
vertebral arteries as well as the cavernous internal carotid
arteries. No fracture is identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No evidence of acute intracranial process.
L ___
FINDINGS: Grayscale, color and Doppler images were obtained of
the left common femoral, femoral, popliteal and tibial veins.
Normal flow, compression and augmentation is seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left leg.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ year old ___ gentleman with history of
COPD, CAD, and aortic stenosis s/p AVR (___),
aspirin-associated GI-bleed, presenting with dizziness and
likely symptomatic anemia.
ACTIVE ISSUES
==============
# Presyncope / Anemia: He does have anemia, (Hb 7.3, previously
___ with worsening microcytosis, pencil cells on smear,
concerning for iron deficiency which appears to be chronic in
nature dating back to at least ___. He has required
transfusions in the past. Stool is guaiac negative, although he
does have a history of aspirin-related GI bleed. He reported
subjective improvement in dizziness after receiving a unit of
pRBCS. Overall, this was the likely cause of dizziness and
malaise. Orthostatics were not done in the ED, and they were
negative after he already received blood once admitted. Other
causes likely contributed: specifically, medication effect- he
does take low dose alprazolam, oxycodone, and theophylline which
could all contribute (especially theophylline). In addition,
PVCs could have contributed to his feeling of malaise (see
discussion below) and they improved after transfusion as well.
He did not have any focal signs of infection (including no
dysuria). There was no hemodynamic evidence of massive PE, no
hypoxia, no tachycardia, and ___ was negative for DVT of the
leg. He did have a history of AS but is s/p valvular repair and
per his cardiologist had an echo in ___ at ___ which was
not concerning.
- anemia workup below
# Ventricular bigeminy: This was new from last several EKGs in
our system. This was likely reactive to anemia and electrolyte
abnormalities; it improved after transfusion and electrolyte
repletion. Per his cardiologist, his echo was not concerning in
___. As such, no need for echo given recent echo and low
suspicion for acute cardiac event. He was HD stable during
admission; he did have a short 8-beat run of v-tach the day of
discharge (not hemodynamically significant). He refused
magnesium at that time.
# iron deficiency anemia: This is acutely worsened, on a chronic
process, but also has chronic microcytosis. Thallasemia is
possible, possibly with superimposed iron deficiency given
worsening recent microcytosis, pencil cells. Stool is guaiac
negative, no melena/hematochezia history to explain new anemia.
- needs ___ as outpatient.
- started ferrous sulfate 325 mg daily - please follow up for
improvement in HCT 3 months from discharge.
# Elevated lactate: Had elevated lactate on admission which
resolved s/p transfusion - this likely reflected poor tissue
perfusion oxygenation due to anemia and dehydration.
CHRONIC ISSUES
===============
# COPD: Continued home nebulizers and theophylline. Theophylline
could potentially be contributing to patient's symptoms. He also
appears to be on chronic prednisone, which may have been started
on last admission to ___. If not needed for acute flare,
consider tapering this off. If necessary, then he should begin
PCP ___. Consider tapering or stopping theophylline as
well given its narrow therapeutic window.
# CAD/CHF: Patient has a signficant history of coronary disease
with multiple interventions and reported history of MI's.
Continued aspirin 81mg and simvastatin 20mg daily. He may
benefit from a beta blocker.
# BPH: Continued tamsulosin qhs.
# Hypertension: Not currently on anti-hypertensives. He was
intermittently hypertensive during this admission.
# Anxiety: He is on alprazolam at home, which was restarted at
half the dose and PRN.
# Arthritis: He called his daughter repeatedly to report pain -
his home oxycodone had initially been held in the context of
dizziness. This was restarted given his pain.
TRANSITIONAL ISSUES
====================
- Code status: Full code, confirmed.
- Emergency contact: daughter, ___ ___.
- Studies pending on discharge: None.
- Received 1unit pRBCs for HCT 26 --> 30, with improvement in
PVCs (also electrolyte repletion).
- found to have iron deficiency anemia; started on ferrous
sulfate once daily, please reheck for ~2point improvement in ~3
months. Low retic.
- On prednisone 20mg daily (prescribed here in ___ - please
consider stopping chronic prednisone). IF prednisone is
necessary, please start PCP ___. Also on theophylline;
given its narrow therapeutic window and side effect profile,
please consider decreasing or stopping this medication. He
should have a theophylline level checked as well.
- Consider HTN treatment and initiation of BB given history of
CAD.
- Recheck HCT at outpatient follow-up.
- Needs EGD/colonoscopy (done reportedly w/i ___ years, but
records are not available).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY:PRN Constipation
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Tamsulosin 0.4 mg PO HS
5. Simvastatin 20 mg PO DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
7. Theophylline SR 200 mg PO BID
8. ALPRAZolam 1 mg PO Q6H
9. PredniSONE 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Pantoprazole 40 mg PO Q24H
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Loratadine *NF* 10 mg Oral daily
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN Constipation
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Pantoprazole 40 mg PO Q24H
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. PredniSONE 20 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Theophylline SR 200 mg PO BID
12. Acetaminophen 1000 mg PO Q8H
13. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) one tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Loratadine *NF* 10 mg Oral daily
16. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute blood loss anemia, orthostasis, Ventricular
arrythmia (bigeminy)
Secondary: COPD, CAD, prior GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were feeling dizzy and
tired. You were found to have a low blood count (also called
anemia), which you have had before. You did not have any
evidence of active bleeding. You were seen by Neurology and they
did not feel you had any acute neurological issues. It was also
reassuring that your ENT doctor did not think any ear issues
were contributing. Overall, we think you felt unwell because of
your low blood count - we prescribed you iron pills, which you
can take daily with orange juice to help improve your blood
count. You should also talk with your PCP about getting ___
colonoscopy/EGD to evaluate the cause of your low blood count.
You had some changes in your heart rhythm which improved after
you received blood and electrolytes.
You also reported previous leg swelling, but did not have
evidence of a blood clot. The physical therapists will follow
your progress at home.
You should also decrease the dose and frequency of alprazolam,
or not use it at all, if possible, because it can also make you
dizzy.
Please do not take extra doses of tamsulosin for leg swelling
as this can decrease your blood pressure and make you dizzy.
Followup Instructions:
___
|
10625498-DS-16
| 10,625,498 | 23,718,521 |
DS
| 16 |
2185-05-13 00:00:00
|
2185-05-13 15:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Lumbar puncture
attach
Pertinent Results:
___ 06:55PM BLOOD WBC-8.3 RBC-3.78* Hgb-12.4* Hct-37.1*
MCV-98 MCH-32.8* MCHC-33.4 RDW-15.2 RDWSD-54.9* Plt ___
___ 06:55PM BLOOD ___ PTT-26.3 ___
___ 07:10AM BLOOD Glucose-105* UreaN-24* Creat-1.2 Na-139
K-4.3 Cl-101 HCO3-26 AnGap-12
___ 07:10AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.2
___ 07:10AM BLOOD Lyme Ab-PND
___ 06:55PM BLOOD Lactate-0.8
CT ABD:
IMPRESSION:
No acute abdominopelvic pathology, specifically no evidence of
obstructing
renal stones, hydronephrosis or perinephric abscess.
CXR:
FINDINGS:
The lungs are well expanded and clear. There is no pleural
effusion or
pneumothorax. The thoracic aorta is slightly tortuous. The
cardiomediastinal
silhouette is otherwise within normal limits. There is no acute
osseous
abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality.
MRI BRAIN/ORBITS:
IMPRESSION:
1. Study is moderately degraded by motion.
2. Question minimal residual abnormal enhancement and fat
stranding around
bilateral optic nerves versus artifact, overall decreased
compared to ___ prior exam.
3. No acute intracranial abnormality, no definite evidence of
acute infarct.
4. Within limits of study, no definite evidence of enhancing
intracranial
mass.
5. Paranasal sinus disease and nonspecific left mastoid fluid,
as described.
6. Grossly stable left suboccipital probable sebaceous cyst.
7. Grossly stable approximately 1 cm left frontal calvarial
lesion
corresponding to well-circumscribed sclerotic lesion on ___TA, suggestive of bone island, with differential
consideration of
hemangioma and sclerotic metastatic lesion less likely. If
concern for
metastatic lesion, consider correlation with any available prior
outside
imaging. If prior outside imaging is not available, consider
bone scan for
further evaluation.
Brief Hospital Course:
Pleasant ___ with hx of TN, HLD, diverticulosis, GCA on
pred 15 and Bactrim/acyclovir proph who was transferred from
outside hospital for further management fever I/s/o prednisone
use and subacute non-specific neurologic sxs including
imbalance, transient blindness and more recently
confusion/difficulty walking.
# Sepsis due to presumed UTI
Patient improved with empiric treatment of UTI. Only focal
symptoms were recent
dysuria. Infectious work up largely negative. UCx was NOT
taken at ___ per my discussion with micro lab there. UCx
here with <10cfu. Given fever and urinary symptoms we treated
for presumed complicated UTI. He had no signs for pyelo. He
had no signs for meningitis, PNA, GI infection. Blood cx neg x
48 hrs. He was initially on CTX and then on DC was transitioned
to Nitrofurantoin to complete a total 7 day course (cipro was
considered but given resistance patterns we decided to use
nitrofurantoin)
# ? GCA:
# Optic Neuritis:
Admitted to neurology in ___, temp artery biopsy was negative
however given high suspicion for GCA and worsening sxs with
steroid taper, he was continued on steroids. This improved his
symptoms and worsened with taper. He currently had no worsening
of symptoms. We reviewed case with outpatient neurologist and
LP
was performed. Initial testing was neg for infection or
inflammation. We will await final PCR results and cytology.
Flow cytometry was ordered but there were scant cells and thus
was unable to be run. He has close follow up in early
___. CSF was saved for further testing as needed. MRI
brain and orbits were performed documenting stability
# HTN: Resumed on DC
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Omeprazole 40 mg PO DAILY
4. PredniSONE 15 mg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
6. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*9 Capsule Refills:*0
2. Calcium Carbonate 500 mg PO TID
3. Lisinopril 10 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. PredniSONE 15 mg PO DAILY
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
7. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis due to UTI
Optic neuritis/GCA
Hypertension
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 fever and diagnosed with a
likely urinary tract infection. You improved on antibiotics and
will be discharged to complete a course of treatment.
You also had a lumbar puncture and MRI to evaluate your vision
symptoms and inflammation of the nerve of your eye. There are
several pending tests. It is very important that you follow up
as scheduled with your providers for ongoing care
Followup Instructions:
___
|
10625523-DS-11
| 10,625,523 | 23,102,271 |
DS
| 11 |
2141-06-03 00:00:00
|
2141-06-06 23:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nafcillin
Attending: ___
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
___ placed ___
History of Present Illness:
Ms. ___ is a ___ with history of alcoholic cirrhosis who was
referred from ___ clinic for hypotension to ___ systolic.
Of note, she was admitted most recently in ___ for worsening
peripheral edema attributed to progressive portal hypertension,
prompting large-volume paracentesis and initiation of furosemide
and spironolactone, and intermittent melena and bright red blood
per rectum ascribed to congestive gastropathy and hemorrhoids.
She was seen in ___ clinic in routine follow-up on the
day of admission and noted to be asymptomatically hypotensive to
___ systolic, denying lightheadedness or chest pain, and
referred to the ED for further evaluation; baseline blood
pressure appears to be 110s-120s systolic. It appears that
spironolactone was uptitrated from 100mg to 150mg in ___,
though she is no longer on furosemide due to association with
electrolyte abnormalities.
In the ED, initial vital signs were as follows: 98.0, 91,
149/59, 16, 100% RA. Admission labs were notable for Wbc of 15.6
(76% PMNs, 10% eos), Hct of 30.1, platelets of 96, INR of 2.5,
ALT/AST of 43/82, AlkP of 183, TBili of 6.3, lipase of 28,
bicarbonate of 19, lactate of 2.4, negative urine toxicology
screen and urine hCG, and urinalysis with trace leukocytes and
negative nitrite. Diagnostic paracentesis was performed and
demonstrated 166 Wbc with 29% PMNs. Blood and urine cultures
were drawn. CXR PA/lateral showed focal opacity in the lingula
consistent with pneumonia versus atelectasis and mild pulmonary
edema. CT abdomen/pelvis was without obvious source of
infection. She received ceftriaxone 2g IV prior to diagnostic
paracentesis and 1L of IV normal saline. After lactate was found
to be elevated to 3 on repeat check, she received an additional
1L of IV normal saline. Vital signs at transfer were as follows:
97.7, 94, 97/53, 17, 97% RA.
On arrival to the floor, she is tired, but entirely comfortable,
denying fevers, chills, sweats, or focal infectious symptoms of
any kind or signs of bleeding as below.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Alcoholic cirrhosis
Gastritis and duodenitis
Hypertension
Dysthymia
Heart murmur in ___
Dry eye syndrome
Social History:
___
Family History:
Father with throat cancer, died from unknown cause. Mother with
recent "kidney problem", now resolved.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 99.9, 95/45, 102, 96% RA
General: Well-appearing in NAD
HEENT: +Scleral icterus
Neck: No apparent JVD
CV: RRR, ___ SM throughout precordium (previously documented)
Lungs: CTAB, breathing comfortably
Abdomen: Nontender throughout without shifting dullness
GU: No CVA tenderness
Ext: Trace pitting edema to shins bilaterally
Neuro: Alert, oriented, appropriately conversant, no asterixis
Skin: Warm, well-perfused, jaundiced, bilaterally lower
extremities with mild venous stasis changes, right lower
extremity with well-circumscribed excoriation with overlying
scab and mild circumferential warmth, erythema, and tenderness,
no cutaneous stigmata of endocarditis
DISCHARGE PHYSICAL:
98.5 103/53 92 18 98 on RA
General: comfortable appearing, on nasal cannula
CV: RRR, pansystolic murmur loudest LUS border
Lungs: CTAB
Abdomen: Soft, nontender, mild distension
GU: No Foley
Neuro: Alert oriented x3, appropriately conversant, faint
asterixis
Skin:punctate 3 x 3 lesion on anterior shin, good granulation
tissue, no purulence expressed
Pertinent Results:
ADMISSION LABS
___ 10:15PM ___ PH-7.45 COMMENTS-GREEN TOP
___ 10:15PM LACTATE-3.0*
___ 04:00PM ASCITES TOT PROT-0.8 GLUCOSE-117
___ 04:00PM ASCITES WBC-166* RBC-1205* POLYS-29*
LYMPHS-15* MONOS-0 EOS-1* MACROPHAG-53* OTHER-2*
___ 01:43PM LACTATE-2.4*
___ 01:30PM GLUCOSE-108* UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-19* ANION GAP-15
___ 01:30PM ALT(SGPT)-43* AST(SGOT)-82* ALK PHOS-183* TOT
BILI-6.3*
___ 01:30PM LIPASE-28
___ 01:30PM ALBUMIN-2.5*
___ 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:30PM WBC-15.6*# RBC-2.82* HGB-9.7* HCT-30.1*
MCV-107* MCH-34.4* MCHC-32.2 RDW-17.5*
___ 01:30PM NEUTS-76* LYMPHS-10* MONOS-4 EOS-10* BASOS-0
___ 01:30PM PLT COUNT-96*
___ 01:30PM ___ PTT-43.0* ___
___ 01:14PM URINE UCG-NEG
___ 01:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:14PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-2* PH-6.0 LEUK-TR
___ 01:14PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-13
___ 01:14PM URINE MUCOUS-RARE
DISCHARGE LABS
___ 06:00AM BLOOD WBC-10.4 RBC-2.16* Hgb-7.6* Hct-23.9*
MCV-111* MCH-35.3* MCHC-31.9 RDW-23.6* Plt ___
___ 06:14AM BLOOD Neuts-65 Bands-1 ___ Monos-4 Eos-8*
Baso-0 Atyps-1* Metas-1* Myelos-0
___ 06:14AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Target-OCCASIONAL
Schisto-1+ Acantho-1+
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-44.8* ___
___ 06:00AM BLOOD Glucose-121* UreaN-16 Creat-1.6* Na-134
K-3.8 Cl-102 HCO3-25 AnGap-11
___ 06:00AM BLOOD ALT-16 AST-42* AlkPhos-132* TotBili-9.9*
___ 06:00AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9
___ 12:54PM BLOOD PTH-16
___ 06:20AM BLOOD 25VitD-21*
___ 06:20AM BLOOD CRP-36.1*
___ 06:03AM BLOOD Vanco-16.3
___ 07:09AM BLOOD Lactate-1.1
STUDIES
___ ABD & PELVIS WITH CO
IMPRESSION:
1. Hepatic cirrhosis, esophageal varices and large volume,
nonhemorrhagic
ascites.
2. Wedge-shaped compression deformity of the L1 vertebral body,
unknown in chronicity given the lack of relevant all comparison
studies.
3. Cholelithiasis without cholecystitis.
4. Extensive atherosclerotic vascular calcifications.
___ TTE
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. There is a probable vegetation on the
aortic valve. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. The mitral valve leaflets are mildly thickened. There is
a probable vegetation on the mitral valve. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild symmetric LVH with hyperdynamic systolic
function. Mobile echodensity on the mitral valve (seen best on
images #44,#45, #54 and #55). At least mild mitral regurgitation
is present. The aortic valve is thickened, particularly at the
tips of the leaflets - cannot exclude a vegetation. Mild
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___, the
mitral valve mass is new. The appearance of the aortic valve is
similar.
Cardiovascular ReportECGStudy Date of ___ 1:18:10 ___
Sinus rhythm at upper limits of normal rate. Mild inferior and
lateral
precordial ST segment depression. On the previous tracing of
___, there was
more artifact. ST-T wave abnormalities are now more apparent.
Clinical
correlation is suggested.
Read ___.
IntervalsAxes
___
___ LIVER/GALLBLADDER US
IMPRESSION:
1. No focal hepatic lesion is identified.
2. Moderate ascites, somewhat increased as compared to the prior
exam.
3. Patent portal vein demonstrating hepatopetal flow, suggestive
of underlying
portal hypertension and cirrhosis.
4. Minimal dilation of the extrahepatic CBD, unchanged from the
prior
examination. No intrahepatic biliary ductal dilatation.
5. Cholelithiasis without evidence of cholecystitis.
___ TTE
Conclusions
The left atrium is mildly dilated. 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) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Thickened aortic and mitral valves without discrete
visualized vegetations.
Compared with the prior study (images reviewed) of ___,
MV vegetation is not appreciated on the current study. A
transesophageal study, if feasible, would better define the
mitral valvular and aanular morphology.
Brief Hospital Course:
___ with history of EtOH-related cirrhosis (admission MELD score
25), prior hospitalizations for alcoholic hepatitis (___) and
edema/BRBPR (___) p/w hypotension to ___, rigors, and fever to
102. She was found to have endocarditis.
ACTIVE ISSUES
# SEVERE SEPSIS ___ ENDOCARDITIS: Patient admitted with ___ SIRS
criteria (tachycardia, leukocytosis), in setting of
immunosuppression, lactate of 3, also with MSSA bacteremia.
History notable for recent dental procedure. Infectious workup
at admission otherwise negative. TTE significant for vegetations
in mitral and aortic valve. Patient was treated with vancomycin
and cefepime narrowed to vancomycin due to nafcillin allergy.
She is to complete a 6 day course (Day 1 ___ -
___.
# HCAP: Hospital course complicated by increasing leukocytosis
and fever while on appropriate treatment for endocarditis above.
Patient started on meropenem for presumed HCAP. Beta lactams
avoided due to nafcillin allergy. d1 ___ ___, anticipate
___ x 8 days for HCAP (end date ___
# FLASH PULMONARY EDEMA: Hospital course complicated by
desaturations and increasasing oxygen requirement to 5 L face
mask in the setting of fluid resuscitation for ___ and
administration of packed red blood cells. CXR consistent with
moderate to severe pulmonary edema. EKG and troponins negative
for acute coronary syndrome. TTE negative for worsening valvular
abnormalities. Blood Bank ruled out TACO and TRALI. It is
possible that patient's desaturations
# ACUTE KIDNEY INJURY: Hospital course complicated by new onset
kidney injury two days after nafcillin administration. Renal
consulted. Low suspicion for acure interstitial nephritis,
despite new onset eosinophilia due to inappropriate timing of
onset. Hepatorenal syndrome unlikely due to good diuresis. Most
likely a result of poor fluid flow due to overdistention of
heart from colloid administration v. obstruction, as patient put
out 7 L with conservative diuresis and foley administration.
Creatinine plateaued.
#BRBPR: Hospital course complicated by 1 unit hemoglobin drop
transfused with PRBCs x 1 unit. Thereafter stable. Patient with
known hemorrhoids; only grade 1 varices on EGD ___.
CHRONIC ISSUES
# Alcoholic cirrhosis: Patient with h/o alcoholic cirrhosis,
with admission LFTs essentially at baseline. No evidence at this
time of alcoholic hepatitis given AST/ALT at baseline.
Transplant status: Currently pre-transplant. Will require workup
after stabilization of severe sepsis as described above.
- panorex done in-house, unremarkable. ___ need colonoscopy
pending endocarditis. Stress test and DEXA scan also needed,
will check if necessary in-house.
--Hepatic Encephalopathy: H/o HE, although currently AAOx3
without asterixis. Continue rifaximin and lactulose
--Varices/GIB: Most recent EGD ___ with grade I varices. H/H
stable between admissions, no e/o bleed currently. Currently not
on nadolol d/t low grade varices. Continue home pantoprazole.
STABLE CHRONIC ISSUES
# Thrombocytopenia: Platelets are consistent with baseline. Most
likely ___ cirrhosis.
# Depression: Continue home paroxetine.
TRANSTIONAL ISSUES:
- Patient still to have Pap, mammogram, colonoscopy, dental
evaluation for pre-transplant liver evaluation
- Patient will need to finish six week course of Vancomycin 1g
IV Q24; pt has ___ set up. Medication will be delivered on ___
in the ___. Patient will have first outpatient infusion on
___. Last dose of medication should be given on ___.
-Patient will follow up with her Liver specialist, PCP, and ___
as an outpatient
-Patient will stop taking her Lasix and Spironolactone until she
sees her Liver Doctor in clinic.
-If patient notes increased weight gain she will call the liver
clinic immediately
-Patient will continue all other home medications including
lactulose and rifaximen.
-Please draw CBC with diff, BUN, Cr, and Vancomycin trough
___ for 4 weeks; ICD 9: 424.90 Endocarditis
Should be faxed to ___. MD ___
Disease ___ ___ FAX: ___
Results should also be faxed to ___ ___ LIVER
CENTER ___ FAX: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Paroxetine 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 150 mg PO DAILY
8. Ursodiol 300 mg PO TID
9. Vitamin D 1000 UNIT PO DAILY
10. Magnesium Oxide 400 mg PO BID
11. Thiamine 100 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Paroxetine 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*56 Tablet Refills:*0
7. Thiamine 100 mg PO DAILY
8. Ursodiol 300 mg PO TID
9. Vitamin D 1000 UNIT PO DAILY
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. Magnesium Oxide 400 mg PO BID
12. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1 gram IV Daily Disp #*26 Vial Refills:*0
13. Outpatient Lab Work
Please draw CBC with diff, BUN, Cr, and Vancomycin trough
___ for 4 weeks-- ICD 9: 424.90 Endocarditis
Should be faxed to ___. ___
Disease ___ ___ FAX: ___
Results should also be faxed to ___ ___ LIVER
CENTER ___ FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
--------------------
SEVERE SEPSIS ___ MSSA ENDOCARDITIS
ACUTE KIDNEY INJURY
SECONDARY DIAGNOSIS
ETOH CIRRHOSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
___ were admitted for low blood pressure. ___ were found to have
an infection of your heart valves. ___ are to continue your
antibiotics for 6 weeks. After ___ antibiotics are done, please
get an repeat echocardiogram of your heart to make sure the
infection went away.
During your hospital course, ___ also had some injury to your
kidneys. This was treated with fluids initially. Your kidneys
only responded minimally to the fluids. ___ were then restarted
your diuretic medications, and were able to reduce the fluid in
your lungs and abdomen. At the time of discharge we decided to
hold your Lasix and Spironolactone until seeing your Liver
Doctor. ___ should not start these medications until instructed
to do so by your Liver Doctor.
___ should also monitor your weights daily wearing the same
clothes. If ___ notice any increase in weight greater than 3 lbs
___ should call the liver clinic immediately.
It has been a pleasure taking care of ___ at ___. We wish ___
well.
Sincerely,
Your Team at ___
Followup Instructions:
___
|
10625523-DS-12
| 10,625,523 | 27,245,469 |
DS
| 12 |
2141-07-10 00:00:00
|
2141-07-11 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nafcillin / ceftriaxone / cefepime / vancomycin
Attending: ___
Chief Complaint:
Shortness of breath on exertion
Major Surgical or Invasive Procedure:
EGD/Colonoscopy ___
History of Present Illness:
___ with hx of alcoholic cirrhosis (being evaluated for liver
transplant), found to have Aortic/Mitral valve MSSA endocarditis
during recent admission, who p/w DOE, weight gain, and chills.
Patient was d/c from ___ ___ on 6 weeks of vancomycin to
treat MSSA endocarditis. Over the past week, she noticed dyspnea
with household activities that improves with rest; she has no
problems lying down flat; no cough. Per ___, she has gained
weight recently; patient thinks swelling in her legs have
improved, but her abdomen has become more distended. During this
time, she has also experienced chills (full body tremors),
though has not had spiked temp (has been checking every day).
Denies feeling pain of any sort at this time.
In the ED, initial vitals: 99.2 89 126/84 20 98%
- WBC=15.0 (73.6% N, 12.3% E), Hgb=8.1 (MCV 111), PLT=113
- ALT=16 -> 44, AST=42 -> 151, AP=132 -> 106, TBILI=9.9 -> 14.7,
ALB=2.9 -> 2.8
- ___ < 0.01
127 95 21
------------ 88
3.0 16 2.0
- Creat=1.6 -> 2.0
- ___: 6283
- Lactate:2.6
- ___: 35.2 PTT: 51.2 INR: 2.6 -> 3.3
- UA: Bili (Lg), 0 WBCs, Nitrite (neg), Leuk (neg), Bact (None)
- Peritoneal fluid: WBC=81, Protein=1.3
CXR clear. Patient has R PICC in place. Given 80KCl, cefepime 2g
+ daily vanc, 1500 cc NS, and 75g 25% albumin.
On transfer, vitals were: 98.5 85 101/54 20 97% RA
Review of systems:
(+) diarrhea (4 loose BMs yesterday)
(-) Denies fever, cough, nausea, vomiting, constipation,
abdominal pain, dysuria, myalgias, melena, hematochezia.
Past Medical History:
- MSSA Endocarditis (Aortic / Mitral Valve)
- Alcoholic cirrhosis
- Gastritis and duodenitis
- Hemorrhoids
- Grade 1 varices (EGD ___
- Hypertension
- Dysthymia
- Heart murmur in ___
- Dry eye syndrome
Social History:
___
Family History:
Father with throat cancer, died from unknown cause. Mother with
recent "kidney problem", now resolved.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals 98.5 99 128/50 23 94% RA
GENERAL: A&Ox3, shaking throughout body
HEENT: Sclera icteric, mucous membranes with white exudate on
tongue and around edge of mouth
LUNGS: short shallow breaths, expiratory wheezing
CV: tachycardic, regular rate, no m/r/g appreciated
ABD: bs+, distended, slight ttp in LLQ, no rebound/guarding,
bandage in LLQ at site of paracentesis
EXT: Warm, well perfused, sores on anterior surfaces of BLE with
yellow exudate from each, 1+ pitting edema bilaterally
NEURO: responding appropriately, CN ___ intact, resting tremor
in hands (due to full body shaking) though no asterixis
appreciated
DISCHARGE PHYSICAL EXAM:
VS: 97.4 124/46, 76, 20, 98%RA
General: no apparent distress, jaundiced, AOx3
HEENT: sclerae icteric lips are mildly erythematous with no
ulcerations on lips. Scattered tongue ulcerations
CV: S1 S2 RRR ___ holosystolic murmur heard best at ___
Lungs: CTAB
Abdomen: Soft, mildly distended, ___, normoactive BS
Ext: No edema. RLE ulcers with c/d/i bandage
Neuro: no asterixis
Pertinent Results:
======= ADMISSION LABS =======
___ 04:25PM BLOOD ___
___ Plt ___
___ 04:25PM BLOOD ___
___
___ 06:09PM BLOOD ___ ___
___ 04:25PM BLOOD ___
___
___ 04:25PM BLOOD ___
___
___ 04:25PM BLOOD cTropnT-<0.01 ___
___ 02:49AM BLOOD ___
___ 04:32PM BLOOD ___
___ 04:25PM BLOOD ___
___
======= DISCHARGE LABS =======
___ 06:15AM BLOOD ___
___ Plt ___
___ 06:15AM BLOOD ___ ___
___ 06:15AM BLOOD ___
___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD ___
======= IMAGING =======
CXR (___)
IMPRESSION: Mild edema. Lower lung opacities likely atelectasis
and or pneumonia. PICC line terminates in the right atrium.
ABDOMINAL U/S WITH DOPPLER (___)
1. Extremely limited Doppler examination. Within this
limitation, the portal
and hepatic veins appear grossly patent by color Doppler
ultrasound
evaluation.
2. Reversal of flow within the main portal vein, stable from the
prior exam.
3. Moderate ascites.
4. Cholelithiasis without evidence of cholecystitis.
TTE ___:
IMPRESSION: no definite vegetations seen (suboptimal study)
V/Q scan ___
Very low likelihood ratio of pulmonary embolism.
Renal Ultrasound ___
Extremely limited examination secondary to patient's body
habitus and ascites.
No gross renal pathology identified.
TTE ___: IMPRESSION: Normal biventricular cavity sizes with
normal regional and hyperdynamic global systolic function.
Aortic and mitral valve thickening without pathologic
regurgitation.
CT Chest ___: Moderate pulmonary edema with trace bilateral
pleural effusions.
Additional findings of fluid overload including severe anasarca
and upper
abdominal ascites.
Cirrhosis.
Moderately distended partially imaged gallbladder containing
layering
gallstones.
Anemia.
Cardiac perfusion scan ___:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
TTE ___:
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
====STUDIES=====
___ EGD: Esophageal exudates compatible with ___
esophagitis throughout entire esophagus with associated mild
oozing of blood. There were no esophageal varices seen but view
was obscured by exudates. (biopsy)
Small hiatal hernia. Portal hypertensive gastropathy evident by
mosaic pattern of stomach mucosa. No appreciable gastric
varices.
Edematous mucosa of the second portion of the duodenum
compatible with portal hypertension.
Otherwise normal EGD to third part of the duodenum
___ Colonoscopy: Suboptimal prep was found throughout the
colon. Several small diverticuli were seen near transverse
colon. These were non bleeding. No fresh or old blood was seen
throughout the colon and rectum. No large masses were seen but
due to prep quality, smaller polyps can't be excluded. Several
small red spots most compatible with ___ inflammation
were seen scattered throughout the colon.
Otherwise normal colonoscopy to cecum
======= MICRO =======
___ 8:00 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___
10:45AM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1
PLATE.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:25 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:18 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:51 am URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
___ 4:55 am SWAB Source: Rectal swab.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
ENTEROCOCCUS SP.. Sensitivity testing performed by
Etest.
ENTEROCOCCUS SP.. ___ MORPHOLOGY.
Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
VANCOMYCIN------------ >256 R >256 R
___ 10:44 pm URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
___ 10:44 pm BLOOD CULTURE Source: Catheter.
Blood Culture, Routine (Pending):
___ 2:03 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:00 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
___ 9:00 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
___ 12:02 am STOOL CONSISTENCY: LOOSE Source:
Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference ___.
___ 2:00 am BLOOD CULTURE Source: ___.
Blood Culture, Routine Neg
___ Blood Culture Neg
___ Blood Culture NGTD
CRP:
36->3
ESR: 2
Brief Hospital Course:
Patient is a ___ with Child's C Cirrhosis and recently
admitted with MSSA endocarditis being treated with vancomycin,
who presented with worsening SOB and was found to have
leukocytosis, ___, hypotension and volume overload. Hospital
course including ICU admission and was complicated by worsening
___, AIN, partial DRESS, low grade DIC, pulmonary and
hyponatremia. She was also found to have esophageal candidiasis
during hospitalization. Patient completed course of daptomycin
for MSSA endocardiditis and was treated with prednisone (course
ongoing at time of discharge) for DRESS/AIN. She was diuresed
and weaned off supplemental O2. She was also discharged on IV
micafungin for esophageal candidiasis as well as ongoing
diuresis.
# DRESS/AIN: Given patient's clinical instability on admission,
she was started on cefepime in addition to vancomycin (for
ongoing MSSA treatment) for empiric ___ coverage.
However, she was transferred to the MICU on ___ for worsening
respiratory status in the setting of rising creatinine, full
body rash, and rising absolute eosinophilia (2.5k at time of
transfer). The patient's rash, absolute eosinophilia and
worsening renal function were primarily concerning for partial
DRESS. Dermatology was consulted and recommended discontinuation
of possible causative agents (PPI replaced by H2 blocker,
cefepime discontinued, vancomycin switched to daptomycin for
ongoing treatment of her MSSA endocarditis). Renal believed her
urine sediment was consistent with AIN given presence of WBC
casts, and recommended giving steroids. Given the patient's
worsening renal function and rising eosinophilia despite
stopping the possible causative drugs, treatment with prednisone
40mg daily was started on ___ with good effect. She was
treated empirically with ivermectin prior to steroid
administration. Patient was diagnosed with esophageal candidasis
during hospital course (see below), likely due to steroid use.
Given this, steroids were tapered to 30mg daily on ___ and
then 25mg daily on ___. Plan to decrease to 20mg daily on
___ and then further with renal's reccomendations. Creatinine
1 on discharge.
# Thrombophilia: During her hospital course patient experienced
episodes of spontaneous oral or nasal mucosal bleeding. Labs
were consistent with DIC vs Liver Failure with low fibrinogen,
low platelets, and elevated INR. Patient received several unites
of FFP, cryoprecipitate and packed red blood cells. EGD was also
performed on ___ to rule out variceal bleed contributing to
her H/H drop and showed severe esophageal candidasis with
associated oozing of blood (see below). She continued to require
intermittent cryoprecipitate or pack red blood cells but
experienced no hemodynamic instability.
# Pulmonary Edema: ___ hospital course was complicated by
significant pulmonary edema requiring aggressive diuresis.
Pulmonary edema was felt to be secondary to DRESS syndrome and
steroid use. Diuresis was scaled down after bump in Cr and
patient was ultimately titrated to furosemide 40mg PO and
spiranolactone 25mg PO. Her Cr stabilized and patient was weaned
off supplemental O2. She was discharged on furosemide 40mg PO
and spiranolactone 25mg PO.
___: Cr peaked to 3.2 this admission (baseline ___
was felt to be primarily due to AIN, though HRS may have also
been contributing due to decompensated cirrhosis and low urine
Na. Patient was treated with albumin and with octreotide and
midodrine. She was also started on prednisone for AIN, as above.
Her Cr improved to 1 by discharge. Of note, patient had AIN
secondary to nafcillin on previous hospitalization.
___ ESOPHAGITIS: Patient found to have likely ___
esophagitis on EGD on ___ for which she was started on a 2 week
course of micafungin (d1= ___, last day ___ given concern
for ___ resistant to fluconazole in cirrhosis patients.
Patient had a PICC line placed prior to discharge for ongoing
therapy.
#CIRRHOSIS: ___ at time of dischage (up from 18 at last
discharge on ___, peaked to 36 during hospitalization)
Patient has not had EtOH since ___. Decompensation most
likely due to ___ and partial DRESS syndrome. Patient underwent
transplant work up while hospitalized, which has been detailed
below. Hospital course was complicated by hepatic encephalopathy
that improved with lactulose uptitration. SBP prophylaxis was
discontinued ___ despite ascitic fluid with protein of 0.8.
This is because the patient's MSSA is susceptible to both
fluroquinolone and Bactrim, which could alter surveillance blood
cultures drawn prior to potential transplant due to endocarditis
history.
# MSSA Endocarditis: Patient completed course of daptomycin
(swtiched from vancomycin due to AIN/partial DRESS as above) on
___. TTE 48 hours after antibiotic therapy showed no
vegetation (though presence of vegetation may have represented a
sterile vegetation). Blood cultures drawn 48 hours after
antibiotic completion were pending at time of discharge. CRP
downtrending during hospitalization (36.1 on ___, 6.3 on
___. ESR pending at time of discharge.
# LLE shin sores: Patient has open wound with yellow exudate.
Patient was seen by wound care. Wounds may have been source of
endocarditis.
# Hyponatremia/hypernatremia: Na 127 on presentation, which was
likely due to cirrhosis (increased ADH, reduction in SVR ->
activation of RAAS). This eventually normalized and patient
patient became hypernatremic due to aggressive diuresis for
pulmonary edema. The patient was treated with maintenance D5W
with concurrent diuresis. Her sodium and volume status improved.
#Hypertension: SBP increased to 150s on ___. Patient was
restarted on atenolol, which she had previously been on as an
outpatient, for BP control with good effect.
#PROPHYLAXIS: Patient has multiple indications/contraindications
for prophylaxis -
----SBP: ascites fluid has been <1 previously. However, not
pursuing ppx with Bactrim or cipro as her MSSA is susceptible to
this and do not want to partially treat the MSSA such that it
would not be seen on serial blood cultures that are being drawn
for monitoring.
----PCP: patient on long term steroids and may require PCP
___. Are tapering steroids from ___ and will
consider prophylaxis with dapsone pending G6PD
----GI ulcer: on famotidine for ulcer prophylaxis while on high
dose steroids
___ WORKUP performed thus far:
- colonoscopy performed ___: suboptimal prep, large masses
excluded.
- pap smear performed ___, results pending
- ABG performed ___
- Mammogram at ___ on ___
- Panorex performed ___: dentistry recommended that
#11,#12,#23,#24,#25, #26 need to be extracted. Patient will have
to call here at 7am, any day at ___. They will coordinate extraction including being
done in a OR with backup given high risk of bleeding.
Transitional Issues:
- Based on panorex and bedside eval, dentistry recommended that
#11,#12,#23,#24,#25, #26 need to be extracted. Patient will have
to call her at 7am, any day at ___. They will coordinate extraction including OR
backup given high risk of bleeding.
- Follow up results of pap smear done ___ as part of
transplant workup
- Patient requires weekly blood culture, ESR/CRP. If ESR/CRP
normal, blood cultures negative and TEE and then may be
transplant canditate per transplant surgery
- Patient requires weekly CBC, fibrinogen to monitor for DIC.
Also monitor Cr weekly as patient being discharged on diuretics
and with tapered steroids
- Patient requires TEE in ___ weeks for completion of
___ workup
- avoid vancomycin, penicillins, PPIs given AIN
- She will require a total 6 week course of steroids (day ___, end date ___. Steroids to be tapered to 20mg on
___. Continue famotidine for GI prophylaxis while on steriods.
Follow up with renal for steroid course.
- F/u G6PD to start Dapsone for PCP ppx
- ___ 2 week course of micafungin (d1= ___, last day
___
- Consider SBP ppx in the future
- Atenolol added during hospital course for hypertension (had
been on previously)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Paroxetine 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Ursodiol 300 mg PO TID
9. Vitamin D 1000 UNIT PO DAILY
10. Magnesium Oxide 400 mg PO BID
11. Vancomycin 1000 mg IV Q 24H
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Magnesium Oxide 400 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Paroxetine 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Ursodiol 300 mg PO TID
9. Vitamin D 1000 UNIT PO DAILY
10. Aquaphor Ointment 1 Appl TP BID
11. Artificial Tears ___ DROP BOTH EYES PRN itchy eyes
12. Atenolol 25 mg PO DAILY
13. Famotidine 20 mg PO Q24H
14. Ferrous Sulfate 325 mg PO DAILY
15. Furosemide 40 mg PO DAILY
16. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN strep
throat
17. Micafungin 100 mg IV Q24H
18. PredniSONE 25 mg PO DAILY
19. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cirrhosis
Endocarditis
Partial Drug Reaction with eosinophilia and systemic symptoms
(DRESS) syndrome
Acute interstitial nephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for your shortness of breath. You had a
complex hospital course during which we treated you for an
infection of your heart valve, fluid in your lungs, cirrhosis,
an infection in your esophagus, a ___ reaction that
caused problems for your kidneys and skin, and a blood clotting
disorder. It is important that you continue to take your
medications as prescribed and that you follow up with your
doctors as recommended.
You will need certain teeth removed for your transplant
evaluation. You will have to call at 7am, any day at
___. The address is at ___
___. They will coordinate extraction which will be done in an
operating room.
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ care team
Followup Instructions:
___
|
10625726-DS-20
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| 20 |
2183-06-21 00:00:00
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2183-06-21 20:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
Right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
None this admission.
History of Present Illness:
This is a ___ year-old female with recent history of biliary
dyskinesia and gallbladder polyps s/p laparoscopic
cholecystectomy (___), later complicated by duct of Luschka
leak that required placement of common-bile duct stent on POD#5.
She is scheduled to undergo repeat ERCP and stent removal later
this month, however patient presents today with worsening right
upper quadrant pain (described as very similar to the kind she
had when she had gallbladder problems) with concomitant chills
but no fever, nausea but no emesis. Given worsening symptoms,
she contacted Dr ___ today, who instructed her to
present to our hospital for evaluation, and likely admission for
CBD stent removal.
Review of systems:
(+) per HPI
(-) fever, emesis, unexplained weight loss,
fatigue/malaise/lethargy, changes in appetite, trouble with
sleep, pruritus, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest
pain, shortness of breath, cough, edema
Past Medical History:
Depression, migraines, biliary diskynesia/chronic cholecystitis
Past surgical history:
Laparoscopic cholecystectomy, wisdon tooth extraction
Social History:
___
Family History:
Maternal grandmother and great aunts deceased secondary to
advanced breast cancer.
Physical Exam:
VS: Tmax 98.8, Tcurrent 98.8, HR 52, BP 100/56, RR 19, O2 sat
100 RA
Gen: Pt is alert and oriented, in no acute distress.
HEENT: Sclerae anicteric, oropharynx is clear.
Neck: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy.
Chest/pulm: Lungs are clear to auscultation bilaterally,
respirations are unlabored on room air.
Abd: Soft, non-tympanitic, mild tenderness to palpation in right
upper and epigastric regions, otherwise nontender, no
distention, prior surgical incisions are well-healed and intact,
no palpable organomegaly.
GU: No urinary drainage system; patient is voiding independently
without issue.
Ext: No edema, distal extremities feel warm and appear
well-perfused.
Neuro: Grossly intact.
Pertinent Results:
Labs on admission:
WBC 5.9, Hgb 15.0, Hct 43.1, platelets 161
Na 141, K 4.2, Cl 100, HCO3 27, BUN 19, Cr 0.7, glucose 86
___ 10.2, PTT 33.9, INR 0.9
ALT 65, AST 36, AP 92, Lip 42, TBili 0.5, Alb 4.8
Lactate 0.7
RUQ US (___):
Common bile duct stent in place with pneumobilia reflecting
stent patency. Mild amount of free air seen in the gallbladder
fossa may be secondary to the patient's postoperative state. No
fluid collections. 3.1 cm right lower lobe hepatic hemangioma.
___ (___):
1. Susceptibility artifact from cholecystectomy clips slightly
limits evaluation for biliary leak in the gallbladder fossa,
however no leak is identified on delayed imaging. No evidence of
extravasated biliary contrast agent.
2. No intrahepatic or extrahepatic biliary ductal dilatation.
3. Unchanged right hepatic lobe hemangioma.
Brief Hospital Course:
On ___ Ms. ___ presented to the hospital due to burning
right upper quadrant pain and she was admitted to the inpatient
Surgery service for further workup and care. Please refer to
the HPI for additional details regarding her initial
presentation to the hospital. A right upper quadrant ultrasound
was performed, which yielded the following findings: Common bile
duct stent in place with pneumobilia reflecting stent patency.
Mild amount of free air seen in the gallbladder fossa may be
secondary to the patient's postoperative state. No fluid
collections. 3.1 cm right lower lobe hepatic hemangioma. Ms.
___ labs on admission were unremarkable (WBC and LFTs
within normal limits) and are reflected in the pertinent results
section of this report.
She was kept NPO and GI was consulted for possible stent
removal. The GI team reviewed the findings on her ultrasound,
and said that the stent appeared functional and in proper
position, and in the setting of her abdominal pain, they
recommended deferring stent removal until a later date.
On ___ Ms. ___ underwent an ___ to elucidate the
etiology of her abdominal pain. The ___ showed no evidence of
extravasated biliary contrast agent, i.e., no leak. There was
no intrahepatic or extrahepatic biliary ductal dilatation. It
also showed an unchanged right hepatic lobe hemangioma, as
previously noted on ultrasound.
The following day Ms. ___ opted for a regular diet (contrary
to the recommendation to remain NPO should she require any
additional procedures for workup of her abdominal discomfort).
She tolerated the diet without any issues, but continued to
experience the same burning right upper quadrant pain she
presented with.
On ___ Ms. ___ was discharged home. She had no
pertinent imaging or laboratory abnormalities, her physical exam
was benign, and she was tolerating a regular diet. She will
follow-up with Dr. ___ on ___ at 9:00am for stent
removal.
Medications on Admission:
Citalopram 20 mg PO DAILY
Acetaminophen ___ mg PO Q8H:PRN Pain
Alprazolam 0.5 mg PO QHS:PRN anxiety
Docusate Sodium 100 mg PO DAILY:PRN constipation
Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Citalopram 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth BID
PRN Disp #*30 Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 hours Disp #*30
Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID PRN Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for abdominal pain. Imaging of your
surgical region was normal. We are discharging you with
follow-up in our clinic to assess the severity/change in your
pain. You will also follow-up with GI/ERCP for removal of your
stent.
Please resume your regular home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
If you are prescribed analgesic medications, you should take
them if needed. You may not drive or heavy machinery while
taking narcotic analgesic medications. You may also take
acetaminophen (Tylenol), but do not exceed 4000 mg in one day.
For any pills, we recommend crushing and taking with apple
sauce, pudding, or juice.
Please get plenty of rest, but also be sure to to walk several
times per day. Avoid strenuous physical activity until you
follow-up with your surgeon, who will instruct you further
regarding activity restrictions. Please also follow-up with your
primary care physician in addition to your surgical follow-up.
Please call the clinic or come to the Emergency Department:
*If you have increasing abdominal pain
*Fevers or drainage from your incision site
Thank you for allowing us to take part in your care. We look
forward to seeing you at your follow-up appointment in clinic.
Please do not hesitate to call us with any questions or
concerns.
Sincerely,
Your ___ Surgery team
Followup Instructions:
___
|
10625810-DS-21
| 10,625,810 | 27,990,879 |
DS
| 21 |
2171-01-19 00:00:00
|
2171-01-20 23:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine / Codeine
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ yr old woman who was traveling as a passenger
in a ___ going to the airport. Pt was seat belted in the back
seat, sustained fractured sturum and ribs, mesenteric hematoma.
Transfered from an outside hospital.
Past Medical History:
PMH: HLD, surgically hypothyroidism, HTN, GERD
PSH: tonsillectomy, achilles tendon repair
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission:
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
Pelvic: No cervical motion tenderness
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
___: No petechiae
Discharge:
GEN: Alert, awake, oriented,NAD
CV: RRR no m/r/g
Chest: CTAB, minor right lower rib tenderness.
Abdomen: Soft, non-tender, non distended, lower abdominal
hematoma.
Ext: Moving all ext, notenderness, full ROM.
Pertinent Results:
___ 07:35PM BLOOD WBC-11.8* RBC-5.16 Hgb-15.2 Hct-44.6
MCV-87 MCH-29.5 MCHC-34.0 RDW-12.4 Plt ___
___ 07:16AM BLOOD WBC-12.2* RBC-4.49 Hgb-12.9 Hct-39.2
MCV-87 MCH-28.8 MCHC-33.0 RDW-12.8 Plt ___
___ 01:30PM BLOOD Hct-38.3
___ 06:45AM BLOOD WBC-7.6 RBC-4.43 Hgb-13.2 Hct-39.2 MCV-89
MCH-29.7 MCHC-33.6 RDW-12.2 Plt ___
___ 07:35PM BLOOD ___ PTT-26.2 ___
___ 07:35PM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-139
K-3.9 Cl-99 HCO3-27 AnGap-17
___ 05:30AM BLOOD Glucose-94 UreaN-8 Creat-0.6 Na-138 K-3.9
Cl-103 HCO3-26 AnGap-13
___ 07:35PM BLOOD Amylase-65
___ 06:01AM BLOOD ALT-34 AST-32 AlkPhos-61 TotBili-0.7
___ 07:35PM BLOOD Lipase-72*
___ 06:01AM BLOOD Lipase-14
___ 07:16AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
___ 05:30AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1
___ 07:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT abdomen ___
IMPRESSION:
1. Improved but persistent periduodenal/peripancreatic head
stranding with
layering mild blood products in the right paracolic gutter
consistent with
mild hemoperitoneum. No evidence of extraluminal contrast
extravasation or
free air to suggest perforation or duodenal wall thickening to
suggest a
discrete hematoma.
2. No evidence of injuries to the surrounding organs. No
obvious
pseudoaneurysm visualized, within the limits of the examination.
3. Bibasilar subsegmental atelectasis.
4. Acute nondisplaced fractures of the right eleventh rib and
displaced
fracture of the twelfth rib of less apparent chronicity.
Brief Hospital Course:
Ms. ___ was transferred to ___ ___ after a MVC from
and OSH with a sternal fracture, Right ___ non displaced rib
fractures, possible duodenal injury. Repeat CT with PO contrast
at ___ shows a mesenteric hematoma with a small amount of
hemoperitonium, no perforation and contrast passes into the
jejunum making a duodenal injury unlikely. She was monitored
with serial HCTs to check for hemorrhage which were stable. She
was kept NPO with IVF and and an NG tube for 2 days. Her diet
was then advanced tolerated to a regular diet which she
tolerated well after the NGT was removed, started on home meds.
She had areassuring abdominal exam and was able to ambulate
without difficulty. Her O2 sats remained normal and was
provided IS. She was able to move her bowels and felt
comfortable returning home. She was given the ___ clinic
contact information for follow up. Given sternal precautions.
Medications on Admission:
Levothyroxine 137 mcg daily, atorvastatin 20 mg daily,
amlodipine 10 mg PO daily, nexium and zantac daily.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 137 mcg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily
Duration: 1 Months
RX *esomeprazole magnesium [Nexium] 40 mg 1 capsule(s) by mouth
Daily Disp #*30 Capsule Refills:*0
7. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
RX *zolpidem 5 mg 1 tablet(s) by mouth At bedtime Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal hematoma
Right ___ Rib Fractures
Sternal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You suffered multiple injuries after a car accident. You had a
hematoma to a part of your small intestines. We observed you
for several days and were able to tolerate regular food. Call
your doctor or return to the emergency department if you have
increasing pain, nausea, vomiting, are unable to tolerate
food/liquids, are not able to pass gas or have a bowel movement.
Continue your home nexium, zantac.
You sustained rib fractures and a sternal fracture which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain. You should take your pain medicine
as 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. Refrain
from heavy lifting, contact sports until cleared by a doctor.
Avoid anything that will cause impact to your chest.
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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
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 drive or operate heavy
machinery while on oxycodone as it can make you sleepy.
If your doctor allows, non steriodal ___ drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Sternal precautions:
Do not lift more than 8 pounds. (A gallon of milk weighs 8
pounds.)
Do not push or pull with your arms when moving in bed and
getting out of bed.
Do not flex or extend your shoulders over 90°.
Avoid reaching too far across your body.
Avoid twisting or deep bending.
Do not hold your breath during activity.
Brace your chest when coughing or sneezing. This is vital
during the first 2 weeks at home.
No driving until cleared by your doctor.
Avoid long periods of over the shoulder activity.
If you feel any pulling or stretching in your chest, stop what
you are doing. Do not repeat the motion that caused this
feeling.
Report any clicking or popping noise around your chest bone to
your surgeon right away.
Followup Instructions:
___
|
10625923-DS-21
| 10,625,923 | 28,721,403 |
DS
| 21 |
2133-02-14 00:00:00
|
2133-03-02 14:25:00
|
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:
___: CT-guided placement of an ___ pigtail catheter
into pelvic abscess
History of Present Illness:
___ w/h/o colon polyps p/w 5 days of lower abdominal pain. She
has had ongoing fevers this week up to 102.8. She has had some
nausea and NB/NB vomiting as well as diarrhea. No
hematochezia/melena. No previous similar symptoms. Last
colonoscopy ___ with single polyp.
Past Medical History:
PMH: Basal cell carcinoma, colon polyps, TIA.
PSH: T&A, BCC removal
Family History:
noncontributory
Physical Exam:
PE:
Vitals:99.2 89 123/56 18 100%
GEN: NAD
CV: RRR
ABD: softly distended, TTP LLQ/suprapubic
EXT: no c/c/e
Physical Exam on Discharge:
VS: VS stable, afebrile
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
around drain site, non-distended. LLQ drain site: clean, dry and
intact.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
___ 06:09AM BLOOD WBC-11.4* RBC-3.86* Hgb-11.4* Hct-33.7*
MCV-87 MCH-29.7 MCHC-34.0 RDW-12.7 Plt ___
___ 08:35AM BLOOD WBC-12.4* RBC-3.68* Hgb-10.9* Hct-32.2*
MCV-88 MCH-29.6 MCHC-33.7 RDW-12.6 Plt ___
___ 07:04AM BLOOD WBC-14.0* RBC-3.87* Hgb-11.4* Hct-33.6*
MCV-87 MCH-29.4 MCHC-33.9 RDW-12.6 Plt ___
___ 12:15PM BLOOD WBC-14.6*# RBC-4.13* Hgb-12.6 Hct-36.0
MCV-87# MCH-30.5 MCHC-35.0 RDW-12.6 Plt ___
___ 06:09AM BLOOD Glucose-95 UreaN-13 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
___ 08:35AM BLOOD Glucose-111* UreaN-11 Creat-0.6 Na-135
K-3.9 Cl-104 HCO3-25 AnGap-10
___ 07:04AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-140
K-3.6 Cl-104 HCO3-26 AnGap-14
___ 12:15PM BLOOD ALT-29 AST-51* AlkPhos-139* TotBili-0.4
___: CT A/P
1. Fluid collection in the deep pelvis (7.2 x 3.3 x 3.0 cm) and
right adnexa (1.5 x 3.0 x 1.7 cm) concerning for a contained
sigmoid perforation, possibly in the setting of acute
diverticulitis less likely colitis. No free air.
2. Mildly inflamed appearance of the appendix likely reactive.
3. Trace right pleural effusion.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed sigmoid colitis with 6.8
x 3.1 cm abscess posterior to the uterus. WBC was elevated at
14.6. The patient was hemodynamically stable. She was admitted
with likely perforated diverticulitis, and was made nothing by
mouth, given IV fluids, and IV antibiotics. On HD2 she underwent
an ___ of the abscess and a drain was left in place.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, and WBC trending down. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home with services for drain care. She was discharged
on oral antibiotics, to complete a 2-week course and follow-up
in the ___ clinic. 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. Atorvastatin 40 mg PO QPM
2. Aspirin 325 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Ibuprofen 400 mg PO QAM:PRN hip pain
5. Magnesium Oxide 500 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*39 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*26 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Atorvastatin 40 mg PO QPM
6. Ibuprofen 400 mg PO QAM:PRN hip pain
7. Magnesium Oxide 500 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Acute diverticulitis
2. Sigmoid perforation with 6.8 x 3.1 cm abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain and were found to
have sigmoid diverticulitis, likely perforated, with a resulting
fluid collection (abscess). You were put on bowel rest and given
IV fluids, IV antibiotics, and were taken to Interventional
Radiology to have a drain placed in the abscess. You tolerated
this procedure well. Your pain has improved and you are now
tolerating a regular diet. You are ready to be discharged home
with the drain to continue your recovery and to complete a
course of oral antibiotics. Please note the following discharge
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
Followup Instructions:
___
|
10626168-DS-9
| 10,626,168 | 20,169,881 |
DS
| 9 |
2171-02-26 00:00:00
|
2171-02-26 16:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Silver / Vancomycin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with PMHx HFpEF, Afib, chronic bronchitis, HTN
presents with hypoxia.
Patient states over the past several weeks to months she has
been progressively more short of breath. She has also had that
time had increase in her weight which she takes typically once
per week and several weeks ago was less than 200 pounds and she
is now greater than 200 pounds. She does not stick to 2gm Na or
fluid restriction. She does not miss doses of medication. She
presented to her primary care physician today who noted that she
was fluid overloaded who obtained a chest x-ray that was notable
for large amount of fluid.
In the ED, initial VS were: 96.1 79 132/72 18 80% RA
Exam notable for: working hard to breathe, nails clubbed,
decreased breath sounds bilaterally, poor cap refill, bilateral
3+ pitting edema
Labs showed:
- Hgb 8.5 (MCV 77) (last 10.6 ___
- Cr 0.9 (at baseline)
- BNP 3165 (last ___
- Lactate 1.6
- U/A ___, -Nit, 7 WBC, Few Bact, 0 Epi
Imaging showed:
- CXR: no large pneumothorax, effusion or gross signs of
pneumonia
EKG: Afib 74, normal axis, RBBB, possible LVH, non-specific STT
changes, no significant changes since ___
Patient received:
IV Furosemide 80 mg
Transfer VS were: 97.8 62 148/77 27 97% RA
On arrival to the floor, patient reports she has been having
chest heaviness that starts with exertion, lasts 20 minutes,
improves with rest, associated with shortness of breath,
sometimes associated with nausea but not always, not positional,
does not occur at rest. She has stable 2 pillow orthopnea and
significant BLE edema. She also has hemorrhoidal bleeding (small
amounts of bright red blood occasionally with bowel movements).
Denies fevers, cough, sore throat, other chest pain, abdominal
pain, N/V/D, black or dark stools, dysuria, hematuria, focal
weakness or falls.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
___
Chronic AF
Chronic bronchitis
Hypertension
Dyslipidemia
Glanzmann thrombasthenia
Social History:
___
Family History:
HTN, no family history of early MI, cardiomyopathies or sudden
cardiac death.
Physical Exam:
ADMISSION
==========
VS: 98.0 132/82 75 18 93% 4L NC
Weight: 97.5kg
I/Os: neg 1000mL
GENERAL: Obese elderly female in NAD
HEENT: anicteric sclera, PERRL, MOM, OP clear
NECK: supple, no elevated JVP
HEART: regular rate, irregular rhythm, normal S1/S2, no murmurs,
gallops, or rubs
LUNGS: 4L NC in place, no increased WOB, speaking in full
sentences, diffuse bilateral rales without wheezes
ABDOMEN: obese, soft, nondistended, nontender in all quadrants,
+BS
EXTREMITIES: no cyanosis, 3+ pitting edema to hip BLE
PULSES: 1+ DP pulses bilaterally
NEURO: A&O, face symmetric, moving all 4 extremities with
purpose
SKIN: warm and well perfused
Pertinent Results:
ADMISSION
=========
___ 07:51PM BLOOD WBC-8.4 RBC-3.95 Hgb-8.5* Hct-30.2*
MCV-77*# MCH-21.5*# MCHC-28.1* RDW-18.1* RDWSD-49.8* Plt
___
___ 07:51PM BLOOD ___ PTT-25.2 ___
___ 07:51PM BLOOD Glucose-105* UreaN-14 Creat-0.9 Na-140
K-4.7 Cl-99 HCO3-28 AnGap-13
___ 07:51PM BLOOD CK(CPK)-216*
___ 07:51PM BLOOD CK-MB-7 proBNP-3165*
___ 07:51PM BLOOD cTropnT-0.02*
___ 08:10AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:51PM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
___ 08:10AM BLOOD calTIBC-424 Ferritn-12* TRF-326
___ 07:58PM BLOOD Lactate-1.6
DISCHARGE
=========
MICRO
======
UCx negative
IMAGING
========
---CXR ___--
FINDINGS:
AP portable upright view of the chest. Lung volumes are
markedly low limiting assessment. Bibasal atelectasis is
suspected. The heart is poorly assessed. Prominence of the
mediastinal contour could reflect portable AP technique. No
large pneumothorax or effusion. No gross signs of pneumonia
though evaluation in the lower lungs is limited. Bony
structures intact.
IMPRESSION:
As above. Please note evaluation markedly limited due to low
lung volumes.
Brief Hospital Course:
ASSESSMENT AND PLAN:
___ year old ___ woman with PMHx HFpEF (EF 67%), Afib (not on
anticoagulation), chronic bronchitis, HTN with heart failure
exacerbation with hypoxemia s/p IV diuresis now transitioned to
PO diuretic and on room air. Exacerbation likely triggered by
medication non-compliance as patient had not been taking
torsemide on days she goes to adult day care. She was discharged
on PO torsemide 40mg, weight of 94.1 kg and creatinine 0.8.
Course also notable for iron deficiency anemia.
ACUTE ISSUES:
=============
# Acute exacerbation of chronic diastolic heart failure
# HFpEF
# Dyspnea
# Hypoxia
# Exertional chest heaviness: NYHA II-III, stage C. Patient with
HFpEF presents with significant weight gain, elevated BNP (3165
up from baseline 1000 in ___, dyspnea and hypoxia requiring
4L NC (baseline RA), concerning for an acute CHF exacerbation.
Etiology likely non-adherence to diet (often buys prepared
foods) and meds (has not been taking torsemide on days she goes
to adult day care) iso chronic iron deficiency anemia, EKG
without signs of new ischemia, telemetry with stable chronic AF.
For PRELOAD: initial 80mg IV Lasix BID-TID the transitioned to
PO torsemide 40mg, discharge weight of 94.1 kg and creatinine
0.8. AFTERLOAD: Transitioned home Losartan Potassium 100 mg
PO/NG DAILY to olmesartan 20 mg oral DAILY. Discontinued
isosorbide mononitrate ER 60 mg QD as per NEAT trial. For
neruohormonal blockade: continued home metoprolol 100mg XL, and
fractionated diltiazem to 60 mg Q6H. At discharge she is close
to euvolemia but for now will continue on 40mg torsemide until
follow-up on ___, at that time expect torsemide to be reduced
to 20mg daily.
# Anemia
# ?Glanzmann thrombasthenia
# Hemorrhoids: Microcytic anemia in the setting of historical
platelet disorder
(although per report a ___ bleeding time study done in ___ was negative for Glanzmann's) and known hemorrhoidal
bleeding. No evidence of active brisk GI bleed, but patient
reports intermittent BRBPR, which has been attributed to
hemmhroids in the past. Reports never having had a colonoscopy.
Fe studies show severe irondeficiency anemia, hemolysis work-up
negative. Started on IV iron. Patient refused SC heparin
throughout admission. She will discharged on PO iron three times
per week (as per ___ et al Blood ___.
# Chronic atrial fibrillation: CHADS2VASC = 5, R/C = diltiazem
and metoprolol, A/C = None Rate controlled, no anticoagulation
i/s/o prior BRBPR events. Recommended she restart it by her
cardiologist, patient refused. She is on dilt and metoprolol as
above, fractionated during admission
CHRONIC ISSUES:
===============
# Hypertension: JNC-8 goal < 150/90, borderline inclusion
criteria for SPRINT trial ___, as above continued home
losartan (on home olmesartan, held) and isosorbide mononitrate
as above
# Dyslipidemia: continued home simvastatin 20 mg QD
# Constipation continued home lactulose 30 mL PO QHS,
colace/senna PRN.
# GERD: started on lansoprazole (on home dexlansoprazole 60 mg
QD, held)
# Chronic bronchitis: no PFTs or active symptoms, wheezing
TRANSITIONAL ISSUES
====================
[ ] anticipate torsemide will likely need to be reduced to 20mg
daily
[ ] Oxygen saturation dropped to low ___, will have ___ check
home O2 saturation to ensure she would not benefit from home
oxygen therapy
[ ] Chronic bronchitis consider obtaining PFTs or empiric
bronchodilator therapy
[ ] Iron deficiency anemia, would benefit from colonoscopy as
outpatient, continue PO iron three times per week (as per
___ et al Blood ___
[ ] consider PFA testing or hematology referral/evaluation for
questionable h/o Glanzmann Thrombasthenia as she would benefit
from
[ ] DISCHARGE WEIGHT: 94.1 kg
[ ] DISCHARGE DIURETIC: PO torsemide 40mg, weight of 94.1 kg and
creatinine 0.8
[ ] DISCHARGE ANTICOAGULATION: none
[ ] FOLLOW UP LABORATORY TESTING: CHEM 10 at ___ f/up appointment
___
[ ] MEDICATION CHANGES:
[ ] NEW: ferrous sulfate 325 mg 3x per week (___)
[ ] STOPPED: Isosorbide Mononitrate (Extended Release) 60 mg PO
DAILY
[ ] CHANGED: torsemide 20mg daily to 40mg daily
#CODE: Full (confirmed)
#CONTACT: ___ (daughter/HCP) ___ (cell),
___ (work)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexilant (dexlansoprazole) 60 mg oral DAILY
2. Diltiazem Extended-Release 240 mg PO QHS
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. olmesartan 20 mg oral DAILY
6. Potassium Chloride 10 mEq PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Torsemide 20 mg PO DAILY
9. Ascorbic Acid ___ mg PO DAILY
10. Lactulose 30 mL PO QHS
11. Vitamin D 1000 UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
14. flaxseed oil 1200 mg oral BID
15. Fish Oil (Omega 3) 1200 mg PO BID
Discharge Medications:
1. Ferrous GLUCONATE 324 mg PO 3X/WEEK (___)
RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth
3X/WEEK Disp #*30 Tablet Refills:*0
2. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Ascorbic Acid ___ mg PO DAILY
4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
5. Dexilant (dexlansoprazole) 60 mg oral DAILY
6. Diltiazem Extended-Release 240 mg PO QHS
7. Docusate Sodium 100 mg PO BID
8. Fish Oil (Omega 3) 1200 mg PO BID
9. flaxseed oil 1200 mg oral BID
10. Lactulose 30 mL PO QHS
11. Metoprolol Succinate XL 100 mg PO DAILY
12. olmesartan 20 mg oral DAILY
13. Simvastatin 20 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- Potassium Chloride 10 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until told to by
your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute Exacerbation of Diastolic Heart Failure
SECONDARY DIAGNOSES
Chronic Atrial Fibrillation
Iron deficiency anemia
Chronic bronchitis
Hypertension
Dyslipidemia
Constipation
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had been feeling
short of breath and you were found to have fluid on your lungs.
This was felt to be due to a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs. You were given a diuretic medication through
the IV to help get the fluid out. You improved considerably and
were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 2 lbs in one day or 5 lbs in one week.
Your weight on discharge is 94.1 kg
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10626477-DS-8
| 10,626,477 | 20,688,698 |
DS
| 8 |
2174-07-23 00:00:00
|
2174-07-24 08:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
================================
MICU ADMISSION NOTE
Date of ICU Admission: ___
Reason for ICU Admission: pulmonary embolism
================================
HISTORY OF PRESENT ILLNESS:
================================
Ms. ___ is a ___ woman with a history of HTN, HLD,
CVA (___), DM2, hypothyroid, obesity, GERD, Crohn's, recent C.
diff, osteoarthritis with a recent admission to ___ from ___
- ___ for elective L hip replacement surgery, discharged to
rehab facility. She was taking ASA 81mg BID at rehab. She
initially presented to ___ with mild BLE swelling,
fatigue, SOB on exertion and severe back pain. She was
transferred from ___ to ___ given her surgery was at
___. After the patient had been transferred, a CTA chest
performed at ___ resulted as a "large amount of pulmonary
embolus in the interlobar pulmonary artery and right lower lobe
pulmonary artery extending into multiple segmental and
subsegmental right lower pulmonary artery branches w/ large R
lower lobe pulmonary infarction." BNP was negative at ___
and EKG showed no signs of right heart strain. Other labs
notable for Hgb 8.5, WBC 12, K 3.1, Procalcitonin normal
Upon arrival to the ___ ED, the patient was HDS and was
satting 100% on 2L NC with RR 18. MASCOT and orthopedics were
consulted. Orthopedics recommended therapeutic lovenox and
1mg/kg dose was given (90mg) at 00:00. MASCOT agreed to see the
patient the following morning.
At transfer to ICU, vitals were T 97.7, P 77, RR 18, BP 116/53,
SpO2 97%, SpO2 97% on 2L NC.
Past Medical History:
PMH/PSH:
Arthritis
C. diff colitis
CVA
Diabetes
Hypertension
Thyroid disease
THA
Bladder surgery
Thyroid surgery
Cholecystectomy
Social History:
___
Family History:
No family history of clotting disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: afebrile, HR 85, Spo2 100% on 2L, BP 119/57
GEN: conversant, in no acute distress
HEENT: oropharnyx clear without exudate
NECK: no adenopathy
CV: tachycardic, systolic flow murmur greatest LUSB
RESP: breathing comfortably, no wheezes/rales/rhonci
GI: no abdominal tenderness
MSK: mild ___ edema R > L
SKIN: no rashes or excoriations, incision site without evidence
of infection on left extremity. Painless range of motion of hip
and knee. No pain with compression of calf
NEURO: alert and oriented x 3, conversant, no focal deficits.
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, no m/r/g
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, but peripheral edema, L>R
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 06:04AM BLOOD WBC-12.9* RBC-3.08* Hgb-8.4* Hct-27.0*
MCV-88 MCH-27.3 MCHC-31.1* RDW-15.4 RDWSD-48.9* Plt ___
___ 06:04AM BLOOD ___ PTT-32.6 ___
___ 06:04AM BLOOD Glucose-148* UreaN-12 Creat-0.6 Na-137
K-3.6 Cl-97 HCO3-24 AnGap-16
___ 06:04AM BLOOD ALT-6 AST-14 LD(LDH)-269* AlkPhos-94
TotBili-1.2
___ 06:04AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.0 Mg-1.6
___ 06:15AM BLOOD calTIBC-200* Ferritn-551* TRF-154*
___ 06:17AM BLOOD ___ pO2-28* pCO2-45 pH-7.39
calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 06:17AM BLOOD Lactate-1.5
___ 12:34PM BLOOD WBC-4.8 RBC-3.06* Hgb-8.4* Hct-26.8*
MCV-88 MCH-27.5 MCHC-31.3* RDW-15.6* RDWSD-49.9* Plt ___
___ 05:40AM BLOOD Glucose-102* UreaN-6 Creat-0.6 Na-142
K-3.7 Cl-105 HCO3-24 AnGap-13
___ 06:15AM BLOOD ALT-6 AST-15 AlkPhos-80 TotBili-0.8
___ 05:40AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.6
___ 06:15AM BLOOD calTIBC-200* Ferritn-551* TRF-154*
___ TRANSTHORACIC ECHO:
CONCLUSION:
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. Overall
left ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection
fraction is >=75%. Left ventricular cardiac index is high (>4.0
L/min/m2). There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Normal right ventricular cavity
size with normal free wall motion. The aortic sinus diameter is
normal for gender with a normal
ascending aorta diameter for gender. The aortic arch diameter is
normal. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve
stenosis. The increased velocity is due to high stroke volume.
There is trace aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are not well seen.
The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness,
biventricular cavity sizes, and
hyperdynamic regional/global biventricular systolic function. No
valvular pathology or pathologic
flow identified. Mild pulmonary artery systolic hypertension.
___
CXR
IMPRESSION:
Pulmonary edema has improved. Cardiomediastinal silhouette is
stable. There
is no pleural effusion. No pneumothorax.
___ 1:28 am BLOOD CULTURE Source: Venipuncture.
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 ___:
Reported to and read back by ___ @ ___ ON
___ -
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of HTN, HLD,
CVA (___), DM2, hypothyroid, obesity, GERD, who presented with
provoked pulmonary embolism in the setting of hip surgery.
Patient managed with anticoagulation and discharged on apixaban.
TRANSITIONAL ISSUES:
=======================
[ ] Patient is being loaded on apixaban 10mg bid until ___ (last day). After that day, patient should be transitioned to
apixaban 5 bid.
[ ] Patient had a provoked PE in setting of hip surgery. Should
be anticoagulated for ___ months. Consideration of optimal
length of anticoagulation necessary.
[ ] Patient was started on ferrous gluconate 325 every other day
for iron deficiency, monitor for side effects. If unable to
tolerate due to constipation then would consider IV iron
[ ] F/u CBC at PCP ___ to assess for stability. Discharge
Hb 8.4.
[ ] Aspirin 81 was discontinued in setting of apixaban. Unclear
indication for ASA. Patient may not need this after apixaban
course finished, but please reassess.
[ ] HCTZ and amlodipine stopped at d/c in the setting of
relative normotension. Consider resuming back if patient is
hypertensive as outpatient.
#Code status: Full
#Contact HCP ___ ___
ACTIVE ISSUES:
=====================
#Pulmonary Embolism
Patient with provoked PE in setting of recent hip surgery. Large
on CT however non-massive given no biomarker abnormalities,
hemodynamically stable, EKG unchanged, and no evidence of right
heart strain. TTE with hyperdynamic EF and mild pulmonary artery
systolic hypertension. Decision was that this can be managed
with anticoagulation. Initially on lovenox, transitioned to
apixaban. Apixaban loading of 10mg bid, first day ___
and last day ___, after which patient should be
transitioned to 5mg bid. Will need ___ months of anticoagulation
for provoked VTE.
#Gram positive cocci bacteremia, coagulase negative
Found to have positive blood cx, fever x 1 to ___. Grew coag
negative in one bottle so likely contaminant. Was initially on
IV Vancomycin which was discontinued in setting of blood cx
being likely contaminant, patient being afebrile, and having no
elevated WBC count.
#Hx of C diff. Recent c diff infection, unclear if patient
finished course. Complaining of constipation instead of
diarrhea. Initially
started PO Vanc, however C diff returned negative. Discontinued
PO vancomycin.
#Anemia. Hb fluctuated in 7 to 8s. Iron studies consistent with
___. Likely related to recent surgery. No signs of bleeding
during this admission. Received IV iron and 1u pRBCs. Started on
PO supplementation of iron at the time of discharge. Iron
deficit calculated at 1.3g.
CHRONIC ISSUES
=======================
#Osteoarthritis. Patient with recent hip surgery. ___ recommended
home ___.
# HTN. Held home amlodipine, hydrochlorothiazide in setting of
normotensive, critical illness. BPS were stable without it.
Restarted atenolol at the time of discharge.
#HLD
#PAD. Continue atorvastatin 40mg and cilostazole 100mg PO BID.
ASA 81mg held in the setting of anticoagulation.
#hypothyroidism. Continued levothyroxine 75mcg PO daily
#GERD. Continued omeprazole 20mg PO daily
Greater than 40 mins were spent in discharge planning and
coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Atenolol 25 mg PO QHS
7. Atorvastatin 40 mg PO QPM
8. Cilostazol 100 mg PO BID
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (MO)
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 3 Days
Last day ___
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
2. Apixaban 5 mg PO BID Duration: 1 Month
Please do not start reduced dose until ___
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Ferrous GLUCONATE 324 mg PO EVERY OTHER DAY
RX *ferrous gluconate 324 mg (38 mg iron) 1 tablet(s) by mouth
every other day Disp #*15 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
5. Atenolol 25 mg PO QHS
6. Atorvastatin 40 mg PO QPM
7. Cilostazol 100 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO QHS
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
13. Senna 8.6 mg PO BID
14. Vitamin D ___ UNIT PO 1X/WEEK (MO)
15. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until reassess if needed
16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until reassess if
needed
17. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until decide if
needed
Discharge Disposition:
Home With Service
Facility:
___
services of ___
Discharge Diagnosis:
Primary:
Pulmonary embolism
Osteoarthritis
Iron deficiency anemia
Secondary:
HTN
HLD
PAD
Hypothyrodism
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure to care for you at the ___
___.
Why did I come to the hospital?
- You were found to have a clot in your lungs, which is likely
a complication of the orthopedic surgery
What happened while I was in the hospital?
- We did several lab and imaging tests to show that the clot
was not impacting your heart function. We treated you with a
medication to help prevent further clot formation in your lungs
(blood thinner). You will need to take this medication when you
leave the hospital for at least 3 months. Your primary care
doctor ___ help determine when it's ok to stop the medications
What should I do once I leave the hospital?
- We started you on iron supplementation for your low iron
levels. This sometimes can cause constipation so if you become
constipated you should use more of your stool softeners or start
taking miralax every day to keep you regular. If you become too
constipated then talk to your doctor about receiving iron
through the IV.
- Be sure to take your blood thinner every day until your
primary care doctor says you should stop. You will take 10 mg
twice a day for 3 more days and then on ___ you should start
5mg twice a day.
- Take your medications as prescribed and follow up with your
doctor appointments as listed below.
We wish you the best!
___ Care Team
Followup Instructions:
___
|
10626542-DS-16
| 10,626,542 | 21,419,975 |
DS
| 16 |
2193-09-30 00:00:00
|
2193-10-05 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest Pain, AF with RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o F with a h/o CAD s/p MI in ___ with
PCI with 1 DES to the LAD, DM, HTN, HL who initially presented
to the ER with 12 hours of chest pain. She was previously on
clopidogrel due to her history of ___, this was
discontinued in ___ after completing one year of therapy.
At this time her Aspirin dose was increased from 81mg to 325mg.
The patient reports chest "pressure" across precordium with no
radiating sensation to the neck, arms or back. This began in the
afternoon during usual activities, continued through the night
and eventually resolved on its own. The patient reports that the
sensation was constant in severity since onset with no
identifiable aggravating/alleviating factors. She denies
associated dyspnea, lightheadedness, diaphoresis, cough,
pleurisy. She denies association with exertion or meals. She
denies recent URI, travel, ___ swelling, fevers or chills. She
reports that chest pressure is different in character from
previous MI.
.
In addition over the past year she has also been having
intermittent palpitations, but denies any history of known AF.
These episodes occur sporadically last minutes and are not
associated with nausea/vomiting, chest pain, diaphoresis or
lightheadedness. She does report some sujective shortness of
breath occuring largely at onset of exercise and improves as she
continues. She denies exetional dyspnea, chest pain ___ pain.
.
In the ED, initial vitals were 97.7, 71, 145/57, 16, 99% on RA.
Labs and imaging significant for trop <0.01 x 2, CBC and
electrolytes within normal limits, EKG initially showed SR at
63bpm, NANI with TWF in III, aVF, V2, V3. CXR was negative for
any acute intrathoracic process. She was given 324mg of ASA and
the initial plan had been to observe her in the ER for two sets
of cardiac enzymes and an exercise MIBI. However this morning
in she triggered for tachycardia to the 140's, an EKG done at
that time demonstrated atrial fibrillation. The patient reported
palpitations similar but more severe than previous episodes at
that time. She was given a total of 35mg of IV diltiazem and
30mg po diltiazem, with improvement in her heart rate up down to
the 60's, with intermittent HR bursts up to 100's. After
discussion with the on call atrius attending, it was decided
that she should be admitted for rate control and likely stress
test. Vitals on transfer were 64 NSR, RR 20, 97% RA, 107/50.
.
On arrival to the floor, patient reports that she is pain free
and not currently having any palpitations.
.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes Mellitus ___, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
CAD s/p MI in ___ with 1 DES to LAD, complicated by
pericarditis
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: PCI in ___ s/p 1 DES to
LAD
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Obesity
History of colonic polyps
cataracts
S/P TONSILLECTOMY
Social History:
___
Family History:
Father - hypertension, aortic aneurysm rupture in ___
Brother - type ___ diabetes
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death, or DVT/PE; otherwise non-contributory.
Physical Exam:
ADMISSION
VS: T=.97.9.BP=.138/65..HR= 71.RR=20.O2 sat= 97RA 75kg
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
DISCHARGE
97.8 134/62 58 18 97 RA
GENERAL: NAD. Oriented x3.
HEENT: PERRL, most mucous membranes
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: CTABL.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. 2+ distal pulses
Pertinent Results:
ADMISSION
___ 08:50AM BLOOD WBC-10.4 RBC-4.46 Hgb-13.6 Hct-37.8
MCV-85 MCH-30.4 MCHC-35.9* RDW-12.8 Plt ___
___ 08:50AM BLOOD Neuts-72.6* ___ Monos-3.9 Eos-2.1
Baso-1.2
___ 07:05AM BLOOD ___ PTT-35.6 ___
___ 08:50AM BLOOD Glucose-140* UreaN-22* Creat-0.9 Na-141
K-4.4 Cl-105 HCO3-27 AnGap-13
___ 07:05AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
.
PERTINENT
___ 08:00AM BLOOD ___ PTT-33.4 ___
___ 02:08PM BLOOD cTropnT-<0.01
___ 08:50AM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD TSH-4.3*
___ 08:50AM BLOOD TSH-4.5*
.
DISCHARGE
___ 08:00AM BLOOD WBC-6.8 RBC-4.70 Hgb-13.9 Hct-40.8 MCV-87
MCH-29.7 MCHC-34.1 RDW-12.5 Plt ___
___ 08:00AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-140
K-4.6 Cl-104 HCO3-26 AnGap-15
___ 08:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
.
EKG: ___ #1: NSR at 63, ?___, TW flat in V2-V3, III,
aVF (all noted on EKG from ___ also) and consistent w/ old
anterior MI.
EKG: ___ #2: NSR 61, increased TW flattening in leads V2-V5
EKG: ___ #3: Afib at 140
.
CXR
FINDINGS: There is a well-defined round opacity abutting the
posterior aspect of the left hemidiaphragm, that projects over
the cardiac shadow in the frontal view, unchanged from ___. The
remaining of the left lung is clear. There are no other focal
opacities in the left lung. The cardiomediastinal and hilar
contours are unremarkable. There is no pleural effusion or
pneumothorax.
IMPRESSION: No acute intrathoracic process. Stable round density
at the posterior left costophrenic angle most compatible with a
diaphragmatic hernia.
.
TTE ___
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. 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 no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal global
biventricular systolic function. Technically suboptimal to
exclude focal wall motion abnormality.
.
STRESS TEST
The patient exercised for 10 minutes of a modified ___
protocol (~ ___ METS), representing an excellent exercise
tolerance for
her age. The test was stopped due to fatigue. No chest, neck,
back, or
arm discomforts were reported by the patient throughout the
study. At
peak exercise, there was 0.5-1 mm of slow upsloping/horizontal
ST
segment depression in the inferolateral leads, resolving by
minute 12 of
recovery. The rhythm was sinus with occcasional/frequent,
isolated
apbs, including periods of bi/trigeminy pre/post exercise. No
ectopy
during exercise. Appropriate blood pressure response to
exercise.
Slightly blunted heart rate response to exercise in the presence
of beta
blocker therapy.
IMPRESSION: Non-specific EKG changes in the absence of anginal
type
symptoms. Nuclear report sent separately.
.
Sestamibi Stress
The image quality is limited by motion artifact. Left
ventricular cavity size is normal. Resting and stress perfusion
images reveal a small decrease in counts in the anteroseptal
wall seen on the stress images, not seen on the rest images that
is likely due to motion artifact. Gated images reveal normal
wall motion. The calculated left ventricular ejection fraction
is 71%. No prior studies available for comparison.
IMPRESSION: Probably normal cardiac perfusion study at the level
of exercise achieved.
.
Brief Hospital Course:
Ms. ___ is a ___ y/o F with a h/o CAD s/p MI in ___ with PCI
with 1 DES to the LAD, DM, HTN, HL who initially presented to
the ER with 12 hours of intermittent chest pain. While
undergoing work-up for ACS the patient was found to be in atrial
fibrillation with rapid ventricular rhythm.
.
# CHEST PAIN/PAROXYSMAL ATRIAL FIBRILLATION
Patient was found to be in Afib with RVR in the ED and was
symptomatic at the time with palpitations. She had no previous
documented history of Afib, however, she reported history of
palpitations for the past year. Given numerous risk factors for
Afib, including age, HTN, CAD, it is likely that she has had
paroxysmal Afib for some time. Nonetheless, evaluation was
undertaken for other potential cause of new onset Afib as this
was first documentation of this arrhythmia. Given her
presentation of chest pain and h/o CAD, ACS was of concern. MI
was ruled out with serial cardiac enzymes and Stress test was
essentially negative. She was continued on medical therapy with
ASA, Crestor and BB. Question of atrial abnormality was noted on
EKG, although no significant structural abnormalities were noted
on last echo from ___. Repeat Echocardiogram revealed no
significant valvular disease, normal ejection fraction and only
mildly dilated RA. Laboratory studies ruled out electrolyte
abnormalities or hyperthyroidism.
The patient was changed from Atenolol to Metoprolol tartrate for
ease of titration to achieve rate control in the inpatient
setting. She was ultimately discharged on Metoprolol succinate
50mg Qday. Given her CHADS 2 score of 2, anticoagulation was
deemed necessary. She was started enoxaparin in the inpatient
setting and ultimately discharged on warfarin with instructions
to follow up with ___ clinic to check INR and
titrate warfarin dose. (Patient was not bridged with enoxaparin
given relatively low daily risk of stroke w/ PAF in this patient
and the significant cost of enoxaparin for her). The patient
will also follow up with her primary cardiologist upon
discharge.
.
# HYPERTENSION
Patient's home regimen prior to admission included Atenolol 50mg
daily, Amlodipine 5mg daily, and Irbesartan 75mg daily.
Amlodipine was held in order to allow blood pressure room while
uptitrating beta blocker for rate control of atrial
fibrillation. The patient was ultimately discharged on
metoprolol succinate 50 mg daily and Irbesartan 75 mg daily.
The patient will follow up with her cardiologist for further
assessment.
.
# DM ___
Patient's Diabetes is relatively well controlled with recent
HGBA1C 7.1 in ___. She was maintained on sliding scale
insulin in the inpatient setting and discharged on her previous
dose of Metformin.
.
# HLP
Well controlled on current regimen with recent LDL 70 and HDL 62
in ___. She was continued on Crestor 20mg daily.
.
TRANSITION OF CARE
- Patient instructed to follow up with PCP, cardiologist and
___ clinic upon discharge.
- She maintained full code status throughout her course.
Medications on Admission:
Rosuvastatin 20mg daily
Atenolol 50mg daily
Amlodipine 5mg daily
Metformin 500mg twice daily
Irbesartan 75mg daily
Aspirin 325mg daily
Calcium 300mg BID
Multivitamin 1 tablet daily
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day:
Take 5mg daily for now. Your doctor may change your dose after
checking your labs based on your INR levels.
Disp:*0 Tablet(s)* Refills:*0*
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
4. irbesartan 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. calcium carbonate 300 mg (750 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease, Atrial fibrillation
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 chest pain. Your
tests showed that you did not have a heart attack. You were
found to have an irregular and fast heart beat called "atrial
fibrillation." This is likely caused by longstanding high blood
pressure. We did an ultrasound of your heart which showed that
you have normal valves and normal heart muscle function. Your
stress test was also very reassuring with no evidence of any
blocked arteries around your heart. Because this abnormal
rhythm can predispose you to forming clots and cause a stroke,
we are starting you on a blood thinner, Warfarin (Coumadin). We
also started you on Metoprolol, a medication to prevent your
heart from going too fast, as a result we stopped your atenolol.
.
Medication changes
START Metoprolol
START Warfarin
STOP Atenolol
STOP Amlodipine
Please continue taking all of your other medications as
previously prescribed. It was a pleasure taking care of you.
Followup Instructions:
___
|
10626795-DS-18
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DS
| 18 |
2168-11-27 00:00:00
|
2168-11-27 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female with a history of chronic
hepatitis C s/p treatment who presented to the ED today with
palpitations and possible syncopal episode. The patient was in
her normal state of health until earlier today when she
suddently developed 20 minutes of palpitations, which were
associated with shortness of breath, non-raidating chest
pressure, blurry vision and dizziness. She works at a ___
___ and reports that her heart rate was 158 as measured by a
nurse at work during the episode. She reports being in a chair
and then being unclear what happened next and was told she
fainted. The palpitations resolved spontaneously but for 10min
after she had substernal chest pressure. These symptoms resolved
prior to coming to the Emergency Department.
.
She reports a longstanding history of episodic palpitations.
The palpitations were initially associated with her periods but
since she started having less regular periods, there is no
particular pattern. She was seen by Dr. ___ in
electrocardiology in the past who through that at the time her
history was consistant with AVNRT but she has never followed up
with holter or event monitoring for this. Of note, she believes
palpitations are occuring more frequently. ___ she was in ___
and had several hours of palptitions. Then on ___ she had 4
hours of palpitations. She took valerian root and valitol? and
her symptoms resolved.
.
Initial VS in the ED: 98.4 84 106/62 20 100%RA. On exam, heart
was regular rate and rhythm and neurological exam non-focal.
Labs notable for platelets of 63 (previously 120s), normal
chemistry, trop-T <0.01, b-HCG negative. D-Dimer 509, CT PE
protocol obtained and was negative for pulmonary embolism. UA
bland. EKG per report was NSR w/out concern for STEMI. Patient
was given aspirin 325mg daily. Per RN ambulates w/ steady gait.
PCP notified of plan to admit to medicine for syncope. VS prior
to transfer: 98.0, 105/69, 75, 16, 97%, ___
Past Medical History:
- chronic hepatitis C genotype ___ s/p interferon and ribavarin
- chronic back pain
- benign thyroid nodule -> hashimoto thyroiditis
Social History:
___
Family History:
-Father passed away from an MI at age ___
Physical Exam:
General: Caucasian female in NAD, Alert, oriented
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, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: oriented x3, tongue midline, face symmetric, strength
grossly intact, gait not assessed
Pertinent Results:
___ 10:50AM BLOOD WBC-5.4 RBC-5.07 Hgb-15.2 Hct-45.6 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.0 Plt Ct-63*#
___ 06:45AM BLOOD WBC-4.5 RBC-4.96 Hgb-14.8 Hct-44.8 MCV-90
MCH-29.9 MCHC-33.2 RDW-12.8 Plt Ct-62*
___ 10:50AM BLOOD cTropnT-<0.01
___ 04:45PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:50AM BLOOD D-Dimer-509*
___ 10:50AM BLOOD TSH-0.88
.
CTA CHEST IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolism.
2. No pulmonary nodules. The previously seen density on the
recent chest
x-ray is likely a vessel.
Brief Hospital Course:
This is a ___ year old female with a history of chronic hepatitis
C s/p treatment and intermittent palpitations of unclear
etiology who presented to the ED today with palpitations and
possible syncopal event today.
.
# PALPITATIONS: Patient with long-standing history of
intermittent palpitations admitted after an episode of
palpitations with associated symptoms. She was monitored on
telemetry and no events were recorded during her stay. Cardiac
enzymes were checked in the ED and were normal. TSH was normal.
CT scan obtained in the ED was negative for pulmonary embolism.
She has seen electrophysiology in the past for this likely
supraventricular tachycardia. We discussed follow up with
electrophysiology and patient was interested in seeing Dr.
___ again in the next several weeks. An appointment was
made through care connections, which was pending at discharge.
.
#THROMBOCYTOPENIA: Her platelet count was found to be in the
___, down from 120s a year ago. She denied acute bleeding or
bruising, though she noted a lifetime of easier bleeding.
Hematology lab reviewed the smear, which showed only decreased
number of platelets (see report). This was discussed with the
hematology fellow. This is most likely due to her hepatitis C,
under production and/or sequestration. Hematology recommended
only close follow up for repeat Plt count and further testing as
necessary. We discussed the importance of outpatient follow up
with hematology for further evaluation.
.
#HISTORY OF HEPATITIS C: Patient with history of chronic
hepatitis C, genotype1, treated in ___ in the past. She has
evidence of mild transaminitis but intact synthetic function.
- Recommended close GI follow up with her.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Palpitations
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
with palpitations (fast heart rate). Your heart rhythm by the
time you got to the hospital was normal. You heart rhythm was
monitored overnight and was also in the normal rhythm. We are
in the process of scheduling you with a follow up appointment
with Dr. ___ to further evaluate this. He may consider to
do a heart rate monitor.
You were found to have a low platelet count. This is likely due
to your hepatitis C. I would recommend that you follow up with
the hematology and gastrointestinology doctors. ___ are trying to
arrange for an appointment with you. Please contact the below
phone number to schedule an appointment.
Continue your home medications without changes.
Followup Instructions:
___
|
10626933-DS-9
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DS
| 9 |
2183-05-17 00:00:00
|
2183-05-17 17:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
___ with HTN, DM, AFib, DM on recent victoza presents with one
day of diffuse abdominal pain especially in the RUQ.
Pain started at 1 am, started at 5 out of ten, increased to 9,
increasingly irritating. Could not find a comfortable position,
in the epigastrium radiation to RLQ, lying down made it worse.
Never happened before. Came into ED at 6:15. vomiting all night
as well, tums did not help, some nausea, no diarrhea, no
constipation. No change in stool caliber or color, no blood in
stool. No jaundice or scleral icterus noted. No radiation to
back. Lost 60 lbs since ___ that was intentional, was on
victoza (pt reports risk of panc ca with this drug). Vomiting
bile. Afebrile. No sick contacts. Notes distension. Never had
this pain before. Does have hx of gastroparesis but states usual
just nausea, not abdominal pain. Vomiting preceded this pain by
a few weeks, but not too severe.
In the ED, initial vitals: 51 133/89 16 100% ra. A CT scan
showed pancreatic mass and ?omental caking likely from
metastatic disease. He also had a tap of his ascitic fluid. He
received morphine iv 5 mg x 2, and zofran.
Vitals prior to transfer: 98.0 55 128/81 16 99%
Currently, the patient reports feeling better at ___ pain. He
wants to "move forward," states he's in a state of shock, but
wants to focus on the plan.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Chronic atrial fibrillation first dxed in ___
2. HTN well controlled
3. Type ___ontrolled
4. Dyslipidemia well controlled
5. Obesity
6. Osteoarthritis
Social History:
___
Family History:
+ breast ca in aunt. +DM, HTN, CAD in father, + HTN in mother.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - T98, BP 120/86, HR 102, RR 18, 97/RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple
HEART - irregularly irregular, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/ND, obese, TTP in RUQ with guarding, TTP in
other quadrants however elicits pain in RUQ. No "Courvosier's
sign"
EXTREMITIES - WWP, no c/c, 1+ edema ___ halfway up to the knees
SKIN - hemosiderin deposition on shins
NEURO - awake, A&Ox3, grossly wnl, MAE
DISCHARGE PHYSICAL EXAM
VS - T98.3, BP 110s-130s/70s-90s, HR ___, 18, 96/RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple
HEART - irregularly irregular, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/ND, obese, TTP in RUQ with guarding
(improved), TTP in other quadrants however elicits pain in RUQ.
No "Courvosier's sign"
EXTREMITIES - WWP, no c/c, 1+ edema ___ halfway up to the knees
SKIN - hemosiderin deposition on shins
NEURO - awake, A&Ox3, grossly wnl, MAE
Pertinent Results:
ADMISSION LABS
___ 06:50AM BLOOD WBC-9.9 RBC-5.31 Hgb-14.9 Hct-45.6 MCV-86
MCH-28.0 MCHC-32.6 RDW-13.7 Plt ___
___ 06:50AM BLOOD Neuts-83.7* Lymphs-11.0* Monos-4.2
Eos-0.5 Baso-0.6
___ 06:50AM BLOOD ___ PTT-32.7 ___
___ 06:50AM BLOOD Glucose-167* UreaN-18 Creat-0.7 Na-137
K-5.2* Cl-96 HCO3-27 AnGap-19
___ 06:50AM BLOOD ALT-45* AST-101* AlkPhos-165* TotBili-1.5
___ 06:50AM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.4 Mg-1.5*
___ 07:05AM BLOOD Lactate-1.6
DISCHARGE LABS
___ 07:20AM BLOOD WBC-7.2 RBC-4.88 Hgb-14.4 Hct-42.1 MCV-86
MCH-29.4 MCHC-34.1 RDW-14.3 Plt ___
___ 07:20AM BLOOD ___ PTT-37.7* ___
___ 07:20AM BLOOD Glucose-130* UreaN-18 Creat-0.6 Na-136
K-4.2 Cl-98 HCO3-31 AnGap-11
___ 07:20AM BLOOD ALT-49* AST-47* LD(LDH)-179 AlkPhos-152*
TotBili-0.8
___ 07:20AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.6 Mg-1.5*
CT ABDOMEN PELVIS
FINDINGS:
LUNG BASES: There is a moderate-sized nonhemorrhagic right
pleural effusion. There is a small left pleural effusion.
Associated basilar atelectasis is present. There is no discrete
nodule. The base of the heart is normal. There is no
pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There are
no focal
hepatic lesions. The portal vein is patent. Mild periportal
edema is present. The gallbladder is not distended and normal in
appearance. There is no intra-or extra-hepatic biliary duct
dilation. The spleen is normal in size. There are no focal
splenic lesions. The bilateral adrenal glands are normal. In
the left kidney, there are multiple hypodense lesions, the
largest of which measures 2.7 cm (2, 36). This is most
consistent with a simple cyst. Several other smaller
hypodensities are too small to fully characterize, but
statistically represent cysts. There are no lesions in the
right kidney. there is no evidence of pyelonephritis or
hydronephrosis. The kidneys enhance and excrete contrast
symmetrically.
In the body and tail of the pancreas, there is a 5.4 x 2.7 x 2.9
cm hypodense mass which is concerning for a primary malignancy(
2, 32 and 601B, 35). The mass extends almost to the tail of the
pancreas. The very distal duct is prominent measuring
approximately 4 mm (2, 31). No other focal pancreatic lesions
are identified. The proximal pancreatic duct is normal. There
is a moderate amount of nonhemorrhagic ascites, mostly confined
to the anterior abdomen, perihepatic space, perisplenic space,
and pelvis. There is diffuse omental caking, most consistent
with metastatic disease.
There is no retroperitoneal lymphadenopathy. In the perihepatic
space, there is a prominent lymph node which measures 8 mm in
the short axis (2, 32). Multiple small lymph nodes are
scattered throughout the mesentery, although none meet criteria
for pathologic enlargement. The abdominal vasculature is normal
in course and caliber. There is mild atherosclerotic disease.
The stomach and small bowel are unremarkable. There is no
evidence of
obstruction. Evaluation of focal inflammatory changes is
somewhat limited by the omental caking and ascites. There is no
free air.
PELVIS: The large bowel is normal in course and caliber. Again
evaluation for inflammatory changes is difficult given the
surrounding ascites. The appendix is not definitely visualized,
although there are no specific focal inflammatory changes in the
right lower quadrant to suggest appendicitis. The bladder is
unremarkable. The prostate is minimally enlarged with several
coarse calcifications. It measures 5 cm. There is no pelvic or
inguinal lymphadenopathy. There are small fat-containing
bilateral inguinal hernias.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
osseous
lesions. No fracture is identified. Multilevel degenerative
changes are
noted throughout the spine.
IMPRESSION:
1. Large pancreatic mass, concerning for a primary malignancy.
Diffuse
omental caking and ascites is likely from metastatic spread.
2. Moderate right and small left pleural effusions with
associated
atelectasis.
Brief Hospital Course:
___ with HTN, DM, AFib, DM on recent victoza presents with one
day of diffuse abdominal pain especially in the RUQ.
BRIEF HOSPITAL COURSE
Mr. ___ was admitted after having a pancreatic mass, omental
caking, and retroperitoneal lymphadenopathy, c/f pancreatic CA.
Abdominal pain was controlled with oxycodone. No meds for
nausea needed. Tolerated PO diet well. Pain ___ when arrived,
___ at discharge. Set up for EUS on ___ after discharge,
with Onc f/u within 2 weeks to review pathology. SW
consultation active during admission.
HOSPITAL COURSE BY PROBLEM
# Pancreatic mass/Abdominal pain: Concerning for primary
pancreatic malignancy with metastatic spread given omental
caking and retroperitoneal lad. Pt reports that this he thinks
is from the Victoza he was taking. Reportedly side effect of
victoza is papillary thyroid carcinoma, as opposed to pancreatic
CA, however FDA reports of possible pancreatic ampullary
metaplasia. Thus far, on a brief lit review, only a published
theoretical risk [Labuzek et al; Eur J Intern Med, ___
Apr;24(3)207-12]. We touched base with gastroenterology and
oncology regarding proper work up. Given likelihood of
pancreatic CA, we sent ___ (not for diagnosis, but for future
monitoring). As he is anticoagulated for his afib, we will need
to stop this to allow INR to drift down and so that he can get
EUS on ___ (already scheduled) with Dr. ___. Before
this, he needs INR checked on ___ morning. If INR <1.5, will
proceed with procedure. If >1.5, can have rechecked on ___
AM. If elevated and need to postpone procedure, ___
providers are to page the GI fellow oncall in order to postpone
exam. The oncology f/u has been set for ___ with Dr.
___. Cytology from a paracentesis is pending at time of
diagnosis (see below). His pain was controlled with oxycodone
adequately, and he was discharged with this medication. We also
discharged him with zofran for nausea.
# Ascites: concerning for malignancy causing this. No hx to
suggest chronic liver disease causing cirrhosis, and no report
of cirrhosis on the CT scan. As above, cytology is pending
which will need to be followed up. If this worsens more, he may
require periodic paracentesis as an outpatient.
# Elevated transaminases: ? irritation effect from other
intraabdominal process? Could consider ___, however
would like to focus on primary pathology in abdomen. Of note, pt
is on statin, so could be related to drug effect. Also of note,
concern for metastatic disease, but nothing noted on CT. We
trended his lfts while here. The values were stable/decreased on
HD2.
# N/V: Likely from mass and ascites, preceded sxs of pain. He
was able to tolerate POs on day of discharge. He has zofran prn
on discharge for this; I do worry that pain is the primary
process that is triggering this in this stage, as pain control
helped his nausea as well in house.
# Chronic atrial fibrillation: chronic, no h/o CVA/TIA, ___
score of 2, and on warfarin with INR 2.4 at time of admission.
No need for tele given chronic and well controlled. We
discontinued coumadin and aspirin at time of discharge as he
will require no blood thinners and INR<1.5 in order to undergo
EUS. After the procedure, he will continue having his INR
titrated at ___.
# HTN: on dilt, lisinopril, which we continued while he was in
house.
# Type 2 DM - on metformin, glimepiride, and recently
liraglutide (victoza). We held these in house and kept him on
insulin sliding scale. We restarted these meds on discharge.
INACTIVE ISSUES
# Dyslipidemia - hold statin in house as nonformulary, restarted
at discharge
# Primary prevention: stopped aspirin at discharge as above.
# Allergies: used fexofenadine here instead
TRANSITIONAL ISSUES
# Plan as per GI and Oncology: Pt is scheduled for EUS on
___. He is to get INr checked at ___ on ___. If
INR<1.5, can proceed to ___ on ___. If >1.5, can have
procedure postponed by paging GI fellow on call (there is an OMR
note about this plan). If close to 1.5, can also recheck INR on
___ AM for possible procedure on ___. Onc follow up scheduled
for ___ with Dr. ___. Coumadin and Aspirin being held
currently, to be restarted after procedure and managed by ___
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 360 mg PO DAILY
hold for sbp<100, hr<55
2. Lisinopril 20 mg PO DAILY
hold for sbp<100
3. Aspirin 81 mg PO DAYS (___)
4. Warfarin 5 mg PO DAILY16
5. Lovastatin *NF* 80 mg Oral daily
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. glimepiride *NF* 4 mg Oral daily
8. Cetirizine *NF* 10 mg Oral daily
Discharge Medications:
1. Cetirizine *NF* 10 mg Oral daily
2. Diltiazem Extended-Release 360 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. glimepiride *NF* 4 mg ORAL DAILY
5. Lovastatin *NF* 80 mg ORAL DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
four times a day Disp #*30 Tablet Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron [ZOFRAN ODT] 4 mg 1 tablet,disintegrating(s) by
mouth three times a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Pancreatic Mass
SECONDARY
Abdominal Pain
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 during your hospitalization
at ___. You were admitted with abdominal pain and a
pancreatic mass. We asked both oncology and gastroenterology to
weigh in on how best to proceed. Both departments have set up
appointments with you (see below). The plan is for you to have
a procedure on ___ (scope called EUS). In order to do this,
you can't be on warfarin, so stop this now, and you will need to
have your INR checked on ___ morning at ___. Otherwise,
we controlled your pain while you were here, and discharged you
without warfarin or aspirin so you could have this procedure
done safely.
Please follow up with your providers as listed below, and make
the changes to your medications as listed on the following page.
Followup Instructions:
___
|
10627012-DS-22
| 10,627,012 | 25,442,185 |
DS
| 22 |
2149-01-29 00:00:00
|
2149-01-29 11:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Supraventricular tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ampullary adenoma resected on ___ c/b
hemorrhage from mesenteric vessel with immediate take back and
ligation and also c/b PE. Patient has history of tachycardia and
called ___ on ___ for fats heart rate sensation. EMT measured
HR at 160, gave adenosine and transported to OSH. At OSH
additional adenosine then Lopressor then esmolol gtt given with
heart rate to 130s. Reportedly patient had AF with RVR at OSH,
which he had post-operatively, but all EKGs appear to be SVT. On
arrival to our ED esmolol gtt stopped and patient given 2l IVF.
CT torso performed which showed no PE but ongoing
___
fluid collections, seen on CT scan at OSH done three days prior
for poor PO intake related to appetite.
Past Medical History:
Hypertension, SVT
Social History:
___
Family History:
His family history is not significant for cardiopulmonary
disease
or for cancer, or gallstones to his knowledge.
Physical Exam:
Upon Admission:
98.3 68 135/76 18 99RA
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, healing ridge along abd wall incision
with overlying ecchymosis, drain site without erythema but small
purulent drainage on gauze. midline wound without drainage or
induration/erythema, appropriately tender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: ___ warm and well perfused
Upon Discharge:
98.0 58 130/81 18 98RA
Gen: NAD
CV: RRR, no m/r/g
Abd: soft, midline incision c/d/i with steri strips in place; R
trocar site open with erythema packed with wick; appropriately
tender
___: WWP
Pertinent Results:
CT A/P ___
IMPRESSION:
1. No pulmonary embolism or aortic dissection. Pulmonary
emboli from prior
exam have resolved.
2. Peripancreatic fluid collections and peripancreatic fat
stranding, likely
representing a combination of postsurgical changes and evolving
hematomas,
with the collection adjacent to the pancreatic tail appearing
more hypodense
and decreased in size compared to the prior chest CTA. Mildly
complex
collection in the deep pelvis posterior to the bladder also
likely reflects an
evolving hemorrhagic collection. Infections of these fluid
collections cannot
be excluded based on this exam.
3. Mild pulmonary edema with trace bilateral pleural effusions
and bibasilar
atelectasis, somewhat improved compared to the prior exam.
4. Stent within the common bile duct has slightly migrated
distally with the
majority of the stent residing within the duodenum. Distal
pancreatic stent is
in appropriate location.
Brief Hospital Course:
___ with ampullary adenoma resected on ___ c/b hemorrhage
from mesenteric vessel with immediate take back to OR and
ligation, and
also c/b PE and atrial fibrillation. Patient presented on ___
with SVT that broke in ED with return of HR to ___. Patient was
mentating well and HD stable throughout this.
Despite that his his surgical incisions do not show signs of
infection, and his peripancreatic collections were most likely
post surgical. His SVT was worrisome for an inflammatroy
reaction. He was therefore admitted to the ___ service for
observation. Cardiology was consulted and they recommended
re-starting his home amiodarone and metoprolol. He was advanced
to a regular diet, zosyn was started, and nutrition was
consulted for poor po intake. On HD#2, he had an episode of
bradycardia to the 40's. His metoprolol was decreased from 50mg
tid to 37.5mg tid. He tolerated it well. He also tolerated a
regular diet and his supplements. Calorie counts were started.
He was re-started on his home coumadin for Atrial fibrillation
with an INR goal of ___. He remained afebrile with stable
vitals. He was passing gas and having bowel movements. Reglan
was started for symptoms of early satiety. On HD#3, his heart
rate was well controlled with the new regimen. An iodoform wic
was placed in his right 5mm incision site, as more purulent
drainage was noted from the site. Zosyn was discontinued. He
continued to tolerate a regular diet with nutrional supplements.
On HD#4, he was switched to Meoprolol XL 100mg daily. He was
discharged with ___ for management of his wic. He was asked to
follow up with his PCP who is also his cardiologist post
discharge. He was also discharged on 2 weeks of Reglan to help
his gastric emptying.
Medications on Admission:
simvastatin 20', coumadin (for PE) 7.5', pantoprazole 40',
oxycdone PRN, metoprolol 150', amiodarone 200'', ASA 81, Kelfex
___
Discharge Medications:
1. Amiodarone 200 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tab(s) by mouth four times a day
and bedtime Disp #*70 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Simvastatin 20 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Supraventricular tachycardia
Benign ampullary Adenoma
Atrial Fibrillation
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 or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Site Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, increasing yellow or
bloody discharge, warm to touch, fever).
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
Please eat 6 small meals daily, including nutritional
supplements.
Followup Instructions:
___
|
10627213-DS-3
| 10,627,213 | 28,170,690 |
DS
| 3 |
2178-08-21 00:00:00
|
2178-09-05 17:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure management
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ is a ___ old woman with a history of EtOH
abuse, EtOH w/d seizures complicated by presumed excitotoxic
injury and resultant aphasia, on ___ and Dilantin who
presented after a fall, CT head was concerning for contusion,
dilantin level was toxic, and she had a convulsive seizure in
the
ED.
Ms. ___ suffered an unwitnessed fall yesterday afternoon
in
the context of drinking all day. Her boyfriend found her on the
floor at the foot of the stairs, awake and alert with a
laceration over her right eye. She thinks that it was a
mechanical fall but cannot recall any details of the incident.
She was taken to ___ where her examination
was
notable for slurred speech and disorientation as well as
evidence
of trauma. Her workup showed a Dilantin level of 32.2, alcohol
level was 224 with tox otherwise negative, mild hyponatremia and
no leukocytosis. CT head showed a linear hyperdensity in the
right frontal lobe concerning for SAH, and CT neck showed no
fracture. Given the presence of SAH she was transferred to ___
for neurosurgical evaluation.
Here, her EtOH level had dropped to 70. Around 0200, she
reportedly had a generalized convulsion which apparently lasted
several minutes and resolved without intervention. Head CT was
stable from the OSH image and she was given a dose of 1000 mg
___ IV. She did not receive any of her schedule doses of
AEDs.
She was seen by neurosurgery, who recommended no intervention,
but recommended neurology consult for AED management. She was
admitted to the traumatic brain injury observation pathway.
According to our records, Ms. ___ was admitted to ___ in
___ with fever and status epilepticus. During her
hospitalization she had left temporoparietal periodic discharges
which evolved into electrographic seizures. MRI brain was
concerning for left-sided atrophy and MRI was bland. Her
seizures
were controlled on ___ and phenytoin and she was discharged
on
this regimen. At the time of discharge she had a mixed aphasia
and impaired verbal memory. Her left-sided atrophy was thought
to
be "out of proportion to the degree of seizure activity that she
suffered. One possibility is that she had excitotoxic cell death
due to the metabolic stress of a prolonged seizure, in a patient
with vulnerabilities due to malnutrition due to chronic alcohol
consumption."
At her last clinic visit in ___, she had had a stable
interval MRI (though only spaced 2 weeks from prior), and had
persistent aphasia and verbal memory deficits. She had had toxic
Dilantin levels with medication adjustments recommended over the
telephone, but was apparently continuing to take the higher dose
on which she had been discharged. The plan at that time was for
a
serum paraneoplastic panel and follow-up in neurology clinic in
three months. However, there are no subsequent visits and she is
now being prescribed her AEDs by Dr. ___. I spoke to Dr.
___ saw Ms. ___ once in clinic to follow up after an
ED visit to ___ in ___. She described Ms. ___
as having alcohol withdrawal seizures. Her language was
apparently normal at that visit.
Ms. ___ is unable to describe her seizure semiology. Her
boyfriend says that her last seizures was about eight months
ago,
and she was seen in the ED and sent home without admission. He
reports that she used to have more frequent seizures prior to
her
admission to ___ in ___, with seizures nearly every month.
However, on the current medication regimen the frequency is
closer to once yearly. Her boyfriend administers her
medications,
which are phenytoin 100 mg BID and ___ 1500 mg BID (or
perhaps
750 mg QAM/1500 mg QPM; her boyfriend tells me that this was
changed by Dr. ___ about a year ago; however this is not
reflected in our OMR.
Review of systems conducted and was pan-negative per patient
report.
According to her boyfriend, Ms ___ has "good days and bad
days," but she has persistent difficulty with her memory, cannot
cook because she will put plastic dishes in the oven or run the
microwave for an hour and forget about it; and has difficulty
coming up with the right words, although her comprehension is
relatively preserved. This has been the case since her
hospitalization here ___ years ago.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- ETOH
- ETOH withdrawal seizures
- PRES
- HTN
- HLP
- NSTEMI ___
- B12 deficiency
- GI bleed
- Anxiety
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Exam:
Vitals:
T: 97.9; HR 78; BP 114/68
RR 18; SpO2 99% RA
General: Thin woman, crying, calms nearly instantly and is
cheerful.
HEENT: Laceration over right eyebrow with brusing and edema
extending into right eyelid. Tongue and cheek bite.
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Thin, soft.
Extremities: No lower extremity edema
Skin: Abrasions and ecchymoses noted in right knee and right
hand.
Neurologic:
-Mental Status: Awake, alert, oriented to person and hospital
but
not date (___). Language is fluent with frequent paraphasias
and occasional neologisms. Repetition is intact to phrases of up
to five simple words; cannot repeat phonemically complicated or
longer phrases. Naming is intact to a few high-frequency objects
("thumb") but no low frequency objects (knuckles are "nickels,".
Digit span forwards is 4 and backwards is 3. Encoding of ___
items with paraphasic errors, but recalls ___ at 3 min.
Comprehension intact to following appendicular commands, but not
cross-body or multi-step commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 3mm, both directly and consentually; brisk
bilaterally. VFF to confrontation with finger counting
bilaterally.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch, temperature in all
distributions.
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk throughout. No pronator drift bilaterally.
No
tremor or asterixis.
Also has right APB weakness.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ 4+ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 3 2 0
R 2 2 3 2 0
- Plantar response was marked withdrawal bilaterally.
-Sensory: No deficits to light touch, cold sensation throughout.
Proprioception intact in great toes bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No truncal ataxia.
-Gait: Rises to standing position pushing off and feels somewhat
unsteady. Gait is wide based and slow with normal stride length.
Occasionally takes step to the left. Turns en bloc. Romberg
absent.
Discharge Exam
Speech is fluent with mildly disrupted prosody. Her recall of
recent events is improved. Poor spelling. Cannot do MOYIR, on
DOWIR goes reverse x2 days and then switches to months. Cannot
name parts of a watch or stethoscope. Registers ___, recalls ___
spontaneously (could not pick them from a list).
No nystagmus.
No tremulousness or asterixis.
No focal deficits.
No ataxia.
Pertinent Results:
___ 06:19AM BLOOD WBC-4.2# RBC-3.38* Hgb-11.0* Hct-32.9*
MCV-97 MCH-32.5* MCHC-33.4 RDW-12.8 RDWSD-45.4 Plt ___
___ 12:23AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNBALE
TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO RDWSD-UNABLE TO Plt Ct-UNABLE TO
___ 06:19AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-141
K-3.9 Cl-106 HCO3-26 AnGap-13
___ 12:23AM BLOOD Glucose-101* UreaN-6 Creat-0.5 Na-140
K-3.9 Cl-102 HCO3-19* AnGap-23*
___ 06:19AM BLOOD ALT-27 AST-29 AlkPhos-168* TotBili-0.6
___ 06:30AM BLOOD Albumin-4.1 Calcium-9.6 Phos-4.0 Mg-1.7
___ 06:19AM BLOOD Albumin-4.1 Calcium-9.2 Phos-4.0 Mg-1.7
___ 06:30AM BLOOD Phenyto-20.1*
___ 07:14PM BLOOD Phenyto-19.7
___ 06:19AM BLOOD Phenyto-20.9*
___ 01:57PM BLOOD Phenyto-21.6*
___ 12:23AM BLOOD ASA-NEG Ethanol-70* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ EEG
HISTORY: FALL WITH HEMORRHAGE, EVALUATE FOR SEIZURE.
This is a 23 electrode EEG ___ placement with T1/T2) recorded
with video,
with additional EOG and EKG electrodes.
BACKGROUND: Waking background is characterized by a ___ Hz
alpha rhythm,
which attenuates symmetrically with eye opening. Symmetric ___
mcV beta
activity is present, maximal over bilateral frontal regions.
HYPERVENTILATION: Hyperventilation is performed for 180 seconds
with good
cooperation, and produces no effect.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from
___ flashes
per second (fps) produces no activation of the record.
SLEEP: During brief drowsiness, the alpha rhythm attenuates, and
___ Hz slow
waves appear diffusely, followed by symmetric vertex waves.
Stage 2 sleep is
not recorded.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm with an
average rate of 72-75 bpm.
IMPRESSION: This is a normal awake and drowsy EEG. Stage 2 sleep
is not
recorded.
___
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with iph now with seizure // eval for
worsening
bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex
were obtained
without intravenous contrast. Coronal and sagittal reformations
and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 46.8 mGy
(Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside CT head ___
FINDINGS:
There is no evidence of acute territorial infarction, edema, or
large mass.
Questionable hyperdensity along a right frontal lobe sulcus is
indeterminate.
Mild periventricular and subcortical white matter hypodensities
are
nonspecific, but likely represent chronic small vessel ischemic
disease.
Prominence of the ventricles and sulci is suggestive of
involutional changes.
No fracture seen. The imaged portion of the paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
Questionable hyperdensity along a right frontal lobe sulcus is
indeterminate(400b:52), but may represent a tiny focus of
hemorrhage. No
significant change since prior.
Brief Hospital Course:
___ is a ___ old woman with a history of EtOH
abuse, EtOH w/d seizures complicated by excitotoxic injury and
resultant seizure disorder and aphasia, on ___ and Dilantin.
She presented after a fall and was found to have hyperdensity in
the right frontal lobe consistent with contusion. She also was
found to have a random Dilantin level of 32. She was transferred
to ___ for neurosurgical evaluation, where she reportedly had
a
convulsive seizure which resolved without intervention. On
admission examination, she was awake, alert, and pleasant but
inattentive with
a mixed aphasia (fluent with grammatical errors, phonemic
paraphasic errors, neologisms and anomia), reduced forward and
backward digit span, and impaired short term memory. She was
unsteady on her feet and felt
lightheaded. Her examination is similar to that documented in
neurology clinic here ___ years ago. However, her neurologist
stated that she did not have an aphasia one year ago in clinic,
and so it was unclear if this was her baseline. Given the
uncertainty of her baseline, and the toxic phenytoin level which
may have provoked her seizure, we was admitted to the neurology
service for monitoring.
Neurosurgery evaluated her and felt that she did not need
surgery. She was monitored on EEG, and there were no further
seizures. Her language returned to her baseline aphasia, per her
boyfriend. Her ___ dose was increased to 2000mg twice daily.
Her Dilantin level was too high, so we decreased her dose to
100mg in the morning, 90mg at night (for a total dose of 190mg
per day). This is a reduction from her previous dose of 100mg
twice per day. The plan was to continue on 100 mg twice per day
till she get the prescription filled on the ___ after
discharge for the new reduced dose ( 100 mg in the morning and
90 mg at night).
Transitional issues:
1. Dilantin level on ___ which corresponds to 1 week after
decreasing the Dilantin dose. Plan to have that level FAXED to
both Dr. ___ ___ and Dr. ___ ___.
2. Follow-up with Dr. ___
3. Formal EEG reports pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. LevETIRAcetam 1500 mg PO BID
5. Magnesium Oxide 400 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO QPM
8. Thiamine 100 mg PO DAILY
9. Phenytoin Infatab 100 mg PO BID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. Magnesium Oxide 400 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Outpatient Lab Work
PLease have a PHENYTOIN LEVEL checked ON ___ 1 week from
changing her dose after discharge. It is EXTREMELY IMPORTANT
THAT YOU HAVE THIS INFORMATION FAXED to both Dr. ___ ___ and Dr. ___ ___.
10. LevETIRAcetam ___ mg PO BID
RX *levetiracetam 1,000 mg 2 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*3
11. Phenytoin Sodium Extended 100 mg PO QAM
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth q am
Disp #*30 Capsule Refills:*3
12. Phenytoin Sodium Extended 90 mg PO QPM
RX *phenytoin sodium extended [Dilantin] 30 mg 3 capsule(s) by
mouth q pm Disp #*30 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Aphasia (Language difficulty)
Supratherapuetic phenytoin level
Cerebral hemorrhage
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted after having 1) a small bleed in your head
after a fall 2) seizure 3) language problem (aphasia) that your
neurologist said was new. Neurosurgery evaluated you and felt
that you did not need surgery. Your phenytoin level was found to
be too high, and your doses were adjusted accordingly. You were
monitored on EEG. Your ___ dose was increased to 2000mg twice
daily. Your Dilantin level was too high when you came to the
hospital so we plan to decrease your dose to 100mg in the
morning, 90mg at night (for a total dose of 190mg per day).
This is a reduction from your previous dose of 100mg twice per
day. PLEASE continue on 100 mg twice per day till you get the
prescription filled on ___ for the new reduced dose ( 100 mg
in the morning and 90 mg at night )
Please check a Dilantin level on ___ which corresponds to 1
week after decreasing the Dilantin dose. Have that level FAXED
to both Dr. ___ ___ and Dr. ___ ___. We will call Dr. ___ office on ___ to arrange
a follow up appointment and they will contact you with that
information.
It was a pleasure meeting you!
Your ___ Team
Followup Instructions:
___
|
10627268-DS-11
| 10,627,268 | 20,198,195 |
DS
| 11 |
2180-10-22 00:00:00
|
2180-10-25 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
bicalutamide / aspirin / Motrin
Attending: ___.
Chief Complaint:
Left hip fracture
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty ___ ___
History of Present Illness:
___ male with metastatic
prostate cancer with a history of left hip pain, known bony
metastasis to left hip status post chemotherapy and radiation to
this location, found to have left femoral neck fracture on x-ray
imaging in clinic today. He has had 2 months of worsening pain,
requiring use of crutches. No recent falls. No nombness weakness
or tingling. Has chronic ulcer on lateral surface of left calf
in
setting of NIDDM.
Past Medical History:
- Prostate adenocarcinoma diagnosed in ___. He is status post
radical prostatectomy in ___. ___ score 3+4=7 and pathology
staging pT2c, pN0. His surgery was complicated by incontinence.
He is status post a urinary sphincter placement and penile
prosthesis in the cuff of the scrotum in ___. He had a local
recurrence ___ on surveillance PSA and ___. He started
external beam radiation therapy to the surgical bed ___ and
completed this ___.
- Type II DM
Hypertension, prostate cancer
with a complex oncologic course including chemotherapy,
radiation
including to the left hip for chronic left hip pain in the
setting of bony metastasis to the left femoral head
Social History:
___
Family History:
No family history of GI bleeds or GI malignancy.
Physical Exam:
Upon Discharge:
Exam: alert, oriented, interactive; follows commands
Temp: 98.8 PO BP: 146/80 L Lying HR: 84
RR: 18 O2 sat: 98% O2 delivery: ra
General: Well-appearing, breathing comfortably
MSK: LLE: incisional dressing c/d/I; fires TA, ___, ___
well-perfused
Pertinent Results:
___:40PM BLOOD WBC-9.9 RBC-4.19* Hgb-10.3* Hct-32.0*
MCV-76* MCH-24.6* MCHC-32.2 RDW-18.1* RDWSD-49.5* Plt ___
___ 01:29PM BLOOD WBC-7.1 RBC-4.15* Hgb-10.2* Hct-31.1*
MCV-75* MCH-24.6* MCHC-32.8 RDW-18.0* RDWSD-47.9* Plt ___
___ 01:40PM BLOOD Neuts-68.0 ___ Monos-5.1 Eos-2.3
Baso-0.2 Im ___ AbsNeut-6.73* AbsLymp-2.38 AbsMono-0.51
AbsEos-0.23 AbsBaso-0.02
___ 01:29PM BLOOD AbsNeut-4.16
___ 01:40PM BLOOD Plt ___
___ 01:40PM BLOOD ___ PTT-28.8 ___
___ 06:18PM BLOOD ___ PTT-29.7 ___
___ 01:29PM BLOOD Plt ___
___ 10:10AM BLOOD Glucose-196* UreaN-8 Creat-0.8 Na-139
K-3.8 Cl-101 HCO3-25 AnGap-13
___ 01:40PM BLOOD Glucose-161* UreaN-10 Creat-0.8 Na-142
K-4.4 Cl-105 HCO3-25 AnGap-12
___ 01:29PM BLOOD UreaN-14 Creat-0.8 Na-142 K-4.2 Cl-105
HCO3-23 AnGap-14
___ 01:29PM BLOOD ALT-12 AST-17 AlkPhos-60 TotBili-0.2
___ 10:10AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8
___ 01:29PM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9
___ 01:29PM BLOOD PSA-5.9*
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 hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left 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. 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 daily 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:
Atenolol, celecoxib glipizide metformin morphine
omeprazole ondansetron oxycodone polyethylene glycol
acetaminophen calcium carbonate docusate
Discharge Medications:
1. Acetaminophen 650 mg PO 5 TIMES DAILY WHILE AWAKE
Use for baseline pain control. You may discontinue when no
longer needed.
RX *acetaminophen 650 mg 1 tablet(s) by mouth 5 times daily
while awake Disp #*120 Tablet Refills:*1
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Use daily as needed for constipation not relieved by Senna.
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*20 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC Q24H
Use for 4 week post-operatively to prevent blood clots.
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously every
evening Disp #*25 Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain
Don't take before driving, operating machinery, or with
alcohol/sedatives/hypnotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*40 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constip
Use daily as needed for constipation not relieved by Senna.
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily as needed Disp #*10 Packet Refills:*0
6. Senna 8.6 mg PO DAILY
Use to prevent post-operatively constipation. Hold for diarrhea
or loose stools.
RX *sennosides [senna] 8.6 mg 2 tablets by mouth every evening
Disp #*20 Tablet Refills:*0
7. Atenolol 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip 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:
- WBAT, ROMAT
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.
- Your Metformin was held and you were instead started on an
insulin sliding scale regimen while you were an inpatient. You
should resume your home Metformin on discharge.
ANTICOAGULATION:
- Please use Enoxaparin (Lovenox) daily for 4 weeks
post-operatively to prevent blood clots.
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
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Left lower extremity: Full weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
WBAT; ROMAT.
Treatments Frequency:
staples x 2 weeks post-op (___) - remain in until f/u
appointment
change dressing PRN for drainage or leave open to air
Followup Instructions:
___
|
10627268-DS-12
| 10,627,268 | 22,833,286 |
DS
| 12 |
2182-03-23 00:00:00
|
2182-03-24 15:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bicalutamide / aspirin / Motrin
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with a history of HTN, DM, and
prostate cancer who presents after having a syncopal episode.
Patient was he was working when he felt tired and sat down. That
is last thing he recalls. The next thing he recalls is being
covered in vomit. He noted no prodromal symptoms prior to
syncope. He has no chest pain, shortness of breath palpitations.
He denies any abdominal pain or pressure, constipation or
diarrhea. He has no lower extremity swelling. He notes no
dizziness headaches or vertigo.
- In the ED, initial vitals were: T 98.1, HR 89, BP 103/53, RR
16, SPO2 98% RA
- Exam was notable for: not documented
- Labs were notable for: Hgb 8.0, WBC 6.2, plt 220, D dimer
1275,
BUN 17, Cr 1.3
UA large leuks, many bacteria, 69 WBC
- Studies were notable for:
CXR no acute process
CTA chest with no PE
- The patient was given: 1L IVF
On arrival to the floor, the patient reports he feels like his
normal self. He denies dizziness, chest pain, palpitations,
abdominal pain, shortness of breath, coughing, leg swelling.
Past Medical History:
- Prostate adenocarcinoma diagnosed in ___. He is status post
radical prostatectomy in ___. ___ score 3+4=7 and pathology
staging pT2c, pN0. His surgery was complicated by incontinence.
He is status post a urinary sphincter placement and penile
prosthesis in the cuff of the scrotum in ___. He had a local
recurrence ___ on surveillance PSA and ___. He started
external beam radiation therapy to the surgical bed ___ and
completed this ___.
- Type II DM
Hypertension, prostate cancer
with a complex oncologic course including chemotherapy,
radiation
including to the left hip for chronic left hip pain in the
setting of bony metastasis to the left femoral head
Social History:
___
Family History:
No family history of GI bleeds or GI malignancy.
Physical Exam:
24 HR Data (last updated ___ @ 723)
Temp: 98.5 (Tm 98.8), BP: 126/73 (107-154/66-79), HR: 78
(69-86), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: Ra
Orthostatics negative.
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
GU: Foley in place
EXTREMITIES: No clubbing, cyanosis. 1+ blt edema. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation
Pertinent Results:
___ 06:36AM BLOOD WBC-4.3 RBC-3.01* Hgb-8.0* Hct-25.4*
MCV-84 MCH-26.6 MCHC-31.5* RDW-20.4* RDWSD-62.4* Plt ___
___ 06:28PM BLOOD ___ PTT-27.6 ___
___ 06:28PM BLOOD D-Dimer-1275*
___ 06:36AM BLOOD Glucose-131* UreaN-14 Creat-1.1 Na-141
K-4.5 Cl-106 HCO3-24 AnGap-11
___ 06:28PM BLOOD cTropnT-<0.01
___ 06:36AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.9
___ 10:46PM BLOOD Lactate-1.4
Brief Hospital Course:
Transitional issues:
[] Please follow up the results of the zio patch to evaluate for
possible arrhythmia.
[] Evaluate for further syncopal episodes. Consider
echocardiogram for further diagnostic purposes if repeat
episodes.
Mr. ___ is a ___ gentleman with a history of HTN, DM,
and prostate cancer who presents after having a syncopal
episode.
ACUTE/ACTIVE ISSUES:
====================
# Syncope/presyncope: patient presented after a syncopal episode
and woke up covered
in emesis. His description of the event was most consistent with
vasovagal,
given prodrome of feeling abnormal and the associated emesis.
However, unclear trigger for the event, so patient monitored for
arrhythmia but remained in NSR throughout hospitalization.
Orthostatics were negative and trop <0.01. CTA without evidence
of PE. No known seizure history, and patient denied any
post-ictal confusion or incontinence. Electrophysiology was
consulted and recommended that the patient be discharged on a
zio patch to rule out arrhythmia.
# Normocytic anemia: Hgb 8.0 on presentation, from a baseline of
~9. HgB stable between ___ during hospitalization. No signs or
symptoms of bleeding. As patient with history of anemia, no
further workup was done while inpatient.
# Prostate cancer: patient continued on his home olaparib during
admission.
# ___/ Indwelling Foley: Cre elevated to 1.3 on admission, but
improved to 1.0 with IVF. UA c/w infection, however in the
setting of indwelling Foley without symptoms of UTI or
leukocytosis or fevers. Not started on antibiotics during
hospitalization.
CHRONIC/STABLE ISSUES:
======================
# HTN: patient was continued on his home atenolol, lisinopril.
# DM: patient's metformin and glipizide were held during
hospitalization and he was switched to an insulin sliding scale.
His home medications were restarted at discharge.
# GERD: patient continued on his home ranitidine
# Sleep: patient continued on his home mirtazapine
CODE STATUS: Full Code
CONTACT: Wife ___: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 10 mg PO DAILY
2. Mirtazapine 15 mg PO QHS
3. Ranitidine 150 mg PO BID
4. Atenolol 50 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. olaparib 300 mg oral BID
7. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Mirtazapine 15 mg PO QHS
6. olaparib 300 mg oral BID
7. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope, likely vasovagal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because you fainted.
What happened while I was in the hospital?
- Your heart rate was monitored and there was no evidence of
arrhythmia
- You were given a heart monitor to go home with
- You felt better and had no more symptoms
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Continue the ZIOPATCH as instructed and follow up with your
PCP regarding the results
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10627407-DS-13
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DS
| 13 |
2126-11-11 00:00:00
|
2126-11-11 21:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Losartan
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
LHC with POBA to OM2 (___)
History of Present Illness:
Ms. ___ is an ___ woman with a PMH CAD (s/p MI,
CABG, multiple stents as below), HTN, HL, T2DM (on insulin), CVA
c/b residual L hemiplegia and hemisensory loss who presented via
EMS ___ substernal chest pain and dyspnea since 9am the morning
of admission. Per the daughter, the patient was celebrating her
grandson's birthday, when suddenly experienced substernal chest
pressure radiating down the L arm and shoulder a/w diaphoresis,
LH, and dyspnea. She took 4 ASA 81 and 3 SL NTG without relief.
Although the patient has experienced similar CP episodes in the
past, she said this episode was particularly refractory to
treatment and reminded her of the CP she experienced in ___ when she was last admitted. No F/C/dysuria/changes in
BM/recent falls/trauma.
On ___, patient's daughter spoke with her cardiologist Dr.
___ who reviewed the ___ findings that her EF was
slightly reduced, but grafts from a recent cardiac cath were
still patent. EKG revealed a LBBB. They discussed that she is
likely not a candidate for CABG or CRT ___ age and
comorbidities.
Of note, patient was last hospitalized from ___ ___nd dyspnea. During that admission, her CP was difficult to
control from a symptomatic standpoint. She was on maximal nitro
gtt, despite her troponins being normal. Multiple sets of
biomarkers - including those drawn 24 hours after the onset of
the continuous pain - were negative. She underwent a cardiac
catheterization back in ___ that showed 3-vessel disease not
amenable to PCI and she was not a
candidate for repeat CABG. A decision was made to optimize her
medical management and ranolazine was up titrated to 1000 BID.
She was also started on some oxycodone for chest pain. For
hypertension, she was started on losartan. Though her CP never
completely resolved, it remained minimal after withdrawing the
nitro drip. Since her discharge, she continues to have chest
pain at least ___ times a week, some lasting briefly, others
lasting the full day. But each time, these episodes are
responsive to ASA and SL NTG. Her DOE has also been worsening
over the past month with occasional PND. She initially slept on
one pillow, but currently requires 2 pillows at night. Weight
has been stable without any ___ edema. She reports being
compliant with all of her medications. She denied any
claudication symptoms or syncopal events.
In the ED initial vitals were: T 97.3 HR 67 BP 124/46 RR
18 O2 97% RA. On exam, JVD flat, decreased breath sounds
bilaterally, prominent S1, no ___ edema, abdomen was TTP in LUQ
and RUQ without guarding or rebound, mildly distended. EKG was
unchanged from prio ___. CXR was unchanged from previous.
Labs were significant for H/H 8.0/26.9, down from 9.8/30.8
(___). Two sets of trops were found to be negative (0.02
and 0.01). UA was negative. Patient was ___: morphine 5mg
IV with improvement of her CP from 10 to ___. Patient was also
___ atorvastatin 80mg, levothyroxine 25 mcg, metoprolol
tartrate 25 mg, omeprazole 20 mg, ASA 325 mg, sertraline 100 mg,
isosorbide mononitrate XL 150 mg, and ranolazine ER 1000 mg.
On the floor, she endorses the history above and denies any
current symptoms of chest discomfort.
Past Medical History:
PMH
- Cardiac: CAD s/p MI (CABG ___, LAD stent X2 and RCA stent,
cath x3; HTN, HL, sCHF (EF 45-50% ___ but not on diuretics)
- Neuro: s/p stroke in ___ (___) w residual L
hemiplegia and L hemisensory loss. R frontal infarct on last CT
with basal ganglia and R internal capsule lacunes
- Endo: T2DM, osteoporosis, hypothyroidism
- GI: GERD
- Ophtho: Glaucoma
PSH
- CABG ___
Social History:
___
Family History:
Mother - died age ___
Father - died age ___
___ - 10 siblings - only 4 left. All died of CAD. 2 sistes had
stroke in their ___ (one had breast ca and seemingly 5x
strokes),
brother with ___ dementia
Children - well
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98.9 135/56 72 20 O2 97% RA
General: NAD, frail
HEENT: No icterus. PERRLA. MMM.
Neck: Supple, JVD flat.
CV: RRR, nl S1, paradoxical split S2. ___ holosystolic murmur
at the apex radiating to the axilla. Soft diastolic murmur at
the LUSB.
Lungs: Unlabored respirations, CTAB.
Abdomen: soft, obese, nontender, BS+. Reversible hernia. Good
bowel sounds. Mid-reducible incisional hernia.
Ext: WWP, no BLE edema. 2+ ___ pulses.
Neuro: AOx1. Post CVA: ___ RUE/RLE strength and normal
sensation. ___ LUE strength, decreased sensation to LT; ___ LLE
strength in hip
flex, knee flex/extensors, and ___ in foot dorsi- and plantar
flexion, decreased sensation to LT throughout.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98 110-124/50-55 ___ 98% 2L NC desats to 86% on RA
Wt: 52.6 kg kg <- 116 lbs <- 55.3kg <- NR <- 56.5kg <- 56.5 kg
<- NR
General: NAD, frail
HEENT: No icterus. PERRLA. MMM.
Neck: Supple, JVD flat.
CV: RRR, nl S1, paradoxical split S2. ___ holosystolic murmur
at the apex radiating to the axilla. Soft diastolic murmur at
the LUSB.
Lungs: Unlabored respirations, CTAB.
Abdomen: soft, obese, nontender, BS+. Reversible hernia. Good
bowel sounds. Mid-reducible incisional hernia.
Ext: WWP, no BLE edema. 2+ ___ pulses.
Neuro: AOx1. Post CVA: ___ RUE/RLE strength and normal
sensation. ___ LUE strength, decreased sensation to LT; ___ LLE
strength in hip
flex, knee flex/extensors, and ___ in foot dorsi- and plantar
flexion, decreased sensation to LT throughout.
Cath site: c/d/i. No hematoma or drainage.
Pertinent Results:
ADMISSION LABS:
================
___ 12:45AM BLOOD WBC-5.8 RBC-3.64* Hgb-8.0* Hct-26.9*
MCV-74* MCH-22.0* MCHC-29.7* RDW-17.5* RDWSD-46.8* Plt ___
___ 12:45AM BLOOD ___ PTT-31.1 ___
___ 12:45AM BLOOD Glucose-124* UreaN-29* Creat-1.0 Na-141
K-3.8 Cl-103 HCO3-20* AnGap-22*
___ 12:45AM BLOOD ALT-30 AST-42* CK(CPK)-88 AlkPhos-40
TotBili-0.2
___ 07:43AM BLOOD ALT-30 AST-54* AlkPhos-31* TotBili-0.2
___:45AM BLOOD Lipase-48
___ 12:45AM BLOOD CK-MB-3 proBNP-567
___ 12:45AM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.3 Mg-2.6
DISCHARGE LABS:
================
___ 06:42AM BLOOD Plt ___
___ 06:42AM BLOOD WBC-8.3 RBC-3.70* Hgb-8.0* Hct-27.7*
MCV-75*# MCH-21.6* MCHC-28.9* RDW-18.5* RDWSD-48.7* Plt ___
___ 06:42AM BLOOD ___ PTT-29.6 ___
___ 06:42AM BLOOD Glucose-142* UreaN-24* Creat-1.1 Na-140
K-3.4 Cl-100 HCO3-26 AnGap-17
___ 06:42AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.5
CARDIAC LABS:
==============
___ 05:40AM BLOOD CK-MB-5 cTropnT-0.96*
___ 05:30PM BLOOD cTropnT-0.83*
___ 07:40AM BLOOD CK-MB-9 cTropnT-0.76*
___ 06:50AM BLOOD CK-MB-19* cTropnT-0.52*
___ 12:15AM BLOOD CK-MB-32* cTropnT-0.54*
___ 07:43AM BLOOD cTropnT-0.02*
___ 12:45AM BLOOD cTropnT-<0.01
Brief Hospital Course:
Ms. ___ is an ___ woman with a PMH CAD (s/p MI,
CABG, multiple stents as below), HTN, HL, T2DM (on insulin), CVA
c/b residual L hemiplegia and hemisensory loss who presented
with substernal chest pain and dyspnea found to have an NSTEMI
s/p LHC with POBA to OM2 (___).
# UA/NSTEMI: Patient has a PMH of CAD s/p MI (CABG ___, LAD
stent X2 and RCA stent, cath x3 and presented with unstable
angina refractory to SL NTG or ranolazine. She has had chronic
UA since ___ that has been medically managed at home, but her
UA became worse on the morning of admission and she was
therefore admitted for symptomatic management. Two days
following admission, on ___, patient developed chest pain
overnight, triggered for NSTEMI with trops 0.54 up from 0.02 on
admission. EKG unchanged from prior with LBBB > 150 ms. ___
___ load 300 mg x 1, patient was started on heparin gtt, ASA
81, nitro 0.3 SLNTG x 2 with improvement in CP from ___ to
___. Her SBPs were stable at 128/61, RR 25, HR 84 and O2 97% RA
during her episodes of CP. However, she developed an increased
O2 requirement when desat to 86%. Patient underwent LHC on ___
with POBA to LCx. She was largely symptom free until on ___,
the patient reported CP, improved with SL NTG, but no changes on
EKG. We continued her regimen for secondary prevention, which
included: ASA, ___, imdur, storvastatin, metoprolol.
# HFpEF: On admission, patient did not appear volume overloaded
on exam; her weight had been stable per daughter. Recent ___
showed LVH with moderate LV systolic dysfunction with
hypokinesis of the inferior, inferolateral, inferoseptal and
anteroseptal walls. On ___, patient with new crackles on lung
exam, no peripheral edema, CXR appeared wet. NYHA Class III-IV,
Stage C. ___ ___: LVEF ___. In ___ EF 45-50%. On
___, patient repetitively desatting to 86% on room air with
slight increased O2 requirement. We asked her to increase her
use of incentive spirometry and gave her a PO dose of Lasix 20
mg. We successfully weaned her off O2.
# Abdominal pain: While hospitalized, patient began complaining
of pain out of proportion to exam. ___ cardiac risk factors,
concern for mesenteric ischemia vs obstruction. Lactate, LFTs,
lipase normal. KUB was not concerning for obstruction. We
optimized her bowel regimen and gave her Tylenol for pain. Her
symptoms improved without any further intervention.
# Anemia: Labs were significant for H/H 8.0/26.9, down from
9.8/30.8 (___) without any evidence of any active bleeding
and therefore did not require any further workup as her H/H was
stable.
# AMS: Patient became altered after started on morphine in the
ED. Patient tried to leave, thought she was at home
intermittently. Delirium likely secondary to morphine. Patient's
mental status improved as the morphine wore off. We continued
Quetiapine, Ranexa, and Sertraline with good effect.
# DM2: A1c 7.7 (___) c/b peripheral neuropathy. On Metformin
1000 q.a.m. and 500 mg q.p.m at home and Gabapentin 300 in the
a.m., 300 p.m., and 600 at bedtime.
We held her metformin while inhouse and continued her on an
insulin sliding scale.
# HTN: well-controlled at home, but on admission SBPs in the
130s. We continued amlodipine 10 mg daily and stopped HCTZ 25 mg
daily.
# h/o CVA: ___ with left-sided hemiplegia and left
hemisensory loss, right frontal infarct on last CT and basic
angular closing right internal capsule. We continued Aggrenox.
# GERD: We continued omeprazole 20 mg daily.
# Hypothyroidism: Last TSH unknown. We continue Levothyroxine 25
mg daily.
# HPL: We continued Atorvastatin 80 mg daily.
# Constipation: We continued senna and Colace.
=================================
TRANSITIONAL ISSUES:
=================================
- Discharge weight: 52.6 kg
- Follow-up with your PCP ___ on ___ and
cardiologist, Dr. ___
- ___ for outpatient CRT with Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Atorvastatin 80 mg PO QPM
4. Gabapentin 300 mg PO TID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. QUEtiapine Fumarate 25 mg PO QHS
13. Ranolazine ER 1000 mg PO BID
14. Sertraline 100 mg PO DAILY
15. Aspirin 325 mg PO DAILY
16. Docusate Sodium 100 mg PO DAILY
17. Senna 8.6 mg PO BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 0.083 % Nebulization
every six (6) hours Disp #*30 Vial Refills:*1
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. Gabapentin 300 mg PO TID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*1
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
11. Omeprazole 20 mg PO DAILY
12. QUEtiapine Fumarate 25 mg PO BID
13. Ranolazine ER 1000 mg PO BID
14. Senna 17.2 mg PO HS Constipation
15. Sertraline 100 mg PO DAILY
16. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
17. Glargine 30 Units Breakfast
Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. MetFORMIN (Glucophage) 500 mg PO BID
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
21. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheezing, dyspnea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
- Coronary artery disease
- NSTEMI
- Chronic unstable angina
Secondary diagnoses:
- Hypertension
- Hyperlipidemia
- Type 2 diabetes
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 while you were a patient at
___. You came to us with chest
pain. We treated you with medications and had you undergo a
cardiac catheterization which resulted in improvement in your
symptoms. During the catheterization, we used a procedure called
balloon angioplasty to unblock one of your coronary arteries.
During your hospitalization, you developed some shortness of
breath, so we treated you with a medication called Lasix to take
off excess fluid from your body and your symptoms improved.
Please remember to weigh yourself every morning, call MD if
weight goes up more than 3 lb.
We have arranged for you to follow-up with your PCP on ___. The Cardiology department is working on an appointment for
you and will call you at home with an appointment. If you do not
hear from the office within two business days please call them
directly to book call ___.
We wish you all the best,
Your care team at ___
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a pmh of cardiac bypass, diabetes,
hyperlipidemia, stroke in ___ with residual left sided
weakness who presents with syncopal episode and increased left
sided weakness. She presented to the emergency department two
weeks ago with similar complaints; an MRI at that time was
negative for a new stroke. Tonight she had a witnessed syncopal
episode with a LOC of several minutes while being assested onto
the bathroom. When EMS arrivived, patient was, per report,
dramatically clenching her eyes shut.
She currently is complaining of some chest pain and shortness of
breath X 1 week, dizziness, and increased left sided weakness
and pain. She also has continual dysphagia; she has not
undergone her scheduled swallow evaluation.
Past Medical History:
- T2DM on insulin
- HTN
- HLD
- CAD s/p MI and CABG in ___
- Stroke in ___ in ___ with L hemiplegia and left
hemisensory loss now improving post rehab with residual left
arm>leg hemiparesis. Right frontal infarct on CT and basal
ganglia lacunes with right internal capsule lacune.
- osteoporosis
- GERD
- Glaucoma
- Hypothyroidism
Social History:
___
Family History:
Mother - died age ___
Father - died age ___
___ - 10 siblings - only 4 left. all died of CAD. 2 sistes had
stroke in their ___ (one had breast ca and seemingly 5x
strokes);
brother with ___ dementia
Children - well
Physical Exam:
Admission Physical Exam:
Vitals: T:98.3 BP:168/56 P:55 R:18 O2:97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no teeth
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. Sternotomy scar well healed.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Midline
incision well healed.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact. EOMI, PERRLA, ocular fields intact. Str
5+ on the right, 5+ in left shoulder, biceps and triceps, 3+ in
grip, 3+ dorsiflexion, 3+ hip flexion.
Discharge Physical Exam:
Vitals: T:98.3 BP:168/56 P:55 R:18 O2:97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no teeth
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. Sternotomy scar well healed.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Midline
incision well healed.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact. EOMI, PERRLA, ocular fields intact. Str
5+ on the right, 5+ in left shoulder, biceps and triceps, 3+ in
grip, 3+ dorsiflexion, 3+ hip flexion.
Pertinent Results:
Labs on admission:
___ 01:45AM BLOOD WBC-7.0 RBC-3.97* Hgb-12.2 Hct-37.1
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.1 Plt ___
___ 01:45AM BLOOD Neuts-63.3 ___ Monos-6.4 Eos-2.1
Baso-0.8
___ 01:45AM BLOOD ___ PTT-27.8 ___
___ 01:45AM BLOOD Plt ___
___ 01:45AM BLOOD Glucose-69* UreaN-23* Creat-0.8 Na-145
K-3.1* Cl-106 HCO3-27 AnGap-15
___ 01:45AM BLOOD cTropnT-<0.01
___ 01:05PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:45AM BLOOD Calcium-9.9 Phos-3.2 Mg-2.4
Labs on discharge:
___ 06:55AM BLOOD WBC-6.1 RBC-4.22 Hgb-13.1 Hct-38.7 MCV-92
MCH-31.0 MCHC-33.8 RDW-13.2 Plt ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-118* UreaN-19 Creat-0.9 Na-140
K-3.9 Cl-106 HCO3-25 AnGap-13
___ 06:55AM BLOOD Calcium-9.9 Phos-4.6* Mg-2.2
CXR FINDINGS: Chest AP and lateral radiograph demonstrates
normal
cardiomediastinal and hilar contours. Lung volumes are somewhat
decreased compared to prior study, giving the appearance of
prominent pulmonary vasculature, though this likely represents
crowding. No overt pulmonary edema identified. Minimal
atelectasis present in the bilateral lower lungs. No pleural
effusion identified. Sternotomy sutures are midline and intact.
No fracture is identified. IMPRESSION: No acute intrathoracic
process. No cardiomegaly or pneumothorax
evident
VIDEO OROPHARYNGEAL SWALLOW FINDINGS: Barium passes freely
through the oropharynx and esophagus. Penetration was noted
with thin consistency barium without aspiration. Note is made
of osteophytes at the anterior C4 and C5 vertebrae causing mild
esophageal impingement. For details, please refer to speech and
swallow division note in OMR. IMPRESSION: Penetration with thin
consistency barium, without aspiration.
EEG: preliminarily negative but final result PENDING at time of
discharge
Brief Hospital Course:
___ year old female with a pmh of cardiac bypass, diabetes,
hyperlipidemia, stroke in ___ with residual left sided
weakness who presents with syncopal episode and increased left
sided weakness.
# Syncope/ weakness: Patient presented after witnessed syncopal
episode. She had no recollection of the event. The family
witnessed the fall and denied any headstrike, convulsions, bowel
or bladder incontinence. However, given the duration of LOC and
a possible post-ictal state, seizure was considered. She
underwent an EEG which was preliminarily read as normal (final
read pending at time of discharge). Stroke was felt to be
unlikely as neurologic exam was unchanged on presentation. TIA
possible however recent head and neck imaging demonstrated no
acute process and no significant stenosis in the cervical common
carotid, internal carotid, or vertebral arteries. Cardiac causes
were also considered. However, the patient had no preceding
chest pain or palpitations. Her ECG was unchanged and troponins
were negative x 2. She was evaluated on telemetry overnight with
no events. Patient was not orthostatic on admission and denied
recent poor po intake. Hypoglycemia was considered given that
her admission chem 7 showed a low/normal glucose, however her
family reports that her finger stick was in the ___ during the
event. The patient remained stable throughout admission. She was
evaluated by ___ who felt that she was safe to return home with
___. Overall the etiology of her syncope could not be determined
but the above dangerous processes were felt to be unlikely.
# CAD s/p CABG in ___: ECG unchanged. Troponin and CK MB
negative x2. Continued dipyridamiole/ASA, statin, beta blocker,
and imdur.
# Dysphagia: Since ___ stroke. Scheduled for speech and
swallow evaluation in ___. Has been tolerating liquids and
small solids. Speech and swallow evaluated her and throught she
was doing well, without aspiration and recommended continued
thin liquid diet and soft solids if using her dentures.
# HTN: Changed to metropolol tartrate 12.5mg, continued
Isosorbide
# HLD: Continued Simvastatin and ezetimibe
# T2DM: Continued Glargine 30mg bedtime and ISS
# Osteoporosis: Continued alendronate
# Hypothyroidism: Continud levothyroxine
# Asthma: Continued montelukast
# Depression: Continued sertraline
# Code: DNI, ok to resuscitate
# Communication: Patient and daughter ___ ___
TRANSITIONAL ISSUES
[] final EEG read pending at time of discharge
[] consider outpatient TTE
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverwebOMR.
1. Alendronate Sodium 70 mg PO QWED
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Ezetimibe 10 mg PO DAILY
4. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. Sertraline 50 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QWED
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Ezetimibe 10 mg PO DAILY
4. Glargine 30 Units Bedtime
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. Sertraline 50 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: syncope
secondary diagnosis: coronary artery disease, diabetes type 2,
hypothyroid, depression, asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted to the hospital after you fell. Given
that you did not remember this event, you had more extensive
monitoring and evaluation including an electrocardiogram of your
heart, heart monitoring, blood work, and a study of your brain
which were all reassuring. You were evaluated by physical
therapy who felt that you were safe to return home with physical
therapy.
There were no changes made to your medication regimen.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Followup Instructions:
___
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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 Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
___ F with T2DM, HTN, HLD, CAD s/p MI and CABG in ___, recent
CVA w L sided weakness presents with chest pain at rest. Patient
has had intermittent chest pain for past 2 days. Today had chest
pain while resting that was more intense in character, radiating
to L arm and Jaw. In ED chest pain was relieved with
nitroglycerin. patient denies any fevers, chills, SOB. In the ED
patient noted to have new LBBB not seen on EKG in ___.
Patient was given hep, asa, morphine, nitro. Patient was
immediately transferred to Cath lab. In the Cath lab, patient
was noted to have patent grafts. Admitted to ___ for unstable
angina vs ACS rule out and medication optimization.
In the ED, initial vitals were ___ 66 112/57 20 .
On arrival to floor patient was complaining of ___ continued
___ pain
REVIEW OF SYSTEMS:
(+) Per HPI.
(-) Cardiac: Denies dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, peripheral edema/swelling, syncope or
presyncope.
(-) General: Denies weight change, subjective fevers at home,
chills, rigors, night sweats, headache, diplopia, odynophagia,
dysphagia, lymphadenopathy, cyanosis, cough, hemoptysis,
pleuritic chest pain, nausea, vomiting, diarrhea, melena,
hematochezia, hematemesis, myalgias, joint pains, new brusing,
new bleeding, dysuria, exertional buttock or calf pain.
Past Medical History:
- DM on insulin
- HTN
- HLD
- CAD s/p MI and CABG (___)
- CVA (___) w residual L hemiplegia
- Osteoporosis
- GERD
- Glaucoma
- Hypothyroidism
Social History:
___
Family History:
Mother - died age ___
Father - died age ___
___ - 10 siblings - only 4 left. all died of CAD. 2 sistes had
stroke in their ___ (one had breast ca and seemingly 5x
strokes);
brother with ___ dementia
Children - well
Physical Exam:
ADMISSION
VS: T 98.2 58 133/50 19 99% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple. Flat JVP .
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. R femoral site w/o hematoma. C/d/i. No
bruit heard.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
Neuro: AOx3 (name ___, CN II-XII wnl; PERRL
3mm to 2mm; LUE ___ distally, ___ proximally; LLE 4+/5; R side
___ throughout; +2 DTRs at patella, toes downgoing on the R,
equivocal on the L; finger-nose-finger intact bilaterally; neck
supple without meningismus; gait not observed;
DISCHARGE
VS: T 98.4 56-60 124-148/52-60 19 96% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple. Flat JVP .
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. Tender to palpation in Left shoulder,
range of motion at L shoulder decreased ___ neurologic deficits,
otherwise full range of motion throughout LUE
Neuro: AOx3, CN II-XII wnl; LUE ___ distally, ___ proximally;
LLE 4+/5; R side ___ throughout; +2 DTRs at patella
___ Results:
___ 01:30PM BLOOD WBC-7.6 RBC-4.42 Hgb-13.9 Hct-41.7 MCV-94
MCH-31.4 MCHC-33.2 RDW-12.4 Plt ___
___ 08:09AM BLOOD WBC-6.3 RBC-3.87* Hgb-12.2 Hct-36.6
MCV-94 MCH-31.5 MCHC-33.3 RDW-12.3 Plt ___
___ 01:30PM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-142
K-4.3 Cl-106 HCO3-29 AnGap-11
___ 08:09AM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-142
K-4.3 Cl-107 HCO3-27 AnGap-12
___ 01:30PM BLOOD cTropnT-<0.01
___ 06:03PM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:09AM BLOOD CK-MB-3 cTropnT-<0.01
Cardiac Catheterization (not yet finalized)
Coronary angiography: right dominant
LMCA: No angiographically apparent CAD
LAD: Diffuse disease with prtoximal 50% into 90% stenosis
proximal to LIMA touchdown. D1 is 2.0 mm vessel that
trifurcates
and has 70% stenosis and is not suitable for PCI.
LCX: OM1 and OM2 are small (1.5) mm vessel with origin 80%
stenoses and are not suitable for PCI. There are 40-50%
stenoses
into OM3 that is bypassed.
RCA: Proximal patent stent with mid vessel 90% proximal to
touchdown.
SVG-OM3: Widely patent with mild luminal irregularties. OM3
has mild disease after the touchdown.
SVG-PDA: Widely patent. There is diffuse disease in 1.5 mm
vessels after the touchdown of the graft in the PDA and PL.
LIMA-LAD: Widely patent to LAD with patent stents in distal LAD
Brief Hospital Course:
Summary
This is an ___ F PMHx CAD s/p CABG, CVA w L residual L-sided
weakness who p/w L arm pain, found to have new new LBBB, cardiac
cath demonstrating patent grafts, ruled out for ACS, optimized
cardiac regimen, cleared by physical therapy and discharged
home.
# CAD s/p CABG / Musculoskeletal/Neuropathic Pain: Patient with
CAD s/p CABG who presented w L arm pain radiating to neck, taken
for stat cardiac catheterization. Grafts were patent, ruled out
for ACS with enzymes. TTE unchanged from prior. No evidence of
acute pulmonary process on imaging. Neurologic exam unchanged
from prior. Exam overall notable for tenderness to palpation
over shoulder. Felt this to most likely represent
musculoskeletal and neuropathic pain. Continued home aggravnox
and metoprolol. Uptitrated her imdur and lisinopril to address
poorly controlled blood pressure, and converted her simvastatin
to atorvastatin. ___ evaluated patient and cleared for home with
physical therapy.
# HTN Uptitrated lisinopril and imdur as above
# T2DM: Continued home glargine and humalog
# Hypothyroidism: Continued levothyroxine
# Asthma: Continued montelukast and nebs
# Depression: Continued sertraline
TRANSITIONAL ISSUES
1. Code status: DNR/DNI
2. ___: scheduled PCP ___ and recommended repeat
electrolytes, kidney function testing given lisinopril
uptitration; communicated to PCP via email
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 100 mg PO TID
5. Isosorbide Mononitrate 60 mg PO DAILY Duration: 1 Doses
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nabumetone 500 mg PO DAILY
10. Sertraline 50 mg PO DAILY
11. Zolpidem Tartrate 10 mg PO HS
12. Montelukast Sodium 10 mg PO DAILY
13. Glargine 30 Units Bedtime
Humalog 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
14. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Dipyridamole-Aspirin 1 CAP PO BID
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 100 mg PO TID
4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
5. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Alendronate Sodium 70 mg PO AS DIRECTED
10. Nabumetone 500 mg PO DAILY
11. Zolpidem Tartrate 10 mg PO HS
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Duration: 1 Weeks
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
13. Montelukast Sodium 10 mg PO DAILY
14. Levothyroxine Sodium 25 mcg PO DAILY
15. Glargine 30 Units Bedtime
Humalog 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
16. Outpatient Lab Work
Please have your electrolytes and kidney function checked at
your next primary care doctor appointment
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___
___.
You were admitted with left arm pain and changes on your EKG.
You underwent a "cardiac catheterization" that did not show a
new heart attack. Your blood tests were all normal. Your
medications were adjusted to treat your high blood pressure.
We think that your pain is from a pulled muscle. We recommend
tylenol and tramadol to treat your pain.
--------------
Fue un placer atenderlo en ___
___.
Usted fue admitido con dolor en ___ y ___ ___ ECG. Se sometió a un "cateterismo cardíaco" ___ no se
presentó un ataque al corazón nuevo. Sus análisis de sangre
fueron normales. ___ ajustaron para ___ la
presión arterial ___.
Creemos ___ dolor es de un tirón muscular. Recomendamos
tylenol y tramadol para ___ dolor.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
___ Right craniotomy for ___ evacuation, resection of
membranes, implantation of subdural JP drain, and duraplasty
___ Blood transfusion
History of Present Illness:
Mr. ___ is a ___ with history of recent admission to ___
(___) for a R SDH managed conservatively, who had a
mechanical fall with head strike at rehab, brought to ___
found to have CT head with a new SDH and transferred to ___,
s/p right-sided craniotomy for evacuation on ___ found to
have a PNA and bacteremia.
Patient had a recent admission to ___ (___) after a fall
with a right SDH that was conservatively managed. The patient
was stabilized and sent to rehab. Per notes, the patient was
doing well at rehab, without systemic complaints, but had a
mechanical fall and hit his head on ___, so was brought to
___ where CT head revealed an acute on subacute bleed
measuring 2.6cm with 13mm midline shift and he was transferred
to ___ for further management. On ___, he was taken to
the OR emergently for evacuation and tolerated the procedure
well.
His hospital course was complicated by LLL PNA, coag. negative
staph bacteremia, and anemia. ID was consulted and he was
started on vancomycin and cefepime. He was hemodynamically
stable and transferred to the medicine service for further
management of his PNA, bacteremia, and anemia.
On transfer to the floor, vital signs were: Tc 98.2 Tm 98.6 BP
100/50 HR 69 RR 18 O2 95% on RA (was on 98% on 2L earlier in the
day).
Past Medical History:
Dyslipidemia
Hypertension
CAD, s/p CABG (___)
Diastolic heart failure
Former tobacco use
TIA with bilateral carotid endarterectomy (___)
Peripheral vascular disease
Chronic kidney disease
Gout
BPH
Right subclavian stenosis
MGUS
Social History:
___
Family History:
Brother with MI
Father with liver disease and heavy alcohol use
Family history of DM, HLD
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: reactive EOMs intact
Neuro:
Mental status: Lethargic but easily arousable, cooperative with
exam, normal
affect.
Orientation: Oriented to person, place, but not date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
On discharge:
Vitals: 98.3 98.0 ___ 138/45-145/85 18 93% on RA (was 89% on
RA yesterday in evening)
I/O yest: 600 PO | 260 UOP + BRP + 500 straight cath
General: Elderly gentleman sleeping in bed, laying flat, easily
arousable conversant, in no acute distress
HEENT: MMM
Neck: No JVD
Lungs: mildly decreased lung sounds on R>L lower base, no cough
appreciated, otherwise CTAB
CV: II/VI holosystolic murmur loudest at the RUSB, normal S1/S2
Abdomen: Soft, NT, mildly distended, normoactive bowel sounds.
GU: No foley
Ext: Warm, well-perfused, no edema
Neuro: AAOx2 (to name and hospital), CN2-12 intact with mild,
unchanged left facial droop. ___ strength in left upper
extremity, otherwise ___ strength in left upper and bilateral
lower extremities. + anti-gravity hand tremor R>L. Appears
deconditioned and has difficulty sitting up in bed. Sensation
intact bilaterally.
Pertinent Results:
LABS
==================
On admission:
___ 09:50AM BLOOD WBC-7.8# RBC-2.73* Hgb-9.6* Hct-29.1*
MCV-107* MCH-35.2* MCHC-33.0 RDW-14.6 RDWSD-57.5* Plt ___
___ 09:50AM BLOOD Neuts-71.5* Lymphs-12.2* Monos-13.8*
Eos-1.5 Baso-0.5 Im ___ AbsNeut-5.56 AbsLymp-0.95*
AbsMono-1.07* AbsEos-0.12 AbsBaso-0.04
___ 09:50AM BLOOD Plt ___
___ 09:50AM BLOOD Glucose-93 UreaN-30* Creat-2.1* Na-134
K-4.4 Cl-98 HCO3-21* AnGap-19
___ 09:50AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1
___ 01:05PM BLOOD Type-ART pO2-225* pCO2-34* pH-7.44
calTCO2-24 Base XS-0
___ 09:52AM BLOOD Lactate-0.8
___ 01:05PM BLOOD Glucose-92 Na-134 K-4.1 Cl-104
On discharge:
___ 06:30AM BLOOD WBC-5.3 RBC-2.43* Hgb-8.4* Hct-26.6*
MCV-110* MCH-34.6* MCHC-31.6* RDW-16.7* RDWSD-64.5* Plt ___
___ 06:30AM BLOOD Glucose-93 UreaN-35* Creat-2.1* Na-139
K-4.7 Cl-106 HCO3-26 AnGap-12
___ 06:30AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.6
IMAGING
==================
___ CT head (___): Mixed attenuation right
hemispheric subdural hematoma measuring 2.6cm in greatest
thickness, increased in size compared to ___. There is a
13-14 mm right to left midline shift. There is subtle
contralateral hydrocephalus indicating midline herniation.
Ill-defined areas of low attenuation are noted in the
supratentorial white matter. Age related microvascular/ischemic
disease may be considered.
___ CT chest (___): No evidence of acute fracture,
subluxation or prevertebral swelling. Moderate multilevel
spondylosis with ossification of the anterior of the anterior
longitudinal ligament at C7-T3. Prior median sternotomy.
___ CT head (post-op): Expected postsurgical changes seen
in the right subdural space with decreased mass effect from
prior study. Subfalcine herniation is improved. No evidence of
new hemorrhage
___ CXR: Interval development of patchy bibasilar
airspace opacities which may reflect aspiration or infection in
the correct clinical setting.
___ CT head:
1. Expected postsurgical changes in the right subdural space
with similar to slightly decreased mass-effect from the prior
study with residual
pneumocephalus and subdural hematoma.
2. Subfalcine herniation continues to improve.
3. No new intracranial hemorrhage identified.
___ CT head:
1. Compared with the study from the prior day, the right-sided
extra-axial subdural drain has been removed.
2. Expected postsurgical changes with residual pneumocephalus
and subdural hematoma, with decreased mass effect from the prior
study.
3. No new intracranial hemorrhage identified.
___ CXR:
IMPRESSION:In comparison with the study of ___ is
increased prominence of the cardiac silhouette with substantial
pulmonary edema.
___ TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change.
___ CXR:
IMPRESSION:
Since a recent radiograph of ___, a Dobhoff tube is
been placed, initially terminating in the proximal thoracic
esophagus, in subsequently terminating in the distal thoracic
esophagus above the level of the diaphragm. Persistent
cardiomegaly is accompanied by slight decrease in severity of
pulmonary edema and persistent bilateral moderate pleural
effusions.
[___ was subsequently self-d/c'd by patient]
ECG
==================
___:
Baseline artifact. Sinus rhythm.
Borderline P-R interval prolongation. Left axis deviation. RSR'
pattern in
lead V2. Mild Q-T interval prolongation. Compared to the
previous tracing
of ___ the rate is now slower. Lateral ST-T wave
abnormalities are now
less prominent. Otherwise, no change.
Rate PR QRS QT QTc (___) P QRS T
65 ___ 49 -60 77
___:
Sinus rhythm. Left anterior fascicular block. Minor non-specific
ST segment changes. Compared to the previous tracing of ___
ST segment abnormalities are now less marked.
Rate PR QRS QT QTc (___) P QRS T
82 180 90 392 430 65 -45 74
___:
Sinus rhythm. Left axis deviation. Q waves in leads V1-V2.
Compared to the
previous tracing of ___ differences in early R wave
progression may be due to lead position change, particularly in
lead V2. The QTc interval is somewhat shorter. ST segment
depression is now more prominent in the lateral leads. Clinical
correlation is suggested.
Rate PR QRS QT QTc (___) P QRS T
69 160 92 428 443 68 -51 98
MICROBIOLOGY
==================
___ BCx: STAPHYLOCOCCUS, COAGULASE NEGATIVE
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 0.5 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
VANCOMYCIN------------ 1 S
___ BCx x2: STAPHYLOCOCCUS, COAGULASE NEGATIVE.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
___ BCx (1 of 2): No growth
___ BCx (2 of 2): No growth
___ Urine Legionella: NEGATIVE FOR LEGIONELLA SEROGROUP 1
ANTIGEN.
___ URINE CULTURE (Final ___: NO GROWTH.
___ SPUTUM:
GRAM STAIN (Final ___: <10 PMNs and >10 epithelial
cells/100X field.
___ BCx (1 of 2): No growth
___ BCx (2 of 2): No growth
Brief Hospital Course:
Mr. ___ is a ___ with recent admission to ___ (___)
after fall with a conservatively managed right SDH, and a repeat
mechanical fall after that discharge with head strike, found to
have a new SDH. Hospital course notable for operative SDH
management, HCAP and coag negative staph bacteremia (both s/p
Abx courses), lack of appetite, and occasional urinary
retention.
In brief, patient had been at his rehab following a stay for SDH
which was managed conservatively. He had a fall on ___ and was
evaluated at an OSH where imaging revealed an enlarging SDH. He
was transferred to ___ and after evaluation underwent a right
craniotomy for evacuation of SDH. He had a subdural drain placed
to bulb suction in the OR, was extubated after the procedure,
and transferred to the PACU for further management and care. On
___, he spiked a fever to 101.5F and was found to have PNA and
pyuria; his subdural drain was pulled; he was also found to have
coagulase negative staph bacteremia; ID was consulted and he was
started on vancomycin and cefepime (see below).
Active Issues:
# Lack of appetite, concern for low nutrition: Pt had nausea and
odynophagia as above with meals. He was initially unable to take
his medications ___ pain with swallowing. He was seen by speech
and swallow, and the nutrition team. Unclear etiology, but
appears most likely ___ odynophagia, possibly depression, and
lack of appetite in setting of acute illness and neurosurgery;
constipation may have contributed and his bowel regimen was
uptitrated. We started him on pantoprazole 40mg daily and
Maalox/Lidocaine with meals, ondansetron with meals, and
low-dose mirtazapine. After several days of encouraging PO
intake and ensure supplements, intake was still low and dobhoff
was placed on ___, but it was self-d/c'd by pt due to mild
confusion. Dobhoff was not replaced; pt has been intaking about
800kcal/day which is likely an underestimate; his PO intake
should be strongly encouraged and nutrition f/u will be
necessary at rehab.
# Urinary retention: During ___ week of admission pt had foley
catheter, which was removed; foley had to be replaced after 1
day due to low UOP; after several days foley was removed again
on ___ for voiding trial. Pt's bladder scans showed >500cc's
but upon straight cath x 2 the void amount was about 300cc's. Pt
should be monitored for urinary retention, and foley catheter
placed if low UOP or bladder scan showing >500-600cc's, and
voiding trial held several days or 1 week after foley placement.
Treated/Improving Issues:
# Odynophagia vs demand ischemia vs NSTEMI: On ___, he
complained of chest pain and was found to have an unchanged EKG,
with troponins at 5.18 at 0520 (added-on), 4.55 at 1255, and
4.53 at ___ with CK-MB at 7-->6-->5. He was given 1 unit of
pRBCs given concern for demand ischemia. Cardiology and
neurosurgery were consulted and he was started on aspirin 81mg
daily. On ___, he was triggered for ___ chest pain after
receiving his PO pain meds and had an unchanged EKG with
troponins downtrending at 4.21 and CK-MB at 4, his pain improved
slightly with nitroglycerin x2. His troponins were down-trending
and CK-MB was not elevated c/w a possible MI several days ago,
but no evidence of an acute event. It is possible that an MI
precipitated his fall at the rehab. His chest discomfort
appeared to occur in the setting of PO med administration and he
was visibly uncomfortable while swallowing water. Speech and
swallow observed odynophagia as well. His TTE was unchanged from
prior, which further argued against an acute cardiac event. His
chest pain and swallowing gradually improved with a PPI and
Maalox/Lidocaine with meals.
# SDH: He presented with an acute on chronic SDH ___ mechanical
fall s/p right-sided craniotomy for evacuation, resection of
membranes, and duraplasty. He had fluctuating levels of
attention during his hospitalization with no focal neurological
changes. He had a mild stable left facial droop. His systolic
blood pressure was maintained below 160. He was started on
levetiracetam 750mg twice a day, which he should continue until
he has a neurosurgery follow-up appointment. Per neurosurgery,
his Coumadin (for afib) should still be held until neurosurgery
f/u in early ___.
# Pulmonary edema: During his hospitalization, he had
intermittent ___ NC oxygen requirement off and on. He had a
chest x-ray on ___ that showed increased prominence of the
cardiac silhouette with substantial pulmonary edema likely ___
volume overload in the setting of receiving IVF. He received
Lasix and had good urine output. He was then mostly saturating
well on room air but occasionally desatted to low ___ and
improved with ___ NC, which was then weaned within 0.5 to 1
day. His latest CXR on ___ showed interval mild improvement in
pulmonary edema and pleural effusions.
# HCAP: He was febrile on ___ and had a chest x-ray that
showed His pneumonia was likely secondary to aspiration. He
completed a one week course of cefepime and on discharge, he was
afebrile, without a leukocytosis.
# GPC Bacteremia: He had a blood culture that grew coagulase
negative staph with resistance to oxacillin. Per ID, he was
started on vancomycin and completed a one week course with no
other growth on follow-up bacterial cultures. He had a TTE that
did not show endocarditis. On discharge, he was afebrile and
without a leukocytosis.
# Macrocytic anemia: He was found to have a hematocrit that was
reduced from his baseline and he received 1 unit of pRBCs when
his hematocrit was 22.9 and having chest discomfort, which was
concerning for demand ischemia. His hematocrit appropriately
increased. There was no evidence of bleeding. He was discharged
with a stable hematocrit and on ferrous sulfate 325mg twice a
day.
# Pyuria: On ___, he was febrile to 101.5F, with a urine of 73
WBC, 21 RBC, few bacteria, mod leuks. We monitored his urine
output and discontinued his foley prior to discharge.
# H/o atrial fibrillation: We continued his amiodarone 200 mg PO
SUN, TUES, THURS, SAT.
# HTN: We increased his home metoprolol tartrate to 25mg
succinate daily from his home dose of 6.25mg in the setting of
his NSTEMI. We continued his isosorbide mononitrate 30 mg daily.
# CVD: We continued his home atorvastatin 80 mg and aspirin
81mg.
# CKD: His creatinine remained elevated at his baseline of
around 2.0. We renally dosed his medications.
# Gout: We continued his home allopurinol ___ mg daily.
# Pain: He did not endorse significant amounts of pain during
the hospitalization and was treated with acetaminophen 650mg
TID, and several PRN medications postop including tramadol,
oxycodone, and morphine.
# Angina: We continued his home ranolazine 500 mg BID.
TRANSITIONAL ISSUES:
[] Needs continued nutrition monitoring and support with ensure
supplements.
[] Pt should be monitored for urinary retention. The patient had
one episode of urinary retention during his
hospitalization.
[] Pt was constipated for several days despite standing bowel
regimen; had observed bowel movement ___ monitor for
constipation
[] Continue levetiracetam (Keppra) at 750mg daily until seen by
Dr. ___ in 4 weeks.
[] Continue metoprolol on higher dose at 25mg metroprolol
succinate daily.
prevention. Please do not start anticoagulation unless approved
by neurosurgery.
[] Tamsulosin is a new medication started to try to help with
urinary retention
FOLLOWUP NEEDED:
[] Follow-up with Dr. ___ in first or second week of
___, with a CT head without contrast (call ___ for
appointment)
[] Cardiology follow-up with Dr. ___ (___)
in ___ weeks after discharge.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (HCP, daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO SUN, TUES, THURS, SAT
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Ferrous Sulfate 325 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. LeVETiracetam 750 mg PO BID
8. Ranolazine ER 500 mg PO BID
9. Senna 8.6 mg PO BID Constipation
10. Bisacodyl 10 mg PO/PR DAILY Constipation
11. Heparin 5000 UNIT SC BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Metoprolol Tartrate 6.25 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO SUN, TUES, THURS, SAT
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY Constipation
6. Ferrous Sulfate 325 mg PO BID
7. Heparin 5000 UNIT SC BID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. LeVETiracetam 750 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Ranolazine ER 500 mg PO BID
12. Senna 8.6 mg PO BID Constipation
13. Acetaminophen 650 mg PO TID
14. Docusate Sodium 100 mg PO BID
15. Maalox/Lidocaine 30 mL ORAL TID W/MEALS
16. Mirtazapine 15 mg PO QHS
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Ondansetron ___ mg PO TID W/MEALS
20. Pantoprazole 40 mg PO Q24H
21. Tamsulosin 0.4 mg PO QHS
22. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
1. Subdural Hematoma
Secondary Diagnosis:
1. Pneumonia
2. Bacteremia
3. Anemia
4. Pulmonary edema
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 medical care during your
stay at the ___. You came into
the hospital from your rehabilitation center after a fall during
which you hit your head. When you came into the hospital a CT
scan of your head was performed and found bleeding in your head.
The neurosurgery team performed a surgical procedure called a
craniotomy to have fix the bleeding. There were no complications
with the procedure and afterward, we started you on a medication
to prevent seizures called Keppra (levetiracetam). While you
were recovering from the surgery, we found that you had an
infection in your blood and in your lungs. We treated you with
antibiotics for these two infections. During your hospital stay,
you also had chest pain and we performed tests of your heart and
your blood, which showed that you likely had an old heart
attack, but not a new one while you were in the hospital. We
think your chest pressure was likely from pain when you were
swallowing. We continued your home Aspirin 81mg and increased
your metoprolol to 25mg of Metoprolol succinate daily.
You were also having trouble eating because of your nausea and
we worked with the nutrition, and speech and swallow teams to
help you eat more. We gave you a spray (Maalox/Lidocaine) to
help with your through discomfort and started you on a
medication called Mirtazapine to improve your mood and appetite.
Please do your best to have three meals a day and speak with
your primary care physician if you feel nauseous, cannot
tolerate eating, or start losing weight.
Please also follow these recommendations from the neurosurgery
team:
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
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
Thank you for letting us participate in your care.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
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2161-10-11 22:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M w/ PMH of chronic kidney disease
(Baseline cr now 4.1), HTN, uremic pruritis, type II DM with
recent hospitalization for viral gastroenteritis who presents
with nausea/vomiting and diarrhea. His symptoms started on
___ with coughing, rhinorrhea as well as nose bleeding. His
upper respiratory symptoms resolved but on ___ began to have
abdominal pain, diarrhea and nausea and vomiting. Patient
reports fever and chills but has not taken his temperature. He
has been unable to tolerate any PO intake including fluid
intake.
Of note on his last hospitalization, he had diarrhea and acute
on chronic renal failure in the setting of decrease po intake
and labs consistent with prerenal etiology.
In the ED, initial vital signs were 98.5 90 163/91 18 100%.
His labs were notable for Cr of 5.4 which has increased from
baseline 4.1. Patient was given 1L NS and 1L LR, morphine 5mg
IV and zofran 4mg IV x 2.
On the floor, T96 BP ___ 100%RA. He was wretching
clear sputum, and endorsing abdominal pain and nausea which had
improved with zofran in ED.
Review of Systems:
(+) endorses subjective fevers, chills.
(-) night sweats, headache, rhinorrhea, congestion, sore throat,
cough, chest pain, shortness of breath, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Uremic Pruritis
Orthostatic Hypotension
Diabetes Type II
Hypertension
Neuropathy
Chronic Kidney Disease thought to be ___ HTN and DMII
Social History:
___
Family History:
Some family history of kidney disease; his uncle passed away
from kidney disease. Brother passed away from MI in his ___.
Father died from ___.
Physical Exam:
Admission Physical Exam:
Vitals- T96 BP ___ 100%RA
General- Alert, oriented x3, in no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, Loud S1, S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present, TTP over RUQ
and epigastrum, no rebound tenderness or guarding, no
organomegaly
GU- No CVAT
Ext- warm, well perfused, s/p left toe amputation, no edema
Skin- Macules and papules noted over upper arms and back.
Neuro- CNs2-12 intact, motor function grossly normal, ___
strenght in upper and lower extremeties and sensation intact to
LT.
Discharge Physical Exam:
98.2, 154/86, 78, 16, 100%RA
General- Alert, oriented, in no acute distress
HEENT- R pupil larger than L, R sclera mildly injected, Sclera
anicteric, MMM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, Loud S1, S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present, TTP over
epigastrum, no rebound tenderness or guarding
Ext- warm, well perfused, s/p left toe amputation, no edema
Skin- Macules and papules noted over upper arms and back.
Pertinent Results:
Admission Labs
___ 11:20AM BLOOD WBC-7.3 RBC-3.63* Hgb-9.7* Hct-30.2*
MCV-83 MCH-26.8* MCHC-32.3 RDW-13.7 Plt ___
___ 11:20AM BLOOD Neuts-70.7* ___ Monos-5.2 Eos-2.0
Baso-0.4
___ 11:20AM BLOOD ___
___ 11:20AM BLOOD Glucose-125* UreaN-57* Creat-5.4* Na-138
K-4.2 Cl-110* HCO3-16* AnGap-16
___ 11:20AM BLOOD ALT-26 AST-17 CK(CPK)-1475* AlkPhos-88
TotBili-0.1
___ 11:20AM BLOOD Calcium-6.8* Phos-4.4 Mg-1.9
Pertinent Labs
___ 06:00AM BLOOD Albumin-2.7* Calcium-6.0* Phos-4.6*
Mg-1.7
___ 06:25AM BLOOD Calcium-6.0* Phos-4.5 Mg-1.8
___ 06:25AM BLOOD PTH-213*
Urine
___ 09:31AM URINE Color-Straw Appear-Clear Sp ___
___ 09:31AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:31AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:05PM URINE Hours-RANDOM Creat-60 Na-59 K-19 Cl-54
Discharge Labs
___ 06:10AM BLOOD Glucose-101* UreaN-63* Creat-5.0* Na-140
K-4.2 Cl-113* HCO3-18* AnGap-13
___ 06:10AM BLOOD Calcium-6.6* Phos-4.2 Mg-1.9
CT A&P without contrast ___
FINDINGS:
The bases of the lungs are clear. No pleural or pericardial
effusion is seen.
CT abdomen: The study is limited by the lack of IV contrast.
The liver is
homogeneous and without focal lesions or intra or extrahepatic
biliary duct
dilatation. There is a tiny calcification in the right lobe.
The gallbladder
is surgically absent. The spleen is homogeneous and normal in
size. The
pancreas is without focal lesions, peripancreatic stranding or
fluid
collection. The adrenal glands are unremarkable. The kidneys
appear normal,
without stones or focal lesions.
The small bowel is distended with contrast material and the
terminal ileum is
collapsed. There is no clear transition point or clear small
bowel
obstruction. The appendix is visualized and appears normal.
There are a few
scattered diverticula within the descending and sigmoid colon.
No area of fat
stranding or inflammation is identified. The intra-abdominal
vasculature is
unremarkable. There is there is no retroperitoneal or
mesenteric lymph node
enlargement by CT size criteria. There is no ascites, free air,
or abdominal
wall hernia.
CT pelvis: The urinary bladder appears normal. There is no
pelvic wall or
inguinal lymph node enlargement by CT size criteria. There is
no pelvic free
fluid.
Osseous structures: No blastic or lytic lesions suspicious for
malignancy
present.
IMPRESSION:
Normal appendix. No acute CT findings.
Brief Hospital Course:
Mr. ___ is a ___ yo M w/ PMH of CKD, uremic pruritis, HTN,
HLP and DMII who presents with nausea/vomiting and diarrhea and
found to have acute on chronic renal failure.
___ on CKD: Patient presented with Cr of 5.4 from baseline
4.1, likely pre-renal azotemia and ATN from poor po intake and
dehydration in the setting of symptoms of viral gastroenteritis.
Review of prior admission showed that work up for HIV, hep B,
C, SPEP/UPEP were all negative for alternative cause of his
renal failure. There was no urgent need for dialysis given his
only symptoms of uremia was pruritis, his K and Mg were within
range, and he was not volume overloaded. He was dehydrated on
exam, and given IVF with his Cr 5.0 at discharge. His
bicarbonate was low and he was started sodium bicarb pills. He
is in discussion with outpatient nephrologist regarding
impending dialysis initiation and discussions regarding
transplant and is scheduled for options teaching and transplant
surgery consult appointments.
# Hypocalcemia. His corrected Ca was 7.0 without signs on exam.
He has been on vitamin D2 and D3 at home and calcium
supplements. His PTH was checked and was >200. He was started
on calcitriol on discussion with Dr. ___ which is continued
at discharge.
# Diarrhea/vomiting. He presented with symptoms consistent with
viral gastroenteritis, with nausea and vomiting with subjective
fever and chills. Abdominal exam was positive for epigastric
and RUQ TTP but there were no signs of acute abdomen and CT A&P
was negative. He had normal LFTs and lipase. He was afebrile
and had no leukocytosis. Given multiple recurrences, and
diabetic complications in other organ systems, diabetic
gastroparesis was considered but his overall picture and
subjective fever and chills were thought more consistent with an
infectious etiology. His symptoms improved with zofran and he
was tolerating PO intake at discharge.
#Hypertension/Orthostatic Hypotension: He was profoundly
orthostatic with supine measurements at times as high into the
190s SBP and standing SBPs as low as ___. He had been taking
his home BP meds as PRN BP >150. He was restarted on prescribed
home hydral, amlodipine as well as midodrine for orthostatic
hypotension. He continued to be orthostatic but improved with
his medications and IVF.
# Diabetic retinopathy: Patient had vitreous hemorrhage of his
right eye and is s/p PPV in late ___. Was seen on ___ by
Dr. ___ who felt that his ocular pressure was
dangerously high despite eye drops. He gave Acetazolamide 250mg
PO x1 and started Dorzolamide. Recommended that patient go to
the Mass Eye and
Ear Emergency Department for further evaluation and management
as he likely requires surgery. Of note, patient was noted on
admission to be on multiple eye drops, many of which are
duplicates. Patient has poor vision which has also been
limiting his ability to manage his eye drops.
# Pruritus/Rash:
- Continued home meds, with substitutions for lotions/ointments
that were not available.
# T2DM. Continued on ISS. Per OMR review, patient has not been
seen by an endocrinologist since ___ and there are
discrepancies in his ISS (please see PACT note dated ___.
His insulin prescription was renewed but he should have his ISS
managed by endocrinology.
TRANSITIONAL ISSUES:
#Started on bicarb and calcitriol per Dr. ___.
#Started on dorzolamide and being discharged to Mass Eye and Ear
for management of dangerously high ocular pressures.
#Patient needs his medications reconciled carefully at visits,
particularly given poor vision and multiple medications.
#Patient needs ___ endocrinology followup, which has not been
scheduled prior to discharge. Per OMR review, patient has not
been seen by an endocrinologist since ___ and there are
discrepancies in his ISS (please see PACT note dated ___.
#Scheduled for options teaching for dialysis and transplant
surgery consult clinic appointments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fexofenadine 60 mg PO BID:PRN pruritus
5. HydrALAzine 10 mg PO TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Mupirocin Cream 2% 1 Appl TP BID
8. Vitamin D 800 UNIT PO DAILY
9. Gabapentin 100 mg PO Q24H
10. chlorhexidine gluconate 2 % Topical twice weekly
11. HumuLIN N Pen (NPH insulin human recomb) 100 unit/mL (3 mL)
Subcutaneous per sliding scale
12. Calcium Acetate 1334 mg PO TID W/MEALS
13. HydrOXYzine 25 mg PO TID itching
14. Midodrine 5 mg PO BID
15. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
16. Combigan (brimonidine-timolol) 0.2-0.5 % R eye BID
17. Lumigan (bimatoprost) 0.01 % R eye QHS
18. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
19. ammonium lactate 12 % topical daily
20. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
21. Anti-Itch (menthol/camphor) (camphor-menthol) 0.5-0.5 %
topical QID
22. Drisdol (ergocalciferol (vitamin D2)) 50,000 unit oral
weekly
23. HumuLIN R (insulin regular human) 100 unit/mL injection
QACHS sliding scale
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. ammonium lactate 12 % topical daily
4. Aspirin 81 mg PO DAILY
5. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. Combigan (brimonidine-timolol) 0.2-0.5 % R eye twice a day
8. Fexofenadine 60 mg PO BID:PRN pruritus
9. Gabapentin 100 mg PO Q24H
10. HydrALAzine 10 mg PO TID
11. HydrOXYzine 25 mg PO TID itching
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Lumigan (bimatoprost) 0.01 % R eye QHS
14. Midodrine 5 mg PO BID
15. Mupirocin Cream 2% 1 Appl TP BID
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
18. Vitamin D 800 UNIT PO DAILY
19. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*10 Tablet Refills:*0
20. Anti-Itch (menthol/camphor) (camphor-menthol) 0.5-0.5 %
topical QID
21. chlorhexidine gluconate 2 % Topical twice weekly
22. Drisdol (ergocalciferol (vitamin D2)) 50,000 unit oral
weekly
23. HumaLOG KwikPen (insulin lispro) 100 unit/mL Subcutaneous
per sliding scale
24. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
25. HumuLIN N Pen (NPH insulin human recomb) 100 unit/mL (3 mL)
Subcutaneous per sliding scale
26. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
27. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
RX *dorzolamide [Trusopt] 2 % 1 drop to right eye twice a day
Disp #*1 Bottle Refills:*3
28. HumuLIN R (insulin regular human) 100 unit/mL injection
QACHS sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Viral gastroenteritis
Acute on chronic kidney injury
SECONDARY
Type II diabetes mellitus with peripheral neuropathy and
retinopathy
Orthostatic hypotension
Hypertension
Ghost cell glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with nausea, vomiting and diarrhea
likely due to a viral illness. In the setting of poor oral
intake, your kidney function worsened. You were given IV
fluids, and your kidney began to improve. Your bicarbonate
level is low and you should take supplements as instructed.
Please follow-up with your appointments below where you will
learn more about options for dialysis and transplant.
While you were here, you went to ___ for an Ophthalmology
exam - the pressure in your eye is extremely high so you were
given one dose of Acetazolamide (250mg x1 dose today due to
kidney function) and you were started on a new eye drop
(Dorzolamide) in addition to your prior drops. You might
require surgery for this very soon; since it is the weekend, you
are being discharged with plans to go from here to the ___ Eye
and Ear Emergency Department for further immediate management.
The address is ___. Phone# is
___.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team
====================
REFERRAL to the ___ Eye and Ear Emergency Department:
Patient had vitreous hemorrhage of his right eye and is s/p PPV
in late ___. Was seen on ___ by Dr. ___
who felt that his ocular pressure was dangerously high despite
eye drops. He gave Acetazolamide 250mg PO x1 and started
Dorzolamide. Recommended that patient go to the ___ Eye and
Ear Emergency Department for further evaluation and management
as he likely requires surgery.
Followup Instructions:
___
|
10627650-DS-20
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DS
| 20 |
2162-01-06 00:00:00
|
2162-01-07 14:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Edema, dyspnea on exertion.
Major Surgical or Invasive Procedure:
Tunneled HD line placement.
History of Present Illness:
___ M with history of diabetes, hypertension, CKD with recent
placement of AV fistula presents with edema and dyspnea on
exertion. Pt recently admitted ___ for abdominal pain and
acute on chronic kidney disease with Cr of 7.4. Renal felt
decline in renal function ___ progression of CKD, but did not
require urgent initiation of dialysis. A left arm AV fistula was
placed ___ in preparation for hemodialysis. The patient's Cr
at the time of discharge was 7.9. Dry weight was 86.4 kg. BPs
were difficult to control.
One day after discharge he was admitted to ___ with
fevers/chills, T to 103, found to have PNA, started on Levaquin
and discharged on ___. His lasix was held during that admission
and was not restarted at discharge. His total body swelling and
SOB has gotten worse since stopping the lasix. He notes ongoing
itchiness and sour taste in his mouth. He has stable orthopnea.
Fevers/chills have resolved since starting on abx. Besides the
lasix, he had a number of meds stopped at ___ per his d/c med
list, including metoprolol, isosorbide mononitrate, gabapentin,
and had his dose of amlodipine reduced to 5mg daily.
One day after discharge from ___, patient noticed that his lower
extremities and scrotum were edematous, as were around his eyes.
L arm has been more swollen than R since fistula was placed. He
reports he has to stop several times while walking up the stairs
to catch his breath. Has had some R sided chest pain
intermittently over the last few weeks, non-extertional, sharp,
lasts for minutes, non-pleuritic, reproducible to palp. No
fevers, chills, abdominal pain, nausea, vomiting. He reports
that he is making his normal amount of urine, but is urinating
more frequently. No hematuria or dysuria.
In the ED intial vitals were: 99 81 131/107 18 100%
- Labs were significant for: K of 6 (hemolyzed), BUN/Cr 104/8.7,
bicarb 19, AG 14, Hct 23.2 --> repeat K 5.4
- CXR: Mild pulmonary vascular congestion and a moderate
left-sided pleural effusion, not significantly changed since
prior.
- Patient was given no medication
- Admit to medicine for worsening renal failure. No evidence of
electrolyte abnormalities or pulmonary edema that would require
emergent dialysis.
- Vitals prior to transfer were stable.
On arrival to the floor, vitals stable as below.
Review of Systems: +/- per HPI. Also denies dysuria.
Past Medical History:
Uremic Pruritis
Orthostatic Hypotension
Diabetes Type II
Hypertension
Neuropathy
Chronic Kidney Disease thought to be ___ HTN and DMII
Social History:
___
Family History:
Some family history of kidney disease; his uncle passed away
from kidney disease. Brother passed away from MI in his ___.
Father died from ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 98.1 137/74 82 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP at mid neck at 45 deg, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Mild focal TTP at R chest at site of pain, regular rate and
rhythm, normal S1 + S2, ___ SEM LUSB, no rub/gallop
Abdomen: Soft, mild TTP in RLQ and epigastrium without
rebound/guarding, slightly distended, normoactive BS
Back: No CVA tenderness
Ext: Warm, well perfused, 2+ pulses, 2+ edema bilaterally with
e/o venous stasis bilaterally, LUE with palpable thrill and
audible bruit at site of newly created AVF, slightly larger than
L
Skin: Surgical dressing clean/dry/intact, no surrounding
warmth/erythema
DISCHARGE PHYSICAL EXAM
========================
Vitals: Tc/Tm 98.8 140/72 (130-146/72-86) 84 (80-90) 18 99% RA
I/O: 100/BRP
Wt 86.2kg (pre-HD on day of discharge)
General: Alert, oriented, no acute distress, undergoing HD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD
Lungs: Dependent lung fields clear to auscultation
CV: RRR, normal S1 + S2, no M/R/G
Abdomen: Soft, non-tender, normoactive BS
Ext: WWP, 2+ pulses, 1+ edema b/l and e/o venous stasis, no foot
ulcers.
AV fistula: LUE with palpable thrill and audible bruit at site
of newly created AVF. 1x2cm swelling at AVF site,
non-tender/non-erythematous, L arm neurovascularly intact.
Skin: Catheter insertion site with minimal TTP, no bleeding
Pertinent Results:
ADMISSION LABS
===============
___ 04:30AM PLT COUNT-287
___ 04:30AM NEUTS-60.7 ___ MONOS-6.1 EOS-7.7*
BASOS-0.7
___ 04:30AM WBC-7.5 RBC-2.81* HGB-7.4* HCT-23.2* MCV-82
MCH-26.4* MCHC-32.1 RDW-14.1
___ 04:30AM ALBUMIN-2.9* CALCIUM-7.1* PHOSPHATE-5.4*
MAGNESIUM-2.1
___ 04:30AM ___
___ 04:30AM LIPASE-72*
___ 04:30AM ALT(SGPT)-63* AST(SGOT)-74* ALK PHOS-181* TOT
BILI-0.2
___ 04:30AM GLUCOSE-139* UREA N-104* CREAT-8.7*
SODIUM-134 POTASSIUM-6.0* CHLORIDE-101 TOTAL CO2-19* ANION
GAP-20
DISCHARGE LABS
===============
___ 06:45AM BLOOD WBC-6.9 RBC-3.06* Hgb-7.8* Hct-25.6*
MCV-84 MCH-25.5* MCHC-30.5* RDW-15.0 Plt ___
___ 06:45AM BLOOD Glucose-162* UreaN-57* Creat-6.1* Na-135
K-4.3 Cl-100 HCO3-26 AnGap-13
___ 06:45AM BLOOD Calcium-8.2* Phos-5.0* Mg-2.0
___ 06:35AM BLOOD calTIBC-186* Ferritn-328 TRF-143*
MICRO
======
___ 7:45 pm IMMUNOLOGY
**FINAL REPORT ___
HBV Viral Load (Final ___:
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ 10:30 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
IMAGING
=======
CXR ___. Mild pulmonary vascular congestion.
2. Moderate left-sided pleural effusion, not significantly
changed since prior examination with overlying atelectasis.
KUB ___
There is relatively little bowel gas. No evidence of free
intraperitoneal gas, though this would be difficult to detect on
this study. If there is serious clinical concern for small bowel
obstruction with the dilated loops containing only fluid and not
gas, or serious concern for perforation, CT would be the next
imaging procedure.
Brief Hospital Course:
___ with h/o DM2, HTN, CKD with recent placement of AV fistula
presents with edema, DOE.
ACUTE ISSUES
# ESRD: BUN and Cr were mildly elevated from recent admission.
GFR already so poor that doesnt represent significant loss, but
does have sx c/w uremia (itching, metallic taste, nausea).
Additionally, patient with significant volume overload at home
despite lasix, worsened recently when lasix was stopped at ___.
No e/o pericarditis on exam/EKG. K 5.2 with lasix. Main concern
and indication for starting HD on this admission was volume
overload. Fistula recently placed, with good thrill, but not
mature enough for HD. As such, pt received a tunneled HD line on
___, and HD was initiated on the same day. He received 3
consecutive days of HD on ___. Pruritus, abdominal pain,
dyspnea, and metallic taste in mouth all improved on HD. Repeat
HBV serologies showed no HBV infection, but also no HBV immunity
s/p re-vaccination in ___. Therefore, HBV vaccine was
re-administered on ___. PPD planted on ___ and was negative on
___. Patient will continue with outpatient HD on ___ at
___, and is being discharged home with services. Per renal,
his home calcitriol and calcium supplementation were continued,
along with Nephrocaps, sodium bicarbonate.
# Anasarca: Weight was up to 198 lb on admission, from 191 lb at
discharge on ___. Likely ___ ESRD and having diuretics stopped
this week. CXR w/ congestion. BNP elevated but likely not from
primary CHF as had nml stress ECHO during last hospitalization.
EKG non-ischemic. His swelling was responsive to high dose
diuretics. He continued on daily IV Lasix, with low Na diet and
2L fluid restriction, and monitoring of daily weight, Is/Os,
then was started on HD. Following initiation of HD patient had
significant improvement in anasarca. Patient will continue HD
MWF as above at ___.
# Dyspnea: Likely ___ pulmonary edema in the setting of recent
diuretic cessation. CXR with vascular congestion and stable L
pleural effusion. EKG neg, recent neg stress test. ECHO with nl
EF on previous admission. Patient improved with HD.
# Anemia: Hct 24 from baseline ___, stable. Microcytic. Per pt
he was guaic negative at ___ two days PTA. Got Epo on day prior
to admission. Iron studies not c/w iron deficiency. Likely ___
worsening renal fxn, ACD. Patient will receive Epo injections as
outpatient as part of his HD prescription.
# HTN: Difficult to control during last admission, thought to be
___ ESRD. Regimen adjusted during recent admission at ___.
Currently normotensive. Orthostasis neg.
Initial regimen on this admission was hydralazine 10 mg TID,
labetalol 100 mg TID, amlodipine 10 mg QD. Per renal, a 2-drug
regimen was preferred, so his hydralazine was discontinued and
the labetalol was increased to 200 mg TID. On this regimen his
BP was relatively well-controlled at 130s-140s/70s. Attention
should be paid to this patient's blood pressures, as he
continues HD, given that he may not need as high doses of
anti-hypertensives as he has been on.
# Abd pain: Chronic, similar to prior, stable. Improvement with
diuresis and BMs, could be ___ uremia, constipation, and gut
edema. Pt with broad ___ pain during last admission, w/o
evidence of serious abdominal pathology. Does have known PUD, no
hematemesis. Has mild transadminitis w/ alk phos elevation, may
be ___ hepatic congestion, had neg RUQUS 2 weeks ago. Also, he
is s/p cholecystectomy. Bowel reg, lasix, and PPI were
continued. He also had improvement when started on HD.
# Hypocalcemia: likely ___ CKD. Corrects to 8 with albumin.
Continued home calcium and vitamin D regimen.
CHRONIC ISSUES
# T2DM: Gabapentin stopped at ___. Patient on Humalog insulin
sliding scale during this admission.
# Diabetic retinopathy: Stable. Continued eye drops.
# Pruritus/Rash: Stable. Continued ointments and hydroxizine.
TRANSITIONAL ISSUES
- Question of indirect inguinal hernia on exam
- Outpatient HD MWF at ___
- Follow-up with anti-HBV titers in ___ months
- Follow-up with blood pressures and monitor as outpatient;
patient is known to have autonomic insufficiency/orthostasis,
and his blood pressure regimen may need to be modified as he
progresses on dialysis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. HydrALAzine 10 mg PO QID
3. Labetalol 100 mg PO Q8H
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Docusate Sodium 100 mg PO BID
6. Omeprazole 40 mg PO BID
7. Calcium Carbonate 1250 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Levofloxacin 750 mg PO Q48H
10. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
11. Calcitriol 0.25 mcg PO DAILY
12. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
14. Miralax (polyethylene glycol 3350) 17 gram oral daily prn
constipation
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
16. petrolatum, hydrophilic 36 % topical QID prn dry skin
17. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Acetate 1334 mg PO TID W/MEALS
RX *calcium acetate 667 mg 2 tablet(s) by mouth TID with meals
Disp #*180 Tablet Refills:*0
6. Calcium Carbonate 1250 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Labetalol 200 mg PO TID hypertension
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
9. Levothyroxine Sodium 25 mcg PO QAM
10. Omeprazole 40 mg PO BID
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
12. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*60 Tablet Refills:*0
13. Miralax (polyethylene glycol 3350) 17 gram oral daily prn
constipation
14. petrolatum, hydrophilic 36 % topical QID prn dry skin
15. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
16. Senna 8.6 mg PO BID:PRN constipation
17. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
18. HydrOXYzine 10 mg PO TID:PRN itching
19. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % (700 mg/patch) APPLY PATCH once a day Disp
#*30 Box Refills:*0
20. Metoclopramide 5 mg PO TID:PRN N/V
RX *metoclopramide HCl 5 mg 5 mg by mouth three times a day Disp
#*90 Tablet Refills:*0
21. HumuLIN N Pen (NPH insulin human recomb) 100 unit/mL (3 mL)
Subcutaneous per sliding scale
RX *NPH insulin human recomb [Humulin N Pen] 100 unit/mL (3 mL)
3 ml SC per sliding scale Disp #*90 Syringe Refills:*0
22. HumuLIN R (insulin regular human) 100 unit/mL INJECTION
QACHS sliding scale
RX *insulin regular human [Humulin R] 100 unit/mL 100 u/ml SC
QACHS per sliding scale Disp #*30 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS:
ESRD s/p tunneled line placement and initiation of HD
SECONDARY DIAGNOSES:
Uremic Pruritis
Orthostatic Hypotension
Diabetes Type II
Hypertension
Neuropathy
ESRD thought to be ___ HTN and DMII
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
You were admitted to this hospital because of swelling in your
groin and legs, and shortness of breath with exertion. You were
found to have increased fluid in your lungs and body that led to
those symptoms, which was a result of your kidney disease. We
treated you with diuretics to remove the excess fluid. Also, we
placed a tunneled line to start hemodialysis, since the AV
fistula in your left arm was not mature enough to use for
dialysis. You were started on dialysis and improved
significantly during your stay.
You should continue with dialysis as an outpatient every ___,
___, and ___.
Please follow-up at your appointments, as below. Also, please
continue to take your medications as prescribed.
Followup Instructions:
___
|
10627650-DS-25
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2162-08-12 13:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Foot Ulcer, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with hx of ESRD on HD, HTN DM type
II complicated by nephropathy, peripheral neuropathy,
retinapathy, and gastroparesis who p/w left foot infection as
well as worsening abomdinal pain and vomiting.
He reports an ulceration on the sole of his left foot for the
past 2 weeks, which started draining purulent foul-smelling
material over the last 5 days. He has had subjective fevers and
chills at home, and measured his temperature twice with Tmax
100.8 while taking tylenol. At HD yesterday (___) he was
advised to seek medical attention for treatment of the
infection, so he presented to the ED.
Pt's major current complaint is sharp epigastric pain with
nausea and vomiting. He reports sharp, non-radiating epigastric
pain for the past 4 days, improved with eating. It feels similar
to his recent previous episodes of pain that were diagnosed as
gastroparesis flares. However, he notes that it feels different
than gastroparesis, which are typically characterized as a
fullness. He feels his gastroparesis has been much improved
after starting erythromycin, and reports regular bowel
movements. Of note, he has had ~10 admissions to ___ over the
past year, plus several visits to ___ for symptoms of
gastroparesis flaring. The most recent were an admission to
___ ___ ___ and an admission to ___ ___ mid ___. His most
recent gastric emptying study done ___ showed evidence of
gastroparesis with residual tracer ___ the stomach.
Regarding his nausea and vomiting, he had acute worsening of his
chronic sx last ___. He reports that he typically wakes up
with nausea ___ the morning, with associated vomitting. Vomiting
is markedly worsened by HD, often causing him to stop HD early.
Emesis is non-bloody, non-bilious. Eating improves his symptoms.
He also reports an electrical type pain along his right flank,
which feels similar to the peripheral neuropathy pain he has ___
his legs. He has also been having chest pain over the past 2
days, which he describes as a left-sided pressure. It has been
intermittent during this time, occuring with both rest and
activity. He cannot identify any triggers, denies radiation,
SOB, diaphoresis.
___ the ED, pt was afebrile, hypertensiveto 178/83. Labs were
notable for trop 0.40 (though this is baseline for him), Cr 6.2
(at baseline), normal lactate. Exam showed diffusely tender
abdomen but soft and nondistended, as well as L foot 1x2cm
ulceration with purulent drainage but no crepitus or notable
abscess. Pt was seen by podiatry, who noted superficial
infection noted to L sub met head (malodor, purulence) with no
deep probing, fluctuance, or concern for deep infection. They
debrided the wound and sent cx. Pt was started on vanc 1g IV and
given zofran for nausea.
Past Medical History:
-Diabetes Type II, c/b neuropathy, nephropathy, retinopathy,
gastroparesis
-ESRD, on HD thought to be ___ HTN and DMII
-H/o gastric ulcer ___ ___
-Hypertension
-Uremic Pruritis
-Orthostatic Hypotension
Social History:
___
Family History:
Some family history of kidney disease; his uncle passed away
from kidney disease. Brother passed away from MI ___ his ___.
Father died from ___.
Physical Exam:
===============
ADMISSION EXAM
===============
Vitals - T: 98.2 BP: 163/77 HR: 75 RR: 18 02 sat: 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: LUE fistual with good bruit and thrill. Moving all
extremities well, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Papular rash on R flank, puritic. L foot 1x2cm ulceration
with purulent drainage. No crepitus or abscess palpated. Lowe
extremities warm and well perfused.
===============
DISCHARGE EXAM
===============
Vitals: Tm=Tc98.6 137/70-156/72 75 -80 18 100%RA
GENERAL - Alert, interactive, laying comfortably ___ bed, NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG (though can hear bruit from AVF
throughout)
LUNGS - CTAB
ABDOMEN - NABS, soft/NT. Tender over epigastrium, otherwise
nontender.
EXTREMITIES - LUE fistula with bruit and palpable thrill. Lower
extremities with dry skin and chronic venous stasis changes. No
edema. L foot with bandage clean, dry, and intact.
NEURO - awake, A&Ox3,
Pertinent Results:
===============
ADMISSION LABS
===============
___ 08:38PM BLOOD WBC-8.0 RBC-4.97# Hgb-13.5* Hct-43.4#
MCV-87 MCH-27.2 MCHC-31.1 RDW-18.3* Plt ___
___ 08:38PM BLOOD Neuts-56.9 ___ Monos-7.5 Eos-4.2*
Baso-0.8
___:38PM BLOOD Glucose-83 UreaN-22* Creat-6.2*# Na-135
K-6.6* Cl-95* HCO3-29 AnGap-18
___ 08:38PM BLOOD CK(CPK)-319
___ 08:38PM BLOOD CK-MB-7
___ 08:38PM BLOOD cTropnT-0.40*
___ 08:38PM BLOOD Albumin-4.1 Calcium-8.1* Phos-3.5# Mg-2.2
___ 08:41PM BLOOD Lactate-1.5
=====================
OTHER PERTINENT LABS
=====================
___ 05:50AM BLOOD ___ PTT-30.4 ___
___ 05:50AM BLOOD ALT-18 AST-20 AlkPhos-74 TotBili-0.3
___ 05:50AM BLOOD Lipase-46
___ 05:50AM BLOOD CK-MB-7 cTropnT-0.40*
======
MICRO
======
Blood culture x2 ___: pending, no growth to date
L foot wound swab:
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
H. pylori serology: pending
========
IMAGING
========
CXR ___-
The cardiac, mediastinal and hilar contours appear stable. There
is no
pleural effusion or pneumothorax. The lungs appear clear. There
is no free air. Impression: No evidence of acute cardiopulmonary
disease.
CTA ABD & PELVIS ___-
1. 8 mm avidly enhancing nodule ___ the left adrenal gland which
could possibly represent a pheochromocytoma, though adenoma is
also possible. Recommend correlation with labs such as urine
metanephrines and if negative, consider 6 month followup with
dedicated MR.
___. Otherwise unremarkable CT examination of the abdomen pelvis
without evidence of mesenteric ischemia or other acute findings.
Normal appearing abdominal aorta with preserved branch
vasculature.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with hx of ESRD on HD, HTN DM type
II complicated by nephropathy, peripheral neuropathy,
retinapathy, and gastroparesis who p/w left foot infection as
well as worsening abomdinal pain and vomiting.
==============
ACTIVE ISSUES
==============
# Diabetic Foot ulcer: Pt p/w superficial ulceration on plantar
surface of ___ ray of the L foot with foul-smelling purulent
discharge. He has DM, putting him at risk for polymicrobial
infection. He also has significant healthcare exposure, with HD
treatments and many recent hospitalizations. Pt had Xray at OSH,
which was negative for bony involvement. Podiatry was consulted,
debrided the wound, and confirmed no evidence of deep infection.
Pt received 1g vanc ___ the ED and then was started on
vanc/augmentin to be dosed with HD for broad coverage. For wound
care, podiatry also recommended QD betadine dressing changes,
felted foam dressing at discharge, and nonweight bearing to left
forefoot.
# Epigastric Pain: Patient with history of known gastroparesis
___ DM, though sx did not sound c/w gastroparesis flare given
that pain had different quality, erythromycin had been working
well, and sx improved with food. Improvement with food was
suggestive of duodenal ulcer, so pt had serology test for H.
pylori, which was still pending at the time of discharge. Pt
does have h/o gastric ulcer, unknown whether he was treated for
H. pylori at that time. Stool guaiac neg x1. Given known
vascular dz and worsening sx after dialysis, he may have
underlying mesenteric ischemia exacerbated by HD-related fluid
shifts. CTA did not show evidence of major occlusion, but he may
have some milder mesenteric vascular disease leading to more of
a steal phenomenon. CTA did show adrenal mass concerning for
possible pheochromocytoma, so plasma metanephrines were sent
(urine metanephrines are not reliable ___ renal failure pts, but
plasma free metanephrines are not as dependent on renal
function). This test is a send-out and should be followed up by
pt's PCP. He was continued on his home erythromycin and high
dose PPI, and treated symptomatically with zofran for nausea and
tramadol for pain. Nutrition was consulted to help identify any
dietary strategies he could use to manage his gastroparesis.
===============
CHRONIC ISSUES
===============
# ESRD: Dialysis team was consulted for inpatient management. He
was continued on his ___ HD schedule and continued on home
calcitrilol and nephrocaps.
# Type 2 Diabetes Uncontrolled with complications: He was
continued on his home ISS. He does not have a standing dose,
apparently because his nausea and vomiting makes his intake very
irregular. He may benefit from outpatient follow-up to optimize
his DM management.
# Benign Hypertension: He was continued on home amlodipine.
Continued on labetalol and lasix on non-HD days.
# Hypothyroidism: He was continued on home levothyroxine.
====================
TRANSITIONAL ISSUES
====================
# Patient will complete a 10 day course of augmentin with the
last day on ___
# H. pylori serology and stool studies were sent given concern
for ulcer, pending at time of d/c.
# Plasma metanephrines were sent to w/u adrenal mass, pending at
time of d/c.
# Pt. with enhancing left adrenal nodule that needs 6 month f/up
w/ dedicated MR if ___ for pheo is negative.
# Pt currently on ISS given flux ___ meals from n/v; should
discuss with PCP whether this is the optimal regimen.
# Code: Full
# Emergency Contact: ___, niece, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN acid reflux
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Erythromycin 250 mg PO TID W/MEALS
6. Furosemide 40 mg PO 4X/WEEK (___)
7. Gabapentin 100 mg PO DAILY:PRN pain
8. HumuLIN R (insulin regular human) 100 unit/mL INJECTION QACHS
sliding scale
9. HydrOXYzine 10 mg PO TID:PRN itching
10. Labetalol 200 mg PO TID hypertension
11. Levothyroxine Sodium 25 mcg PO QAM
12. Midodrine 5 mg PO DIALYSIS DAYS ONLY orthostatic hypotension
13. Nephrocaps 1 CAP PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
16. Avage (tazarotene) 0.1 % topical daily
17. Calcitriol 0.25 mcg PO DAILY
18. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
19. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID
Apply to right eye
20. Drisdol (ergocalciferol (vitamin D2)) 50,000 unit oral qweek
21. Nepro (nut.tx.impaired renal fxn,soy) 0.08-1.80 gram-kcal/mL
oral tid
22. Ondansetron 4 mg PO Q8H:PRN nausea
23. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN acid reflux
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Erythromycin 250 mg PO TID W/MEALS
7. Furosemide 40 mg PO 4X/WEEK (___)
8. Gabapentin 100 mg PO DAILY:PRN pain
9. HumuLIN R (insulin regular human) 100 unit/mL INJECTION QACHS
sliding scale
10. HydrOXYzine 10 mg PO TID:PRN itching
11. Labetalol 200 mg PO TID hypertension
12. Levothyroxine Sodium 25 mcg PO QAM
13. Nephrocaps 1 CAP PO DAILY
RX *B complex & C ___ acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
14. Pantoprazole 40 mg PO Q12H
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
16. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
17. Amoxicillin-Clavulanic Acid ___ mg PO Q24H
On dialysis days, please take the pill after dialysis.
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth daily Disp #*6 Tablet Refills:*0
18. Vancomycin 750 mg IV HD PROTOCOL
Vanco Level < 15: 1000 mg ONCE
Vanco Level 15 - 25: 500 mg ONCE
Vanco Level > 25: Hold Dose
19. Avage (tazarotene) 0.1 % topical daily
20. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
21. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID
Apply to right eye
22. Drisdol (ergocalciferol (vitamin D2)) 50,000 unit oral qweek
23. Nepro (nut.tx.impaired renal fxn,soy) 0.08-1.80 gram-kcal/mL
oral tid
24. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS:
Diabetic Foot ulcer
Epigastric pain
Gastroparesis
SECONDARY DIAGNOSIS:
Type II diabetes, uncontrolled with complications
ESRD ON HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for an infected left foot ulcer. The podiatry
team was consulted ___ the emergency room and debridged the
ulcer. The infection is being treated with 2 antibiotics:
Augmentin (amoxicillin-clavulanate), which you should continue
to take by mouth daily, and Vancomycin, which is an IV
medication that you will get after dialysis. When you leave the
hospital, you should protect your foot with a cushion/pillow
when ambulating and limit the amount of pressure you place on
foot with ulcer. You should follow-up with podiatry as an
outpatient within the next ___ weeks for further management and
therapeutic devices as needed. For your convenience, we have
scheduled an appointment for ___ at 3:30 ___.
Regarding your abdominal pain, it is still unclear what's
causing this. It may be partly related to your gastroparesis,
although it doesn't sound entirely consistent with your usual
symptoms. We did a scan looking for blockage ___ the vessels
feeding your GI track, but did not find any obstruction.
However, the scan did show that you have a small mass on your
left adrenal gland. This could be nothing, but could also be
producing adrenaline hormones contributing to your blood
pressure swings. We sent a blood test to check your levels of
these hormones, but it will take some time to come back. You
should follow-up with your primary care doctor for the results.
If the test is negative, you should get an MRI ___ 6 months to
make sure that the mass hasn't changed. We will communicate this
information to your doctor. You should continue taking your home
zofran and tramadol to control your symptoms.
It's been a pleasure taking part ___ your care, and we wish you
all the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10627650-DS-35
| 10,627,650 | 28,605,013 |
DS
| 35 |
2167-02-14 00:00:00
|
2167-02-18 19:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / metoprolol
Attending: ___.
Chief Complaint:
Second left toe laceration - Chest pain and left eye blood
level
Major Surgical or Invasive Procedure:
___ left second toe amputation
History of Present Illness:
Mr. ___ is a ___ y/o M with a h/o ESRD on dialysis ___, DM
s/p multiple toe amputations (Last approx. ___ year ago), and PVD
who presents to the ED as a transfer from ___ with a
left foot laceration, left visual field defect and left-sided
chest pain.
He reports he sustained a laceration to the ___ digit on his L
foot. He is unsure how this happened, but noted blood when he
went to take a bath earlier this evening.
He also reports ___ weeks of intermittent, dull, non-exertional
chest pain. He reports, he was worked up at ___ for this 2
weeks ago and was diagnosed with pleurisy and reports this feels
like that. He denies any fever, chills, or n/v. He presented to
___, however was transferred here at his request for
further evaluation of possible amputation, as his prior
amputations have been performed here.
In the ED, patient afebrile w/ blood pressures in the 160s-190s
systolic, satting well on RA. Cr 11.4 but lytes otherwise WNL,
trop 0.17, BNP 7338. CBC relatively WNL. Patient sent to OR for
amputation from the ED
Patient seen post-operatively. Reports feeling OK. No pain at
present other than in chest wall. No SOB, orthopnea.
Upon arrival to the medical ward, patient reports that during
his
HD session on ___, he was hypotensive and had blurry
vision
with blood level that moves with head movement.
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
ESRD on HD, ___ DM
DM2, complicated by neuropathy, nephropathy, retinopathy,
gastroparesis
h/o gastric ulcer in ___ Negative H.pylori ___
Hypertension
uremic Pruritis
severe orthostatic hypotension
Social History:
___
Family History:
- Father died from ___
- Brother passed away from MI in his ___.
- Uncle passed away from kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1312)
Temp: 97.7 (Tm 97.7), BP: 195/103, HR: 77, RR: 18, O2 sat:
99%, O2 delivery: Ra, Wt: 215.39 lb/97.7 kg
GENERAL: NAD adult man. Comfortably laying in bed.
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: No cervical lymphadenopathy. No JVD appreciated
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: left foot wrapped with dressing. Black
discoloration
of the left foot, likely diabetic dermatopathy Vs venous stasis.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&Ox3, moving all 4 extremities with purpose
Access: AV fistula on the left arm +bruit +thrill.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 645)
Temp: 97.3 (Tm 98.4), BP: 160/84 (116-165/70-86), HR: 76
(68-76), RR: 18 (___), O2 sat: 99% (94-100), Wt: 209.22
lb/94.9
kg
GENERAL: NAD adult man. Comfortably laying in bed.
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: Left sided neck tenderness with no swelling, no focal
lymphadenopathy
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. Bruit is heard radiating to the chest.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: left foot wrapped with dressing c/d/I, no ___ edema
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&Ox3, moving all 4 extremities with purpose
Access: AV fistula on the left arm +bruit +thrill.
Pertinent Results:
ADMISSION LABS
___ 03:38AM BLOOD WBC-7.3 RBC-3.70* Hgb-10.1* Hct-32.0*
MCV-87 MCH-27.3 MCHC-31.6* RDW-13.8 RDWSD-43.2 Plt ___
___ 03:38AM BLOOD Neuts-60.1 ___ Monos-11.1 Eos-2.2
Baso-0.4 Im ___ AbsNeut-4.40 AbsLymp-1.89 AbsMono-0.81*
AbsEos-0.16 AbsBaso-0.03
___ 03:38AM BLOOD ___ PTT-26.1 ___
___ 03:38AM BLOOD Glucose-214* UreaN-55* Creat-11.4* Na-137
K-4.5 Cl-95* HCO3-25 AnGap-17
___ 12:55PM BLOOD Calcium-10.2 Phos-3.4 Mg-2.6 Iron-49
___ 03:38AM BLOOD ALT-13 AST-18 CK(CPK)-265 AlkPhos-80
TotBili-0.3
___ 03:38AM BLOOD cTropnT-0.17*
___ 06:05AM BLOOD cTropnT-0.16* proBNP-7338*
___ 07:20AM BLOOD cTropnT-0.14*
___ 12:55PM BLOOD calTIBC-179* Ferritn-797* TRF-138*
___ 04:50AM BLOOD %HbA1c-6.8* eAG-148*
___ 03:38AM BLOOD CRP-24.0*
PERTINENT STUDIES
___ CHEST XRAY
FINDINGS:
AP and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax.
Mild cardiomegaly is stable since ___. There is
cephalization of
the pulmonary vasculature with indistinct vascular borders
indicate
interstitial edema. Mediastinal contours are normal. No focal
consolidations.
IMPRESSION:
Findings suggest acute heart failure with interstitial pulmonary
edema.
Correlate with clinical symptoms and BNP values.
LEFT FOOT XRAY ___
FINDINGS:
Vascular calcifications are heavy. There has been new
amputation of the second ray at the level of the proximal
phalanx with increased soft tissue swelling and subcutaneous gas
about the forefoot, which is likely postoperative. There is
significantly worsened bony irregularity and deformity of the
medial cuneiform and medial navicular at their articulation.
There is increased bony irregularity and patchy sclerosis and
erosion at the TMT joints, diffusely. Additional deformities of
the phalanges appear similar to ___.
LEFT NECK ULTRASOUND ___
FINDINGS:
Transverse and sagittal images were obtained of the superficial
tissues of the left neck in the region of clinical concern there
are several prominent, the largest of which measures 2.2 x 1.6 x
1.1 cm. No abnormal masses or drainable fluid collections are
demonstrated..
IMPRESSION:
Mildly prominent lymph nodes in the region of symptoms. No mass
or drainable fluid collections.
NON CONTRAST CHEST CT ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber.
Mild
coronary artery calcifications are demonstrated. Heart is
mildly enlarged.
Pericardium and great vessels are unremarkable. No pericardial
effusion is
seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal
lymphadenopathy is
present. No mediastinal mass or hematoma. Note is made of
bilateral
gynecomastia.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Linear atelectasis is demonstrated in the
bilateral lower
lobes. Lungs are clear without masses or areas of parenchymal
opacification.
The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: The thyroid is unremarkable. No supraclavicular
lymphadenopathy
is identified.
ABDOMEN: Included portion of the unenhanced upper abdomen is
notable for
changes status post cholecystectomy and multiple pancreatic
calcifications
which may reflect sequelae of chronic pancreatitis. A punctate
posterior
right hepatic lobe calcification likely reflects a hepatic
granuloma.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
No acute abnormalities identified within the thorax,
specifically no findings
of focal consolidations, pulmonary masses, or lymphadenopathy.
Minor
atelectasis at each lung base. Mildly enlarged heart.
TRANSTHORACIC ECHOCARDIOGRAM ___
CONCLUSION: The left atrial volume index is moderately
increased. There is mild symmetric left
ventricular hypertrophy with a mildly increased/dilated cavity.
There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 56 %. There is
no resting left ventricular outflow tract gradient. Tissue
Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free
wall motion. Tricuspid annular plane systolic excursion (TAPSE)
is normal. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal
with a normal descending aorta diameter. 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 mild [1+] mitral
regurgitation. The pulmonic valve
leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal regional/global
biventricular systolic function. Mild mitral regurgitation. Mild
pulmonary hypertension
CARDIAC PERFUSION PHARM STRESS TEST ___
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was
infused
intravenously over 20 seconds followed by a saline flush.
COMPARISON: Cardiac perfusion from ___
TECHNIQUE: ISOTOPE DATA: (___) 10.9 mCi Tc-99m Sestamibi
Rest; (___)
11.0 mCi Tc-99m Sestamibi Rest; (___) 31.7 mCi Tc-99m
Sestamibi Stress;
DRUG DATA: 000 None Regadenoson.
Resting images were obtained approximately 45 minutes following
the intravenous
injection of tracer.
Stress images were obtained after resting images and
approximately 30 minutes
following the intravenous injection of tracer.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
FINDINGS: Left ventricular cavity size is moderately enlarged.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 55%
IMPRESSION: 1. Normal cardiac perfusion. 2. Moderately enlarged
left ventricular
cavity size. Normal left ventricular ejection fraction of 55%.
INTERPRETATION: This ___ year old IDDM man with a history of
non-flow
limiting CAD, PAD and ESRD was referred to the lab for
evaluation of
chest discomfort. The patient was infused with 0.4 mg/5ml of
regadenoson over 20 seconds followed immediately by isotope
infusion.
No arm, neck, back or chest discomfort was reported by the
patient
throughout the study. There were no significant ST segment
changes
during the infusion or in recovery. The rhythm was sinus with no
ectopy. Appropriate hemodynamic response to the infusion and
recovery.
IMPRESSION: No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-6.3 RBC-3.47* Hgb-9.5* Hct-29.6*
MCV-85 MCH-27.4 MCHC-32.1 RDW-14.0 RDWSD-43.8 Plt ___
___ 07:00AM BLOOD Glucose-259* UreaN-71* Creat-12.4* Na-137
K-4.5 Cl-94* HCO3-22 AnGap-21*
___ 07:00AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3
Brief Hospital Course:
SUMMARY STATEMENT:
====================
The patient is a ___ male with a history of ESRD on
dialysis and WF, diabetes mellitus status post multiple toe
amputations, peripheral vascular disease who presented to the ED
as a transfer with a left foot laceration as well as left-sided
chest pain and left visual defect. He was evaluated by podiatry
who took him to the OR for partial amputation of the left second
metatarsal and received perioperative antibiotics but there is
no concern for osteomyelitis in the remaining bone. For his
chest pain he was evaluated with EKG, serial troponins which
identified an elevated troponin in the setting of ESRD, as well
as a transthoracic echo. He was evaluated ophthalmology team who
determined he likely had a vitreal hemorrhage and recommended
outpatient follow-up. He received dialysis per his usual MWF
schedule.
ACTIVE ISSUES:
==============
#Left foot laceration
Patient presented after sustaining a laceration of the second
digit on his left foot. He is unsure how it happened but noted
blood when he went to take a bath the evening prior to
presentation. He had a history of several toe amputations in the
setting of severe diabetes mellitus with nephropathy. He was
advised by the podiatry team and underwent left second toe
amputation. He received perioperative antibiotics but there was
low suspicion for osteomyelitis. Following the operation, the
podiatry team managed his dressing changes and recommended every
other day Betadine dressing changes to the surgical site.
#Left-sided chest pain
Patient presented with ___ weeks of left-sided chest pain. He
reported that it was positional, worsening with leaning forward
and feeling better with laying down and leaning back. EKG showed
some anterior ST elevations consistent with past EKGs in the
setting of left ventricular hypertrophy. Troponin was positive
at 0.17 in the setting of ESRD and down trended from there.
Transthoracic echo was performed which showed no effusion or
identified cause of chest pain. Noncontrast CT of the chest was
similarly unremarkable. Patient had pharmacologic nuclear stress
test on ___ and ___ which was negative for any sign of ischemia;
patient did not have any anginal symptoms during the test.
#Left neck pain
Patient complained of left neck pain which started during the
hospitalization. Ultrasound of the neck (without Doppler)
identified lymphadenopathy and no other cause of neck pain
including no hematoma or fluid collection.
#Left visual defect
#Blood floaters
Patient complained of 3 days of having a "blood level" with
blurry vision. Ophthalmology was consulted and did not feel that
this was an emergency and likely represented vitreal hemorrhage.
His vision worsened on ___ and was reevaluated by ophthalmology
who gave the same diagnosis, with low concern for retinal
detachment. He was scheduled for outpatient follow up in the
next week. He was discharged home.
#ESRD
Continued dialysis per usual ___ schedule.
#Diabetes mellitus
Patient was placed on insulin sliding scale.
#dispo: Counseled pt on recommendation for rehab and risks of
returning home without initial rehab based on medical conditions
(vision loss, toe amputation, ESRD) and ___ recommendations. Pt
was able to state expected benefits of rehab and risks of
returning home, and chose to return home/declined discharge to
rehab.
CHRONIC ISSUES:
===============
#Anemia
Chronic and likely secondary to chronic kidney disease. Labs
were not consistent with iron deficiency anemia.
#Hypertension
Continued home amlodipine, hydralazine and labetalol as needed
with high blood pressures on nondialysis days. On midodrine when
orthostatic or hypotensive.
#Hypothyroidism
Continued levothyroxine
#Neuropathic pain
Continued home gabapentin, tramadol
#Decreased bone mineral density
Continued calcium supplementation, nephrocaps.
TRANSITIONAL ISSUES:
====================
[] Patient should have follow-up with ___ clinic in 1 week
[] PCP can refer patient to endocrinology as needed for
management of diabetes.
[] Patient will need follow-up in ophthalmology clinic for his
visual symptoms
[] Patient should have follow-up with ophthalmology within a
week for possible vitreal hemorrhage.
[] Per inpatient podiatry team, recommend every other day
dressing changes with Betadine dressing to the wound.
[] Change in management of antihypertensives and midodrine on HD
days. Midodrine now scheduled for pre-HD ___,
___. Amlodipine now scheduled for non-HD days only.
Hydralazine scheduled for non-HD days only as needed.
[] Oral furosemide changed to non-HD days only.
CONTACT:
Name of health care proxy: ___
Relationship: Niece
Phone number: ___
CODE STATUS: full presumed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. ammonium lactate 12 % topical DAILY
3. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) DAILY
4. Famotidine 20 mg PO QAM:PRN Nausea
5. Furosemide 40 mg PO DAILY
6. Gabapentin 100 mg PO TID:PRN Pain
7. HydrALAZINE 10 mg PO BID:PRN Elevated BP
8. Labetalol 100 mg PO BID:PRN When Blood pressure is elevated
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Midodrine 5 mg PO BID:PRN For hypotension
11. Pantoprazole 40 mg PO Q12H
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
13. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash
15. urea 40 % topical DAILY:PRN
16. Aspirin 81 mg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. benzoyl peroxide 10 % topical DAILY
19. Calcium Carbonate 1000 mg PO TID W/MEALS
20. Calcium Carbonate 500 mg PO QHS
21. Senna 8.6 mg PO BID:PRN Constipation - First Line
22. Humalog 4 Units Lunch
NPH 4 Units Breakfast
NPH 4 Units Dinner
Regular 2 Units Breakfast
Regular 2 Units Lunch
Regular 2 Units Dinner
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
2. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
3. Humalog 4 Units Lunch
NPH 4 Units Breakfast
NPH 4 Units Dinner
Regular 2 Units Breakfast
Regular 2 Units Lunch
Regular 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. amLODIPine 10 mg PO DAILY
5. ammonium lactate 12 % topical DAILY
6. Aspirin 81 mg PO DAILY
7. benzoyl peroxide 10 % topical DAILY
8. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) DAILY
9. Calcium Carbonate 1000 mg PO TID W/MEALS
10. Calcium Carbonate 500 mg PO QHS
11. Famotidine 20 mg PO QAM:PRN Nausea
12. Furosemide 40 mg PO DAILY
13. HydrALAZINE 10 mg PO BID:PRN Elevated BP
14. Labetalol 100 mg PO BID:PRN When Blood pressure is elevated
15. Levothyroxine Sodium 25 mcg PO DAILY
16. Midodrine 5 mg PO BID:PRN For hypotension
17. Nephrocaps 1 CAP PO DAILY
18. Pantoprazole 40 mg PO Q12H
19. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
20. Senna 8.6 mg PO BID:PRN Constipation - First Line
21. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash
23. urea 40 % topical DAILY:PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
End-stage renal disease
Left second toe laceration requiring amputation
Insulin-dependent diabetes mellitus
SECONDARY DIAGNOSES:
Peripheral vascular disease
Vitreal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain
and a laceration of your left ___ toe.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you were evaluated by the podiatry team who
determined that you needed a surgery to remove your left second
toe. This surgery was performed and you were given antibiotics
to prevent infection.
- You complained of chest pain, so studies including EKG and
blood tests were performed to rule out a cardiac cause of your
chest pain. You also had an ultrasound of your heart to look
for inflammation around your heart causing this pain. You also
had a stress test to see if blood flow to your heart was
appropriate. All of these tests were reassuring.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
- You should have follow-up with an ophthalmologist for
assessment of your visual symptoms.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10627667-DS-17
| 10,627,667 | 24,467,971 |
DS
| 17 |
2190-03-27 00:00:00
|
2190-03-27 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
syncope, fall s/p head injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS (as acquired in the ED, see note
below
for history acquired upon the floor):
Patient is a ___ with PMH of dementia, HTN, HLD, DM, and
multiple
falls who presents with a syncopal episode as well as head
lacerations acquired during his fall.
This morning, patient started feeling dizzy when standing up
from
the toilet and fell. He hit his head on a cabinet, causing
lacerations. His wife found him on the floor. She reports blood
coming from his head and rectum.
Of note, patient only takes 81 mg aspirin but is not
anticoagulated otherwise. He denied chest pain, shortness of
breath, palpitations, abdominal pain, diarrhea, constipation,
melena, BRBPR, and dysuria.
In the ED:
-Initial vital signs were notable for: 96.7, 66, 188/80, 18, 96%
RA
-Exam notable for:
HEENT: 2 2inch lacerations over forehead
GU: no hemorrhoids, no blood
-Labs were notable for:
Lactate = 2.6
proBNP= 1027
-Studies performed include:
CXR:
1. Mild pulmonary vascular congestion without interstitial
edema.
2. No evidence of pneumonia.
CT Head non-contrast:
1. Mild left frontal scalp swelling. No fracture or intracranial
hemorrhage.
2. Multifocal chronic encephalomalacia redemonstrated.
3. Chronic moderate cerebral atrophy with central predominance,
somewhat progressed in the interval, with normal pressure
hydrocephalus not excluded in the correct clinical setting.
CT Spine non-contrast:
1. No acute fracture or traumatic malalignment.
-Patient was given: 1L NS, Tetanus-DiphTox-Acellular Pertuss
(Adacel) .5 mL, Simvastatin 20 mg, amLODIPine 10 mg, Donepezil 5
mg, Citalopram 10 mg, Losartan Potassium 100 mg, IV Furosemide
20
mg
Consults:
- ___: Pt unsteady with multiple LOB on eval. Given impaired
balance and frequent falls will require rehab.
Vitals on transfer: 97.4, 171/83, 55, 18, 98% RA
Of note, patient may not a reliable historian. Upon arrival to
the floor, another history was taken. Patient stated that in the
afternoon of ___, he felt nauseous and dizzy on the toilet
while
having a bowel movement, and had non-bloody non-bilious emesis.
He remembers falling to the floor from the toilet without
attempting to stand up. He lost consciousness, but does not
remember for how long. He denied diarrhea, melena, BRBPR,
hematemesis, chest pain, dyspnea, dysuria, and constipation. He
remembers regaining consciousness, and then his wife coming in
to
find him blood on his clothing and his head.
He endorses previous falls, usually preceded by lightheadedness
and diziness. He denies hitting his head or injuring himself in
previous falls.
REVIEW OF SYSTEMS:
Per HPI.
Past Medical History:
DEMENTIA - unclear etiology (presumed Frontotemporal Dementia
but multi-infarct dementia is on DDx and is also unclear if NPH
has ever been ruled out)
HTN - essential
Dermatitis - eczematous
Obesity
Hyperlipidemia
Senile nuclear cataract
Ocular migraine
Diabetes mellitus type 2
Anxiety & Depression
History of stroke
Syncope ___: work-up unrevealing for etiology)
Fall with head-strike (___)
Social History:
___
Family History:
Family history is significant for father with
throat cancer and mother with CHF without myocardial infarction.
No history of stroke. No other neurological illnesses.
Physical Exam:
Admission
VITALS: 97.4, 171/83, 55, 18, 98% RA
GENERAL: Alert and interactive. Lying down in bed.
HEENT: NCAT. Lacerations on forehead s/p stitches and
steri-strips.
CARDIAC: No murmurs, rubs, or gallops. No JVD.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: NBS, non-distended, non-tender
EXTREMITIES: Left leg with 1+ pitting edema halfway up to knee.
Per wife, this is baseline.
GU: Swollen left testicle.
SKIN: Warm and dry.
NEUROLOGIC: Alert and oriented to self, month, and location. ___
strength ___.
Discharge
==========
24 HR Data (last updated ___ @ 2354)
Temp: 97.6 (Tm 98.7), BP: 145/72 (124-207/67-90), HR: 58
(58-70), RR: 18 (___), O2 sat: 97% (96-99), O2 delivery: RA
GENERAL: AAOx3. Lying down in bed.
HEENT: NCAT. Lacerations on central forehead s/p stitches and
steri-strips.
CARDIAC: RRR, S1S2, no murmurs appreciated
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: NBS, non-distended, non-tender
EXTREMITIES: Left leg with 1+ pitting edema halfway up to knee.
Per wife, this is baseline.
SKIN: Warm and dry.
NEUROLOGIC: Alert and oriented to self, month, and location.
Moving all extremities with purpose.
Pertinent Results:
Admission
=========
___ 03:27PM BLOOD WBC-6.9 RBC-4.48* Hgb-14.4 Hct-44.4
MCV-99* MCH-32.1* MCHC-32.4 RDW-12.8 RDWSD-46.7* Plt ___
___ 03:27PM BLOOD Neuts-76.4* Lymphs-11.0* Monos-10.9
Eos-1.0 Baso-0.3 Im ___ AbsNeut-5.26 AbsLymp-0.76*
AbsMono-0.75 AbsEos-0.07 AbsBaso-0.02
___ 06:40AM BLOOD ___ PTT-30.6 ___
___ 03:27PM BLOOD Glucose-130* UreaN-10 Creat-1.2 Na-141
K-3.8 Cl-99 HCO3-26 AnGap-16
___ 06:40AM BLOOD ALT-8 AST-24 AlkPhos-70 TotBili-1.0
___ 06:40AM BLOOD Lipase-43
___ 06:40AM BLOOD proBNP-1027*
___ 06:40AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.0 Mg-1.8
___ 06:35AM BLOOD VitB12-246
___ 03:50PM BLOOD Lactate-2.9*
___ 12:05PM BLOOD Lactate-2.6*
Discharge
=========
___ 07:50AM BLOOD WBC-4.6 RBC-4.62 Hgb-15.4 Hct-45.2 MCV-98
MCH-33.3* MCHC-34.1 RDW-12.2 RDWSD-44.0 Plt ___
___ 07:00AM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-140
K-4.0 Cl-100 HCO3-29 AnGap-11
___ 07:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Micro
======
___ 7:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging
=======
___
TTE
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a
normal cavity size. There is normal regional and global left
ventricular systolic function. The visually
estimated left ventricular ejection fraction is 55-60%. There is
no left ventricular outflow tract gradient
at rest or with Valsalva. 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 mildly dilated
ascending aorta. The aortic arch diameter is
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse.
There is no mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/
global biventricular systolic function. No structural cardiac
cause of syncope identified. Mildly
dilated ascending aorta.
___ CXR
IMPRESSION:
1. Minimal pulmonary vascular congestion without interstitial
edema.
2. No focal consolidation to suggest pneumonia.
CT head ___
IMPRESSION:
1. Mild left frontal scalp swelling.No fracture or intracranial
hemorrhage.
2. Multifocal chronic encephalomalacia redemonstrated.
3. Chronic moderate cerebral atrophy with central predominance,
somewhat
progressed in the interval, with normal pressure hydrocephalus
not excluded in
the correct clinical setting.
Brief Hospital Course:
___ with PMH of dementia, HTN, HLD, DM, and multiple falls who
presents with syncope and fall from seated position with
headstrike.
ACUTE ISSUES:
=============
# Syncope:
Presented after episode of syncope. Patient has dementia at
baseline and history reliability is uncertain on admission. In
ED, patient endorses preceding bowel movement and episode of N/V
before syncope suggesting vasovagal as etiology, however later
on floor he denied any presyncopal symptoms including N/V, and
states he was disoriented for about 15 minutes afterwards by his
estimate. Patient was sitting at time of syncope so loss of
consciousness from mechanical fall less likely. Patient had no
signs/symptoms of infection.Vasovagal still remains the most
likely, and seizure is on the differential though if he really
was only disoriented for 15 minutes, this would be atypically
short for a postictal period. Per neurology eval,his prodromal
symptoms and his recollection thereof are more suggestive of
syncope than seizure, and it would ultimately be difficult to
evaluate for a post-ictal state in the absence of information
from bystanders. Moreover, the absence of focal neurology
findings on exam or imaging reassuringly argue against a new
structural lesion that would demographically be the most likely
etiology of a new seizure. DDx includes arrhythmia v. structural
heart disease. Given he has some cardiac risk factors - proBNP
elevation >1K, pulmonary vascular congestion on CXR, HTN,
systolic murmur, EKG abnormalities (left axis deviation, flat T
waves in leads V5-V6, U waves in leads V2-V3), slight
bradycardia (HR ___, a cardiac workup was indicated.
Orthostatics in ED and repeated on floor were negative. Hb
stable. Repeat EKG on ___ stable (compared to ___ ED EKG).
Telemetry and TTE w/o e/o cardiac etiology. In conclusion,
etiology of his syncope felt most likely to be vasovagal.
# Fall:
# Head laceration:
S/p fall at home i/s/o likely vasovagal syncope. Traumatic
work-up including noncontrast head CT was unremarkable. ___
evaluated patient in ED and there were mobility concerns,
recommended rehab.
# Frontotemporal Dementia:
# ?Normal pressure hydrocephalus iso head ct findings, dementia,
gait instability, urinary incontinence
Patient has history of dementia and is on donepezil. Had
neurology workup at ___ ___ years ago, where a tentative diagnosis
of frontotemporal dementia was given in the setting of patient
refusing a lumbar puncture. Patient has not had any neuro workup
since. Given patient has hx of multiple falls, significant
balance issues as assessed by ___ in
ED, a ___ history of urinary incontinence, and having refused an
lumbar puncture during his previous workup, there was concern
for normal pressure hydrocephalus. Head CT this admission showed
chronic moderate cerebral atrophy with central\ predominance,
somewhat progressed in the interval (last comparison ___ years
ago), with normal pressure hydrocephalus not excluded in the
correct clinical setting. Per neuro eval this admission,
his exam was largely notable for an element of gait apraxia out
of proportion to his sensory deficits and without significant
cerebellar findings (despite chronic-appearing infarcts on
imaging); this gait apraxia may, in turn, account for his
difficulty rising after a fall despite preserved motor power on
exam. His reports of incontinence also appeared to be related to
limited mobility rather than a lack of awareness of or
motivation towards the need to void. Additionally, the slight
increase in his ventriculomegaly on his imaging may reflect
progression of his underlying neurodegenerative disorder and
associated ex vacuo dilatation. Taken together, these findings
reduced suspicion for normal pressure hydrocephalus and further
workup, including a lumbar puncture, was not indicated. Also per
neuro, his social withdrawal at his living facility, limited
medication adherence, and significant apathy may reflect an
undertreated underlying mood disorder. A more activating
antidepressant (such as bupropion or an SNRI) was recommended,
and his home citalopram (held given severe interaction with
donepezil for QT prolongation) was switched for Venlafaxine ER,
started at 75mg daily. This should be uptitrated as an
outpatient.
#HTN
Systolics in 180s-200s while inpatient and taking losartan 100mg
PO daily (converted from his home Irbesartan 300mg PO daily).
Started amlodipine 10mg PO daily and increased his home HCTZ to
25mg PO daily. Systolics to 140s-150s following changes.
CHRONIC ISSUES:
===============
# DM:
Stable. Was on HISS while inpatient. Home metformin held while
inpatient and restarted at discharge.
#HLD
Stable. Continued home simvastatin.
#Depression
Stable. Citalopram held given severe interaction with donepezil
for QT prolongation. Started venlafaxine ER 75mg daily as above
per neuro.
TRANSITIONAL ISSUES:
* Patient discharged with condom cath in place.
* Started Amlodipine 10 mg PO daily and increased home HCTZ to
25 mg PO daily (was taking 12.5 mg) for systolics in 180s-200s.
Also replaced irbesartan 300 mg oral DAILY with losartan 100mg
daily, will continue this med on discharge.
[] If HTN persists despite aggressive multidrug regimen that
includes diuretic, consider additional workup for renal artery
stenosis and obstructive sleep apnea.
[] If HTN persists, consider adding spironolactone.
* Discontinued his prior medication of citalopram given
interaction with donepezil and finding of prolonged QTc,
replaced this with venlafaxine ER 75mg daily per neuro recs.
This should be uptitrated on an outpatient basis.
* Patient had evidence of HFpEF on TTE and mildly elevated pBNP,
no obvious volume overload but may benefit from Lasix in the
future, possible cardiology follow up.
[] Please monitor daily weights and assess for developing volume
overload intermittently.
#CONTACT: ___ (Wife), ___
.
.
.
.
Time in care: greater than 30 minutes in discharge-related
activities today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. irbesartan 300 mg oral DAILY
3. Donepezil 5 mg PO QHS
4. Aspirin 81 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. MetFORMIN (Glucophage) 250 mg PO BID W/MEALS
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Losartan Potassium 100 mg PO DAILY
3. Venlafaxine XR 75 mg PO DAILY
RX *venlafaxine 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Donepezil 5 mg PO QHS
7. MetFORMIN (Glucophage) 250 mg PO BID W/MEALS
8. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Syncope (likely vasovagal)
Fall
dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
-You lost consciousness for unclear reasons.
What was done for you in the hospital:
-We monitored your heart activity on telemetry and performed an
ultrasound of your heart to rule out cardiac causes for your
loss of consciousness. These tests were reassuring.
-You were seen by the neurology service, who felt it was
unlikely that you had a seizure.
-We felt your loss of consciousness was most likely due to a
benign condition called "vasovagal syncope."
-Neurology felt that you would benefit from a new medication for
your depression, venlafaxine. Your citalopram was discontinued
in favor of this medication.
-Your blood pressures were very high and we prescribed
additional medications to help lower them to a safer level.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10627720-DS-19
| 10,627,720 | 25,436,499 |
DS
| 19 |
2151-08-16 00:00:00
|
2151-08-16 22:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
obtundation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ transferred from ___
with a concern for a benzodiazepine overdose.
Report from EMS and from the hospital is that the patient
ambulated into the department complaining of losing control of
his vehicle multiple times and perhaps running into ___ with
? low-speed MVC. He drove then to the ED per report. Shortly
after being placed in room the patient became obtunded and
hypoxic to the ___. He was given narcan x2 without response. He
was intubated subsequently. Tox came back positive for benzos
(utox with benzos and cannabinoids). At OSH< EtOH <0.005%.
Patient had CT scans of the head, neck and abd/pelvis and were
reportedly negative for any traumatic injuries. Transferred here
because they have no ICU beds there. Pt transferred on propofol.
He was following commands on arrival and then would quickly
drift back to sleep.
Past Medical History:
- polysubstance abuse
- obesity
Social History:
___
Family History:
unknown, patient sedated and intubated
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 100.8, 87, 123/63, 100% on vent
General- intubated, sedated
HEENT- pinpoint pupils symmetric bilaterally
Neck- C-collar in place
CV- RRR, no murmurs
Lungs- CTAB
Abdomen- soft, non-tender, non-distended, +BS
Ext- warm, well perfused, no ___ edema; abrasions on the R
knuckles, injection marks in bilateral antecubs
Neuro- intubated, sedated, lifts head off bed to sternal rub
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
PERTINENT LABS:
___ 02:59AM BLOOD WBC-15.0* RBC-4.94 Hgb-14.4 Hct-43.9
MCV-89 MCH-29.1 MCHC-32.7 RDW-12.2 Plt ___
___ 02:59AM BLOOD UreaN-6 Creat-0.7
___ 03:15AM BLOOD Type-ART Temp-38.2 Tidal V-500 PEEP-5
FiO2-100 pO2-427* pCO2-51* pH-7.41 calTCO2-33* Base XS-6
AADO2-241 REQ O2-47 Intubat-INTUBATED Comment-AXILLARY T
___ 02:59AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:59AM BLOOD Lipase-9
___ 03:00AM BLOOD Glucose-109* Lactate-1.6 Na-143 K-4.2
Cl-97 calHCO3-32*
___ 02:59AM URINE Color-Straw Appear-Clear Sp ___
___ 02:59AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:59AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
IMAGING:
___ portable CXR
FINDINGS: Endotracheal tube terminates 4.2 cm cranial to the
carina in
standard position. An upper enteric tube terminates in the
mid-to-distal
gastric body. Lung volumes are extremely low, exaggerating the
cardiac
silhouette and pulmonary vasculature though compared to the
earlier
examination there appears to be mild volume overload. Heart
size is likely normal. Lungs are clear taking into account low
lung volumes. Pleural surfaces are clear without effusion or
pneumothorax.
IMPRESSION: Mild volume overload in the background of low lung
volumes.
Endotracheal tube and upper enteric tube in standard position.
Discharge Labs:
___ 06:20AM BLOOD WBC-12.1* RBC-4.74 Hgb-13.8* Hct-42.8
MCV-90 MCH-29.1 MCHC-32.1 RDW-12.1 Plt ___
Micro:
Blood culture x2 pending at discharge
Brief Hospital Course:
___ transferred from an OSH with concern for a benzodiazepine
overdose.
# Obtundation/respiratory failure
Etiology of his obtundation and hypoxemia was related to
hypoxemia in the setting of an unknown ingestion. Patient denies
recent heroin use, and did not improve with narcan, which argued
against opioid overdose. His urine tox was positive for
benzodiazepines. The morning after admission Mr. ___ was
weaned off the ventilator and extubated. Prior to transfer he
had a CT of his C-spine at ___ which was negative for
fracture or other acute process. His C-spine was cleared
clinically and his protective collar was removed. As he remained
stable from a hemodynamic and respiratory status, he was then
called out to the medical floor. Upon clearing, he stated that
he took "one suboxone and one clonazepam" prior to the events
that led to his intubation. Upon extubation he had no further
respiratory issues.
# Fever/cellulitis/thrombophlebitis: Upon arriving on the floor
from the ICU, he spiked a fever, with an exam consistent with
thrombophlebitis/cellulitis at the site of a former blood
draw/IV in his right antecubital fossa. There was no area of
fluctuance amendable to drainage. WBC 12 (down from 15) and
afebrile for the remainder of his stay. He was started on
Bactrim and hot packs as treatment. Given his history of IVDU
(he denies any recent use) and fever, blood cultures were drawn.
No murmurs on exam concerning for endocarditis. We discussed
that he has infectious studies pending and if any culture data
comes back positive, I would contact him and he would need to go
to ___ for immediate attention. He provided 2 phone
numbers (placed in ___) and he was agreeable to the plan.
Unfortunately, the patient left prior to signing his discharge
paperwork and did not take his Bactrim prescription. The
prescription was faxed to the pharmacy he has used in the past.
# Substance use: Social work consulted and he expressed a desire
to give up substances, however he did not accept information on
programs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 60 mg PO DAILY
2. Aripiprazole 15 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Mirtazapine 15 mg PO HS
5. CloniDINE 0.2 mg PO TID
6. ClonazePAM 1 mg PO QID
Discharge Medications:
1. Aripiprazole 15 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. Mirtazapine 15 mg PO HS
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Polysubstance abuse
Respiratory failure
Cellulitis/thrombophlebitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___
You were admitted to ___ after you developed low oxygen levels
at ___ and needed to be intubated (breathing tube
placed). This was likely related to medications that you took.
The breathing tube was removed and your breathing returned to
normal.
You developed a skin infection at the site of an IV and need to
continue antibiotics for 7 days. Please follow-up at the
appointment below.
Followup Instructions:
___
|
10628370-DS-14
| 10,628,370 | 28,657,144 |
DS
| 14 |
2123-09-23 00:00:00
|
2123-09-24 23:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
Right trans-jugular liver biopsy (___)
Liver, allograft, biopsy:
1. Findings compatible with acute cellular rejection. See note.
2. Moderate portal/septal, and mild periportal and lobular
inflammation including small and activated lymphocytes,
eosinophils, rare neutrophils and plasma cells, with lymphocytic
infiltration and
endothelialitis of portal/septal veins.
3. Lymphocytic cholangitis with bile duct injury and bile
ductular proliferation.
4. Hepatocyte anisonucleosis with patchy hemorrhage and
hepatocyte dropout (highlighted by reticulin stain).
5. Trichome stain shows sinusoidal and septal fibrosis with
bridging and nodule formation, consistent with cirrhosis.
6. Iron stain shows no stainable iron.
7. CMV immunostain negative.
Note: While the bile duct and vascular findings in the fibrous
septae are compatible with mild acute cellular rejection, the
presence of advanced fibrosis in the liver complicates
assessment of definitive portal tract structures. Clinical and
laboratory correlation is suggested to exclude other potential
causes of inflammation such as infection or drug injury.
History of Present Illness:
I have evaluated the patient and agree with accepting his care.
Please refer to excellent nightfloat admission note for detailed
H&P.
In brief, Mr. ___ is a ___ y/o man with ___ notable for
fulminant liver failure s/p transplant in ___ (___) on
___ with re-development of cirrhosis and multiple skin cancers
i/s/o possible ___ Syndrome, admitted after having been
found to have elevated LFTs in transplant clinic.
Per review of NF note and further discussion with patient this
morning, he was in his usual state of health about 1 week ago.
He does state that at baseline, he has some fatigue and diffuse,
non-specific aches and pains, which have been stable over the
past year or so, since he found out that his liver function has
been worsening again.
However, about ___ of last week (10 days PTA), he developed
gradually increasing abdominal discomfort (crampy lower
quandrants, but with some diffuse radiation involving RUQ),
increased reflux symptoms, bloating (especially after meals),
and watery diarrhea. At baseline, he makes ~3 BM's per day, but
he was going a couple additional times a day with non-bloody
loose stool. He was able to keep up with fluid intake and denies
any sx of lightheadedness or dizziness. However, he felt even
more fatigue than usual. This diarrhea lasted for about 7 days
overall and began to subside about 3 days PTA. He denies any
associated fevers, chills, N/V, SOB, cough, or increased ___
swelling. He denies any new joint pains, but again feels that
this is difficult to discern from his baseline diffuse pains. To
his knowledge, he has not had any sick contacts. He and his wife
did eat some fish out (at a place he has previously dined
multiple times) and no other new foods. He has no pets or
children at home. He works in ___, but mostly does
___ work. He does not think he has had any tick bites and
does not spend much time in wooded areas (lives in ___.
About 3 days into his disease course, he did call the transplant
clinic and was encouraged to present to clinic and possibly be
admitted prior to the long weekend. However, he did not want to
be in the hospital over ___ day and felt that his symptoms
may have been improving. Since then, he has begun to feel back
to normal. He does endorse some mild constipation - small, but
formed stools, about ___ times per day. He has been taking all
of his medications as prescribed without any changes. No recent
medication changes or new medications.
On day of admission, Mr. ___ presented to f/u with ___
___, his hepatologist, in clinic. On lab draw, he had a new
transaminitis (ALT 118, AST 175, ALP 221 from previous ALT 42,
AST 60, ALP 134) and was asked to present to ___ for probable
admission. Tbili and Cr were at baseline.
Past Medical History:
-fulminant liver failure s/p liver transplant (___) with now
recurrent advanced liver fibrosis
-multiple skin cancers (___)
- Likely ___ syndrome
- L ___ s/p Mohs ___
- L forearm SCCIS s/p excision ___
- R shoulder mod-severely dysplastic nevus s/p excision ___
- R clavicle sebaceous adenoma with negative MSH2,6; high
correlation with ___ ___ syndrome.
-hypertension
-?CKD as patient's Cr at "baseline" in our records has been 1.4
(at lowest)
Social History:
___
Family History:
Mother with colon cancer age ___. No FH of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.3 128/71 59 18 99%RA
GENERAL: sitting up in bed in NAD
HEENT: NCAT, MMM, sclera nonicteric, EOMI, PERRL, tongue midline
on protrusion, symmetric palatal elevation
NECK: supple, symmetric, shotty anterior LAD b/l, non-tender; no
supraclavicular or posterior chain LAD
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no c/r/w
ABDOMEN: soft, nontender, nondistended; scar as below; no r/g,
BS+
GU: No foley
EXTREMITIES: WWP, no peripheral edema appreciated
SKIN: numerous small facial growths, no spider angiomata, no
jaundice; large abdominal scar, well healed from prior
transplant
NEUROLOGIC: no asterixis on exam; symmetric smile and eyebrow
raise; strength ___ in b/l UE throughout; able to lift both legs
up against gravity and downward pressure; sensation to light
touch intact and symmetric bilaterally throughout b/l UE, torso,
and ___
ACCESS: PIV
DISCHARGE PHYSICAL EXAM
=========================
VS: T 97.9 BP 127/77 HR 63 RR 18 O2 sat 100%RA
GENERAL: sitting up in bed in NAD, alert and oriented.
HEENT: Sclerae anicteric, MMM. Numerous small facial growths.
CARDIAC: RRR, ___ early systolic murmur, best heard in LLSB
LUNGS: CTAB, no c/r/w
ABDOMEN: Palpable hepatosplenomegaly. Abdomen is soft,
nontender and nondistended in all four quadrants.
EXTREMITIES: WWP, no peripheral edema appreciated
SKIN: No spider angiomata or jaundice. With large abdominal
scar, well healed from prior transplant
NEUROLOGIC: A&O x3. Moves all four extremities spontaneously.
No asterixis.
Pertinent Results:
ADMISSION LABS
=======================
___ 12:40AM BLOOD WBC-5.1 RBC-3.44* Hgb-11.3* Hct-31.4*
MCV-91 MCH-32.8* MCHC-36.0 RDW-16.4* RDWSD-53.4* Plt Ct-29*
___ 12:40AM BLOOD Neuts-41.6 Lymphs-15.8* Monos-7.9
Eos-33.5* Baso-1.0 Im ___ AbsNeut-2.10 AbsLymp-0.80*
AbsMono-0.40 AbsEos-1.69* AbsBaso-0.05
___ 02:37AM BLOOD ___ PTT-33.9 ___
___ 12:40AM BLOOD Glucose-101* UreaN-38* Creat-1.6* Na-137
K-3.8 Cl-104 HCO3-23 AnGap-14
___ 12:40AM BLOOD ALT-144* AST-185* AlkPhos-217*
TotBili-1.2
___ 12:40AM BLOOD Lipase-228*
___ 10:00AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.3 Mg-1.7
___ 10:00AM BLOOD tacroFK-3.9*
___ 04:35AM BLOOD tTG-IgA-12
___ 04:35AM BLOOD HCV Ab-Negative
___ 04:35AM BLOOD CMV VL-NOT DETECT
DISCHARGE LABS
=========================
___ 05:55AM BLOOD WBC-7.9 RBC-3.75* Hgb-12.3* Hct-34.8*
MCV-93 MCH-32.8* MCHC-35.3 RDW-16.9* RDWSD-56.9* Plt Ct-31*
___ 05:55AM BLOOD ___ PTT-27.2 ___
___ 05:55AM BLOOD Glucose-125* UreaN-42* Creat-1.6* Na-136
K-3.9 Cl-106 HCO3-22 AnGap-12
___ 05:55AM BLOOD ALT-109* AST-83* LD(LDH)-146 AlkPhos-186*
TotBili-3.1*
MICROBIOLOGY
=========================
___ 3:40 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
___ CRYSTALS PRESENT.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 10:09 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:19 am BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:51 am Blood (LYME) ADDED HAV,HEPC,HBVSC ___.
**FINAL REPORT ___
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
IMAGING
========================
ABDOMINAL US ___ IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms.
2. Chronic non occlusive portal vein thrombus also seen on MRI
from ___.
3. No intrahepatic biliary dilation.
4. Stable splenomegaly.
PATHOLOGY
========================
LIVER BIOPSY ___:
1. Findings compatible with acute cellular rejection. See note.
2. Moderate portal/septal, and mild periportal and lobular
inflammation including small and activated lymphocytes,
eosinophils, rare neutrophils and plasma cells, with lymphocytic
infiltration and endothelialitis of portal/septal veins.
3. Lymphocytic cholangitis with bile duct injury and bile
ductular proliferation.
4. Hepatocyte anisonucleosis with patchy hemorrhage and
hepatocyte dropout (highlighted by reticulin stain).
5. Trichome stain shows sinusoidal and septal fibrosis with
bridging and nodule formation, consistentwith cirrhosis.
6. Iron stain shows no stainable iron.
7. CMV immunostain negative.
Note: While the bile duct and vascular findings in the fibrous
septae are compatible with mild acute cellular rejection, the
presence of advanced fibrosis in the liver complicates
assessment of definitive portal tract structures. Clinical and
laboratory correlation is suggested to exclude other potential
causes of inflammation such as infection or drug injury.
Brief Hospital Course:
___ y/o gentleman with PMH notable for h/o fulminant liver
failure s/p liver transplant (___) on tacrolimus, with
recurrent advanced liver fibrosis/cirrhosis, and recent
admission for rising LFTs felt due to recent GI illness (normal
RUQUS and gradual improvement on ___, readmitted for
expedited work-up for rejection with ___ guided biopsy i/s/o
persistently elevated LFTs.
He underwent an uncomplicated trans-jugular liver biopsy on ___.
His biopsy showed evidence of acute rejection. He was treated
with IV methylprednisolone (1000 mg IV daily for 72 hours).
Other infectious studies such as CMV and EBV were negative. TSH,
Smooth Muscle Ab, ___, hepatitis B serologies, CMV VL were
normal/negative. Tacrolimus was increased to 1 mg PO BID (goal
level ___. Other medications were added- MMF 1000 mg PO BID,
single strength bactrim, 450 mg PO valganciclovir and vitamin D
800 units. After three days of IV methylprednisolone he was
started on 20 mg of prednisone, to be tapered on weekly basis
and decreased by 2.5 mg each week.
# Acute rejection:
# Transaminitis:
Biopsy results showed acute rejection. Of note, patient has
recurrent cirrhosis of his graft with unclear etiology. Workup
for viral or autoimmune causes of rejection was negative. He was
treated with 3 days IV methylprednisolone, and transitioned to
steroid taper with bactrim prophylaxis. LFTs improved.
Tacrolimus was increased to reach goal trough of 8. MMF was
started at 1000 mg BID.
# H/O fulminant liver failure s/p transplant
# Recurrent post-transplant cirrhosis:
The patient has what appears to be cryptogenic etiology of his
cirrhosis which has recurred after what seemed to be a
successful transplant. Throughout admission was compensated
without jaundice, HE, or ascites per ultrasound. Home lactuose,
rifaximin, Lasix, and nadolol continued.
# ___ on ?CKD: the patient does not have prior documented CKD,
but does have chronically elevated Cr of 1.4 in OMR. Peak Cr of
1.7; 1.6 on discharge. Slight rise possibly in the setting of
increasing
# Hypertension: Continue on home amlodipine and nadolol.
TRANSITIONAL ISSUES:
# CODE: Confirmed FULL
# HCP: wife, ___ ___
CHANGED MEDICATIONS:
-Tacrolimus 1 mg PO Q12H
NEW MEDICATIONS:
-Prednisone 20 mg daily. You should go down on your prednisone
by 2.5 mg each ___. Continue taking 20 mg until ___
___ and then decrease by ___ tablet or 2.5 mg to 17.5 mg.
--> Now through ___ mg per day
--> ___- 17.5 mg per day
--> ___- 15.0 mg per day
--> ___ - ___ mg per day
--> ___- 10.0 mg per day
--> ___- 7.5 mg per day
--> ___- 5.0 mg per day
--> ___ - 2.5 mg per day
-Mycophenolate Mofetil 1000 mg PO BID
-Pantoprazole 40 mg PO Q24H
-Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
-ValGANCIclovir 450 mg PO Q24H
-Vitamin D 800 UNIT PO/NG DAILY
-Patient will need CBC w/diff, LFTs, CHEM 10, tacrolimus level
drawn before the week ends (likely ___ and once next
week. He will then require monthy lab draws.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Rifaximin 550 mg PO BID
5. Tacrolimus 0.5 mg PO DAILY
6. Nadolol 20 mg PO DAILY
Discharge Medications:
1. Mycophenolate Mofetil 1000 mg PO BID
RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice per
day Disp #*120 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. PredniSONE 20 mg PO DAILY
RX *prednisone 5 mg 4 tablet(s) by mouth daily Disp #*114 Tablet
Refills:*0
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
5. ValGANCIclovir 450 mg PO Q24H
RX *valganciclovir 450 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
7. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 0.5 mg 2 capsule(s) by mouth twice daily Disp
#*120 Capsule Refills:*0
8. amLODIPine 5 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Lactulose 30 mL PO TID
11. Nadolol 20 mg PO DAILY
12. Rifaximin 550 mg PO BID
13.Outpatient Lab Work
ICD-10 K74.60: Cirrhosis
Please draw CBC, chem-10, LFT's, and coags on ___. Fax
results to ___, MD at the ___ ___ at
___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Transaminitis with concern for rejection
Acute kidney injury on possible chronic kidney disease
Thrombocytopenia
SECONDARY DIAGNOSES:
History of fulminant liver failure status post transplant with
recurrent post-transplant cirrhosis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
- You were having worsening liver function tests concerning for
possible rejection.
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- You had a biopsy of your liver, which showed that you had
rejection of your liver. You were treated with steroids. Your
liver function tests improved. You were also started on some new
medications for rejection and infection prevention.
WHAT SHOULD I DO WHEN I AM AT HOME?
- Please take your medications as prescribed. We have added some
new medications to your list because of your rejection and
increased immunosuppression. Please have your labs checked this
week and again next week.
MEDICATION CHANGES:
CHANGED MEDICATIONS:
-Tacrolimus 1 mg PO Q12H
NEW MEDICATIONS:
-Prednisone 20 mg daily. You should go down on your prednisone
by 2.5 mg each ___. Continue taking 20 mg until ___
___ and then decrease by ___ tablet or 2.5 mg to 17.5 mg.
--> Now through ___ mg per day
--> ___- 17.5 mg per day
--> ___- 15.0 mg per day
--> ___ - ___ mg per day
--> ___- 10.0 mg per day
--> ___- 7.5 mg per day
--> ___- 5.0 mg per day
--> ___ - 2.5 mg per day
-Mycophenolate Mofetil 1000 mg PO BID
-Pantoprazole 40 mg PO Q24H
-Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
-ValGANCIclovir 450 mg PO Q24H
-Vitamin D 800 UNIT PO/NG DAILY
Please see below for your appointments and please call your
doctors with any questions.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10628370-DS-19
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2125-06-07 00:00:00
|
2125-06-11 20:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ fulminant liver failure from cryptogenic disease (s/p
liver transplant ___ years ago), post-liver transplant course c/b
CKD ___ 1.6-2.1), skin cancers, graft cirrhosis (ascites, EV,
HE,
portal HTN, PVT, on re-transplant list), L pleural effusion with
recent admission for hyperglycemia now re-presenting with
nausea,
vomiting.
The patient was recently admitted to ___ with hyperglycemia
and
ascites from ___. He had paracentesis on ___. ___ was
consulted and adjusted the insulin regimen. He was feeling well
and discharged. The morning of re-admission he developed nausea,
vomiting, hypertension. These symptoms began around 8 am and
ended in the early afternoon. He was feeling lightheaded with
breakfast. He called the liver clinic and was advised to seek
medical care. ___ at home 83-130
Patient denies headache, vision changes, sore throat, runny
nose,
chest pain, or dysuria. No fevers of chills. Cough stable for
1.5
months.
In the ED initial vitals: T 97.9 HR 61 BP 165/93 RR 16 SaO2 99%
RA
- Exam notable for:
Blood sugar 279-378
- Labs notable for:
CBC: 7.4>13.2/37.6<45
Chem7: Cr 2 BUN 51
LFTs: Bili 10
Peritoneal fluid WBC 101, 33% poly
- Imaging notable for:
CXR
1. Slight interval decrease in size of a moderate left pleural
effusion.
2. Opacification of the left lower lung likely reflects
atelectasis, although
superimposed infection cannot be excluded.
3. Moderate cardiomegaly.
- Patient was given:
___ 22:30IVFLR 1000 mL
___ 22:52SCInsulin 6 Units
___ 22:___ 1 gm
On interview, the patient feels improved. He had multiple
episodes of nausea in the Ed that self resolved. He is having
___
bowel movements per day with only one dose of lactulose. Unclear
to him whether this is a change or just ongoing loose stools
associated with lactulose. No fevers. Nausea is present.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
EPISTAXIS
SKIN CANCERS
ACUTE MILD CELLULAR REJECTION
LIVER TRANSPLANT
___ SYNDROME
CHRONIC RENAL FAILURE
MULTIPLE SKIN CANCERS
HYPERTENSION
UMBILICAL HERNIA
INCISIONAL HERNIA
RECURRENT EPISTAXIS ___ NASAL VESTIBULITIS
THROMBOCYTOPENIA
PULMONARY HYPERTENSION
DYSPNEA ON EXERTION
CHRONIC COUGH
PANCREATIC CYST
ABNORMAL CHEST XRAY
PLEURAL EFFUSIONS
H/O FULMINANT HEPATIC FAILURE
Social History:
___
Family History:
mother age ___ with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:
___ 0024 Temp: 98.0 PO BP: 146/83 HR: 69 RR: 18 O2 sat: 94%
O2 delivery: RA
General: Fatigued, jaundiced
HEENT: Normal oropharynx, no exudates/erythema, icterus
Cardiac: RRR no mrg, no chest tenderness
Pulmonary: Clear to auscultation bilaterally, no
crackles/wheezes
Abdominal/GI: Distended, diffuse tenderness
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted
Neuro: no focal deficits noted moving all extremities
Derm: Jaundice
Psych: Normal judgment, mood appropriate for situation
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 458)
Temp: 98.0 (Tm 98.2), BP: 114/68 (114-142/68-81), HR: 69
(67-72), RR: 18, O2 sat: 97% (94-97), O2 delivery: Ra
General: NAD, fatigued, mildly jaundiced
HEENT: Normal oropharynx, no exudates/erythema, scleral icterus
Cardiac: RRR, no MRG, no chest tenderness
Pulmonary: Clear to auscultation bilaterally, no
crackles/wheezes
Abdominal/GI: Distended, diffuse tenderness throughout, no
rebound, no guarding
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted
Neuro: A&Ox3, no asterixis, moving all 4 extremities with
purpose
Skin: Jaundice, warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 07:20AM BLOOD WBC-3.6* RBC-3.37* Hgb-11.1* Hct-32.7*
MCV-97 MCH-32.9* MCHC-33.9 RDW-15.9* RDWSD-55.8* Plt Ct-27*
___ 07:20AM BLOOD ___ PTT-29.0 ___
___ 07:20AM BLOOD Glucose-115* UreaN-35* Creat-1.7* Na-139
K-4.4 Cl-106 HCO3-24 AnGap-9*
___ 07:20AM BLOOD ALT-39 AST-53* AlkPhos-131* TotBili-5.0*
___ 07:20AM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.6 Mg-1.7
___ 07:20AM BLOOD tacroFK-7.8
OTHER FLUID STUDIES:
___ 08:54PM ASCITES TNC-101* ___ Polys-33*
Lymphs-55* Monos-9* Mesothe-3*
MICROBIOLOGY:
___ 6:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 8:54 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 11:16 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
IMAGING:
CXR ___:
IMPRESSION:
1. Slight interval decrease in size of a moderate left pleural
effusion.
2. Opacification of the left lower lung likely reflects
atelectasis, although
superimposed infection cannot be excluded.
3. Moderate cardiomegaly.
DISCHARGE LABS:
___ 06:23AM BLOOD WBC-1.9* RBC-2.88* Hgb-9.5* Hct-28.6*
MCV-99* MCH-33.0* MCHC-33.2 RDW-15.8* RDWSD-56.6* Plt Ct-15*
___ 06:23AM BLOOD ___ PTT-31.0 ___
___ 06:23AM BLOOD Glucose-162* UreaN-44* Creat-1.6* Na-143
K-4.4 Cl-108 HCO3-23 AnGap-12
___ 06:23AM BLOOD ALT-30 AST-45* LD(LDH)-111 AlkPhos-100
TotBili-4.4*
___ 06:23AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.3 Mg-2.1
___ 06:23AM BLOOD tacroFK-5.3
Brief Hospital Course:
Mr. ___ is a ___ w/ fulminant liver failure from cryptogenic
disease (s/p liver transplant ___ years ago), post-liver
transplant course c/b CKD ___ 1.6-2.1), skin cancers, graft
cirrhosis (ascites, EV, HE, portal HTN, PVT, on transplant
list), L pleural effusion with recent admission for
hyperglycemia, who represented with nausea and vomiting and was
found to have ___.
ACUTE ISSUES:
=============
# Nausea
# Vomiting
Recently hospitalized for hyperglycemia and ascites now with
nausea and vomiting, possible diarrhea. Differential included
viral gastroenteritis and C. difficile. Unlikely SBP by cell
count criteria. No dysuria. No change in respiratory symptoms.
No gap to suggest DKA. The patient's nausea and vomiting
resolved without further intervention and he was tolerating a
regular diet at the time of discharge. C. diff and stool studies
negative at the time of discharge.
# ___ on CKD
Baseline Cr 1.7. Patient presented with Cr elevated to 2.0.
Elevated BUN and concentrated CBC and given clinical history of
nausea/vomiting suggesting hypovolemia as likely etiology.
Patient administered albumin for volume resuscitation with
improvement in Cr to 1.6 at time of discharge.
# Insulin-dependent diabetes mellitus
Recently diagnosed, with recent admission with hyperglycemia.
A1C 8.7%.
GAD65 antibody negative, Islet antibody cell negative. Patient
continued on recently established insulin regimen of Mealtime
standing Humalog of 10mg, Lantus 26 in evenings with sliding
scale. Patient with modest control, BS ranging from 160s-200s
while in house.
# s/p liver transplant
# graft cirrhosis
# transaminitis
# hyperbilirubinemia
# thrombocytopenia
# h/o HE, ascites, varices (EGD ___, PVT
MELD 28 on admission. Patient with transient elevation in T.
Bili and LFTs that resolved on recheck. No SBP on paracentesis.
Cross sectional imaging last admission without PVT. No HE.
Notably during recent hospitalization underwent therapeutic
paracentesis performed ___ with removal of 2.5 L.
Maintained on lactulose, rifaximin, tacrolimus 0.5mg daily. Held
furosemide and spironolactone while in house, will continue at
discharge.
# L pleural effusion:
Has a pulmonologist at ___. Had a ___ recently
w/transudate per notes. Does not appear to be a
hepatic-hydrothorax, but do not know what outpatient lab work
found. CXR while in house demonstrated slight interval decrease
in size.
TRANSITIONAL ISSUES:
====================
[] Discharge prednisone 5mg, from 7.5mg, beginning slow taper
given cirrhosis of graft and difficult glycemic control
[] Held nadolol at discharge would consider reintroduction once
care established with ___ and improved glycemic control
[] Tacrolimus 0.5mg daily
[] Discharge creatinine 1.6.
[] Recommend endocrine outpatient follow up regarding prednisone
taper and risk for underlying adrenal insufficiency given
prolonged course of prednisone.
[] Patient scheduled with ___ clinic on ___ as new patient
for further work up and management of recently diagnosed insulin
dependent diabetes mellitus
[] Consider TTE as an outpatient to r/o cardiac cause of
effusion
#CODE: Full code
#CONTACT: ___
Relationship: Wife
Phone: ___
#DISPO: HOME
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. Lactulose 30 mL PO TID
4. Magnesium Oxide 400 mg PO DAILY
5. Nadolol 40 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. PredniSONE 7.5 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Clindamycin 1% Solution 1 Appl TP DAILY
14. eszopiclone 1 mg oral QHS:PRN insomnia
15. Ferrous GLUCONATE 324 mg PO DAILY
16. melatonin 1 mg oral QHS:PRN insomnia
17. Nephrocaps 1 CAP PO DAILY
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
19. OneTouch Verio System (blood-glucose meter) 1 device
miscellaneous ONCE
20. OneTouch Delica Lancets (lancets) 33 gauge miscellaneous
QACHS
21. OneTouch Delica Lanc Device (lancing device with lancets) 1
device miscellaneous QACHS
22. OneTouch Ultra Blue Test Strip (blood sugar diagnostic) 1
strip miscellaneous QACHS
23. Tacrolimus 0.5 mg PO Q24H
24. Furosemide 20 mg PO DAILY
25. Spironolactone 50 mg PO DAILY
26. Simethicone 40-80 mg PO QID:PRN Bloating, gas pain
27. Glargine 26 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Calcium Carbonate 500 mg PO DAILY
3. Clindamycin 1% Solution 1 Appl TP DAILY
4. eszopiclone 1 mg oral QHS:PRN insomnia
5. Ferrous GLUCONATE 324 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Gabapentin 100 mg PO TID
9. Glargine 26 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Lactulose 30 mL PO TID
11. Magnesium Oxide 400 mg PO DAILY
12. melatonin 1 mg oral QHS:PRN insomnia
13. Multivitamins 1 TAB PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. OneTouch Delica Lanc Device (lancing device with lancets) 1
device miscellaneous QACHS
16. OneTouch Delica Lancets (lancets) 33 gauge miscellaneous
QACHS
17. OneTouch Ultra Blue Test Strip (blood sugar diagnostic) 1
strip miscellaneous QACHS
18. OneTouch Verio System (blood-glucose meter) 1 device
miscellaneous ONCE
19. Pantoprazole 40 mg PO Q24H
20. Rifaximin 550 mg PO BID
21. Simethicone 40-80 mg PO QID:PRN Bloating, gas pain
22. Spironolactone 50 mg PO DAILY
23. Tacrolimus 0.5 mg PO Q24H
24. Thiamine 100 mg PO DAILY
25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
26. Vitamin D 800 UNIT PO DAILY
27. HELD- Nadolol 40 mg PO DAILY This medication was held. Do
not restart Nadolol until you speak with your liver doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Insulin-dependent diabetes
Nausea
Vomiting
Secondary:
Cryptogenic cirrhosis
Acute kidney injury on chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You developed nausea and vomiting; your kidney tests were also
mildly elevated
What was done while I was in the hospital?
- You were given fluids, which improved your kidney tests
- Your nausea and vomiting improved and you were able to
tolerate a regular diet
What should I do when I get home from the hospital?
- Continue to take your medications as prescribed
- We are reducing the dose of your prednisone to 5mg daily
- Make sure to go to your follow-up appointments
- If you have fevers, chills, nausea, vomiting, belly pain, or
generally feel unwell, please call your doctor or go to the
emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
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10628370-DS-23
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2125-09-21 15:43:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
TIPS angioplasty and coronary varix embolization ___
History of Present Illness:
___ PMH acute liver failure s/p OLT in ___ now with graft
failure and recurrent cirrhosis c/b HE, EV, ascites, multiple
portosystemic collaterals s/p recent TIPS, admitted for hepatic
encephalopathy.
Since discharge approximately 2 weeks ago, ___ endorses that
he has been self-titrating his lactulose to have ___ bowel
movements per day. He had been discharged on TID dosing, but he
is using up to ___ day. With this regimen, he is feeling well,
with no episodes of confusion, agitation, weakness.
The patient had a gastric emptying study yesterday for nausea
that has been worsening gradually since ___ of this year, and
was unable to take ___ lactulose at the usual time,
despite bringing it in the car with him. His wife gave him five
doses between 1pm and 9pm, but he had only one episode of
non-bloody stool at 9pm yesterday, but hasn't had a bowel
movement since. He then proceeded to urinate indiscriminately
all over the bathroom and became agitated when his wife
suggested he take more medications. This is unfortunately
classic behavior for him when he becomes encephalopathic, and so
she called EMS.
She denies that he has had any recent falls, injuries, recent
illnesses. He denies chest pain, abdominal pain, n/v/d/c/o,
fevers/chills, dysuria. The patient has had multiple admissions
for encephalopathy, most recent ___. No acute
precipitant for that presentation was identified, though there
is mention in the documentation regarding the need for a TIPS
revision.
Past Medical History:
LIVER TRANSPLANT
CHRONIC RENAL FAILURE
HYPERTENSION
THROMBOCYTOPENIA
H/O FULMINANT HEPATIC FAILURE
Social History:
___
Family History:
Noncontributory to present complaint
Physical Exam:
Admission Exam:
VS: T97.8, BP 145/77, HR77, RR 18, O2 99 RA
GENERAL: NAD, muscle wasting, sitting up in bed eating a
sandwich
HEENT: PERRL, icteric sclera, small conjunctival hemorrhage in R
eye inferiorally
NECK: supple, no LAD, prominent jugular venous pulsation
HEART: S1/S2 regular with ___ systolic murmur loudest at LUSB
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: trace edema BLE
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving four extremities with purpose, able to do
days of the week backwards without difficulty, positive mild
asterixis
SKIN: warm and well perfused
Discharge Exam:
VITALS: ___ ___ Temp: 98.3 PO BP: 121/60 L Lying HR: 75
RR: 18 O2 sat: 95% O2 delivery: Ra
GEN: Well appearing, in no acute distress
HEENT: Scleral icterus, PERRL, MMM
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: Soft, mildly distended, NT
EXT: Right UE without any clear swelling, edema erythema or
tenderness. ___ with 1+ pitting edema bilaterally
NEURO: AOx3. No asterixis.
Pertinent Results:
Admission Labs:
___ 01:45PM BLOOD WBC-4.1 RBC-2.47* Hgb-8.4* Hct-25.9*
MCV-105* MCH-34.0* MCHC-32.4 RDW-15.4 RDWSD-59.3* Plt Ct-18*
___ 03:54PM BLOOD ___ PTT-31.1 ___
___ 01:45PM BLOOD UreaN-51* Creat-1.9* Na-139 K-5.2 Cl-103
HCO3-23 AnGap-13
___ 01:45PM BLOOD ALT-58* AST-81* AlkPhos-163* TotBili-5.8*
___ 09:44AM BLOOD Calcium-9.7 Phos-4.3 Mg-1.6
Discharge Labs:
___ 05:27AM BLOOD WBC-3.0* RBC-2.33* Hgb-7.8* Hct-24.3*
MCV-104* MCH-33.5* MCHC-32.1 RDW-18.8* RDWSD-71.3* Plt Ct-15*
___ 05:27AM BLOOD Glucose-148* UreaN-66* Creat-1.8* Na-141
K-4.4 Cl-105 HCO3-25 AnGap-11
___ 05:27AM BLOOD ALT-34 AST-69* AlkPhos-131* TotBili-5.4*
___ 05:27AM BLOOD Albumin-3.5 Calcium-10.1 Phos-4.1 Mg-2.2
___ 05:27AM BLOOD tacroFK-3.4*
Studies:
___ RUQUS
1. Patent TIPS, with more normalized velocities compared to the
prior study.
2. Cirrhotic appearance of the liver with small volume ascites
and stable
splenomegaly.
3. Small right pleural effusion.
4. Variceal dilation of the portal venous branches.
___ RUE Doppler
No evidence of deep vein thrombosis in the right upper
extremity.
___ Renal Transplant
Unremarkable renal ultrasound. No hydronephrosis is identified.
___ CT A/P:
1. Cirrhotic liver morphology status post liver transplant with
unchanged
dilatation of the intrahepatic portal venous branches. Interval
TIPS and
varix embolization. The TIPS appears patent. No evidence of
venous
thrombosis. Extensive paraesophageal, splenic and mesenteric
varices,
unchanged.
2. Moderate to severe splenomegaly.
3. Mild ascites.
4. Moderate right and small left low-density pleural effusions
are unchanged.
5. A 2.1 cm cystic lesion arising from the tail the pancreas,
unchanged,
likely side branch IPMN. Non urgent MRI is recommended for
further
characterization
___ Right Elbow XRAY:
No acute fractures or dislocations are seen. Joint spaces are
preserved
without significant degenerative changes. There is no elbow
joint effusion. There is normal osseous mineralization.
___ PORTAL VENOGRAPHY:
1. Pre-procedure right atrial pressure of 16 and portal pressure
measurement of 28 resulting in portosystemic gradient of 12
mmHg.
2. Splenic venogram demonstrates patent main portal vein however
there is
sluggish antegrade flow and no definite flow seen through the
TIPS.
3. Superior mesenteric venogram demonstrates patent superior
mesenteric vein and portal vein with sluggish antegrade flow and
no definite flow seen through the TIPS. There is opacification
of the coronary vein through the existing coil pack. Coronary
venogram demonstrates large coronary varices.
4. Post angioplasty splenic venogram demonstrates patent main
portal vein
however there is continued sluggish antegrade flow within the
portal vein and no definite flow is seen through the TIPS. No
opacification of the coronary vein.
5. Pull-back CO2 and contrast venogram through the main portal
vein and TIPS demonstrates brisk antegrade flow through the
TIPS.
6. Completion right atrial pressure of 15 and portal pressure
measurement of 27 resulting in portosystemic gradient of 12
mmHg.
Brief Hospital Course:
Mr ___ is a ___ y/o M with PMH of acute liver failure s/p OLT
in ___, now with graft failure and recurrent cirrhosis (c/b HE,
EV, ascites, multiple portosystemic collaterals s/p recent TIPS
___ who presented to the ED with worsening encephalopathy.
He was dosed with q2 hr lactulose and his mental status quickly
improved to baseline. He also underwent ___ guided shunt
embolization on ___. His Cr was elevated from recent
baseline on admission, and despite albumin and blood
transfusions, his Cr remained at 1.8-1.9 which is likely his new
baseline.
TRANSITIONAL ISSUES:
[ ] Should have repeat Chem-7 checked in 1 week at his follow-up
liver appointment
[ ] Discharged on Lasix 40mg (home dose Lasix 20mg). Held
spironolactone in the setting of recent high potassium. Will
likely need slow uptitration of diuretics as outpatient
[ ] Ensure that patient is taking lactulose and rifaximin as
prescribed
[ ] Should have further ___ as outpatient for R arm pain. RUE
US was negative for DVT and X-ray was negative for fracture or
other acute pathology[ ] Will continue discussions about dexcom
with outpatient ___ provider
ACTIVE ISSUES:
==============
# Hepatic Encephalopathy
Symptoms were consistent with his prior episodes of HE.
Precipitant in this case was likely missing several doses of
lactulose but also has multiple portosystemic collaterals that
likely were contributing. Encephalopathy resolved with lactulose
titrated to at least 4 BM daily and rifaximin 550 BID. He
underwent uncomplicated TIPS angioplasty and coronary varix
embolization ___ with pre- and post- portosystemic gradient
of 12 mmHg.
# ___ on CKD
Pt with Cr 1.8, up from recent baseline ~1.2-1.5. Patient was
s/p 75g of albumin on ___, with Cr remaining elevated. He
also received 1 u PRBC. Cr stable 1.8-1.9 throughout admission
likely representing new baseline.
# Cryptogenic cirrhosis s/p OLT ___ c/b graft failure
Pt with known graft failure and recurrent cirrhosis. Admission
MELD-Na 25. LISTED for transplant. Previous cryptogenic
cirrhosis s/p transplant @ ___ complicated by
post-transplant cirrhosis & acute cellular refection. S/P TIPS
on ___. He had minimal ascites at admission and his home
diuretics were initially held given ___. At time of discharge,
his Lasix was increased from 20mg to 40mg. His spirinolactone
was held given recent high potassium. He was continued on tacro
0.5mg QAM, prednisone 5mg po daily for immunosuppression.
# Right arm pain
Patient reported that he has had this pain for past month after
a fall. No neuro deficits. Right upper extremity ultrasound
showed no clot. Xray showed no fracture or effusion. Seen by
occupational therapy who recommended continued therapy as an
outpatient.
CHRONIC ISSUES:
==============
# Diabetes mellitus, insulin dependent
Decreased home glargine 20u to 18u given hypoglycemia with 20u.
Also started meal time Humalog (___) and continued SSI.
___ was following his blood glucose while in-house. He is
being discharged on this regimen. He will require follow-up with
___ as an outpatient
# Neuropathy/lower extremity pain
Continue gabapentin 300 mg TID.
# HTN
Continued on carvedilol 12.5mg BID (started on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild/Fever
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Hyoscyamine 0.125 mg SL TID:PRN abdominal cramps
6. Lactulose 30 mL PO QID
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 5 mg PO DAILY
10. rifAXIMin 550 mg PO BID
11. Spironolactone 50 mg PO DAILY
12. Tacrolimus 0.5 mg PO QAM
13. Thiamine 100 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
15. CARVedilol 12.5 mg PO BID
16. Calcium Carbonate 500 mg PO DAILY
17. Magnesium Oxide 400 mg PO DAILY
18. melatonin 1 mg oral QHS:PRN insomnia
19. Simethicone 80-160 mg PO QID:PRN gas pain
20. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Glargine 18 Units Bedtime
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild/Fever
4. Calcium Carbonate 500 mg PO DAILY
5. CARVedilol 12.5 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. Hyoscyamine 0.125 mg SL TID:PRN abdominal cramps
9. Lactulose 30 mL PO QID
10. Magnesium Oxide 400 mg PO DAILY
11. melatonin 1 mg oral QHS:PRN insomnia
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. PredniSONE 5 mg PO DAILY
15. rifAXIMin 550 mg PO BID
16. Simethicone 80-160 mg PO QID:PRN gas pain
17. Tacrolimus 0.5 mg PO QAM
18. Thiamine 100 mg PO DAILY
19. Vitamin D 800 UNIT PO DAILY
20. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until you see your physician
21.Outpatient Occupational Therapy
ICD-10: ___.___
Pain in Right Arm
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Hepatic Encephalopathy
___ on CKD
R arm pain
Secondary
Cryptogenic cirrhosis s/p OLT ___ c/b graft failure
DM
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear ___
___ was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because of confusion from
your liver disease called hepatic encephalopathy.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You received lactulose and your mental status improved
-You underwent an interventional radiology procedure to embolize
abnormal blood vessels that could be worsening your episodes of
confusion.
-___ met with you while you were hospitalized and adjusted
your insulin regimen.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Continue to take all your medicines and keep your appointments.
-You will need labs at your next liver appointment to guide us
in adjusting your diuretics
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
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10628370-DS-26
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2126-01-16 00:00:00
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2126-01-17 14:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx cryptogenic cirrhosis s/p transplant in ___ ___/b decompensated cirrhosis MELD 18, ___ C presumed d/t
allograft failure (on pred/tacro) with ascites and HE, acute
cellular rejection ___ i/s/o reducing immunosuppression fo
skin cancers), s/p shunt embolization and TIPS ___ and
revision ___, currently listed for retransplantation; CKD,
skin cancers, presenting with confusion and asterixis concerning
for hepatic encephalopathy.
He has been progressively more confused over the course of the
last week according to him and his wife. He has been unable to
know the date of the month, has been occasionally forgetful. He
reports taking increasing doses of lactulose up to 6 times per
day with minimal stool output (less than 2 ___ per day). He also
underwent an EGD with banding of esophageal varices on ___. He has not had any other symptoms including fever, headache,
blurry vision, focal weakness or numbness. Patient reports
intermittent dry cough since his EGD in ___. Additionally
describes foul-smelling stools which are slightly loose in the
setting of lactulose. No chest pain, no shortness of breath, no
abdominal pain, nausea, vomiting, diarrhea, no black or bloody
stool, no dysuria or hematuria, no leg pain or worsening leg
swelling.
Past Medical History:
LIVER TRANSPLANT
CHRONIC RENAL FAILURE
HYPERTENSION
THROMBOCYTOPENIA
H/O FULMINANT HEPATIC FAILURE
Social History:
___
Family History:
Noncontributory to present complaint
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: ___ Temp: 98.0 PO BP: 150/75 HR: 72 RR: 20 O2 sat:
99% FSBG: 210
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, + scleral icterus, no JVD
HEART: RRR, S1/S2, no gallops, or rubs. ___ murmur over upper
sternal borders, likely flow murmur
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nontender in all quadrants, no rebound/guarding. Soft,
mildly distended (baseline per pt). Edge of spleen palpable
significantly below rib cage
EXTREMITIES: no cyanosis, clubbing. Mild 2+ edema to mid shins
bilaterally, left greater than right
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2-3 (knows it's ___, unable to tell month), able to
recite days of week backwards, +asterixis, moving all 4
extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 827)
Temp: 98.2 (Tm 98.3), BP: 138/72 (128-157/70-83), HR: 65
(64-76), RR: 18 (___), O2 sat: 99% (98-99), O2 delivery: Ra,
Wt: 148.5 lb/67.36 kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, + scleral icterus
HEART: RRR, S1/S2, no gallops, or rubs. ___ murmur over upper
sternal borders
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nontender in all quadrants, no rebound/guarding. Soft,
mildly distended.
EXTREMITIES: no cyanosis, clubbing. mild non-pitting edema to
mid
shins bilaterally
NEURO: A&Ox3 able to recite days of week backwards, mild
asterixis, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions.
Pertinent Results:
ADMISSION LABS
==============
___ 07:50PM WBC-2.6* RBC-2.83* HGB-8.6* HCT-26.8* MCV-95
MCH-30.4 MCHC-32.1 RDW-17.2* RDWSD-59.6*
___ 07:50PM NEUTS-75.7* LYMPHS-9.5* MONOS-8.0 EOS-5.3
BASOS-1.1* IM ___ AbsNeut-1.99 AbsLymp-0.25* AbsMono-0.21
AbsEos-0.14 AbsBaso-0.03
___ 05:01PM GLUCOSE-387* UREA N-45* CREAT-2.1* SODIUM-140
POTASSIUM-7.1* CHLORIDE-110* TOTAL CO2-18* ANION GAP-12
___ 05:01PM ALT(SGPT)-47* AST(SGOT)-158* ALK PHOS-125 TOT
BILI-5.8*
___ 05:01PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 05:01PM ALBUMIN-3.3*
DISCHARGE LABS
===============
___ 07:57AM BLOOD WBC-2.7* RBC-2.95* Hgb-8.9* Hct-27.5*
MCV-93 MCH-30.2 MCHC-32.4 RDW-17.1* RDWSD-58.2* Plt Ct-15*
___ 07:57AM BLOOD ___ PTT-34.3 ___
___ 07:57AM BLOOD Glucose-121* UreaN-38* Creat-2.0* Na-143
K-4.0 Cl-106 HCO3-25 AnGap-12
___ 07:57AM BLOOD ALT-39 AST-75* LD(LDH)-159 AlkPhos-127
TotBili-5.2*
___ 07:57AM BLOOD Albumin-2.8* Calcium-9.1 Phos-3.6 Mg-1.7
___ 07:57AM BLOOD tacroFK-2.7*
MICRO
=====
___ 5:01 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 7:07 am
URINE Site: NOT SPECIFIED
URINE CULTURE (Pending):
IMAGING
=======
Abd Doppler ___
1. Patent TIPS. No substantial change in the TIPS velocities.
The left and right portal veins continue to demonstrate
hepatopetal flow (slow away from the TIPS).
2. Large portal venous varix and unchanged extensive varices,
without clear change.
3. Trace ascites.
4. Stable splenomegaly
5. Cirrhotic liver morphology with no concerning focal liver
lesion
identified.
CT Head w/o contrast ___
No evidence of acute intracranial abnormality.
CXR ___
Comparison to ___. No relevant change is seen.
Moderate cardiomegaly without pulmonary edema. No pleural
effusions. No pneumonia. No pneumothorax.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Hepatic encephalopathy: likely I/s/o not having BMs.
Uptitrated lactulose to 60 ml QID and added miralax prn. Ensure
compliance and that patient is responding, i.e. clear mental
status with this medication change
[] Gastric varices s/p banding on ___: needs repeat EGD 1
month after this procedure
- Post-Discharge Follow-up Labs Needed: CBC, CHEM10, LFTs within
7 days
- Discharge: Cr 2.0, BUN 38, T bili: 5.2, WBC 2.7, Plt 15, Hgb
8.9
- Incidental Findings: n/a
- Discharge weight: 67.36 kg
# CODE: FCp
# CONTACT: ___ ___
BRIEF HOSPITAL SUMMARY
=======================
___ male with history of cryptogenic cirrhosis s/p transplant in
___ ___/b decompensated cirrhosis MELD 18, ___
C presumed d/t
allograft failure (on pred/tacro) with ascites and HE, acute
cellular rejection ___ in setting of reducing
immunosuppression for
skin cancers), s/p shunt embolization and TIPS ___ and
revision ___, currently listed for re-transplantation; CKD,
skin cancers, presenting with confusion and asterixis concerning
for hepatic encephalopathy. Patient was given increased doses of
lactulose with return of his mental status to baseline. He was
discharged on more rigorous bowel regimen to help avert
constipation episodes at home which likely precipitated his
encephalopathy. Infectious work-up negative. He was discharged
home without services.
ACTIVE ISSUES
=============
#Hepatic encephalopathy
Likely HE given confusion, asterixis in setting of cirrhosis c/w
prior presentations, though with unclear trigger. Other than dry
cough after EGD and loose smelly stools in the setting of
lactulose, no
symptoms of infection. No increase in abdominal distention, ___
edema, and no dark stool, BRBPR, hematemesis, to suggest bleed.
Likely due to constipation as patient reports only having 2
bowel movements daily, which in the past has not been sufficient
to prevent hepatic encephalopathy for him. In ED CT head
unremarkable, trace ascites on RUQUS, unable to tap. CXR, U/A,
blood cultures unrevealing. Started on lactulose q2h with
increasing dosage intervals as mental status improved. Diuretics
and beta blockers held due to initial concern for
bleed/infection, but resumed. His lactulose was titrated to 60
ml QID with miralax prn for ___ BM/day with maintenance
clearance of his hepatic encephalopathy.
#Cryptogenic cirrhosis s/p OLT ___ c/b graft failure. MELD-Na
18, ___ C. Listed for transplant. Previous transplant at
___ ___ c/b post-transplant cirrhosis and acute cellular
rejection. Continued home prednisone 5 mg daily and tacrolimus
0.5 mg every other day. S/p TIPS on ___ w/ revision in
___ for HE. TIPS revision w/ portosystemic gradient of
12mmHg. EGD ___ demonstrated medium-sized varices x4 in the
distal esophagus, nonbleeding. Status post banding x2. Findings
consistent with portal hypertensive gastropathy. No gastric
varices. Hgb remained at baseline. Continued home PPI,
sucralfate, simethicone. Trace ascites noted on RUQUS, unable to
tap in ED.
CHRONIC ISSUES
==============
#Type 2 diabetes
Continue home diabetes regimen:
Glargine 24 Units Bedtime
Humalog 6 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
#Neuropathy:
In lower extremities, likely diabetic neuropathy. Home
gabapentin held in setting of confusion.
#HTN:
Resumed home coreg.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild/Fever
3. Calcium Carbonate 500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. Lactulose 30 mL PO QID
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 5 mg PO DAILY
10. rifAXIMin 550 mg PO BID
11. Simethicone 80-160 mg PO QID:PRN gas pain
12. Thiamine 100 mg PO DAILY
13. Vitamin D 800 UNIT PO DAILY
14. aMILoride 10 mg PO DAILY
15. Hyoscyamine 0.125 mg SL TID:PRN abdominal cramps
16. Magnesium Oxide 400 mg PO DAILY
17. melatonin 1 mg oral QHS:PRN insomnia
18. CARVedilol 12.5 mg PO BID
19. Furosemide 40 mg PO DAILY
20. Tacrolimus 0.5 mg PO EVERY OTHER DAY
21. Glargine 24 Units Bedtime
Humalog 6 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
22. Sucralfate 1 gm PO QID
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
Take as needed for ___ bowel movements per day in addition to
your lactulose.
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 dose by mouth
once a day Disp #*30 Packet Refills:*0
2. Glargine 24 Units Bedtime
Humalog 6 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Lactulose 60 mL PO QID
RX *lactulose 10 gram/15 mL 60 ml by mouth four times a day
Refills:*0
4. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild/Fever
5. aMILoride 10 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. CARVedilol 12.5 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Gabapentin 300 mg PO BID
11. Hyoscyamine 0.125 mg SL TID:PRN abdominal cramps
12. Magnesium Oxide 400 mg PO DAILY
13. melatonin 1 mg oral QHS:PRN insomnia
14. Multivitamins 1 TAB PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. PredniSONE 5 mg PO DAILY
17. rifAXIMin 550 mg PO BID
18. Simethicone 80-160 mg PO QID:PRN gas pain
19. Sucralfate 1 gm PO QID
20. Tacrolimus 0.5 mg PO EVERY OTHER DAY
21. Thiamine 100 mg PO DAILY
22. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Hepatic encephalopathy
SECONDARY DIAGNOSES
===================
Cryptogenic cirrhosis status post liver transplant ___
Graft cirrhosis
Type 2 diabetes mellitus
Neuropathy
Hypertension
Chronic kidney disease
Thrombocytopenia
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 confused.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given medications to help reduce your confusion.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10628370-DS-27
| 10,628,370 | 28,091,160 |
DS
| 27 |
2126-02-04 00:00:00
|
2126-02-04 19:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
=============
___ 11:34PM BLOOD WBC-3.3* RBC-2.90* Hgb-9.0* Hct-28.1*
MCV-97 MCH-31.0 MCHC-32.0 RDW-19.9* RDWSD-69.9* Plt Ct-30*
___ 11:34PM BLOOD Neuts-72.4* Lymphs-10.0* Monos-8.8
Eos-7.3* Baso-1.2* Im ___ AbsNeut-2.40 AbsLymp-0.33*
AbsMono-0.29 AbsEos-0.24 AbsBaso-0.04
___ 11:34PM BLOOD Glucose-189* UreaN-59* Creat-2.1* Na-137
K-5.0 Cl-105 HCO3-19* AnGap-13
___ 11:34PM BLOOD ALT-53* AST-114* AlkPhos-162*
TotBili-7.2*
___ 11:34PM BLOOD Albumin-3.2* Calcium-9.4 Phos-4.2 Mg-1.9
DISCHARGE LABS:
==============
___ 06:46AM BLOOD WBC-2.8* RBC-2.68* Hgb-8.3* Hct-26.5*
MCV-99* MCH-31.0 MCHC-31.3* RDW-19.9* RDWSD-70.7* Plt Ct-12*
___ 06:46AM BLOOD Glucose-171* UreaN-37* Creat-1.8* Na-140
K-4.5 Cl-107 HCO3-21* AnGap-12
___ 06:46AM BLOOD ALT-37 AST-77* AlkPhos-118 TotBili-6.5*
___ 06:46AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.8
___ 08:10AM BLOOD tacroFK-2.1*
IMAGING:
=======
CXR ___:
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Moderate, chronic cardiomegaly.
RUQUS ___:
IMPRESSION:
1. Patent TIPS. Redemonstrated flow away from the TIPS shunt
within the left
and right portal veins.
2. No substantial change in chronic appearing nonocclusive
thrombus within the
main and right portal veins, which remain patent.
3. Cirrhotic liver, with sequela of portal hypertension,
including marked
splenomegaly and trace ascites.
MICROBIOLOGY:
=============
Urine culture: Negative
Blood culture: Negative
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
========================
___ PMH cryptogenic cirrhosis s/p transplant in ___ c/b
decompensated cirrhosis due to allograft failure (pred/tacro),
ascites and HE, acute cellular rejection, s/p shunt embolization
TIPS ___ and revision ___, CKD, skin cancer, recent
admission for HE and decompensated cirrhosis, who was admitted
for hepatic encephalopathy and ___. Hepatic encephalopathy
improved with lactulose increase and he will be discharged on
60mL QID. His ___ improved, and home diuretics were restarted
prior to discharge. He was discharged in stable condition with
close outpatient follow-up.
TRANSITIONAL ISSUES:
=====================
[] Consider Panel Reactive Antibodies (PRA) studies as
outpatient if platelets do not increase after transfusion.
[] He was unable to complete 24 hour urine collection for
Osmolality; Sodium; Potassium; Chloride; Bicarbonate; Urea
Nitrogen; Creatinine, Urine. Please order for collection on
outpatient basis.
[] Will need ___ follow-up for repeat TIPS venogram, search and
embolization of portosystemic shunts. Of note, INR would need to
be <1.5 and platelets would need to improve prior to any
intervention.
BRIEF HOSPITAL SUMMARY
======================
#Hepatic encephalopathy
Likely HE given confusion and asterixis in setting of cirrhosis
c/w prior presentations, though with unclear trigger. No
increase
in abdominal distention, ___ edema, and no dark stool, BRBPR,
hematemesis, to suggest bleed. Infectious work-up was
unrevealing. Of note, patient has had uncomplicated TIPS
angioplasty and coronary varix embolization in the setting of
HE, which although appears patent per RUQUS, has redemonstrated
flow away from the TIPS shunt within the left and right portal
veins and could be possible source of current HE. ___ was
consulted for evaluation of TIPS, and per their review, prior
venograms and CTVs demonstrate sluggish hepatopedal flow with
extensive portosystemic shunts, variceal and collateral
formation. Prior TIPS angioplasties to increase hepatopedal flow
have had modest effect. Therefore, a contributing factor to his
repeat episodes of encephalopathy may be related to his native
shunt physiology. It would be reasonable to do a repeat TIPS
venogram, search and embolization of portosystemic shunts.
However, since his ___ was resolving and he was mentating more
clearly with increase in lactulose, this was not done urgently,
especially in the setting of current thrombocytopenia (plt 13),
INR 2.0. Will need outpatient follow-up with ___ and INR and
platelets would need to improve to consider intervention. He was
discharged on home regimen of 60mL QID.
___ on CKD stage III- resolved
Cr slightly elevated upon admission to 2.1 (baseline 1.8-2.0,
but
previously was 1.0-1.2 back in ___. Improved with albumin
challenge with Cr 1.7 and at baseline.
#Cryptogenic cirrhosis s/p OLT ___ c/b graft failure.
MELD-Na 28 upon presentation, ___ C. Previous transplant
at ___ ___ c/b post-transplant cirrhosis and acute cellular
rejection.
[] TRANSPLANT: Listed for transplant.
- Continued home prednisone 5 mg daily and tacrolimus 0.5mg
every
other day. Last tacro level 2.1 a ___.
[] HE: see above.
[] VARICES: EGD ___ demonstrated medium-sized varices x4 in
the distal esophagus, nonbleeding. Status post banding x2.
Findings consistent with portal hypertensive gastropathy. No
gastric varices.
- Continued home PPI, sucralfate, simethicone.
[] ASCITES: Trace ascites noted on RUQUS, unable to tap in ED.
- Held home amiloride 5mg and furosemide 40mg due to ___. He was
restarted on amiloride 5mg and half his home dose of furosemide
(20mg) prior to discharge.
[] NUTRITION: Followed by nutrition. No need for tube feeds.
[] RENAL: see above.
[] COAGULOPATHY: INR 1.7 which is baseline for him
#Macrocytic Anemia
Hgb 8.6 --> 6.9, s/p 1u transfusion with appropriate bump. No
evidence of bleed, bloody or dark BM, hematemesis. No recent
instrumentation in abdomen. Unlikely hemolysis since largely
direct hyperbilirubinemia. Hgb remained stable since
transfusion.
- Receives Epogen shots monthly for CKD. Last shot was given
___.
#Thrombocytopenia
Chronic since ___. In setting of liver disease. Plt 13 and did
not bump to transfusion, concerning for whether he has developed
antibodies to platelets. Consider PRA studies as outpatient if
platelets do not increase after transfusion.
#Itchiness
Likely secondary to liver disease.
- Started on ursodiol 600mg qAM and 300mg qPM.
#Insulin dependent Type 2 diabetes
Follows with ___. Continued home diabetes regimen:
- Glargine 24 Units Bedtime
- Humalog 8 Units Breakfast
- Humalog 10 Units Lunch
- Humalog 10 Units Dinner
- Humalog SSI
#Neuropathy:
- In lower extremities, likely diabetic neuropathy. Held home
gabapentin in setting of confusion but can be re-started upon
discharge.
#HTN:
- Held home coreg due to decompensated cirrhosis but was
restarted prior to discharge.
# CODE: Presumed FULL
# CONTACT:
Name of health care proxy: ___
Relationship: Wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Calcium Carbonate 500 mg PO DAILY
3. CARVedilol 12.5 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PredniSONE 5 mg PO DAILY
9. rifAXIMin 550 mg PO BID
10. Simethicone 80-160 mg PO QID:PRN gas pain
11. Sucralfate 1 gm PO QID
12. Tacrolimus 0.5 mg PO EVERY OTHER DAY
13. Thiamine 100 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
15. Lactulose 60 mL PO QID
16. aMILoride 5 mg PO DAILY
17. Gabapentin 300 mg PO BID
18. Magnesium Oxide 400 mg PO DAILY
19. Hyoscyamine 0.125 mg SL TID:PRN abdominal cramps
20. melatonin 1 mg oral QHS:PRN insomnia
21. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
22. Glargine 24 Units Bedtime
Humalog 6 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ursodiol 300 mg PO QPM
RX *ursodiol 300 mg 1 capsule(s) by mouth every night Disp #*30
Capsule Refills:*0
2. Ursodiol 600 mg PO QAM
RX *ursodiol 300 mg 2 capsule(s) by mouth every morning Disp
#*60 Capsule Refills:*0
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Glargine 24 Units Bedtime
Humalog 8 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild/Fever
6. aMILoride 5 mg PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. CARVedilol 12.5 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 300 mg PO BID
11. Hyoscyamine 0.125 mg SL TID:PRN abdominal cramps
12. Lactulose 60 mL PO QID
13. Magnesium Oxide 400 mg PO DAILY
14. melatonin 1 mg oral QHS:PRN insomnia
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
18. PredniSONE 5 mg PO DAILY
19. rifAXIMin 550 mg PO BID
20. Simethicone 80-160 mg PO QID:PRN gas pain
21. Sucralfate 1 gm PO QID
22. Tacrolimus 0.5 mg PO EVERY OTHER DAY
23. Thiamine 100 mg PO DAILY
24. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Hepatic encephalopathy
SECONDARY DIAGNOSES:
=====================
Acute kidney injury on chronic kidney disease
Cryptogenic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were feeling more
confused and tired.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were diagnosed with hepatic encephalopathy, and your
lactulose were increased until your tremors and confusion
improved.
- Your home diuretics and carvedilol were initially stopped due
to worsening kidney function, which improved and your
medications were restarted.
- You were started on a new medication called ursodiol for your
itchiness.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10628475-DS-18
| 10,628,475 | 20,058,710 |
DS
| 18 |
2171-10-03 00:00:00
|
2171-10-03 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prilosec / Symbicort
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w history of asthma (no prior intubations), non-compliance,
presenting for evaluation of shortness of breath and wheezing
since yesterday. Seen at ___ 5 days ago where felt to have
moderate-severe asthma exacerbation- given Abx and singulair as
patient prefers not to take steroids. She did not take
anything. Since day prior to admission, has been using Benadryl
for symptoms without relief. She notes increased use of flovent.
denies f/c, cp, sore throat, abd pain, n/v/d, dysuria. notes
cough with mucous congestion.
In the ED, VS: 98.3 103 135/84 20 97% RA
21:57 97.7 96 143/99 18 95% RA
22:36 97.9 98 133/75 17 90% RA
00:50 107 122/71 20 97% Nasal Cannula
02:19 105 115/66 19 97% Nasal Cannula
06:00 124 115/74 22 97% Nasal Cannula
06:00 98.2 124 115/74 22 97% Nasal Cannula
PE notable of inspiratory and expiratory wheezing. CXR normal.
EKG NSR, no STE/STD/TWI.
Peak flow 200. Given: duonebs, prednisone. Repeat peak flow was
160.
Patient triggered at ~4am for acute SOB after ambulating to the
bathroom w/ increased RR w/ poor air movement. They were unable
get reliable pleth but sign out per ED SpO2 ___ w/o improvement
with duonebs. Given epipen x 1 in thigh, 125 solumedrol, w/
improvement in resp status, ___ on RA.
On arrival to the FICU, VS: 98.1 BP 130s/90s HR 90-100s RR ___
SpO2 92-94%.
Past Medical History:
Mild Persistent Asthma
Social History:
___
Family History:
FAMILY HISTORY:
CROHN'S DISEASE sister, maternal uncle, cousins
DIABETES ___ paternal grandfather
BREAST CANCER maternal grandmother
Physical Exam:
ADMISSION EXAM
Vitals: VS: 98.1 BP 130s/90s HR 90-100s RR ___ SpO2 92-94%
GENERAL: NAD lying comfortably in bed
HEENT: MMM
NECK: JVP not elevated, no LAD
LUNGS: CTA bl, no wheezes, good respiratory effort
CV: tachycardic, regular rhythm, no MRG
ABD: soft NT ND +BS
EXT: wwp, no peripheral edema
DISCHARGE EXAM
VS: 97.9 103/65 86 18 96%RA
Gen: sitting up in chair, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally without wheezing, crackles, ronchi
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - mildly anxious
Pertinent Results:
___ 06:00AM BLOOD WBC-5.6 RBC-4.41 Hgb-12.7 Hct-39.1 MCV-89
MCH-28.8 MCHC-32.5 RDW-13.4 RDWSD-43.5 Plt ___
___ 06:00AM BLOOD Glucose-234* UreaN-11 Creat-0.8 Na-136
K-4.0 Cl-99 HCO3-21* AnGap-20
___ 06:25AM BLOOD WBC-10.3*# RBC-4.20 Hgb-12.3 Hct-37.9
MCV-90 MCH-29.3 MCHC-32.5 RDW-14.0 RDWSD-45.9 Plt ___
___ 06:25AM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-140
K-4.5 Cl-102 HCO3-29 AnGap-14
___ CXR -
No acute cardiopulmonary process.
Brief Hospital Course:
This is a ___ F PMhx asthma admitted to ICU with acute
respiratory distress secondary to acute asthma exacerbation with
rapid improvement with nebulizers and steroids, now ready for
discharge home to complete 5 day pulse of steroids, on augmented
asthma regimen including montelukast.
# Mild Persistent Asthma with Acute Exacerbation - patient
presented with
several days of cough, and acute worsening of dyspnea and
wheezing, ED course notable for trigger for respiratory
distress, concern for O2 saturation in the ___, prompting
administration of epi, solumedrol and admission to ICU; peak
flow was 160 (<40% expected), suggestive of severe exacerbation,
with poor response to inhalers. Patient reported non-compliance
recent reccomendation to initiate montelukast. She was treated
with steroids, was started on the montelukast she had been
prescribed as an outpatient but hadn't taken, and continued on
flovent and albuterol. She demonstrated rapid and marked
improvement, satting mid-to-high ___ on room air with clear
lungs on exam. At time of discharge was ambulating comfortably.
She was discharged with instructions to complete her 5 day
course of prednisone, as well as with PCP and pulmonary
___, and an appointment to establish with a ___
allergist.
# Barriers to Care - Patient reported favoring a "holistic"
approach to medicine, which she seems to view as being somewhat
at odds with being prescribed medications. Future treatment
approaches may need to involve a discussion with her regarding
how to find a balance between her beliefs and the evidence basis
for medically necessary treatments.
# Transitional Issues
- Discharged home
- Contact - Patient, husband (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Montelukast 10 mg PO DAILY
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Montelukast 10 mg PO DAILY
3. PredniSONE 40 mg PO DAILY Duration: 3 Days
last day = ___
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q6H:PRN SOB
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute Asthma Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with an exacerbation of your asthma. You were treated with
steroids and improved. You are now ready for discharge home.
Please continue taking prednisone for 3 more days, and ___
with at your scheduled visits with your primary care doctor,
your pulmonologist and your new visit with an allergist
Followup Instructions:
___
|
10628475-DS-19
| 10,628,475 | 22,588,269 |
DS
| 19 |
2173-10-10 00:00:00
|
2173-10-10 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prilosec / Symbicort / Singulair
Attending: ___.
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with a past medical
history of asthma requiring ICU admission, no intubations, who
presented with dyspnea and wheezing.
She reports that on ___ she began taking antibiotics for a
tooth infection. The pain and infection have resolved and today
was her last day of antibiotics. On ___ she noticed that her
coworker was sick with a cold. On ___ she began feeling very
tired and was sneezing. She also felt very congested. On
___ she began having some wheezing and used nebulizer
treatments without much benefit. By 4am on ___ morning she
became very dyspenic and presented to the ED.
In the ED she triggered on arrival with RR on the high ___ with
very poor air movement and peak flow of 80. She was given 125mg
IV solumedrol, IV magnesium, and continuous albuterol nebs. With
these treatments her respiratory rate improved to the low ___.
On arrival to the floor she feels much improved. She still feels
mildly dyspneic but is able to speak in full sentences without
issue.
She reports that Dr. ___ pulmonologist) had wanted
her
to increase her flovent to 3 to 4 puffs daily but she had not
yet
done that.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Mild Persistent Asthma
Social History:
___
Family History:
FAMILY HISTORY:
CROHN'S DISEASE sister, maternal uncle, cousins
DIABETES ___ paternal grandfather
BREAST CANCER maternal grandmother
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs with bilateral inspiratory and expiratory wheezes
with good air movement bilaterally. Mildly tachypneic but
speaking in full sentences without accessory muscle use
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:00AM BLOOD WBC-14.2* RBC-4.43 Hgb-12.8 Hct-38.5
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.0 RDWSD-44.9 Plt ___
___ 03:05PM BLOOD WBC-9.6 RBC-4.31 Hgb-12.6 Hct-38.0 MCV-88
MCH-29.2 MCHC-33.2 RDW-13.6 RDWSD-44.2 Plt ___
___ 03:05PM BLOOD Neuts-72.1* Lymphs-14.1* Monos-4.5*
Eos-8.3* Baso-0.8 Im ___ AbsNeut-6.89* AbsLymp-1.35
AbsMono-0.43 AbsEos-0.79* AbsBaso-0.08
___ 07:00AM BLOOD Glucose-107* UreaN-11 Creat-0.6 Na-142
K-4.5 Cl-104 HCO3-24 AnGap-14
___ 07:00AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.4
___ 07:14AM BLOOD Lactate-1.5
___ 05:07AM BLOOD Lactate-1.9
___ 10:50PM BLOOD Lactate-4.1*
CXR:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Ms. ___ is a ___ female with
a past medical history of asthma requiring ICU admission, no
intubations, who presented with dyspnea and wheezing.
ACUTE/ACTIVE PROBLEMS:
# Asthma exacerbation with viral respiratory tract infection:
presented with dyspnea and wheezing consistent with asthma
exacerbation likely triggered by viral URI. On arrival to the ED
symptoms were quite severe with RR in the high ___ and very poor
air movement. She's much improved with steroids and nebulizers.
She did not require oxygen on the medical floor and did not
desaturate with ambulation. Pt requested to be discharged. She
was discharged with a plan to complete a 5 day course of 40mg
prednisone and to continue her home inhaler/nebulizer therapy.
Discussed increasing the dose of her flovent to ___ BID as
per last pulmonary recommendations during this season. Continued
cetirizine and GERD management.
# Lactic acidosis: was not hypotensive so suspect type B lactic
acidosis secondary to albuterol nebs. Received one hour of
continuous albuterol in the ED and more nebs as needed
Lactate normalized. Resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Amoxicillin 875 mg PO Q12H
3. Fluticasone Propionate 110mcg 3 PUFF IH BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
5. Cetirizine 10 mg PO DAILY
6. Ranitidine 75 mg PO BID
Discharge Medications:
1. PredniSONE 40 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
2. Fluticasone Propionate 110mcg ___ PUFF IH BID
increase to ___ puffs BID this season per Dr. ___
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
4. Cetirizine 10 mg PO DAILY
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
6. Ranitidine 75 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
viral respiratory infection leading to acute asthma exacerbation
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 shortness of breath and
wheezing and found to have an asthma exacerbation likely
triggered by a viral infection. Your chest xray did not show any
signs of pneumonia. Your symptoms improved with steroids and
inhalers. Please take all of your inhalers as directed upon
discharge.
Followup Instructions:
___
|
10628510-DS-6
| 10,628,510 | 23,808,829 |
DS
| 6 |
2140-02-12 00:00:00
|
2140-02-12 21:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with rheumatoid arthritis and ILD (currently on
sulfasalazine, plaquenil and cellcept, followed by Dr.
___ who presented with four days of worsening productive
hacking cough and coughing spasms. He has been suffering from
cough and post-nasal drip for the past several weeks. At his
recent Pulmonary appointment with Dr. ___ on ___ he
noted that his symptoms were improving. However, over the past
few days since, his symptoms became progressively worse with
hoarse voice, recurrent coughing spasms, and cough productive of
green and yellow sputum. He did have an episode of post-tussive
emesis. He also noted some looser BMs, wheezing, sinus
congestion, fatigue and poor appetite. No fevers, chills,
abdominal pain, urinary symptoms or pharyngitis. Recent travel
to ___ 3 weeks ago for a 24 hours period. Wife has also had
post-nasal drip for the past few weeks but otherwise no sick
contacts. In fact, he has been avoiding public transportation
and is very diligent about cleanliness. He tried benzonatate,
robitussin D and ___ without abatement of symptoms. He
has not been on prednisone in nearly one year. He is also up to
date on pneumonia and influenza vaccinations.
In the ED, initial vitals were: T98.5, HR95, BP140/76, RR 18,
SpO2 96% RA.
Exam was notable for wheezes and crackles.
Labs were notable for WBC 7.6, Hgb 12.6, plt 203. Chem panel
essentially normal, BNP 166, lactate 1.1. Troponin neg x1.
Influenza test negative.
CXR showed evidence of chronic, fibrotic lung disease, making
it difficult to exclude infiltrate or consolidation.
ECG: rate 85, sinus rhythm, normal axis, normal intervals, ST
segment depressions in V4-V6 and biphasic T waves in III and V6.
After discussion with patient's Pulmonologist, plan was made to
obtain CT chest to evaluate for evidence of pneumonia.
Unofficial CT chest showed possible worsening consolidation in
areas of previous GGOs in the lower lobes, particularly in the
right lower lobe more so than left. Air bronchograms in the RLL.
No obvious effusion. He was given nebulizers which helped.
On the floor, the patient continued to have severe coughing
spells and complained of a headache. He noted that he had blood
work done at PCP ___ ___ which was notable for normal WBC ct,
globulins 1.7 and normal chemistries and LFTs otherwise.
Review of systems: per HPI.
Past Medical History:
- Rheumatoid arthritis, previously treated with prednisone,
MTX, Humira; followed by a physician at ___
___
- Interstitial lung disease, currently on sulfasalazine,
plaquenil and cellcept; he is ordered for portable oxygen which
is used mostly for air travel and higher elevation
- Hemochromatosis, treated with phlebotomy
- Exercise-induced atrial fibrillation, on metoprolol XL
- Hypercholesterolemia
- Mild seasonal allergies, on PRN cromolyn
- s/p R hip arthroplasty
- s/p L knee arthroscopy
- s/p Mohs surgery on the scalp
Social History:
___
Family History:
Mother: Died age ___. Had a chronic cough
Father: Died age ___ MI age ___
Siblings: Sister with UC and polio and lymphoma. Sister with
questionable PE
There is no history of interstitial lung disease or
rheumatologic disease in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vital Signs: T99.1, BP 130/72, HR 87, RR 19, SpO2 90% RA.
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, no
oropharyngeal erythema, EOMI, PERRL, neck supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Patient with much difficulty inhaling without coughing;
notable for rhonchi in the inferior lung fields bilaterally with
occasional wheezes
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, + clubbing of the fingers; there is no
joint swelling
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation; able to move around comfortably in the
bed without assistance
Skin: no rashes
DISCHARGE PHYSICAL EXAM:
=======================
Vital Signs: 98.4 PO 147 / 81 91 20 90 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, no
oropharyngeal erythema, EOMI, PERRL, neck supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Patient with much difficulty inhaling without coughing;
notable for improved rhonchi in the inferior lung fields
bilaterally
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, + clubbing of the fingers; there is no
joint swelling
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation; able to move around comfortably in the
bed without assistance
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 10:18PM LACTATE-1.1
___ 10:00PM GLUCOSE-86 UREA N-13 CREAT-0.7 SODIUM-134
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-26 ANION GAP-18
___ 10:00PM estGFR-Using this
___ 10:00PM CK(CPK)-364*
___ 10:00PM cTropnT-<0.01
___ 10:00PM CK-MB-3 proBNP-166
___ 10:00PM WBC-7.6# RBC-3.93* HGB-12.6* HCT-37.8* MCV-96
MCH-32.1* MCHC-33.3# RDW-12.9 RDWSD-45.7
___ 10:00PM NEUTS-67.2 LYMPHS-10.4* MONOS-17.4* EOS-3.6
BASOS-1.1* IM ___ AbsNeut-5.10 AbsLymp-0.79* AbsMono-1.32*
AbsEos-0.27 AbsBaso-0.08
___ 10:00PM PLT COUNT-203
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-5.7 RBC-4.09* Hgb-13.0* Hct-39.8*
MCV-97 MCH-31.8 MCHC-32.7 RDW-12.9 RDWSD-46.5* Plt ___
___ 07:10AM BLOOD Glucose-85 UreaN-13 Creat-0.6 Na-131*
K-4.0 Cl-94* HCO3-26 AnGap-15
___ 07:10AM BLOOD Phos-3.3 Mg-2.2
IMAGING:
=======
CXR ___
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icious osseous abnormality is seen.? There is no acute fracture.
Brief Hospital Course:
___ year old man with RA, ILD (on MMF, sulfasalazine and
plaquenil) who presents with >2 weeks of URI symptoms which
acutely worsened to include cough and fever.
# ILD flare with acute bronchitis vs bacterial pneumonia
CT Chest not c/f PNA but does show possible worsening of ILD.
Flu swab negative. Urine legionella negative. Given exam,
increased sputum production, cough and fevers, this was thought
to be viral URI with potential superimposed bacterial infection.
Patient was treated with azithromycin and CTX and transitioned
to PO azithromycin and PO cefpodoxime on discharge. Management
was discussed and coordinated with outpatient pulmonologist, Dr.
___. Patient improved clinically throughout
hospitalization. He continued to have cough throughout hospital
course, DC'd with albuterol IH. Patient will have close
follow-up with pulmonologist who will likely do steroid taper
and continue to monitor.
---------------
CHRONIC ISSUES:
---------------
# Normocytic Anemia: pt with Hgb 12.6. Outpt labwork (shown by
the patient to the writer of this note) was ___ with Hgb 13.8.
Given his diagnoses of RA and ILD, suspect anemia of chronic
disease vs. acute infection. Stable throughout hospital course.
# Immunosuppression, ILD, Rheumatoid arthritis: patient on MMF,
plaquenil and sulfasalazine. Continued MMF, plaquenil,
sulfasalazine per outpatient pulmonologist.
# Exercise induced Atrial fibrillation: Noted during pulmonary
rehab session. Followed by ___ Cardiology. Rate control with
metoprolol. Does not qualify for anticoagulation based on
CHADS2-Vasc (score = 1). Home metoprolol continued.
# HLD: continued on home statin.
TRANSITIONAL ISSUES:
====================
# NEW MEDICATIONS: cefpodixime (end ___, azithromycin (end
___, prednisone (end ___
[] Will complete PNA Tx with total 8d course Cefpodoxime, 5d
Zithro
[] Will complete 5d Prednisone 40mg qd burst per outpt Pulm
[] Please assess ongoing O2 supplementation as outpatient for sx
management, had ambulatory O2 sat to 88% on RA
[] Blood Cx, sputum Cx pending at discharge
# CODE: Full (confirmed)
# CONTACT: ___, wife, phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 400 mg PO DAILY
2. Benzonatate 200 mg PO TID:PRN cough
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Mycophenolate Mofetil 1500 mg PO BID
6. SulfaSALAzine_ 1500 mg PO BID
7. Vitamin D Dose is Unknown PO DAILY
8. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU PRN Seasonal
allergies
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate [Ventolin HFA] 90 mcg ___ puffs oral
Q6H:PRN Disp #*1 Inhaler Refills:*0
2. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 6 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN cough, dry
mouth
RX *benzocaine-menthol [Cepacol Sore Throat ___ 15
mg-3.6 mg ___ LOZ Q2H:PRN Disp #*40 Lozenge Refills:*0
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 10 mL by mouth Q6H:PRN
Refills:*0
6. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
7. Sodium Chloride Nasal ___ SPRY NU TID:PRN post nasal drip
RX *sodium chloride [Saline Mist] 0.65 % ___ spry nasal TID:PRN
Disp #*3 Spray Refills:*0
8. Space Chamber Plus (inhalational spacing device)
miscellaneous ASDIR
RX *inhalational spacing device [BreatheRite MDI Spacer] use as
directed with inhaler prn Disp #*1 Kit Refills:*0
9. Benzonatate 200 mg PO TID:PRN cough
10. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU PRN Seasonal
allergies
11. Hydroxychloroquine Sulfate 400 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Mycophenolate Mofetil 1500 mg PO BID
14. Simvastatin 20 mg PO QPM
15. SulfaSALAzine_ 1500 mg PO BID
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Bacterial Upper Respiratory Infection
ILD Flare
SECONDARY DIAGNOSIS:
Atrial Fibrillation
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were in the hospital because you had worsening cough,
shortness of breath and fevers thought to be related to a
bacterial infection or flare of your interstitial lung disease.
You were given antibiotics, steroids and breathing treatments.
Your breathing improved and you began to feel better.
Now that you are leaving the hospital, please continue to take
the antibiotics (azithromycin and cefpodoxime) and steroids. We
are also giving you an inhaler to use if you have shortness of
breath.
Please see this worksheet for your appointment details. Please
call your doctor if you have any of the warning signs in this
paperwork.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
10628620-DS-8
| 10,628,620 | 28,959,959 |
DS
| 8 |
2154-05-22 00:00:00
|
2154-05-22 13:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Mandibular Abscess/Cellulitis
Right Periorbital Abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ y/o M with PMHx of well-controlled HIV, who
presents with facial abscesses. The patient reports that current
symptoms began ___ days ago as two "ingrown hairs" on his face
which he picked at. For the first few days, swelling was not
that bad. However, yesterday, when he woke up, he noted a
significant amount of swelling on his R jawline as well as
around his R eye. Swelling around eye was significant enough
that he could barely open his eye. No trauma to the face. No
fevers/chills. No vision changes. No pain with eye movements. No
oral ulcers. Of note, the patient does have a history of
recurrent abscesses, most recently in ___ (MRSA).
In the ED, the patient underwent bedside I&D. He was started on
IV clinda overnight. However, on re-eval the following day, the
patient continued to have evidence of abscess with purulent
drainage. Repeat incision and drainage was performed, and he was
admitted for further management.
ED Course:
Initial VS: 98.2 98 130/77 20 100% RA Pain ___
Labs significant for mild anemia. Otherwise largely WNL.
Imaging: none
Meds given:
___ 15:52 IV Clindamycin 600 mg
___ 15:54 SC Lidocaine 1% 2 mL
___ 15:57 IV Sodium Chloride 0.9% Flush 5 mL
___ 17:25 PO Acetaminophen 1000 mg ___
___ 23:08 IV Clindamycin 600 mg
___ 23:52 IV Sodium Chloride 0.9% Flush 5 mL
___ 07:37 IV Clindamycin 600 mg
___ 07:37 PO/NG Citalopram 40 mg
___ 08:30 IV Sodium Chloride 0.9% Flush 10 mL
___ 10:10 PO Bictegrav-Emtricit-Tenofov Ala 1 TAB
___ 15:05 IV Sodium Chloride 0.9% Flush 10 mL
___ 16:15 IV Clindamycin 600 mg
ED EXAM:
GEN: Uncomfortable, clearly in pain.
HEENT: 3cm x 1cm area of erythema, firm, tender lateral to R
eye. 4cm diameter area of erythema, tender, fluctuant at R angle
of jaw. 0.5cm diameter abrasion R cheek without underlying
abscess.
VS prior to transfer: 98.6 88 132/88 18 99% RA
On arrival to the floor, the patient reports that the swelling
around his R eye has improved a lot since his initial
presentation. He also reports that the pain and pressure along
his R jaw line are improved following the ___ I&D today. In
addition to the above symptoms, the patient does endorse some
throbbing over his R temple/eyebrow overlying the area of
induration.
ROS: As above. Denies fevers, chills, night sweats,
lightheadedness, dizziness, chest pain, heart palpitations,
shortness of breath, cough, nausea, vomiting, diarrhea,
constipation, urinary symptoms, muscle or joint pains, focal
numbness or tingling. The remainder of the ROS was negative.
Past Medical History:
HIV
Endocarditis
Secondary syphilis s/p tx ___
Positive PPD s/p tx ___
HTN
Recurrent skin abscesses
Social History:
___
Family History:
Denies any significant family history. Does endorse testicular
CA in his grandfather.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - ___ 1719 Temp: 97.5 PO BP: 136/82 HR: 81 RR: 18 O2
sat: 98% O2 delivery: RA
GEN - Alert, NAD
HEENT - Indurated area over superior lateral half of R eyebrow
with overlying scab; some swelling of the eyelid with EOMI; no
fluctuance noted; no significant scleral injection; no pain with
eye movements; PERRL; an additional area of erythema and
swelling noted overlying R mandible - there has been and I&D in
this area with wick in place with ongoing drainage of pus, area
of erythema is within the outlined margin; MMM
NECK - Supple, no cervical LAD
CV - RRR, no m/r/g
RESP - CTA B
ABD - S/NT/ND, BS present
EXT - No ___ edema or calf tenderness
SKIN - As above; in addition, there are skin changes consistent
with other areas of skin picking on the face
NEURO - Nonfocal
PSYCH - Calm, appropriate
DISCHARGE PHYSICAL EXAM
VS:
___ 0816 Temp: 97.2 AdultAxillary BP: 127/76 HR: 82 RR: 18
O2 sat: 98% O2 delivery: Ra
GEN: young man in NAD
Eyes: anicteric, non-injected.
ENT: Indurated and erythematous area over superior lateral half
of right eyebrow with overlying scab, improving; less swelling
of
the eyelid with EOMI; no fluctuance noted; no significant
scleral
injection; no pain with eye movements; PERRL. Additional area of
erythema and swelling over right mandible with wick in place.
Still some minor tenderness and mild fluctuance in this area.
Erythema is within marked boundaries from ___.
CV: RRR nl S1/S2 no g/r/m
CHEST: CTAB no w/r/r
ABD: Soft, NT/ND, NABS
EXT: WWP, no edema
SKIN: As noted in ENT in addition, there are skin changes
consistent with other areas of skin picking on the face
NEURO: EOMI, PERRLA. CN II-XII intact.
PSYCH: Calm, appropriate
Pertinent Results:
ADMISSION LABS:
___ 01:25PM BLOOD WBC-9.6 RBC-4.41* Hgb-11.4* Hct-38.4*
MCV-87 MCH-25.9* MCHC-29.7* RDW-17.4* RDWSD-54.7* Plt ___
___ 01:25PM BLOOD Neuts-70.2 ___ Monos-7.6 Eos-1.7
Baso-0.5 Im ___ AbsNeut-6.71* AbsLymp-1.86 AbsMono-0.73
AbsEos-0.16 AbsBaso-0.05
___ 01:25PM BLOOD Plt ___
___ 01:25PM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-141
K-4.5 Cl-107 HCO3-25 AnGap-9*
___ 01:25PM BLOOD Lactate-1.5
IMAGING:
CT neck ___:
1. Extensive swelling of the subcutaneous tissues within the
right
submandibular region. No focal fluid collections. Small amount
of air within the subcutaneous tissues is likely due to recent
incision. Underlying submandibular gland is unremarkable in
appearance.
2. Periapical lucency surrounding a right maxillary molar,
similar to before, which may represent the source of infection.
3. Prominent right submandibular lymph nodes are likely
reactive.
CT sinus/maxilla/mandible ___:
Moderate right periorbital swelling with a focal fluid
collection measuring up to 2.4 cm, concerning for an abscess.
No evidence of postseptal extension.
MICROBIOLOGY:
___ 3:27 pm SWAB Source: neck.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
ENTEROBACTER AEROGENES. 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.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 4 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
VANCOMYCIN------------ <=0.5 S
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-5.7 RBC-4.66 Hgb-12.2* Hct-38.7*
MCV-83 MCH-26.2 MCHC-31.5* RDW-17.3* RDWSD-52.2* Plt ___
___ 06:55AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-139
K-5.1 Cl-104 HCO3-24 AnGap-11
___ 06:55AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.1
___ 10:00PM BLOOD Vanco-17.9
Brief Hospital Course:
___ is a ___ year old man with a history of
well-controlled HIV and recurrent complicated MRSA abscess and
SSTI who was admitted with facial abscesses.
# Right Mandibular Abscess/Cellulitis
# Right Periorbital Abscess: Patient has a history of
complicated MRSA SSTIs. Presents with similar right periorbital
abscess and right mandibular abscess after picking at his skin.
In the emergency department started on IV clinda and underwent
I&D. Wound cultures were not obtained at that time. He did not
improve while in ED obs, and so was admitted and subsequently
started on vancomycin and augmentin, and then vancomycin,
ceftriaxone and metronidazole. ENT was consulted for further
wound assistance, and recommended BID wick dressing changes.
Wound swab demonstrated MRSA and pan-sensitive Enterobacter. CT
scans of the neck and face demonstrated right mandibular abscess
and right periorbital abscess. With treatment, his condition
improved and he was eventually transitioned to ciprofloxacin and
clindamycin on discharge, for a total 14-day course. By day of
discharge patient had improving clinical exam, was afebrile and
tolerating regular diet. He will do dressing changes at home.
He was referred to follow up with his PCP and allergy/immunology
for possible innate immunodeficiency.
# HIV: Patient was continued on his home ARV regimen.
# Depression: continued home citalopram
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will be on ciprofloxacin and clindamycin on
discharge, for a total 14-day course. By day of discharge
patient had improving clinical exam, was afebrile and tolerating
regular diet. He will do dressing changes at home. He was
referred to follow up with his PCP and allergy/immunology for
possible innate immunodeficiency. Please consider outpatient
staphylococcal decontamination for recurrent MRSA abscesses.
Time spent coordinating discharge > 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
2. chlorhexidine gluconate 4 % topical PRN
3. Multivitamins 1 TAB PO Frequency is Unknown
4. Cetirizine 10 mg PO DAILY
5. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
3. Clindamycin 300 mg PO QID
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*40 Capsule Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
6. Cetirizine 10 mg PO DAILY
7. chlorhexidine gluconate 4 % topical PRN
8. Citalopram 40 mg PO DAILY
9.Outpatient Wound Care
Please change wick dressing twice a day
Discharge Disposition:
Home
Discharge Diagnosis:
Facial Abscess
Mandibular Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to the hospital because you had an infection
along your jaw and eye. The infection was drained and you were
treated with antibiotics. With treatment, your condition
improved and you will now be discharged home to continue a
course of oral antibiotics.
Medication Changes:
- Antibiotic: ciprofloxacin and clindamycin
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:
___
|
10629080-DS-5
| 10,629,080 | 29,337,833 |
DS
| 5 |
2162-03-04 00:00:00
|
2162-03-04 11:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Macrodantin / Naprosyn
Attending: ___
Chief Complaint:
Mechanical fall, C2 fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman who presents today following a
fall. She had immediate onset of acute neck pain afterwards,
but
denies any posterior scalp numbness or pain, paresthesias,
radicular pain, extremity numbness, or weakness. She does
complain of some left leg pain at the site of leg abrasions.
She
did not lose consciousness and feels that the fall was
mechanical. She takes ASA/plavix.
Past Medical History:
CAD s/p MI (___), CHF, HTN, HLD, Vertigo (chronic),
PNA, UTI, cardiac catherization (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
O: T: 96.2 BP: 205/97 HR: 94 RR 16 O2Sats 94%
Gen: WD/WN, comfortable, NAD.
Neck: In rigid hard collar, + midline neck tenderness
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Language: Speech fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1 to 0.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hard of hearing.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally. Unable to
cooperate with JPS testing (moves toes voluntarilly)
Reflexes: B T Pa Ac
Right ___ 1
Left ___ 1
Toes downgoing bilaterally
Upon discharge:
alert & oriented x 3
MAE ___ strength
sensation grossly intact
c collar in place
Pertinent Results:
___ ___: No acute intracranial injury
CT cspine ___: Type 2 C2 fracture; C2-C4 autofusion
___ ECG:
Sinus rhythm. Ventriculara ectopy. The Q-T interval is
prolonged. There is an RSR' pattern in lead V1 which is probably
normal. Non-specific ST-T wave changes. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 ___ 57 81 -61
___ ankle xray
There is generalized demineralization. There are no displaced
fractures or
dislocations. The ankle mortise is preserved. Vascular
calcifications are
seen. Minimal spurring is seen adjacent to the lateral malleoli
suggestive of
previous old avulsion-type injuries. There is a small
calcaneal spur.
Brief Hospital Course:
Mrs. ___ was admitted to the Neurosurgery service for further
management of her non-displaced C2 (type 2 dens) fracture. She
was placed in a hard cervical collar at the outside hospital and
it was maintained while at ___. Her aspirin and Plavix were
held overnight in case the patient were to require a surgical
procedure.
On the morning of ___, Mrs. ___ was neurologically stable.
She had no overt pain on exam. Her aspirin and Plavix were
resumed. Physical Therapy was asked to see the patient prior to
discharge for a safety evaluation. Physical therapy recommended
a discharge plan to rehabilitation.
On ___, the patient's examination remained stable. Case
management was screening the patient for rehabilitation
facilities.
On ___ the patient remained neurologically stable. She
complained of ankle pain. Xrays of the ankle were completed and
were negative for fracture
On ___ Patient complained of some neck pain. She was started on
tramadol with good relief of pain.
On ___ Patient remained neurologically intact. Her pain was
well controlled. She was discharged to rehab with instructions
for follow up.
Medications on Admission:
Simvastatin, meclizine, protonix, micro-K, imdur, metoprolol,
xalatan, asa 81 daily, flonase, proair, advair, furosemide,
supplemental oxygen, lasix, plavix,
losartin
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH HS
7. Furosemide 20 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Meclizine 12.5 mg PO Q12H:PRN dizziness
11. Metoprolol Tartrate 12.5 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Simvastatin 20 mg PO DAILY
14. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type 2 dens fracture
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 after you
sustained a mechanical fall and were found to have a C2
(cervical) fracture. You were ordered to wear a hard collar at
all times (other than for hygiene). While inpatient, you were
seen by Physical Therapy as well.
You are now being discharged with the following instructions:
Wear your hard collar at all times other than when you are
performing daily hygience. Do not abruptly turn your head left
to right when the collar is off...keep you head and neck in
alignment.
You are being discharged on narcotic pain medications which can
cause drowsiness and constipation. Do not drive or operate
heavy machinery while taking this medication. If you become
constipation, you should take Colace, a natural stool softener,
on a daily basis (twice daily).
Followup Instructions:
___
|
10629383-DS-9
| 10,629,383 | 21,239,866 |
DS
| 9 |
2135-09-25 00:00:00
|
2135-09-25 13:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
morphine / codeine / opium tincture / PPD
Attending: ___.
Chief Complaint:
Left knee pain
Major Surgical or Invasive Procedure:
Left distal femur ___ plate
History of Present Illness:
Patient is ___, very limited historian due to developmental
delay in cognition and speech. History is partly from patient
responses and partly from outside nursing home charting. She is
a bedridden resident in ___ home who was brought to the
___ infirmary this evening with a painful, swollen left
knee. Xrays at the facility showed distal left femur fracture
and she was transferred to ___.
Past Medical History:
Developmental delay, schizoaffective disorder,
neurofibromatosis, cirrhosis
Social History:
___
Family History:
NC
Physical Exam:
Gen: comfortable, NAD
LLE:
Incision c/d/i
warm, well-perfused
sensory and motor exam difficult to assess secondary to
patient's baseline mental status, patient intermittently follows
commands
Pertinent Results:
___ Left knee films:
1. Severely comminuted, displaced fracture of the distal femoral
diametaphysis. Difficult to exclude additional injury to the
proximal tibia,
consider further assessment with CT if clinically indicated.
2. Incidental apparent chondroid lesion proximal left tibia
likely
enchondroma. Clinical correlation and followup is advised.
___ 07:25AM BLOOD WBC-7.1 RBC-3.51* Hgb-11.1* Hct-35.2*
MCV-101* MCH-31.6 MCHC-31.5 RDW-15.0 Plt ___
___ 12:40AM BLOOD ___ PTT-31.3 ___
___ 05:56AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-139 K-4.5
Cl-109* HCO3-23 AnGap-12
___ 05:56AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
left distal femur with placement of ___ plate, 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 her baseline diet of pureed liquids and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
Of note, the patient's facture was concerning for elder
abuse/neglect. An abuse/neglect report was filed with the
department of public health with regards to the patient's
previous facility. Social Work and the medical team informed the
patient's previous facility of the department of public health
report. Social Work informed the patient's sister/health care
proxy, ___ did not want the patient to return
to the same facility; therefore, the patient was screened for a
new facility and will be discharged to ___/
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. The patient non-ambulatory at baseline, but is
touch down weight in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient was
written for prescriptions for her chronic pain medications and
should follow-up with her primary care provider for further
management of chronic pain. The patient will follow up in two
weeks per routine. A thorough discussion was had with the
patient's family regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
dexamethasone 4 mg tablet oral
1 tablet(s) Once Daily
divalproex ___ mg sprinkle capsule oral
4 capsule, sprinkle(s) Twice Daily
Refresh Optive 0.5 %-0.9 % eye drops ophthalmic
1 drops(s) in both eyes, tid
senna 8.6 mg capsule oral
2 capsule(s) Twice Daily
sertraline 100 mg tablet oral
1 tablet(s) Once Daily
trazodone 50 mg tablet oral
1 tablet(s) Once Daily, at bedtime
divalproex ___ mg sprinkle capsule oral
2 capsule, sprinkle(s) Once Daily, at 2pm
docusate sodium 100 mg tablet oral
1 tablet(s) Twice Daily
gabapentin 100 mg capsule oral
1 capsule(s) Three times daily
levothyroxine 125 mcg capsule oral
1 capsule(s) Once Daily
lorazepam 0.5 mg tablet oral
1 tablet(s) Twice Daily
methadone 5 mg tablet oral
1 tablet(s) Twice Daily
MS ___ 15 mg tablet,extended release oral
___ tablet extended release(s) Three times daily
bisacodyl 10 mg rectal suppository rectal
1 suppository(s) Once Daily, as needed
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Dexamethasone 4 mg PO DAILY
5. Divalproex Sod. Sprinkles 125 mg PO TID
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
8. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Lorazepam 0.5 mg PO BID
RX *lorazepam 0.5 mg 1 mg by mouth twice a day Disp #*30 Tablet
Refills:*0
11. Methadone 5 mg PO BID
RX *methadone 5 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
12. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 0.5 (One half) tablet(s) by mouth
every twelve (12) hours Disp #*30 Tablet Refills:*0
13. Vitamin D 400 UNIT PO DAILY
14. Morphine Sulfate ___ ___ mg PO Q4H:PRN pain
RX *morphine 15 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Sarna Lotion 1 Appl TP TID:PRN itchiness
17. Sertraline 100 mg PO DAILY
18. TraZODone 50 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left distal femur fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Left lower extremity: touch down weight bearing
Physical Therapy:
Left lower extremity: touch down weight bearing
Treatments Frequency:
Wound Care
Wound: Surgical incision
Location: Left lower extremity
Dressing: Inspect wound daily and change dressing with dry
gauze. If non-draining, can leave open to air.
Followup Instructions:
___
|
10629685-DS-29
| 10,629,685 | 22,648,302 |
DS
| 29 |
2155-05-24 00:00:00
|
2155-05-24 22:50:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ertapenem
Attending: ___
Major Surgical or Invasive Procedure:
EGD
attach
Pertinent Results:
ADMISSION LABS
===============
___ 02:20PM WBC-12.8* RBC-4.12* HGB-12.0* HCT-36.1*
MCV-88 MCH-29.1 MCHC-33.2 RDW-13.3 RDWSD-42.5
___ 02:20PM PLT SMR-NORMAL PLT COUNT-226
___ 02:20PM GLUCOSE-313* UREA N-99* CREAT-2.9*#
SODIUM-132* POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-23 ANION GAP-13
___ 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE->1000* KETONE-TR* BILIRUBIN-NEG UROBILNGN-NORMAL PH-5.5
LEUK-NEG
___ 09:35PM URINE OSMOLAL-507
___ 09:35PM URINE HOURS-RANDOM CREAT-125 SODIUM-31
___ 05:32AM BLOOD tacroFK-20.5*
DISCHARGE LABS
================
___ 05:30AM BLOOD WBC-7.5 RBC-2.41* Hgb-7.1* Hct-22.4*
MCV-93 MCH-29.5 MCHC-31.7* RDW-14.8 RDWSD-49.1* Plt ___
___ 05:30AM BLOOD Ret Aut-4.9* Abs Ret-0.12*
___ 05:19AM BLOOD Hpy IgG-NEG
___ 05:30AM BLOOD calTIBC-186* Ferritn-116 TRF-143*
___ 05:30AM BLOOD tacroFK-3.6*
___ 06:30AM BLOOD CMV VL-NOT DETECT
___ 15:47
GASTRIN - FROZEN
Test Result Reference
Range/Units
GASTRIN 64 <=100 pg/mL
IMAGING
=================
-LLE DOPPLER US (___): NEG FOR DVT
-RENAL ALLOGRAFT US (___)
The left iliac fossa transplant renal morphology is normal.
Specifically, the cortex is of normal thickness and
echogenicity, pyramids are normal, there is no urothelial
thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.68 to
0.77, within the normal range. The main renal artery shows a
normal waveform, with prompt systolic upstroke and continuous
antegrade diastolic flow, with peak systolic velocity of 44.8.
Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform. Previously seen
fluid collection is not identified on today's exam.
IMPRESSION:
Normal renal transplant ultrasound. RIs of the intrarenal
arteries range from 0.68-0.77 (previously 0.79-0.87).
=================
EGD (___):
FINDINGS
ESOPHAGUS: Grade D esophagitis was seen in the whole esophagus
STOMACH: Single superficial nonbleeding ulcer was found in the
stomach body; otherwise the remainder of the stomach appered
normal.
DUODENUM: Multiple cratered ulcers ranging in size from 1cm to
3cm were found in the duodenal bulb extending to D2. Multiple
diffuse nonbleeding erosions were noted in D3. A cratered ulcer
was found in the duodenal bulb. Visible vessel suggested recent
bleeding. Epinephrine ___ injection was successfully applied
for hemostasis. Bi-cap electrocautery was successfully applied
for hemostasis.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=================================
Mr. ___ is a ___ y/o M, h/o kidney/pancreas transplant, ___
native kidney s/p nephrectomy, CAD s/p CABG, PAD, who presented
with LLE cellulitis and coffee ground emesis found to have
severe esophagitis and multiple duodenal ulcers on EGD. His
cellulitis improved with antibiotics, initially on
vancomycin/cefazolin and transitioned to PO Augmentin. He was
monitored for recurrent GI bleeding.
TRANSITIONAL ISSUES:
=================================
[] please check CBC and tacrolimus level on ___, results to be
sent to transplant nephrology and PCP
[] please monitor for recurrent GI bleeding. GI will arrange for
repeat EGD in ___ weeks.
[] please monitor LLE cellulitis and swelling for resolution
[] pt to f/u with ___ for diabetes and insulin titration. Had
labile BGs while inpatient. Discharged on previous home regimen:
- Lantus 20 units at hs
- ___ novolog 1:7
- Sensitivity Factor 35
[] f/u with transplant nephrology, will have repeat labs in 1
week
FOLLOW-UP
- Follow up: PCP, ___, GI, Transplant nephrology
- Tests required after discharge: CBC, electrolytes, and
tacrolimus on ___
OTHER ISSUES:
- Discharge Hemoglobin: 7.1
- Discharge Cr: 1.3
#CODE: Full code (presumed)
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
ACUTE ISSUES:
=============
# UGIB: hemetemesis, melena
# Duodenal ulcers, esophagitis
# Anemia
New onset hematemesis in ED after 1 week of epigastric pain and
odynophagia. Likely source of bleeding from esophagitis and
multiple duodenal ulcers up to 3cm found on EGD (___), had 1
visible vessel cauterized. Unclear etiology, differential
including pill esophagitis, CMV,
malignancy. Had hx of a duodenal bulb ulcer on EGD in ___ with
bx neg for malignancy and neg H. pylori. This admission had
normal gastrin level, neg CMV viral load, neg H. pylor IgG. No
biopsies could be obtained due to risk of bleeding. His Hgb
decreased from acute blood loss and was transfused 1U pRBCs x2,
second transfusion on day of discharge for stable Hgb ~7.1-7.6.
His vitals remained stable throughout admission. GI will arrange
outpatient follow-up with repeat EGD in ___ weeks. He is
discharged on omeprazole 40mg BID and sucralfate QID. He will
have CBC rechecked on ___.
# LLE cellulitis: resolving
Non-purulent appearing. Previously failed 3 days of Bactrim and
Keflex as outpatient.
Given the extent of the cellulitis, he was covered empirically
for strep
and MRSA with vancomycin/cefazolin, then transitioned to PO
Augmentin for planned total 10 day course (last day ___. Pain
was treated with Tylenol PRN.
# ___: resolved
Presented with Cr 2.9 from baseline ~1.2. Most likely pre-renal
in the setting of nausea, cellulitis, poor PO intake and GI
bleeding. Received IVF and his Cr slowly improved to 1.3.
# Hyperkalemia: resolved
Developed K 6.1 on ___, likely from ___, hypoinsulinemia (T1DM,
poor tx pancreas function), and GIB. Treated with calcium
gluconate, insulin+dextrose, and kayexelate. His K normalized.
#Pseudohyponatremia
Na 133 on presentation, but corrected to 137 for hyperglycemia.
# ESRD s/p s/p LRRT in ___ and DDPT in ___
# c/f supratherapeutic tacro
AM tacro 20.5 (checked 6.5 hrs after last dose) on admission
higher than
expected, likely ___ ___. Was taking 1.5 mg tacrolimus BID.
Tacrolimus doses were adjusted based on daily tacro levels and
he was discharged on tacrolimus 1mg BID. Continued home
prednisone 4mg daily. Will have repeat tacro level drawn ___
with repeat labs in 1 week and follow-up with transplant
nephrology.
#Hypoglycemia
#T1DM
Labile blood glucoses with hypoglycemia and hyperglycemia.
___ was consulted. He is discharged on prior home regimen of:
- Lantus 20 units at hs
- ___ novolog 1:7
- Sensitivity Factor 35
He will follow-up with ___ endocrinology in ___ weeks.
#HTN
Held home lisinopril iso ___ and GIB. Continued carvedilol 25mg
BID. Resume lisinopril upon discharge.
CHRONIC ISSUES:
===============
#CAD s/p CABGx3 (LIMA-LAD, SVG-OM, SVG-RCA) ___
#PAD s/p R femoral endarterectomy ___
Holding ASA 81 for GIB. Continued Pravastatin 30 mg PO QPM.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. CARVedilol 25 mg PO BID
3. Omeprazole 20 mg PO BID
4. Pravastatin 30 mg PO QPM
5. PredniSONE 4 mg PO DAILY
6. Tacrolimus 1.5 mg PO Q12H
7. Vitamin B Complex 1 CAP PO DAILY
8. Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Sucralfate 1 gm PO QID
4. Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Omeprazole 40 mg PO BID
6. Tacrolimus 1 mg PO Q12H
7. CARVedilol 25 mg PO BID
8. Lisinopril 20 mg PO DAILY
9. Pravastatin 30 mg PO QPM
10. PredniSONE 4 mg PO DAILY
11. Vitamin B Complex 1 CAP PO DAILY
12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until a doctor tells you to do so
13.Outpatient Lab Work
K___. 2 - Gastrointestinal hemorrhage
Please draw CBC ___ and tacrolimus level. Fax to ___
ATTN: ___ and fax to ___ ATTN: Dr.
___
14.Outpatient Lab Work
ICD9: V42.0
Please draw CBC, CMP, tacrolimus level on ___.
Fax to ___ Dr. ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Duodenal ulcers
SECONDARY DIAGNOSES
====================
Esophagitis
Upper gastrointestinal bleed
Left lower extremity cellulitis
Acute kidney injury
Diabetes mellitus
Renal transplant recipient
Pancreas transplant recipient
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You had celllulitis of your left leg and you started throwing
up blood
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You had a scope (EGD) which showed you have severe esophagitis
(inflammation of your esophagus) and multiple ulcers in the
duodenum, which is the first part of your small intestine.
- You had blood and stool testing that were negative for CMV
virus and H. pylori bacteria, which can cause ulcers
- You got antibiotics for your cellulitis
- You had an ultrasound of your left leg that showed no blood
clots
- ___ endocrinology helped adjust your insulin
- Your tacrolimus doses were adjusted
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- The GI doctors are arranging for you to have another scope
(EGD) in ___ weeks.
- Please have your blood counts and tacrolimus level checked on
___
- Please have transplant labs checked on ___ for monitoring.
- Take omeprazole (40mg twice a day) and sucralfate for your
ulcers
- DO NOT take aspirin again until instructed to by your doctors
- Keep taking the antibiotic Augmentin. Your last day of
antibiotic will be ___.
- Take tacrolimus 1mg in AM and 1mg in ___ until transplant
nephrology instructs you to do otherwise.
- Please follow-up with your PCP to check on your leg.
- Please follow-up with ___ endocrinology for your diabetes.
You should go back to taking the same insulin you took before
you came to the hospital.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10629866-DS-10
| 10,629,866 | 25,312,995 |
DS
| 10 |
2171-06-07 00:00:00
|
2171-06-08 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea and bradycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with PMH of HTN, HLD,
atrial fibrillation/flutter on rivaroxaban with recent
cardioversion on ___ who presented to ___
with bradycardia to the ___, dyspnea, and hypotension with SBP
in ___.
Pt reports that his SOB started about 6 weeks ago when he
visited a wedding with his wife and while driving the car he had
some severe chest pain. He did not stop and it dissipated. Since
then he has developed worsening SOB with eventually minimal
exertion. Today he had an episode with nausea and chest
pressure.
At the ___ pt was started on dopamine and levophed for
hypotension and BiPAP for dyspnea. He was transferred on BiPAP
and with dopamine going through a right EJ. On arrival to ___
ED he denied shortness of breath or chest pain or lower
extremity edema.
In the ED, initial vitals were: HR 58 BP 112/72 RR 14 100%
Bipap
Labs and imaging significant for proBNP: 3344, Cr 2.2 from
baseline of 1.2. INR: 4.4. ALT: 145 AST: 182 AP: 136 Tbili: 1.5
Alb: 3.5. Lactate:2.0. EKG: HR 58, no ST changes. CXR showed
bilateral atelectasis. He was weaned off dopamine and he came
off BiPap and was satting 97% on 3L NC. In the ED pt received
aspirin 325mg x1.
The cardiology fellow performed a bedside echo which showed
basal inferior and basal to mid inferolateral HK. RV was not
well seen. There was also severe mitral regurgitation due to
tethering of the posterior mitral valve.
A decision was made to admit to the CCU on the basis that he may
need BiPAP again overnight. He is hemodynamically stable and
asymptomatic speaking full sentences at time of admission to the
CCU.
Vitals prior to transfer were: 97.4 62 135/92 22 97% on 3L Nasal
Cannula.
Upon arrival to the floor, patient denied chest pressure, chest
pain, nausea or shortness of breath. He complained of a feeling
of pressure in his abdomen which has been chronic for the past 6
weeks.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial Fibrillation/flutter Xarelto and amiodarone, recent
cardioversion now in sinus rhythm
Chronic Fatigue
S/P APPENDECTOMY
Migraines
low testosterone
Social History:
___
Family History:
father: died of lung ca and was a smoker
mother: died of ___ of aorta
1 sister in good health
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: T=97.6 BP=126/77 HR=64 RR=20 O2 sat=97% NC 6L
General: NAD, sitting up in bed. Speaking in full sentences
HEENT: NC/AT, no scleral icterus, moist mucus membranes
Neck: supple, JVD to
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: soft, nontender, distended, normoactive BS
Ext: warm, well perfused
Neuro: AAO x 3
Skin: no rashes
PULSES: 2+ ___
Discharge Physical Exam:
VS: T=98.0 BP=130/70 HR=63 RR=20 O2 sat=96% RA
General: NAD, sitting up in bed.
HEENT: NC/AT, no scleral icterus, moist mucus membranes
Neck: supple, JVD to
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: soft, nontender, distended, normoactive BS
Ext: warm, well perfused
Neuro: AAO x 3
Skin: no rashes
PULSES: 2+ ___
Pertinent Results:
Admission Labs:
___ 07:55PM WBC-10.3 RBC-5.07 HGB-16.8 HCT-53.6* MCV-106*
MCH-33.1* MCHC-31.2 RDW-13.5
___ 07:55PM NEUTS-80.9* LYMPHS-13.9* MONOS-4.3 EOS-0.3
BASOS-0.5
___ 07:55PM PLT COUNT-159
___ 07:55PM ___ PTT-36.1 ___
___ 07:55PM ALBUMIN-3.5
___ 07:55PM CK-MB-5 proBNP-3344*
___ 07:55PM cTropnT-<0.01
___ 07:55PM LIPASE-34
___ 07:55PM ALT(SGPT)-145* AST(SGOT)-182* CK(CPK)-143 ALK
PHOS-136* TOT BILI-1.5
___ 07:55PM estGFR-Using this
___ 07:55PM GLUCOSE-141* UREA N-41* CREAT-2.2* SODIUM-141
POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
___ 08:01PM LACTATE-2.0
Discharge Labs:
___ 07:40AM BLOOD WBC-5.7 RBC-5.58 Hgb-18.4* Hct-58.4*
MCV-105* MCH-32.9* MCHC-31.4 RDW-13.4 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-40.8* ___
___ 07:40AM BLOOD Glucose-113* UreaN-26* Creat-1.8* Na-141
K-4.7 Cl-104 HCO3-30 AnGap-12
___ 07:40AM BLOOD ALT-66* AST-39 AlkPhos-131* TotBili-0.9
___ 01:59AM BLOOD CK-MB-5 cTropnT-<0.01
___ 07:40AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
Studies:
Echo ___
This study was compared to the report of the prior study (images
not available) of ___.
LEFT ATRIUM: Mild ___. No ___ (best
excluded by TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD
by 2D or color Doppler. IVC dilated (>2.1cm) with >50% decrease
with sniff (estimated RA pressure ___ mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.] Estimated cardiac index is normal
(>=2.5L/min/m2).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate to severe (3+) MR.
___ VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. No left atrial ___
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of mitral regurgitation.] The
estimated cardiac index is normal (>=2.5L/min/m2). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate to
severe (3+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Moderate to
severe mitral regurgitation. Pulmonary artery hypertension.
Moderate to severe tricuspid regurgitation. Biatrial dilation.
Compared with the prior report (images unavailble for review) of
___, the findings are new.
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in ___ year.
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Echo ___
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___. No ___ (best
excluded by TEE).
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. [Intrinsic LV systolic
function likely depressed given the severity of valvular
regurgitation.] No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV chamber size. Borderline normal RV systolic function.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
to severe (3+) MR.
___ VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Borderline PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. No left atrial ___
seen (best excluded by transesophageal echocardiography). Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
focal hypokinesis of the distal inferior wall and apex (clips
59, 60). There is low normal systolic function of the remaining
segments (LVEF = 40 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. Right ventricular chamber size is normal.
with borderline normal free wall function. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Moderate to severe (3+) mitral regurgitation is seen. There is
moderate [2+] tricuspid regurgitation. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction suggestive of
CAD. Moderate to severe mitral regurgitation. Borderline PA
systolic hypertension.
Compared with the prior study (images reviewed) of ___,
left ventricuclar systolic function is less vigorous and
regional dysfunction is now suggested. The estimated PA systolic
pressure is now lower.
Brief Hospital Course:
___ year old male with PMH of HTN, HLD, atrial
fibrillation/flutter on rivaroxaban found to have decompensated
heart failure requiring diuresis as well as optimal rate/rhythm
control of atrial fibrillation prior to discharge.
# Dyspnea:
Patient presented with about 6 week history of dyspnea which
progressed to dyspnea at rest. In OSH ED prior to transfer to
___, patient noted to be bradycardic to the ___ with and
hypotensive to SBPs in ___. He was placed on dopamine and
Levophed and requiring BiPAP which was quickly weaned. Patient
thought to have some pulmonary edema secondary to old inferior
MI thought to be subacute in timing. Other etiologies for
dyspnea including pneumonia were ruled out as chest x-ray was
without findings suggestive of consolidation and patient
remained afebriled throughout hospital course. The patient was
diuresed with IV lasix and transition to PO diuretic and without
oxygen requirement prior to discharge.
# CAD/ Old inferior MI:
Patient found to have q waves in leads III and avf which
suggests old RCA infarct on EKG on admission. Given his report
of severe chest pain 6 weeks ago, he may have had an event then
which predisposed him to this progressive dyspnea, nausea,
fatigue and lack of appetite. In patient cardiac catheterization
deferred for now with plan to follow up as outpatient. The
patient was discharged with daily aspirin, high dose statin,
ACE, and beta blocker.
# Afib/aflutter:
Patient with history of chronic aflutter on Atenolol for ___
years which has recently progressed to afib. He was cardioverted
on ___ with successful return to sinus rhythm after being
treated with Rivaroxaban for 3 weeks. However, 48 hours later,
patient went back into afib with RVR and subsequently placed on
Amiodarone 400 BID to continue for 5 days and to then decrease
to 200 mg daily. In addition patient was discharged with
metoprolol 125 XL for rate control as well. In addition warfarin
was started 2mg daily with plan for follow up of INR with
___.
#Acute Diastolic heart failure with EF 40%
The patient was found to be dyspneic on admission requiring IV
diuresis thought to be secondary to pulmonary edema. The patient
was transitioned to PO 20 mg furosemide prior to discharge with
maintenance of euvolemia.
# Acute on CKD: Baseline Cr 1.2.
Patient noted to have elevated creatinine during hospitalization
of up to 2.2 downtrending to 1.8 prior to discharge. Thought to
be related to pre-renal etiology in setting of likely heart
failure exacerbation requiring diuresis. Will need follow up of
creatinine as outpatient to ensure return to baseline. ___ be
___ pre-renal etiology in setting of HF exacerbation.
# HTN:
Patient thought to optimally benefit from ACE and beta blocker
for old inferior MI as above as well as for blood pressure
control on discharge. Patient discharged with 20 mg lisinopril
daily as well as metoprolol 125 XL.
# Hyperlipidemia:
Patient discharged with atorvastatin 80 mg as above.
TRANSITIONAL ISSUES:
-follow up renal function
-INR check
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Ibuprofen 400 mg PO Q6H:PRN headache
5. Rivaroxaban 20 mg PO DAILY
6. Amiodarone 400 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
2. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 125 mg PO DAILY
RX *metoprolol succinate 50 mg 2.5 tablet(s) by mouth daily Disp
#*75 Tablet Refills:*2
6. Amiodarone 400 mg PO BID Duration: 5 Days
Then decrease to 200 mg daily
RX *amiodarone 200 mg two tablet(s) by mouth BID for 5 days only
Disp #*60 Tablet Refills:*2
7. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST elevation myocardial infarction
Atrial fibrillation with rapid ventricular response
Acute Kidney injury
Acute systolic heart failure
Cardiogenic shock
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for ___ at ___.
___ were admitted with low blood pressure and a slow heart rate.
___ needed medicine to keep your blood pressure up and help with
your breathing. An ECHO showed that your mitral valve is not
working well and there is a small part of your heart muscle that
is not functioning well. ___ have been started on medicine to
help your heart pump better and prevent fluid retention. Weigh
your self every day in the morning before breakfast. Call Dr
___ weight increases more than 3 pounds in 1 day or 5
pounds in 3 days. Your weight at discharge is 174 pounds.
___ will see Dr. ___ week to discuss further testing.
Please go to the ___ clinic at ___ on ___
at 8:45am, first floor, ask for ___. They will check your
warfarin level and tell ___ how much warfarin to take from now
on.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, fevers
Major Surgical or Invasive Procedure:
Temporal artery biopsy
History of Present Illness:
CC: ___, headaches
HPI: This is a ___ yo male with a history of AF on
Coumadin/amiodarone, CAD, HTN, who presents with fevers,
headaches, and visual disturbance for the past several days.
Pt reports onset of ___ frontal headaches and visual
changes starting ~10 days ago, associated with fevers and night
sweats. He describes the visual changes as sudden episodes of
"flashing lights" in his left eye, lasting for ___ minutes, then
resolving spontaneously. When he closes his eye, he sees a
residual ___ patch of light in his vision. Yesterday the
symptoms started to involve the right eye as well. He has had
___
episodes of associated diplopia as well. Headache is described
as
frontal/retroorbital and constant, no change with position, not
associated with photo or phonophobia. No worsening with shaking
of his head. He has had fevers and "drenching" night sweats over
the same period.
In addition to the above, he endorses ___ drip and a
nagging cough for the past 3 weeks with no dyspnea or chest
pain.
He has mild burning discomfort with urination. Endorses
decreased
appetite/PO intake and thinks he has not been getting enough
fluids. He endorses aches in his bilateral knees and toes.
Denies any recent sick contacts. Traveled to ___ in ___, none
since then.
Has poor dentition with several crowns, had a root canal ___
years
ago, no dental procedures since then.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial Fibrillation/flutter Xarelto and amiodarone, recent
cardioversion now in sinus rhythm
Chronic Fatigue
S/P APPENDECTOMY
Migraines
low testosterone
Social History:
___
Family History:
father: died of lung ca and was a smoker
mother: died of ___ of aorta
1 sister in good health
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise ___.
Physical Exam:
ADMISSION EXAM:
VS: Tmax 100.0, other vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, + conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, poor dentition with several crowns but no signs of
active tooth infection, no supraclavicular or cervical
lymphadenopathy, no JVD, no thyromegaly or palpable thyroid
nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, large ecchymosis in left AC, macular ___
rash on anterior left shin (old), no stigmata of infectious
endocarditis appreciated.
Rectal: No prostatic tenderness on DRE
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn ___ intact - PERRL, visual fields full
to
confrontation, EOMI. ___ strength throughout. No sensory
deficits to light touch appreciated. No asterixis, no pronator
drift, fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
DISCHARGE EXAM:
VS: 98.5 116 / 54 62 18 98 RA
Gen: Sitting chair, comfortable, pleasant, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear OP, MMM
Cardiac: RRR, no r/g/m
Chest: CTAB
Abd: Soft NT ND +BS
Ext: WWP, no edema
Neuro: AAOx3, face symmetric, moving all four extremities, no
neck stiffness
Pertinent Results:
ADMISSION LABS:
___ 11:15PM BLOOD ___
___ Plt ___
___ 11:15PM BLOOD ___
___ Im ___
___
___ 11:15PM BLOOD ___ ___
___ 11:15PM BLOOD ___
___
___ 11:15PM BLOOD ___
___ 11:15PM BLOOD ___
___ 11:15PM BLOOD ___
___ 11:30PM BLOOD ___
OTHER LABS:
___ 06:35AM BLOOD ___
___ 03:05PM BLOOD ___ B
___ 06:35AM BLOOD ___
___ 03:05PM BLOOD ___ SPECIFI
___ 11:15PM BLOOD ___ TH
___ 03:05PM BLOOD ___
ESR 127 on admission. 96 on discharge.
LAST LABS:
___ 05:00PM BLOOD ___ ___
IMAGING:
___ CT Head: FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
No osseous abnormalities seen. The paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION: Normal study.
___ MRI Head: IMPRESSION:
1. No acute intracranial abnormalities identified. No
concerning enhancement is seen.
2. There are mild chronic small vessel ischemic changes.
PATHOLOGY:
Temporal artery biopsy: Intimal fibroplasia, no active
arteritis.
Brief Hospital Course:
___ hx AFib on Coumadin/amiodarone, CAD, HTN, presented with
symptoms of fevers, headaches, night sweats, anorexia, and
visual disturbance for several days, referred in by PCP after
preliminary unremarkable workup including UA, CXR and blood
cultures.
ACTIVE ISSUES:
# Fever of Unknown Origin
# Presumed Giant Cell Arteritis:
___ presented with low grade fevers, constitutional symptoms
and visual changes concerning for an inflammatory versus
infectious process. Head imaging was negative; inflammatory
markers were high. Ophthalmology was consulted, concerned for
temporal arteritis on their exam. Steroids empirically started
in consultation with Rheumatology while ___ underwent
temporal artery biopsy by Vascular Surgery. While awaiting
biopsy results, ___ felt dramatically improved on steroids
with no further symptoms for three days. Biopsy was ultimately
negative, but given clinical improvement, determination was made
to continue with a steroid taper and have ___ with
Rheumatology. An alternative diagnosis advanced by Rheumatology
for his symptoms (which they did not feel were entirely
consistent with GCA) was a viral syndrome with possible
meningitis possibly triggering ocular migraines which the
___ has suffered from in the past, for which LP was
recommended early in his course. Given his persistently
therapeutic INR despite substantial vitamin K repletion, his
stroke risk (for which bridging was recommended by his
Cardiologist), and resolution of symptoms on steroids, as well
as the probable minimal yield of an LP so late in his course,
determination was made to defer this procedure.
# ___, resolved once taking fluids.
# AFib: Coumadin to be restarted on discharge, continue
amiodarone.
# HTN: Restarted lisinopril once ___ resolved.
TRANSITIONAL ISSUES:
- ___ to have INR checked on ___, with Dr.
___
- ___ taper will be: 60mg on ___, decrease by 10mg every 3
days afterward until off prednisone; if symptoms recur, stop
taper and call PCP
- ___ to take ranitidine while on prednisone
- ___ has ___ with Rheumatology, consider Neurology
evaluation for ocular migraines
- ___ aware that if symptoms recur, he should not only stop
taper and call PCP, but will likely need to be readmitted for
___
Greater than 30mins was spent on care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Amiodarone 100 mg PO DAILY
3. Warfarin 1 mg PO 5X/WEEK (___)
4. Atorvastatin 40 mg PO DAILY
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
Take 60mg on ___, decrease by 10mg every 3 days. If recurrence
of symptoms, stop taper, call PCP.
RX *prednisone 10 mg 6 tablet(s) by mouth once a day Disp #*51
Tablet Refills:*0
2. Amiodarone 100 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Warfarin 1 mg PO 5X/WEEK (___)
6.Outpatient Lab Work
Please draw ___ on ___ and fax results to ___
___ MD at ___. ICD 10 ___.01 (Long Term
Anticoagulation).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Fever of Unknown Origin. Presumed Giant Cell Arteritis
(versus Viral Syndrome with Ocular Migraine.)
Secondary: Atrial Fibrillation.
Discharge Condition:
Ambulating, tolerating diet, clear cognition.
Discharge Instructions:
Dear Mr ___,
You were admitted for fevers, headache, visual changes, and
diminished appetite. Your head imaging was negative, but you had
elevated inflammatory markers a concerning eye exam for temporal
arteritis. Though your temporal artery biopsy was negative, you
will be discharged on a course of steroids for a presumed
inflammatory syndrome. If you again experience visual changes,
headache, fevers, you should call your PCP and present for
medical ___.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Increasing Seizure Activity
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ male with a history of mental retardation,
cerebral palsy and seizure disorder who presents to the ___ ED
from an OSH as a transfer for worsening seizures. The history is
provided by chart review, his parents and group home caregiver
that are by his bedside.
Over the past several months, the patient has had AEDs changed
several times. Briefly, the patient was maintained seizure free
on carbamazepine monotherapy for almost ___ years up until
approximately one year ago. Following a breakthrough seizure, he
has since had some cognitive changes that have been documented
by Dr. ___ in his notes, including worsening attention,
delayed reaction times and he has also noted to have more
behavioral outbursts at his group home. Gabapentin was started
at one point but this caused problems with myoclonus. That was
weaned off, and then levetiracetam was added in it's place. This
did well to control seizures but has since caused problems with
ataxia and gait difficulties that are thought to be an effect of
___ and not CBZ. The first time ___ was weaned off was
approximately few months prior when he had a breakthrough
seizure, and then ___ was restarted. On follow up, Dr. ___
___ that lamotrigine should be started and his LTG has since
been uptitrated to 150mg BID over the course of two months or
so, and consequently ___ was slowly downtitrated with the last
dose approximately 48 hours prior.
As was noticed previously, following the discontinuation of ___,
___ had two seizures today. The first was at his group home,
which was characterized by his parents as a typical "grand mal"
episode where he starts to shiver, lose consciousness, eyes roll
backwards and his whole body starts to shake. He becomes sleepy
afterwards. His first episode today was around 1130AM. He was
taken to an ED, where he had a second episode again at 200PM
approximately. Blood tests were done, but we do not have those
results. Based on contact with Dr. ___ decided to transfer
___ to our facility for a possible LTM admission.
The patient has been in his USOH lately. He has not had any sick
symptoms such as fevers, chills, chest pain, congestion or
rhinorrhea. No diarrhea or abdominal pain. He has been compliant
with his medications. His group home caretaker does admit that
he has been having more of a "short fuse" lately.
Past Medical History:
- Mental retardation and seizure disorder following a presumed
neonatal insult. History of being on valproic acid therapy.
Dilantin was also started at one point but caused in an acute
seizure exacerbation. Dr. ___ review an MRI recently
showing the presence of right medial temporal atrophy, not clear
whether this was worse than prior.
- H/o requiring tracheostomy as an infant
Social History:
___
Family History:
Negative for neurologic illness
Physical Exam:
V/s: ___, 91, 150/86, 16, 94%
General: Awake, cooperative, NAD, wearing thick glasses. Makes
good eye contact and responds and regards. Appears quite
childish at times.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic (examination limited by mental status):
-Mental Status: Awake, alert and follows very simple commands.
Makes good eye contact. He speaks with moderate to severe
dysarthria. He was able to recall the ___ forwards without
difficulty. He would not tell me the date/day/year. He could not
name the month that comes after ___. Was able to name tie,
and glasses and phone. Could not name "stethoscope".
-___ Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk.
III, IV and VI: EOM are intact and full, no nystagmus
V: Light touch was different from left to right, but he would
not tell me how those two sides were different.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to grossly.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Full strength in all major muscle groups tested. Noted
more of bilateral lower extremity increased tone with
hyperreflexia throughout without clonusl. Toes were deferred.
-Sensory: Light touch was intact.
-Gait and Coordination not assessed.
*****************
DISCHARGE EXAM:
VS: BP sitting 132/84 - standing 119/78
General: Awake, cooperative, NAD, wearing thick glasses. Good
eye contact, more interactive than previous days.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic (examination limited by mental status):
-Mental Status: Awake, alert and follows very simple commands.
Makes good eye contact. He speaks with moderate to severe
dysarthria. He was able to recall the ___ forwards without
difficulty. He would not tell me the date/day/year. He could not
name the month that comes after ___. Was able to name tie,
and glasses and phone. Could not name "stethoscope".
-___ Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk.
III, IV and VI: EOM are intact and full, no nystagmus
V: Light touch was different from left to right, but he would
not tell me how those two sides were different.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to grossly.
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 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 3 1
R 3 2 3 3 1
- Plantar response was mute bilaterally.
- No frontal release signs were noted
- No Grasp reflex was noted, nor any glabellar reflex was noted.
-Sensory: Light touch was intact.
-Coordination: Slow but intact Finger-nose-finger, did not
cooperate with HKS.
-Gait: Improvement in degree of ataxia and unsteadiness on feet,
although gait apraxia was still noted in the patient
Pertinent Results:
___ 08:05PM GLUCOSE-94 UREA N-7 CREAT-0.8 SODIUM-131*
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-23 ANION GAP-16
___ 08:05PM estGFR-Using this
___ 08:05PM WBC-4.3 RBC-3.03* HGB-10.6* HCT-33.1*
MCV-109* MCH-35.0* MCHC-32.1 RDW-18.0*
___ 08:05PM NEUTS-68.1 ___ MONOS-10.3 EOS-0.1
BASOS-0.5
___ 08:05PM PLT COUNT-245
___ 06:45PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
MRI IMPRESSION:
1. Relative prominence of the right temporal horn of lateral
ventricle with hippocampal signal abnormality but no definite
hippocampal volume loss within the limits of the motion artifact
on this study. Findings likely reflect hippocampal cortical
dysplasia.
2. No evidence of infarction.
CT SPINE IMPRESSION:
1. Degenerative changes of the cervical spine as above.
2. Age-indeterminate vertebral body height loss of approximately
T11.
3. Age-indeterminate mild anterior wedging of L1. Mild
degenerative changes of the lumbar spine.
4. Lumbosacral transitional anatomy.
___ 03:30PM BLOOD WBC-3.4* RBC-3.10* Hgb-10.9* Hct-34.2*
MCV-110* MCH-35.1* MCHC-31.8 RDW-17.9* Plt ___
___ 06:45AM BLOOD ___ PTT-31.7 ___
___ 03:30PM BLOOD Glucose-118* UreaN-10 Creat-0.8 Na-132*
K-4.3 Cl-93* HCO3-30 AnGap-13
___ 06:45AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-133 K-4.4
Cl-96 HCO3-27 AnGap-14
___ 07:30AM BLOOD ALT-18 AST-23 LD(LDH)-188 CK(CPK)-346*
AlkPhos-74 Amylase-55 TotBili-0.4 DirBili-0.1 IndBili-0.3
___ 03:30PM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9
___ 03:30PM BLOOD Folate-15.8
___ 06:45AM BLOOD Osmolal-274*
___ 06:45AM BLOOD Carbamz-9.8
___ 03:30PM BLOOD METHYLMALONIC ACID-PND
___ 04:20AM BLOOD LAMOTRIGINE-PND
Brief Hospital Course:
#)Seizures
Mr. ___ has life-long seizures but fairly limited in number.
He was on depakote in the past with some behavioral issues, and
has been controlled on Tegretol monotherapy for at least ___
years but then had seizures. He was initially added on
neurontin, which caused myclonus then switched to keppra, but
this caused ataxia, and then trying to now are trying to replace
the keppra with lamictal. His last dose of keppra was 48 hours
before this flurry of seizures. His sodium is 130, which he
hasn't had hyponatremia before, potentially from the tegretol,
but less likely as he has been on it for so long without
problems. Also tegretol can increase the metabolism of the
lamictal, so it may be making it less effective and in the
combination of taking off keppra potentially causing him have
seizures.
EEG LTM captured did capture isolated discharges correlating
with his mycolonic jerks, however, isolated discharges were also
seen without a clinical correlate at other times. He was
titrated up on his Lamictal to 200 mg BID, and he will follow up
with his outpatient Neurologist, ___, for a Lamictal level
and a repeat Sodium given during hospital stay his Na levels
fluctuated. In addition to the Lamical 200mg BID, he was
discharged with lower dose of Tegretol 200mg qAM / 300mg qhs.
The patient will also be maintained on Clonezepam 0.5mg BID to
help control his myoclonic jerks as he showed significant
improvement with the initiation of Clonazepam.
Of note, the patient should not have any changes to his
anti-epileptic medications until follow-up with ___ as an
outpatient. Upon follow up in the clinic with ___, the
patient should also repeat an MRI to further characterize the
evolution of cortical heterotopia as noted during the imaging at
___.
#)Hyponatremia:
The patient should limit the amount of free water to about 1.5
liters per day, in hopes to increase his sodium gradually over
the next few weeks; however, if the patient is noted to have
orthostasis, please increase the restriction to 2 liters as
necessary.
#)HEME:
Ms. ___ CBC was remarkable for low WBC and Hct which has been
stable over the course of 24 hours; Folate and B12 were within
normal limits but high MCV should be monitored. Vit-B12:484
Folate:14.5
#) Transitions of care:
- Follow up with blood work as recommended - periodic checks of
Lamictal Level and Na given hyponatremia, which will be followed
by ___.
- A follow-up MRI should be performed for the possible cortical
heterotopia which was noted in the study obtained during this
admission.
- Please continue Fluid Restriction of 1.5L-2L unless patient
noted to be orthostatic and pending stable Na levels
- Please follow up with the Methylmalonic acid and Lamictal
levels which were pending upon discharge.
- Plans discussed with ___, who will follow as outpatient
Medications on Admission:
Tegretol 300mg qAM, 200mg qnoon, 300mg qPM
Lamotrigine 150mg BID
Discharge Medications:
1. Outpatient Lab Work
Blood, To be collected prior to ___: Sodium; Potassium;
Chloride; Bicarbonate; BUN; Creatinine; Lamotrigine;
Carbamazepine
ICD-9 Diagnosis Codes:
345.10 GENERALIZED CONVULSIVE EPILEPSY WITHOUT INTRACTABLE
EPILEPSY
2. Clonazepam 0.5 mg PO BID
3. Carbamazepine 200 mg PO QAM
4. Carbamazepine 300 mg PO HS
5. Cyanocobalamin 50 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. LaMOTrigine 200 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizures
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 more seizures (2 generalized
convulsions). We took levels of your medications. The Tegretol
was therapeutic but the lamictal level is still pending.
However we have started to increase your lamictal. This will
hopefully help reduce the number of "jerks" that you have as
well. You have been increased the Lamictal to 200 mg twice a
day. We have also added Clonazepam 0.5mg twice daily which was
successful in treating your muscle jerks.
In order to ensure that your Tegretol level is still theraputic,
but is not adversely affecting your sodium, we have decreased
your dosage to 200mg in the morning and 300mg in the evening.
You should continue to follow with Dr. ___ with Neurology.
Please do not adjust Mr. ___ medication regimen until the
patient has had the chance to follow up with Dr. ___.
*Have levels drawn in morning before AM dose prior to the
follow-up appointment on ___ with Dr. ___.
Also, because we have measured your sodium level to be low over
the course of your stay, we are recommending you follow a fluid
restriction of a maximum of 1.5 liters each day.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
increased frequency of myoclonic jerks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old man with cerebral palsy,
intellectual disability, and a longstanding seizure disorder who
was sent to our ED today from Dr. ___ clinic,
where
he was evaluated for increased myoclonic jerking at his rehab
facility despite recent uptitration of one of his AEDs
(Lamictal). He was recently on our inpatient Epilepsy service
(see notes from several weeks ago).
For AED treatment, he was on Depakote long ago, but this was
stopped due to behavioral issues. He was subseqeuntly on
carbamazepine for roughly ___ years. He was also tried on
phenytoin at one point, which was reportedly stopped after it
caused increased seizure activity. After he developed more
seizures, he was tried on gabapentin (stopped due to
?myoclonus)and then levetiracitam (stopped due to ?ataxia). Re.
the carbamazepine with attempted discontinuation of this
medication in ___ pt reportedly had increased myoclonic
activity, so it was restarted and continued. More recently, he
was switched from levetiracitam to lamotrigine. Following this
transition, he was admitted here twice following flurries of
myoclonic activity and generalized clonic seizure activity
lasting up to 5 mins. At that time he had mild hyponatremia in
the low-130s and high-120s (never less than 126) of uncertain
etiology.
His lamotrigine level during his ___ admissions were
subtherapeutic, despite increased doses; this was posited to
result from induction of its metabolism by CBZ. His lamotrigine
was increased to 400mg/day and his CBZ was decreased slightly
(first admission) to 500mg/day. He continued to exhibit
myoclonic
jerking (with epileptiform discharges correlating on surface
EEG), so his clonazepam was increased to 1.0mg TID (from 0.5mg
BID on the prior admission), which reduced the frequency of
jerking behavior. However, sedation from this medication to the
point that he could no longer walk independently and required
discharge to a rehabilitation facility rather than home.
In the weeks since discharge, his father reports that his CLZ
was
weaned down from 1.0 to 0.5mg BID. Also, his LTG has been
increased further, most recently up to 800mg / day (400mg BID)
after seeing Dr. ___ in neurology clinic a little over a month
ago. Each time his LTG is increased, his father reports that for
a couple days, he has fewer myoclonic jerks during daytime
hours,
but then the frqeuency increases to several times every minute,
all day long. This seems to have worsened with the decreases in
dose and frequency of his CLZ. No new AEDs have been tried.
He continues working with ___, but without significant progress
per his parents; he has too frequent myoclonic jerks to allow
him
to walk independently, but he is sometimes able to stand and use
a bedside commode. He remains more sedated than his previous
baseline, with slowed and slurred speech and slowed movements.
An
open MRI was planned (claustrophobia) to evaluate possible
cortical heterotopia, but this has yet to be performed.
___ parents are frustrated with the lack of progress, and
note that he is either too sedated (on increased benzo
medication) or having frequent myoclonic jerks, in either case
limiting his functional capacity. They would like us to find a
AED regimen on which he can be awake and functional again as
with
his previous baseline.
Review of Systems: negative except as above -- patient denies
pain, denies SOB. Denies weakness or numbness. Acknowledges
on-going intermittent jerking activity. Says he feels "fine."
Limited by slow speech and lack of awareness of his own history.
+ parents note episodes of nighttime urinary incontenence
recently.
Past Medical History:
- Mental retardation and seizure disorder following a presumed
neonatal insult. History of being on valproic acid therapy.
Dilantin was also started at one point but caused in an acute
seizure exacerbation. Dr. ___ review an MRI recently
showing the presence of right medial temporal atrophy, not clear
whether this was worse than prior.
- Tracheostomy as an infant
Social History:
___
Family History:
Negative for neurologic illness
Physical Exam:
ADMISSION PHYSICAL EXAM:
General Physical Examination:
Vital signs:
98.0F HR88 BP133/77 RR16 SaO298%RA (later HR up to low-100s,
regular and without any clinical change)
General: Lying in ED stretcher in khaki pants, tennis shoes, and
___. Awake and in NAD. Slow speech. Intermittent jerks as
below.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx.
Neck: Supple. No carotid bruits. No lymphadenopathy. No goiter.
Pulmonary: Lungs clear bilaterally. Non-labored breathing.
Cardiac: RRR, no loud M/R/G.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to name, father's name, home phone number. Does not
answer when asked for year or month or ___. Attention is
impaired
-- best effort is counts forward to 6 and stops (cannot count
backwards or perform ___. Poor historian. Speech is slowed
and non-specifically slurry, but not overtly dysarthric.
Language
is fluent. Repetition and comprehension are grossly intact. Flat
affect as c/w baseline. No paraphasic errors. Able to follow
simple commands. Does not remember Pats-Rams game (father said
he
watched it on ___.
-Cranial Nerves:
II: PERRL. Visual fields are FTC (finger-counting in all
peripheral fields grossly intact).
III, IV, VI: EOMs full and conjugate; no nystagmus. No saccadic
intrusions.
V: Facial sensation intact and subjectively symmetric to light
touch and pinprick V1-V2-V3.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally (sluggish).
XII: Tongue protrusion is midline.
-Motor:
No drift. On-going myoclonic jerks involving legs, arms/hands,
neck/shoulders at different times. Several per minute throughout
exam. Possible asterixis as well (cannot maintain tone holding
arms/hands up and back), although distinction is difficult and
probably irrelevant; there is definitely myoclonus (sudden
movements during rest). Otherwise grossly normal muscle bulk and
tone. Power is full in all muscle groups tested (delts, bis,
tris, IPs, TAs bilaterally).
-Sensory:
No gross deficits to pinprick in any distal extremity. Joint
position sense is grossly normal in the great toes. Eyes-closed
Finger-to-nose testing revealed no gross proprioceptive deficit
(did not miss nose).
-Reflexes (left; right):
Biceps (++;++) brisk bilaterally
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;++) 1-beat clonus bilaterally
Gastroc-soleus / achilles (++++;++++) sustained clonus
bilaterally.
Plantar responses was Extensor bilaterally.
-Coordination:
Finger-nose-finger testing seemed mildly dysmetric bilaterally,
but difficult to disentangle this with frequent myoclonus +/-
asterixis. Did not comply with heel-knee-shin testing.
-Gait: deferred due to frequent jerks and parents' report of
instability with such
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-6.3# RBC-3.46* Hgb-12.4* Hct-40.5
MCV-117* MCH-35.8* MCHC-30.6* RDW-18.0* Plt ___
___ 04:00PM BLOOD Neuts-62.7 ___ Monos-9.3 Eos-0.8
Baso-0.6
___ 04:00PM BLOOD ___ PTT-33.9 ___
___ 04:00PM BLOOD Glucose-126* UreaN-12 Creat-1.0 Na-139
K-4.1 Cl-94* HCO3-15* AnGap-34*
___ 04:25AM BLOOD ALT-15 AST-17 AlkPhos-70 TotBili-0.4
___ 04:00PM BLOOD Calcium-9.8 Phos-5.6*# Mg-2.2
___ 04:25AM BLOOD TSH-1.2
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Carbamz-7.7
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ANTI-EPILEPTIC DRUG LEVELS:
- CARBAMAZEPIME: ___ = 7.7, ___ = 7.3
- VALPROATE: ___ = 56, ___ = 58
EEG (___): This telemetry showed a very rapid background
activity
throughout, likely indicative of beta effect from medications.
There were no
areas of focal slowing. There were several generalized spike
discharges, but
there were no electrographic seizures.
Brief Hospital Course:
Mr. ___ was admitted to the hospital for adjustment of his
anti-epileptic regimen. He had EEG which showed rapid background
activity (likely beta effect from medications) and several
generalized spikes but no electrographic seizures. EEG was then
discontinued and he was monitored clinically for frequency of
myoclonic jerks. His lamotrigine was quickly tapered over the
course of three days, and was cross-titrated with valproic acid.
By HD #4 the lamotrigine had been stopped and valproate was
increased to 750mg PO BID. The frequency of his myoclonic jerks
decreased significantly with this change to his medication
regimen. Per his parents, he remains more sedated and
uncoordinated with his fine motor skills and ability to walk
compared to baseline, which may represent either a side effect
of his clonazepam therapy or a result of physical decompensation
from chronic hospitalization over the past year. In the
hospital, his clonazepam was continued as it is an effective
treatment for myoclonic jerks and did not want to make too many
changes once effective control of the jerks had been obtained.
As an outpatient, will consider slow taper of this medication.
He is being discharged to rehab where he will work with closely
with physical therapy to work at returning to his functional
baseline.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISSUES:
- Seizure disorder (myoclonic jerks, generalized tonic-clonic
seizures)
CHRONIC ISSUES:
- Cerebral palsy
- Intellectual disability
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___. You were admitted to the hospital with
increased frequency of myoclonic jerks (shaking of your arms and
legs). You were monitored on continuous EEG. In the hospital
your lamotrigine, which has been associated with increased
myoclonic jerks, was tapered and stopped. It was replaced with
valproic acid (depakote). With these changes, the frequency of
your myoclonic jerks decreased significantly. You are being
discharged to rehab where you will work with physical therapy.
In the next few weeks, your clonazepam will also likely be
tapered down as an outpatient as this may be slightly sedating
for you.
.
Please attend the follow-up appointments listed below with
Epilepsy (Drs. ___ and Cognitive Neurology (Dr.
___.
.
We made the following changes to your medications:
1. STOPPED lamotrigine (lamictal) 400mg by mouth twice daily
2. STAETED valproic acid (depakote) 750mg by mouth twice daily
Followup Instructions:
___
|
10630317-DS-4
| 10,630,317 | 24,220,586 |
DS
| 4 |
2117-02-01 00:00:00
|
2117-02-01 12:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male who presents to ___ on
___ s/p unwitnessed fall, with a mild TBI. Per the patient
he was at a ___ bake, had a few alcoholic beverages, does not
recall the event, the last thing he remembers is waking up at
the
hospital. The patient denies n/v, dizziness, blurred vision,
fevers, chills, SOB or CP.
Past Medical History:
None on File, per the patient his bp is "up and down".
Social History:
___
Family History:
Non-contributory
Physical Exam:
Upon Admission:
==============
Gen: WD/WN, comfortable, NAD.
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive, right ___, Left ___re full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Handedness Left or Right
Upon Discharge:
==============
Awake, alert, oriented x3, MAE full.
Pertinent Results:
Please see OMR for relevant findings.
Brief Hospital Course:
___ is a ___ year old male who presented after an
unwitnessed fall. NCHCT revealed small traumatic subarachnoid
hemorrhage. On repeat imaging, bleed had converted to a
contusion with subdural hematoma.
#Subdural hematoma
The patient was admitted to the ___ for close neurological
monitoring. He was started on Keppra for seizure prophylaxis.
Repeat ___ showed further blossoming of the contusion. On
___, he remained neurologically intact. Repeat NCHCT was
stable. Physical therapy evaluated him and recommended home
after an additional ___ evaluation. Patient was able to ambulate
independently on nursing report. On ___ the patient was seen by
___ and cleared for home. He was sent home with services.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*9 Tablet Refills:*0
4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Subarachnoid hemorrhage
Cerebral contusion
Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Traumatic Brain Injury
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.
You make take a shower 3 days after surgery.
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. Please continue the Keppra for 7 days.
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 symptoms after traumatic
brain injury. Headaches can be long-lasting.
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.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
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:
___
|
10630336-DS-14
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| 14 |
2133-12-22 00:00:00
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2133-12-23 14:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / azithromycin
Attending: ___.
Chief Complaint:
shortness of breath and acute desaturation to ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ yo male with non small cell lung
cancer, COPD on 4L home oxygen, Afib (rate controlled and on
warfarin most recent INR 1.4), who was recently admitted from
___ during which he was found to have new onset
systolic cardiomyopathy EF25% s/p cath which showed 3VD (70%
___ LAD, 80% OM, fully occluded RCA) s/p ___ 2 who now
presents with with acute episode of syncope, shortness of breath
in the setting of non sustained Vtach/Vfib.
Patient was admitted 2 weeks prior due to shortness of breath,
increased oxygen requirement, lower extremity edema and was
found to have a new systolic cardiomyopathy which responded to
diuresis. At this time he was found to be in Afib and was
cardioverted and was started on amiodarone and anticoagulation
with warfarin and lovenox.
His breathing has been stable since that time and has been
losing weight. Last night he went to sleep at 2 am. He woke up
at 3 am on the floor and with blood dripping from his nose. He
does not remember how he fell and he did not wake up immediately
from the pain.
He went to his scheduled urology appointment today and developed
acute shortness of breath. He was wearing his normal 2 L home
O2. He said he felt mildly nauseous at the time. His O2 sats
were in the mid-low ___ and he was referred to the ED for eval.
He does note cough today and for the past few days. He denies
fever, chest pain, vomiting, headache.
His initial vitals in the ED were T 97 P 49 BP 143/55 RR 16 O2
sat 85% 4L. He was noted to go into 20 beats of Vtach. In the ED
he was not short of breath. He did note waves of nausea
associated with the VTach. He complained mainly of pain on his
neck due to his fall.
His head CT was negative for ICH. CXR showed evidence of L mid
consolidation. Labs were notable for flat troponins, Chemistries
Na134, K4.2, Cl 86, HCO3 33, AG 19. CBC notable for WBC 11.1,
H&H of 13.1, 38.9, platelet 276. In ED he received albuterol,
ipratopium, methylprednisolone 125 mg, azithromycin 500 mg iv,
levofloxacin 750 mg. VS prior to transfer were: T 97.7 P 45 BP
110/43 RR 20 O2 97% 2L NC
Past Medical History:
CAD
non-small cell lung cancer
chronic obstructive pulmonary disease
hypertension
hyperlipidemia
aortic stenosis
cholelithiasis
colonic polyps
coronary artery disease
elevated PSA
nephrolithiasis
appendectomy.
Social History:
___
Family History:
Mother died of congestive heart failure, diabetes, and leukemia
at ___. Father died of myocardial infarction in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: alert and oriented, in no significant distress
HEENT: sclera anicteric, MMM, EOMI
Neck: JVP not assessed due to blood dripping from wound on neck
CV: bradycardic, regular rate and rhythm, III/VI systolic murmur
heard loudest at left upper sternal border
Lungs: breathing comfortably, diminished BS throughout; No
crackles, scattered wheezes
Abdomen: Soft, non distended, non tender
GU: foley
Ext: warm, well perfused, no evidence of pitting edema,
Neuro: strength grossly in tact
PULSES: 2+ pulses bilatearally
DISCHARGE PHYSICAL EXAM
Vitals: 37.7, BP 106/47 (100-116/47-63) HR 54-63, RR 18, SaO2 96
on 3L (baseline 4L)
General: alert and oriented, in no significant distress
HEENT: sclera anicteric, MMM, EOMI
Neck: JVP not assessed
CV: regular rate and rhythm, III/VI systolic murmur heard
loudest at apex
Lungs: scattered wheezes throughout
Abdomen: Soft, non distended, non tender
GU: foley
Ext: warm, well perfused, no evidence of pitting edema,
Neuro: strength grossly in tact
PULSES: 2+ pulses bilaterally
Pertinent Results:
ADMISSION LABS
___ 09:30AM BLOOD WBC-11.1*# RBC-4.18* Hgb-13.1* Hct-38.0*
MCV-91 MCH-31.4 MCHC-34.5 RDW-16.7* Plt ___
___ 09:30AM BLOOD Neuts-88.2* Lymphs-6.8* Monos-4.0 Eos-0.6
Baso-0.4
___ 09:30AM BLOOD ___ PTT-33.7 ___
___ 09:30AM BLOOD Glucose-126* UreaN-18 Creat-1.1 Na-134
K-4.2 Cl-86* HCO3-33* AnGap-19
___ 09:30AM BLOOD ___ 09:30AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
___ 01:13PM BLOOD Comment-GREEN TOP
___ 01:13PM BLOOD Lactate-1.5
DISCHARGE LABS
___ 05:55AM BLOOD WBC-9.6 RBC-3.27* Hgb-10.1* Hct-29.8*
MCV-91 MCH-30.8 MCHC-33.8 RDW-16.4* Plt ___
___ 05:55AM BLOOD Glucose-98 UreaN-19 Creat-0.9 Na-137
K-4.3 Cl-98 HCO3-33* AnGap-10
TROPONINS
___ 09:31PM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:30AM BLOOD cTropnT-<0.01
EKG
___ QTC ___ QTC 513
Brief Hospital Course:
# Tachyarrhythmia: Upon admission, the patient had markedly
prolonged QT interval in association with frequent VPDs, and
episodes of torsade de pointes (polymorphic nonsustained VT).
No episode required cardioversion. The initial K+ was 4.2, but
the specimen was hemolyzed. He had not been eating much for 5
days, and our initial impression was long QT syndrome due to
hypokalemia, superimposed on marked sinus bradycardia (due to
metoprolol and amiodarone) plus some contribution of amiodarone
to the long QT. Superimposed upon this background was
administration of 2 QT prolonging antibiotics in the ER
(azithromycin and levaquin). A cephalosporin was substituted
for treastment of pneumonia. Electrolytes were repleted to
achieve K > 4 and Mg > 2. The patient was initially admitted to
the CCU, then transferred to ___ 3. He was given a lidocaine
drip overnight, which suppressed VT. VT stopped within 12 hours.
Amiodarone was held during hospital stay. Metoprolol was held
given bradycardia. EP team was involved in his care and will
follow up with patient in one month.
.
# Syncope: initially thought to be due to bradycardia to the ___
so BB was held. HRs on discharge were ___. Metoprolol
held on discharge.
.
# Atrial fibrillation: previously rate controlled and
anticoagulated. No known episodes of Afib during admission.
Betablocker and amiodarone held. Warfarin continued at
alternating doses of 1.25 and 2.5 mg. Patient was 2.2 on
discharge. Further mgmt by PCP which was discussed via email.
Next INR check ___. Unclear if actually needs amiodarone,
and will be addressed by ___ clinic visit.
.
# Right neck hematoma: pt has hematoma in his right neck which
stopped spontaneously. ASA and plavix were not held during
hospitalization. Coumadin was held but restated on ___
afternoon after Hct has been stable.
.
# PNA: Per CXR and symptoms. Finished 7 day course of CTX.
Further azithromycin and levaquin was held as above due to QTc
prolongation. Discharged on baseline O2.
.
# Urinary obstruction: issue last admission thought to be due to
BPH. Failed voiding trial after catheter was removed.
Discharged w/ Foley. Started on tamsulosin. Will f/u w/ Urology.
.
# sHF: Etiology ischemic. ECHO ___ LVEF ___. Continued
home furosemide. Euvolemic on discharge.
.
# CAD: s/p cath ___ with significant disease (70% ___ LAD;
80% OM; fully occluded RCA) s/p PCI on ___ with DES to LAD
and OM lesions. Continued on aspirin and clopidogrel.
Metoprolol held for bradycardia w/ hypotension until sees EP.
.
# HTN: SBPs ranged ___. Continued on home lisinopril.
.
# COPD: on 4L NC at home. Continued on home albuterol and
symbicort to advair.
.
# Hematoma on face: self resolved.
.
# Hyperlipidemia: Lipids last checked ___. Chol 130. LDL 76.
Continued on statin.
.
#### TRANSITIONAL ISSUES ####
- Needs INR checked ___ (confirmed with PCP). Coumadin for
Afib, goal 2.0-3.0
- CHF Cardiology appointment: follow up Dr. ___ heart
failure
- EP Cardiology appointment: follow up with Dr. ___
need for amiodarone and when to reinitiate metoprolol (held for
sinus bradycardia & hypotension)
- Urology: follow up regarding acute urinary retention.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H PRN wheezing
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
6. Furosemide 40 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. Simvastatin 20 mg PO DAILY
10. Amiodarone 200 mg PO BID
Discharge Medications:
1. Outpatient Lab Work
INR on ___
Please fax results to: ___, RN
___ (fax)
2. Albuterol Inhaler 2 PUFF IH Q4H PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Warfarin 2.5 mg PO EVERY OTHER DAY
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth one tablet
daily alternating with one half tablet daily Disp #*23 Tablet
Refills:*0
9. Warfarin 1.25 mg PO EVERY OTHER DAY
10. Tamsulosin 0.4 mg PO HS
to treat your prostate to help you urinate better
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth once daily at night Disp #*30 Capsule Refills:*1
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to participate in your care while you
were at the ___.
You were admitted to the hospital after you had shortness of
breath at your urology appointment. When you were here, your
heart was beating slower than it normally should, which
prevented blood from reaching your organs. Your heart was also
not beating normally, which was most likely because of some of
the medications that you took. We stopped you from taking these
medications, and your heart function improved. Please do not
take amiodarone until you see your cardiologist next month.
Please continue to take your beta blocker. You will also need to
follow up in ___ clinic in ___ with ___
___, RN & Dr. ___.
It was truly a pleasure to participate in your care.
Followup Instructions:
___
|
10630941-DS-12
| 10,630,941 | 22,123,600 |
DS
| 12 |
2134-04-13 00:00:00
|
2134-04-13 16:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Perforated diverticulitis
Major Surgical or Invasive Procedure:
___ procedure (sigmoid resection with end descending
colostomy).
History of Present Illness:
The patient is a ___ y.o male who has never seen a physician for
more than ___ years who presents to the ER as a transfer from OSH
for perforated Diverticulitis. Reports having acute onset
supra-pubic tenderness around 8 am yesterday which worsened and
localized to LLQ. He went to an OSH where he was found to have
WBC of 16 and was found to have perforated sigmoid
diverticulitis
with specks of free abdominal air. They planned on taking him to
the OR but an EKG was done which showed TWI in V4-V5 without any
elevation of troponin.
The patient never had any such symptoms before. He has never had
colonoscopy. No weight loss or loss of appetite.
Past Medical History:
Denies any medical condition
No surgery
Social History:
___
Family History:
Father died of MI at age ___. Mother of cancer, unspecified.
Physical Exam:
VITALS: Temp 99.7, HR 86, BP 152/89, RR 18, SO2 92% on Room Air
GEN: NAD
HEENT: NCAT, EOMI, no scleral icterus
CV: irregularly irregular, radial pulses 2+ b/l
RESP: breathing comfortably on room air
GI: soft, appropriate TTP, LLQ Colostomy healthy in appearance,
+ gas and stool in ostomy bag, no R/G/D, laparotomy incision is
stapled and well appearing
EXT: warm and well perfused
Pertinent Results:
___ 06:50AM BLOOD WBC-10.6* RBC-3.86* Hgb-11.5* Hct-36.6*
MCV-95 MCH-29.8 MCHC-31.4* RDW-13.2 RDWSD-45.8 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-94 UreaN-14 Creat-0.9 Na-142
K-3.7 Cl-102 HCO3-26 AnGap-18
___ 06:54PM BLOOD LD(LDH)-168
___ 05:45AM BLOOD Lipase-10
___ 05:45AM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.9
___ 06:54PM BLOOD TSH-2.5
___ 01:56AM BLOOD Triglyc-157* HDL-24 CHOL/HD-4.5
LDLcalc-52
___ 01:56AM BLOOD %HbA1c-6.1* eAG-128*
CTA Abd/Pelvis (AT ___
Acute diverticulitis of the sigmoid colon with a few adjacent
tiny pockets od extraluminal air. Multiple small scattered areas
of free air in the anterior abdomen..
Brief Hospital Course:
Mr. ___ is a ___ year old male who has reportedly not seen a
Medical Doctor in approximately ___ years who was transferred
from OSH with perforated diverticulitis. The patient was taken
urgently back to the OR on ___ for an Exploratory
Laparotomy and Diverting Colostomy with Dr. ___. For further
information regarding this procedure, please refer to the
operative report in the OMR.
Postoperatively, Mr. ___ was transferred to the PACU and
ultimately to the floor where he was noted to be mildly confused
and altered. Per report, he did not have any focal neurologic
deficit. As part of workup, bilateral carotid duplex ultrasound
was completed demonstrating complete Right ICA occlusion and L
ICA stenosis <40%, although this was not thought to be a causal
factor in his acute altered mentation. During his brief stay in
the ICU, the cardiology team was consulted for arrhythmia in the
setting of soft vital signs. The cardiology team suspected
paroxysmal SVT as opposed to AFib and started the patient on a
small dose of Metoprolol. The vascular surgery team was also
consulted for the bilateral carotid artery stenosis who
recommended that the patient receive a CTA Head/Neck to further
evaluate the extent of his carotid artery disease. This was not
performed as an inpatient; the patient was referred to a follow
up appointment with vascular surgery and provided with an order
for the aforementioned CT Scan.
The patient's mentation improved over the ensuing days and he
was returned to the floor to continue his recovery. Once on the
floor, we awaiting return of bowel function through his ostomy.
His pain was controlled first with IV then PO pain medications
when appropriate. His diet was advanced in a step wise fashion,
and once he was passing gas and stools into his ostomy, he was
given a regular diet. Prior to his discharge on ___, Mr.
___ was ambulatory, voiding, comfortably changes his ostomy
appliance, passing stool into his ostomy and his pain was
controlled with PO pain medications. He was discharged home with
all of his appropriate medications and follow up appointments.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Peritonitis due to perforated diverticulitis ___ IV
diverticulitis).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
___ were admitted to the hospital after a colectomy for surgical
management of your diverticulitis. ___ have recovered from this
procedure well and ___ are now ready to return home. Samples
from your colon were taken and this tissue has been sent to the
pathology department for analysis. ___ will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact ___ regarding these
results they will contact ___ before this time. ___ have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. ___ may return home
to finish your recovery.
___ have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. ___ should have ___
bowel movements daily. If ___ notice that ___ have not had any
stool from your stoma in ___ days, please call the office. ___
may take an over the counter stool softener such as Colace if
___ find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as ___
have been instructed by the wound/ostomy nurses. ___ will be
able to make an appointment with the ostomy nurse in the clinic
7 days after surgery. ___ will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until ___ are
comfortable caring for it on your own.
___ have a long vertical incision on your abdomen that is
closed with staples. This incision can be left open to air or
covered with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by your surgical team. ___ may gradually
increase your activity as tolerated but clear heavy exercise
with your surgical team.
___ will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. ___ may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities.
Followup Instructions:
___
|
10631235-DS-22
| 10,631,235 | 24,238,481 |
DS
| 22 |
2114-05-16 00:00:00
|
2114-05-16 16:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain, recurrent endometrial cancer
Major Surgical or Invasive Procedure:
biopsy of pelvic mass, percutaneous nephrostomy tube placement,
ureteral stent placement
History of Present Illness:
___ with suspected recurrence of stage IB FIGO grade 2
endometrial adenocarcinoma who presents to the ED with complaint
of abdominal pain. Please see her oncology history below for
details regarding her initial presentation and treatment, as
well as re-presentation in ___, at which time a
vaginal cuff mass was detected on imaging.
She was seen in the ED on ___ with abdominal pain felt likely
combination of constipation and poor utilization of po pain
meds. Her pain was well controlled on a modified oral regimen
and she was discharged home. She was then seen in the office by
Dr. ___ on ___, where a perineal mass was biopsied and the
patient continued to report adequate pain control with oral
oxycodone and Tylenol. She presented this morning for her PET-CT
scan, which is summarized below and was concerning for
metastatic disease in her liver and mesentery. She reported
increased pain and was encouraged to use her prescribed
oxycodone, which did not improve her pain. She then presented to
the ED for evaluation.
She currently reports ___ left lower abdominal and flank pain
which is constant and worsens intermittently. She has had no
appetite and has not eaten since yesterday. She has had minimal
spotting only with wiping and denies any heavy bleeding. She
denies nausea, vomiting, chest pain or shortness of breath. She
has not had a bowel movement since ___ but continues to pass
flatus and has been taking Colace.
ROS otherwise negative except as noted in the HPI
Past Medical History:
Oncologic history:
- presented with postmenopausal spotting in ___.
Endometrial biopsy in ___ was nondiagnostic. Pelvic
ultrasound showed a markedly thickening endometrium. Dilatation
and curettage on ___ revealed grade 2 endometrioid
adenocarcinoma. On ___, robotic-assisted total
laparoscopic hysterectomy, bilateral salpingo-oophorectomy and
pelvic lymphadenectomy demonstrated a 2.5 cm grade 2
endometrioid adenocarcinoma with 96% myometrial invasion, no
lymphovascular invasion, 45 negative lymph nodes and negative
washings. She had adjuvant vaginal cuff radiation therapy to a
dose of 24 Gy in 6 fractions from ___ to ___.
- Presented to ___ on ___ with complaints
of lower abdominal pain and vaginal bleeding ×2 weeks. She also
complained of worsening constipation. A CT scan was performed
on ___ of the abdomen and pelvis as well as the chest.
This showed a 2 mm nodule in the chest which was indeterminate.
A 3.0 x 3.3 x 4.0 cm lobular partially enhancing mass was seen
superior to the vaginal fornix on the left. There was no
retroperitoneal or mesenteric lymphadenopathy there was no
pelvic or inguinal lymphadenopathy. There was mild to moderate
dilation of the left ureter likely secondary to mass-effect from
the mass at the vaginal fornix. No hydronephrosis was detected.
On physical exam a 2 cm firm friable mass was noted at 6:00 on
the perineum. There was a question of a small nodule at the
left apex.
Health Maintenance: Mammogram: ___, Colonoscopy: ___, Bone
Density: unsure, Routine follow up with PCP
___: G3P3, LMP: ___ years ago, No HRT Use, Last Pap Smear:
___, NIL, No H/O Fibroids, ovarian cysts or other GYN
infections/problems
PMH:
- Hypothyroidism
- Hypertension
- Hypercholesterolemia
- Depression
PSH:
- Tubal ligation
- D&C, hysteroscopy
- RA-TLH, BSO, pLND
Social History:
___
Family History:
no colon ca, no ovarian, uterine or breast cancer.
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision
clean/dry/intact, no rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 03:10PM GLUCOSE-98 UREA N-22* CREAT-1.1 SODIUM-137
POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20
___ 03:10PM WBC-10.2* RBC-4.05 HGB-12.3 HCT-36.1 MCV-89
MCH-30.4 MCHC-34.1 RDW-12.6 RDWSD-41.3
___ 03:10PM NEUTS-77.6* LYMPHS-13.6* MONOS-7.6 EOS-0.1*
BASOS-0.6 IM ___ AbsNeut-7.91* AbsLymp-1.38 AbsMono-0.77
AbsEos-0.01* AbsBaso-0.06
___ 03:10PM PLT COUNT-165
___ 03:01PM URINE HOURS-RANDOM
___ 03:01PM URINE UHOLD-HOLD
___ 03:01PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:01PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM
___ 03:01PM URINE RBC-50* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 03:01PM URINE MUCOUS-RARE
Brief Hospital Course:
Ms. ___ was admitted to the Gynecologic Oncology service for
management of her abdominal pain and suspected recurrence of
stage IB FIGO grade 2 endometrial adenocarcinoma. For her
abdominal pain she was given IV dilaudid and acetaminophen as
well as pyridium. On hospital day #1 she underwent ___
biopsy of her pelvic / vaginal cuff mass.
Regarding her malignant ureteral obstruction, her creatinine was
uptrending on hospital day 1 and she developed new onset
hematuria. She was seen by Urology who recommended placement of
left percutaneous nephrostomy tube and ureteral stent for relief
of malignant urinary obstruction. During the procedure, she
reportedly experience a 5 second asymptomatic asystole and
recovered without incident. Vital signs were normal and she
remained asymptomatic. EKG showed sinus tachycardia with
prolonged QTC. She was placed on telemetry for close cardiac
monitoring. UA and urine culture were negative for infection. By
hospital day #4 her creatinine had normalized to her baseline of
0.5 and her percutaneous nephrostomy tube was capped.
For her hypertension and hypothyroidism, her home medications
were continued.
On hospital day 4, she was tolerating a regular diet, pain was
controlled with oral medications, and she was discharged home in
stable condition with percutaneous nephrostomy tube in place and
outpatient follow-up as scheduled.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Malignant ureteral obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecologic oncology service. You have
recovered well, and the team feels that you are safe to be
discharged home. Please follow these instructions:
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
Nephrostomy Tube:
* You have been set up with a home nurse who will help you take
care of the nephrostomy tube.
* If you start experiencing flank/back pain and difficulty
urinating, please reconnect the tube to a bag with help from
your home nurse
* If you start experiencing a fever or any of the danger signs
listed below, please also reconnect the tube to a bag and either
call Dr. ___ (___) or go to the
emergency room for evaluation of an infection.
* You were prescribed oxybutynin to help with feeling urinary
urgency. You currently do not have insurance coverage until
___. Please call ___ Health to let them know to
backdate your previous insurance coverage for prescription
medication (should take ___ hours). Afterwards, you can go to
the pharmacy to fill this prescription. Please take as needed as
instructed. Oxybutynin may cause urinary retention,
constipation, and dry mouth.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor at ___ for:
* fever > 100.4
* 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
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
10631273-DS-2
| 10,631,273 | 28,907,179 |
DS
| 2 |
2158-01-08 00:00:00
|
2158-01-08 14:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Suicide attempt
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with unknown past medical
history
who presented to ___ with suicide attempt and
medication overdose.
Patient lives in a "transitional residential" setting and was
found by a neighbor with altered mental status, slurred speech.
Reportedly wrote a suicide note dated ___ and had taken all
of her clonidine, propranolol, gabapentin and buproprion with
prescriptions recently filled in ___. She additionally
drank ethanol. Unknown if she had taken any additional
medications. Unclear when ingestion occurred. She presented to
___ initially with a GCS of 15 with slurred
speech, but had quickly worsening mental status changes, was
subsequently intubated with etomidate and succinylcholine and
placed on propofol gtt with fentanyl bolus. She did not receive
any other medications. Her EKG had a QRS of 104.
Of note, she had all Rx filled in ___. She drank ethanol,
no report as to whether or not she took any other medications.
She arrived to ___ with GCS of 15 but slurring her
speech. Her mental status decreased and she was intubated with
etomidate and succinylcholine and place ___ gtt with
fentanyl bolus. SHe did not receive other medication. She had an
EKG with QRS of 104 but otherwise normal axis and intervals. She
had anegative head CT. She was transferred here because they
have no continuous EEG monitoring at ___.
EKG: SR @ 53, NA, NI, no ischemia. QRS 109, QTc 465
In the ED, initial vitals:
96.6 53 136/78 17 98% : vent settings AC Tidal volume 450, PEEP
5, FIO2 50%, RR 14
Labs were notable for: leukopenia WBC 3.3, normocytic anemia
10.9/33.0, plts 169, electrolytes moderately hemolyzed K 5.1,
bicarb 23, BUN 12, Cr 0.6. Mild transaminitis with AST 88, ALT
76, Alk phos 119, T bili 0.3.
Portable CXR showed Status post intubation with ETT 3.1 cm above
the carina. Interval development of mild interstitial edema,
less likely atypical infection. Clinical correlation
recommended.
Patient was evaluated by toxicology for polysubstance overdose
with resultant toxic encephalopathy and likely associated
cardiac toxicity including bradycardia and QRS prolongation.
With concern for propranolol toxicity (QRS >100ms and
bradycardia) start bicarb gtt at 150ml/hr, titrate to QRS <100;
trend LFTs, if rising treat with 21hr NAc protocol, isk of sz
with bupropion and propranolol. Seizure precautions for 24 hours
from time of ingestion given risk of seizures with bupropion and
propranolol, repeat VPA and ASA.
Patient was transitioned to fentanyl and midazolam for sedation,
2G IV calcium gluconate, and 200mg IV sodium bicarbonate,
started on sodium bicarb gtt at 150ml/hr.
Patient was then admitted the the ICU for treatment of
polysubstance overdose, propranolol toxicity.
On transfer, vitals were: 97.2 55 137/79 14 96%
On arrival to the MICU, the patient was intubated & sedated.
Past Medical History:
- Hypertension
- Depression, multiple hospitalizations at ___ for
suicide attempts
- COPD
- History of alcoholism
Social History:
___
Family History:
Father with depression, committed suicide
Physical Exam:
On admission:
GENERAL: Intubated and sedated.
HEENT: Sclera anicteric, pupils miotic but equal and reactive to
light bilaterally. MMM with somewhat large tongue with ETT in
place.
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. Mildly distended. Hypoactive bowel
sounds.
EXT: Warm, well perfused, 2+ pulses. No clubbing, cyanosis or
edema.
SKIN: Warm and dry without marked erythema or pallor.
NEURO: Unable to assess due to sedation.
On discharge:
Vitals: AVSS
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric, mildly injected
ENT: MMM, OP clear, some redness in the posterior pharynx
Cardiovasc: regular, full pulses, no edema
Resp: normal effort, no accessory muscle use
GI: soft, NT, ND, BS+
MSK: No significant kyphosis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Depressed appearing. Intermittently crying. Quite
pleasant
though.
GU: No foley
Pertinent Results:
On admission:
___ 11:45AM BLOOD WBC-3.3* RBC-3.42* Hgb-10.9* Hct-33.0*
MCV-97 MCH-31.9 MCHC-33.0 RDW-12.9 RDWSD-46.0 Plt ___
___ 11:45AM BLOOD Neuts-46.4 ___ Monos-7.8 Eos-3.3
Baso-0.6 Im ___ AbsNeut-1.54* AbsLymp-1.38 AbsMono-0.26
AbsEos-0.11 AbsBaso-0.02
___ 11:45AM BLOOD Plt ___
___ 03:02PM BLOOD ___ PTT-33.2 ___
___ 11:45AM BLOOD Glucose-117* UreaN-12 Creat-0.6 Na-135
K-5.1 Cl-103 HCO3-23 AnGap-14
___ 11:45AM BLOOD ALT-76* AST-88* AlkPhos-119* TotBili-0.3
___ 11:45AM BLOOD Lipase-25
___ 11:45AM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.8 Mg-2.1
___ 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:44AM BLOOD Type-ART PEEP-5 pO2-191* pCO2-47* pH-7.36
calTCO2-28 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
___ 04:19PM BLOOD ___ Temp-35.6 ___ Tidal V-460
PEEP-5 FiO2-30 pO2-61* pCO2-45 pH-7.48* calTCO2-34* Base XS-8
-ASSIST/CON Intubat-INTUBATED
___ 11:47AM BLOOD Lactate-0.9
EKG: sinus bradycardia 50, normal axis, QRS 102, QTc 495, t wave
flattening in II, V2, V3, no TWI or ST segment changes
Brief Hospital Course:
This is a ___ with COPD, HTN, depression, who presented after
high lethality suicide attempt via poly-drug ingestion
(propranolol, clonidine, gabapentin, and buproprion). Patient
has a strong personal and family history of depression and
suicide, with multiple past attempts. She was intubated for
airway protection and started on NAC for c/f APAP toxicity.
Patient also had bradycardia and prolonged QRS, likely ___
propranolol and clonidine overdose. She received calcium
gluconate and was started on bicarb gtt. She was also monitored
for seizures given bupropion overdose, which did not occur
during ICU admission. Patient was successfully extubated. APAP
level was negative and NAC was DC'd. Bicarb gtt was also DC'd
prior to transfer to floor. She is now significantly improved,
and medically clear for psychiatry transfer, though with some
mild URTI/viral symptoms that could also reflect a mild
withdrawal syndrome from her various medications.
# Toxic encephalopathy
# Suicide attempt
# Depression: As above. Had QTc prolongation initially but this
resolved with bicarb and time for metabolism. Repeat EKG on
floor showed normal QTc.
- Continued psychiatric care at psychiatric facility
- Holding psych meds
- Hydroxyzine PRN anxiety
# URT symptoms, headache: Most likely sequelae of intubation,
though could also have mild viral URTI or potentially a mild
drug withdrawal syndrome as all of her medications were
relatively abruptly discontinued for safety. Influenza was ruled
out by PCR swab.
- Continue ibuprofen PRN headache
- Continue saline spray and afrin spray PRN stuffy nose
- Continue Sudafed PRN stuffy nose
- Continue cepacol lozenges PRN sore throat
#Transaminitis: Likely secondary to multiple drug ingestions.
NAC was initially started due to c/f APAP toxicity but was
eventually discontinued given neg APAP level. LFTs were
downtrending during admission.
# Hypertension: Blood pressure within normal range
- Hold propranolol and clonidine for now, restart
anti-hypertensives as needed.
# COPD: Stable and mild at baseline. Continue albuterol inhaler.
# GERD: Continue PPI.
# Code status: Full code
> 30 minutes spent coordinating her discharge to psychiatric
facility
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Propranolol 20 mg PO TID
2. BuPROPion (Sustained Release) 100 mg PO BID
3. CloniDINE 0.1 mg PO TID
4. Gabapentin 300 mg PO TID
Discharge Medications:
1. Sodium Chloride Nasal ___ SPRY NU TID:PRN congestion
2. Pseudoephedrine 30 mg PO Q6H:PRN nasal stuffiness
3. Oxymetazoline 1 SPRY NU BID:PRN nasal stuffiness Duration: 3
Days
4. Omeprazole 40 mg PO DAILY
5. Ibuprofen 800 mg PO Q8H:PRN headache
6. HydrOXYzine 25 mg PO Q3H:PRN anxiety
7. Cepastat (Phenol) Lozenge 2 LOZ PO Q2H:PRN sore throat
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Suicide attempt by ingestion
Depression
URTI symptoms
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after a suicide attempt by drug
ingestion/overdose. You were admitted to the ICU after being
intubated to protect your airway. Your medications were held,
you were given IV fluids, IV barcarbonate, and N-acetylcysteine
for treatment of drug overdose. You improved with these
treatments. You had the breathing tube taken out and breathed
fine on your own thereafter. You did have some upper respiratory
tract symptoms with sore throat and headache and runny nose with
some muscle aches, and these were managed symptomatically. It
was also thought that some of these symptoms could have been
from suddenly stopping your various medications, almost like a
mild drug withdrawal. You were seen by the psychiatry team, who
recommended inpatient psychiatric stay.
Followup Instructions:
___
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2173-12-31 17:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest pain, Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx asthma, HTN, HLD, dHF, BPH, ___ disease,
unclear history of CAD (daughter denies) p/w chest pain and
chest congestion in the setting of recent URI x 2 weeks.
Patient was treated with doxycycline for PNA and prednisone
taper for asthma exacerbation 2 weeks ago. Has had ongoing
productive cough and was seen in ___ clinic today for routine
f/u. He reported substernal chest pain associated with cough
that was also exertional in nature. The patient is a poor
historian but reports having noticed the chest pain radiating to
the L previously. He reports the chest congestion has improved
with his cough but that he has also become more and more
dyspneic with exertion. His daughter reports that he becomes SOB
with walking from his bed to the door; previously was able to
walk blocks w/o DOE. Denies any PND. Daughter reports stable
orthopnea x ___ year.
In the ED, initial VS 98.2, 78, 122/67, 20, 97% on RA. Labs
notable for wnl Chem 7, nml Trop/CKMB, BNP 391. WBC 12.5 with
80.9 neuts. UA negative. ___ Trop negative. EKG showed STE
elevations in V1, V2, AVR; per Cardiology fellow, not c/w STEMI
criteria and changes improved on serial CXR. Per Cards, plan to
admit to ___ for expectant management. CXR showed LLL focal
opacity.
On the floor, initial VS 98.4, 162/69, 74, 20, 97% on RA.
Patient denied any active chest pain.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Asthma
___ disease
BPH
? CAD
HTN
HLD
Idiopathic thrombocytopenia
Social History:
___
Family History:
Uncles and father died of lung disease but did not smoke. No
history of early CAD/MI.
Physical Exam:
ADMISSION EXAM:
Vitals - VS 98.2, 78, 122/67, 20, 97% on RA
GENERAL: NAD
HEENT: NCAT, EOMI, MMM
Neck: no appreciable JVD
Cardiac: RRR, nml S1 and S2, II/VI systolic murmur best heard at
L sternal border, TTP of lower L sternal border and along
mid-clavicular L ribs
Abdomen: soft, NTND, normoactive BS
Extremities: 1+ pitting edema of BLE to mid-tibia
Neuro: grossly nonfocal, intermittently confused, moving all
extremities spontaneously
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
___ 04:10PM BLOOD WBC-12.5*# RBC-5.34 Hgb-16.4 Hct-46.6
MCV-87 MCH-30.7 MCHC-35.1* RDW-14.8 Plt ___
___ 04:10PM BLOOD Neuts-80.9* Lymphs-10.8* Monos-5.9
Eos-2.2 Baso-0.2
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-140* UreaN-18 Creat-1.0 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-14
___ 04:10PM BLOOD ALT-51* AST-25 CK(CPK)-26* AlkPhos-104
TotBili-1.1
___ 04:10PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-391
___ 04:10PM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.5 Mg-2.3
___ 04:10PM BLOOD Lactate-2.0
___ 04:10PM BLOOD Lipase-36
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
OTHER PERTINENT LABS:
___ 06:05AM BLOOD WBC-10.9 RBC-5.12 Hgb-16.0 Hct-44.2
MCV-86 MCH-31.2 MCHC-36.1* RDW-15.0 Plt Ct-96*
___ 06:05AM BLOOD ___ PTT-30.0 ___
___ 06:05AM BLOOD Glucose-84 UreaN-19 Creat-0.9 Na-140
K-3.7 Cl-103 HCO3-28 AnGap-13
___ 02:14AM BLOOD CK(CPK)-28*
___ 07:39PM BLOOD cTropnT-<0.01
___ 02:14AM BLOOD CK-MB-2 cTropnT-<0.01
IMAGING/STUDIES:
Chest XRay (___): Increased opacity at the left lung base,
probably consistent with increased volume loss superimposed on
chronic scarring and atelectasis, although an infectious process
is not excluded.
MICRO:
___ 4:10 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
Brief Hospital Course:
Mr. ___ is a ___ PMHx asthma, HTN, HLD, ?CAD, dCHF, BPH,
and ___ presenting with chest pain and cough in the
setting of recent URI, with negative troponins, and possible
consolidation on CXR.
ACTIVE ISSUES:
# Chest pain: The patient presented with the complaint of
substernal chest pain from ___'s office. Poor historian. ECG
performed in the ED with some ST changes, although not in the
distribution of coronary vessels, and some have been noted on
past ECGs. Troponins negative x 3, and BNP wnl. The pain was
reproducible on physical exam and is likely musculoskeletal,
possibly related to coughing. Echo on ___ was performed with
results pending. Pt was continued on his home metoprolol
tartrate 25mg po BID, aspirin 81 mg, and atorvastatin 80mg po
daily while inpatient.
# Community Acquired Pneumonia. Pt had a recent URI treated with
doxycycline as an outpatient. Reports that his cough has been
improving, although continues to have a leukocytosis up to 12.5
on admission. Chest XRay on admission with possible left lower
lobe infiltrate. This cough may be contributing to chest pain as
documented above. Started on levofloxacin 750mg po daily for a
seven day course for treatment of possible community acquired
pnuemonia.
# Thrombocytopenia: On presentation noted to have mild
thrombocytopenia with platelets of 106, which then trended down
to 96 on day of discharge. The patient has a known history of
ITP treated with steroids back in ___. Could also be related to
recent doxcycline use. Should be followed up on as outpatient.
CHRONIC ISSUES:
# Diastolic congestive heart failure: Stable. Continued on lasix
40 mg daily.
# Asthma: Stable during admission. Continued on albuterol as
needed and home flovent.
- Albuterol prn
- Continue home flovent
# ___. Stable. Continued on home carbidopa/levodopa
___ TID, and donepezil 5 mg daily.
# GERD. Stable. Continued on home omeprazole
# BPH. Stable. Continued on home finasteride 5 mg daily and
tamsulosin 0.4 mg daily.
***TRANSITIONAL ISSUES***
- Pt noted to be thrombocytopenic to 96 on the day of discharge.
___ be due to doxycycline and he has a history of known ITP back
in ___. This should be monitored as outpatient.
- ALT mildly elevated to 50. Should be followed-up as
outpatient.
- Follow-up final blood culture results (from ___
- Follow-up formal echo read results (from ___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Tamsulosin 0.4 mg PO QHS
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Finasteride 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Ranitidine 75 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Donepezil 5 mg PO QHS
9. Furosemide 40 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF ___ BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Donepezil 5 mg PO QHS
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Furosemide 40 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Ranitidine 75 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
RX *dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5
mL 5 mL by mouth every six hours Disp ___ Milliliter
Refills:*0
13. Levofloxacin 750 mg PO DAILY Duration: 6 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*6
Tablet Refills:*0
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 (One)
capsule nebulized four times a day Disp #*30 Ampule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Community acquired pneumonia; Musculoskelatal
chest pain
Secondary Diagnosis: Thrombocytopenia, hypertension, asthma,
Parkinsons disease
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
chest pain. You had an EKG in the emergency department which was
concerning for involvment of your heart, although these changes
have been seen on past EKGs. Blood tests were checked that
showed your pain was unlikely to be related to your heart. You
had a cough and a chest Xray showed you may have a pneumonia.
You were started on an antibiotic called Levofloxacin to treat
your for pneumonia.
Please take Levofloxacin for six more days (until ___.
Continue to use the Ipratropium-Albuterol Nebulizer therapy
every ___ every day for another 7 days. Also please
continue to take the Guaifenesin-Dextromethorphan medication
every six hours as needed for cough. Please called your primary
care provider ___ ___ to make a follow-up appointment.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
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2174-02-27 16:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Urinary retention, increased confusion, low grade temp of 100.4
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of asthma, HTN, HLD, dCHF, BPH, ___
disease w/ dementia, presents with urinary retention. At
baseline he is confused intermitantly but daughter reports he is
more confused now than usual.
Last night was up 10 times to try to urinate and he had small
amount of hematuria. He has a history of urinary retention and
was admitted in ___ had this before in ___ foley was placed
and he was sent home w the ___
Daughter reports her father had a fever overnight 100.4 , no
recent illness per daughter.
Past Medical History:
Asthma
___ disease
BPH
? CAD
HTN
HLD
Idiopathic thrombocytopenia
Social History:
___
Family History:
Uncles and father died of lung disease but did not smoke. No
history of early CAD/MI.
Physical Exam:
ADMISSION EXAM:
Vitals - 98 149/84 84 95%ra
GENERAL: NAD, mumbling in creole
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, non tender
EXTREMITIES: warm 1+ ___ edema
DISCHARGE EXAM:
Vitals: T: 98.0 BP: 149/84 P: 84 R:20 O2: 95%RA
General: Awake, masked facies, unable to verbally communicate
but can follow commands. Has tremor noted in the left hand.
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, JVP not elevated
Lungs: Anterior fields clear, w/o wheezes, rales, rhonchi
CV: RRR, 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, 1+ pitting edema. Cog-wheel rigidity
is appreciated.
Pertinent Results:
ADMISSION LABS:
___ 08:41PM cTropnT-<0.01
___ 07:15PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 05:48PM LACTATE-1.7
___ 02:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:45PM URINE RBC->182* WBC-17* BACTERIA-NONE
YEAST-NONE EPI-0
___ 02:26PM ___ PTT-33.7 ___
___ 01:59PM LACTATE-3.7*
___ 01:40PM GLUCOSE-142* UREA N-14 CREAT-1.4* SODIUM-140
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-21*
___ 01:40PM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-182* TOT
BILI-1.6*
___ 01:40PM LIPASE-29
___ 01:40PM cTropnT-<0.01
___ 01:40PM ALBUMIN-4.4 CALCIUM-9.5 PHOSPHATE-2.5*
MAGNESIUM-2.3
___ 01:40PM WBC-15.4*# RBC-5.65 HGB-17.3 HCT-49.4 MCV-87
MCH-30.7 MCHC-35.1* RDW-14.8
___ 01:40PM NEUTS-86.8* LYMPHS-7.0* MONOS-5.6 EOS-0.3
BASOS-0.2
___ 01:40PM PLT COUNT-120*
IMAGING:
Right Upper Quadrant Ultrasound ___: Cholelithiasis without
evidence of acute cholecystitis.
CT abdomen/pelvis ___:
1. No evidence of acute pathology within the abdomen and pelvis
to explain patient's pain.
2. Massively enlarged prostate with mildly thickened bladder
wall compatible with chronic bladder outlet obstruction.
3. Cholelithiasis.
4. Colonic diverticulosis without evidence of acute
diverticulitis.
5. Stable hepatic hemangioma, extrahepatic porto-hepatic vein
fistula, and hepatic cysts.
6. Stable renal cysts.
CT head ___: No evidence of acute intracranial process.
CXR ___: No acute cardiopulmonary process
EKG ___: Normal sinus rhythm. Left anterior hemiblock.
Non-specific ST-T wave changes. Lateral ST segment depressions.
Compared to the previous tracing of ___ segment
depressions are not as prominent on the current tracing.
MICRO:
URINE CULTURE (Final ___: NO GROWTH.
Blood culture pending at discharge from ___
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-9.0 RBC-4.72 Hgb-14.5 Hct-41.5 MCV-88
MCH-30.6 MCHC-34.8 RDW-15.2 Plt ___
___ 08:00AM BLOOD Glucose-105* UreaN-13 Creat-1.0 Na-143
K-3.3 Cl-105 HCO3-26 AnGap-15
___ 08:00AM BLOOD ALT-12 AST-18 AlkPhos-125 TotBili-1.2
Brief Hospital Course:
Mr. ___ is a ___ man with ___ Disease, Benign
Prostatic Hypertrophy (BPH), and diastolic heart failure who
presented with urinary retention, increased confusion, and
history of low grade temp (100.4), found to have acute on
chronic bladder outlet obstruction as well as possible urinary
tract infection.
ACTIVE ISSUES:
#Urinary Retention: In the ED, bedside bladder ultrasound showed
800cc of urine. A foley catheter was placed, which drained clear
urine. Most likely etiology is BPH, given CT abdomen showed
massive prostate enlargement and chronic bladder outlet
obstruction. Outpatient medications for BPH are: finasteride 5mg
and tamsulosin 0.4mg daily. He was discharged with foley in
place and plans to follow-up with outpatient urologist for
voiding trial.
#Urinary Tract Infection: Began empiric treatment with IV
ceftriaxone on admission for urinary tract infection (versus
prostatitis; although rectal exam was declined by patient's
daughter/healthcare proxy), given 17 WBCs on urinalysis,
increased confusion, WBC on admission of 15.4K, and recent
history of low grade temperature. Antibiotics were switched to
Bactrim on ___. Subsequent urine culture showed no growth.
Vital signs stable throughout hospitalization, without
documented fever. Opted to complete course for urinary tract
infection with 7 day course of Bactrim, given his concerning
presentation.
RESOLVED ISSUES:
#Acute Kidney Injury: On admission, Cr was 1.4, baseline is 0.9.
Etiology most likely post-renal from obstruction related to
severe BPH. Improved with foley placement, back down to 1.0 at
the time of discharge.
#Cholelithiasis: In the ED, alk phos 182 and tbili 1.6 w/ normal
AST and ALT, suggestive of cholestatic picture. RUQ U/S showed
cholelithiasis w/o evidence of acute cholecystitis. LFTs at
discharge were ALT 12, AST 18, alk phos 125 and Tbili 1.2. Most
likely etiology is a passed stone.
CHRONIC ISSUES:
___ with dementia: On carbidopa/levodopa ___ TID and
donepezil 5 mg daily.
#Asthma: Stable. On flovent, and albuterol PRN.
#Diastolic congestive heart failure: On lasix 40 mg daily,
aspirin, and metoprolol tartrate 25mg BID.
#Hyperlipidemia: On Atorvastatin 80mg daily.
TRANSITIONAL ISSUES:
[] Final day of Bactrim is ___ for total of 7 day course
[] Patient discharged with Foley in place- will see urology as
an outpatient for voiding trial
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Donepezil 5 mg PO QHS
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Furosemide 40 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Ranitidine 75 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Donepezil 5 mg PO QHS
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Furosemide 40 mg PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
9. Metoprolol Tartrate 25 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. Ranitidine 75 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
Last day ___
14. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Urinary Retention
Urinary Tract Infection
SECONDARY DIAGNOSIS:
___ disease with dementia
Benign Prostatic Hypertrophy
Asthma
Hypertension
Diastolic Heart Failure
Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were unable to fully
empty your bladder of urine. When you arrived at the emergency
room, we did an imaging test that showed you had nearly 1 liter
of urine in your bladder. To treat this urinary retention, a
Foley catheter was placed in your bladder to drain the urine. We
also started you on antibiotics to treat a urinary tract
infection.
Please keep the Foley in place until you see your urologist, Dr.
___. Please continue taking the antibiotics for 4 more days (end
date ___.
If you continue to have urinary retention, or any other symptoms
- such as pain with urination, back pain, increased confusion,
fever - please call your doctor or come back to the emergency
department.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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2174-05-05 21:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
fever and altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The history is obtained from the daughter and chart review due
to patient's altered mental status.
Mr. ___ is a ___ year old male with history of ___
with severe Demntia, Asthma, HTN, BPH with chronic indwelling
foley, and Idiopathic thrombocytopenia who presents with altered
mental status and fever.
Per daugther, the patient lives at home with her caring for him.
At baseline he spends most of the day in bed now, and can
transition from bed to char with help. He might take a walk
around the room with a walker rarely. He is demented and does
not have meaningful conversation at baseline; when he does speak
he is mostly recalling old memories or calling out names of kids
from back in ___. Most nights he is awake, confused and
trying to pull out his catheter.
The daugther noticed the patient becoming more somnolent over
the last day or two with decreased PO intake. Per the daugther,
this is similar to his previous UTIs. ___ visited today and
measure temperature to 102 and patient was brought by EMS. Per
EMS patient responsive to painful stimuli.
Vitals in the ED: 100.1 104 131/66 14 96% (Tmax 104.4 @ 1740)
Labs notable for: WBC 7.4 with 84.5%N. BUN/Cr ___. Lactate
3.2->1.7 with 1L NS. UA with 120 WBC, Lg Leuks, Positive Nitrate
Patient given: Tylenol ___. 1L NS. Cefepime 2gm IV.
Vitals prior to transfer: 99.1 100 106/54 24 94% RA
On the floor, patient responsive only to pain.
Past Medical History:
Asthma
___ disease
BPH
? CAD
HTN
HLD
Idiopathic thrombocytopenia
Social History:
___
Family History:
Uncles and father died of lung disease but did not smoke. No
history of early CAD/MI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals - 97.9 118/58 93 18 96%RA
GENERAL: lying in bed, responsive only to pain.
HEENT: anicteric sclera, pink conjunctiva, dry, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: trace expiratory wheezing
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities to pain
GU: foley in place
NEURO: moving all extremities to positive doll eyes, PERRL,
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 98.3 143/64 79 24 100RA
I/O over 24H: ___
GENERAL: awake, in NAD
HEENT: No JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Clear to auscultation anteriorly. mild retraction of
accessory muscles
ABDOMEN: Nondistended, +BS, nontender in all quadrants
EXTREMITIES: Warm, well perfused. no cyanosis, clubbing. Trace
non-pitting edema in Lt foot (dependent foot).
NEURO: +Pill rolling tremor of LUE, cogwheeling rigidity.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:40PM BLOOD WBC-7.4 RBC-4.88 Hgb-14.5 Hct-43.1 MCV-88
MCH-29.6 MCHC-33.6 RDW-14.2 Plt Ct-73___ 05:40PM BLOOD Neuts-84.5* Lymphs-8.8* Monos-6.3 Eos-0.3
Baso-0.2
___ 05:40PM BLOOD Plt Smr-VERY LOW Plt Ct-73*
___ 07:24AM BLOOD ___ PTT-34.7 ___
___ 05:40PM BLOOD Glucose-137* UreaN-25* Creat-1.3* Na-134
K-6.1* Cl-99 HCO3-23 AnGap-18
___ 05:51PM BLOOD Lactate-3.2* K-4.5
___ 10:10PM BLOOD Lactate-1.7
___ 05:40PM BLOOD ALT-14 AST-51* AlkPhos-91 TotBili-0.7
___ 05:40PM BLOOD Lipase-23
___ 05:40PM BLOOD Albumin-2.9* Calcium-8.4 Phos-2.6* Mg-2.2
___ 05:40PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 05:40PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:40PM URINE RBC->182* WBC-120* Bacteri-MOD Yeast-NONE
Epi-0
MICRO:
======
___ 12:34 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/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------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
IMAGES/STUDIES:
===============
___ CXR:
Mediastinal contours similar to ___ image from ___
the aorta is tortuous. Subtle bibasilar opacity most likely
represents atelectasis but early infection or aspiration not
excluded. No pleural effusion or
pneumothorax. The cardiac silhouette is top-normal to mildly
enlarged.
___ CT head:
No acute intracranial process.
___ CXR:
In comparison with the study of ___, there is little
overall change in the cardio mediastinal silhouette. Bibasilar
opacifications again are
consistent with atelectasis, though in the appropriate clinical
setting
superimposed pneumonia would have to be considered. Poor
definition of mildly dilated interstitial markings is consistent
with elevated pulmonary venous pressure.
___ CXR:
There is a small left pleural effusion with volume loss in the
left lower
lung. This is increased compared to the study from ___ days prior
there
continues to be mild pulmonary vascular redistribution
IMPRESSION:
Fluid overload. An underlying infectious infiltrate, vertically
on the left lower lobe cannot be excluded
DISCHARGE LABS:
===============
___ 07:12AM BLOOD WBC-6.6 RBC-4.29* Hgb-12.8* Hct-36.8*
MCV-86 MCH-29.8 MCHC-34.7 RDW-14.1 Plt ___
___ 07:12AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-29 AnGap-10
___ 07:12AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
Brief Hospital Course:
Patient is a ___ with ___ disease, BPH with chronic
indwelling foley who presented to ___ with increased
somnolence and fever, found to hvae urosepsis. Patient was
started on ceftriaxone, urine culture grew E. coli susceptible
to ceftriaxone. As mental status improved, patient was
transitioned to cefpodoxime.
Hospital course was complicated by tachypnea and hypernatremia.
Patient was given D5W for hypernatremia, likely secondary to
poor PO intake and insensible losses.
Tachypnea was likely secondary to known asthma and tenuous
volume status. Patient was continued on home albuterol and
ipratropium nebulizers. Symbicort MDI was added to regimen on
discharge. Home furosemide initially held due to volume
depletion, discharged on decreased dose of 20mg daily from 40mg
daily.
BRIEF HOSPITAL COURSE:
# Urosepsis: Patient has chronic indwelling foley due to BPH. He
met SIRS criteria on presentation with tachycardia. Urine
culture grew E coli susceptible to ceftriaxone. The patient was
treated with ceftriaxone and was switched to cefpodoxime as
mental status improved. Patient completed 7 day course of
antibiotic therapy.
# Tachypnea: Likely due to both underlying asthma as well as
volume overload as home diuretics were initially held as he was
volume resuscitated in the setting of sepsis. He was given
albuterol and ipratropium nebs. CXR showed left pleural effusion
and patient was treated with IV lasix and transitioned to
decreased dose of home furosemide of 20mg daily form 40mg daily.
He was also started on symbicort on discharge and was continued
on home flovent.
___ with dementia: Continued on home carbidopa/levodopa
___ TID and donepezil 5 mg daily. While patient's mental
status improved to baseline during hospitalization, family felt
that patient was significantly weaker than prior to
presentation. He was evaluated by ___ who recommended home ___
lift. Arrangements were made for patient to have hospital bed
and ___ lift delivered home.
# Diastolic congestive heart failure: patient continued on ASA
81mg. Metoprolol tartrate 25mg BID was held during admission in
context of sepsis and was restarted on discharge. Home
furosemide dose was decreased to 20mg daily as detailed above.
TRANSITIONAL ISSUES:
====================
- discharge weight: 63.5kg
- follow up with urology
- follow up with PCP ___. Please check chem-7 at PCP follow
up appointment.
- at follow up, consider rechecking UA/UCx to consider
continuing antibiotic treatment
- home furosemide decreased to 20mg daily. Follow up with
primary care doctor to consider dose adjustment.
- symbicort MDI added to asthma regimen
- discontinued tamsulosin given presence of foley
- discontinued ranitidine given patient also on PPI. Omeprazole
replaced with lansoprazole dissolving tabs
- consider discontinuing atorvastatin 80mg daily
- Emergency Contact: ___ (daughter): ___
- Code: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Donepezil 5 mg PO QHS
4. Finasteride 5 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Ranitidine 75 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. walker 1 walker miscellaneous daily
11. Aspirin 81 mg PO DAILY
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/sob
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/sob
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Donepezil 5 mg PO QHS
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
10. walker 1 walker miscellaneous daily
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation
2 puffs INH twice daily Disp #*1 Inhaler Refills:*0
12. Metoprolol Tartrate 25 mg PO BID
13. durable medical equipment
hospital bed
ICD9 332
14. Benzonatate 100 mg PO Q8H:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*25 Capsule Refills:*0
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
16. ___ medical equipment
___ lift
ICD9: 332
17. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Outpatient Lab Work
ICD9 ___
chem 7
Dr. ___: ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
urosepsis due to urinary tract infection
asthma
Secondary:
benign prostatic hypertrophy with chronic indwelling foley
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with tiredness and fevers. You were
found to have a urinary tract infection. Your symptoms improved
with antibiotics for your infection.
While you were here, you also had a little trouble breathing due
to your asthma. We started you on another inhaler called
Symbicort. You should continue to take this in addition to your
ipratropium and albuterol nebulizers. We also decreased your
dose of furosemide to 20mg daily.
Because of your frequent hospitalizations, we recommend you
speak with your primary care physician regarding your wishes in
terms future hospitalizations.
Please take your medications as prescribed and follow up with
your doctors as directed.
Please weigh yourself daily. Call your primary care doctor if
your weight changes by 2 pounds to consider adjusting the dose
of your furosemide.
It has been a pleasure taking care of you and we wish you all
the best.
Your ___ Care Team
Followup Instructions:
___
|
10631298-DS-19
| 10,631,298 | 25,690,475 |
DS
| 19 |
2175-02-25 00:00:00
|
2175-02-28 11:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Abdominal Pain, Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o. ___ speaking man and with multiple
medical problems most notable for ___ disease, dementia,
CAD, BPH complicated by urinary retention with chronic Foley
presenting with hematuria and abdominal pain. Per the patient's
family, the patient presents with confusion mildly above his
dementia baseline, which is nonfocal, minimal Foley output, and
moderate hematuria in the little urine that he is producing. His
family denies fever or chills, recent falls or trauma.
In the ED, initial vitals were: T 98.9 HR 76 BP 223/97 RR 20
SpO2 96% RA. Exam was most notable for confusion and focal
tenderness along suprapubic region. Bladder ultrasound was
notable for 400 cc in bladder,Foley bulb was visible in bladder,
no gross debris. Initial labs notable for leukocytosis to 21.1,
lactate 5.0. UA notable for hematuria otherwise bland. CXR
demonstrated a retrocardiac opacity. Patient was given: 1L LR
and Ceftriaxone 1g IV x1 and Azithromycin 500 mg IV x1. VS on
transfer were: T 97.7 HR 74 BP 145/71 RR 23 SpO2 96% RA.
On the floor, the patient was alert and oriented only to
person. Patient was not in pain and breathing comfortably. The
patient's daughter reports that the patient was complaining of
dyspnea, wheezing, and productive cough and was treated for CAP
with doxycycline last week for CAP and pred taper for asthma
exacerbation. The patient continues to have productive cough and
became more confused this AM. The patient's daughter also
reports oliguria and blood clots in Foley. The patient's
daughter otherwise denied any nausea, vomiting, diarrhea, or
chills.
Review of systems:
As per HPI, otherwise negative in detail
Past Medical History:
Asthma
___ disease
BPH
? CAD
HTN
HLD
Idiopathic thrombocytopenia
Social History:
___
Family History:
Uncles and father died of lung disease but did not smoke. No
history of early CAD/MI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.8 HR 71 BP 154/81 RR 16 SpO2 99% RA
General: Pleasant-appearing in NAD
HEENT: Sclera clear, MMM, no OP lesions
Neck: Supple, no cervical lymphadenopathy, no JVD
CV: RRR, no m,r,g. Normal S1 and S2
Lungs: No wheezing, decreased left sided breath sounds with
inspiratory crackles, no rhonci Abdomen: Suprapubic tenderness,
other soft, ND. Normoactive bowel sounds GU: Foley in place that
is clean, dry, and intact
Ext: Warm, well-perfused, no ___ edema Neuro: Resting tremors,
alert and oriented only to person, moving all extremities with
purpose
DISCHARGE EXAM:
Vitals: T 98.8 HR ___ BP 150s/07s RR 18 SpO2 96% RA
General: NAD, AOx1, rambling speech
HEENT: Sclera clear, MMM, no OP lesions
Neck: Supple, no cervical lymphadenopathy, no JVD
CV: RRR, no m/r/g. Normal S1 and S2
Lungs: No wheezing, decreased left sided breath sounds with
inspiratory crackles, no rhonci
Abdomen: no abdominal or suprapubic tenderness, NT/ND.
Normoactive bowel sounds
GU: Foley in place draining clear yellow urine
Ext: Warm, well-perfused, no ___ edema
Neuro: Resting bilaterally hand tremors, alert and oriented only
to person, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-21.1*# RBC-5.36 Hgb-16.2 Hct-47.4
MCV-88 MCH-30.2 MCHC-34.2 RDW-14.1 RDWSD-44.4 Plt ___
___ 08:00PM BLOOD Neuts-89.7* Lymphs-4.8* Monos-4.2*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-18.89*# AbsLymp-1.02*
AbsMono-0.88* AbsEos-0.00* AbsBaso-0.04
___ 08:00PM BLOOD ___ PTT-27.6 ___
___ 08:00PM BLOOD Glucose-109* UreaN-26* Creat-0.8 Na-142
K-4.2 Cl-101 HCO3-27 AnGap-18
___ 08:00PM BLOOD Calcium-9.7 Phos-4.2 Mg-2.3
___ 08:27PM BLOOD Lactate-5.0*
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-16.0* RBC-5.03 Hgb-15.0 Hct-45.0
MCV-90 MCH-29.8 MCHC-33.3 RDW-14.5 RDWSD-46.7* Plt ___
___ 07:20AM BLOOD ___ PTT-28.4 ___
___ 07:20AM BLOOD Glucose-71 UreaN-24* Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-28 AnGap-16
___ 07:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.1
___ 02:07AM BLOOD Lactate-1.9
IMAGING:
___ CXR: IMPRESSION:
In comparison with the study of ___, the retrocardiac
opacification has substantially cleared. This could represent
improved atelectasis or be a manifestation of a much deeper
inspiration. Mild atelectatic changes are seen at the left base
laterally. The hemidiaphragms are sharply seen at this time. No
vascular congestion or acute focal pneumonia.
___ CXR:
IMPRESSION:
Retrocardiac opacity may reflect sequela of atelectasis though
infectious
process is difficult to exclude. Possible small left pleural
effusion.
Brief Hospital Course:
___ year old ___ speaking man with a history
of ___ disease, dementia, CAD, BPH complicated by
urinary retention with chronic Foley presenting with AMS and
hematuria. Workup overall unremarkable. Patient was being
treated for CAP as an outpatient with 10 day prednisone and
doxycycline. He was transitioned to PO azithromycin and IV
ceftriaxone in house to complete the 10 day course which ended
on the day of discharge ___. Repeat CXR in house showed
improvement in his lung volumes and atelectasis and was without
consolidation. His Foley catheter was flushed with saline which
cleared his obstruction and hematuria. He continued to drain a
moderate volume of clear yellow urine during the rest of his
hospitalization.
After the above interventions, patient's mental status returned
to his most recent baseline per daughter. Daughter provided with
instruction to flush Foley catheter should an acute obstruction
occur in the future. Should this not clear the obstruction she
should reach out to his urologist for further instruction or
bring him to the nearest ED for evaluation.
TRANSITIONAL ISSUES:
====================
[] stop prednisone and doxycycline on discharge
[] f/u blood cultures and urine culture from inpatient stay
[] continued ___ services at discharge
[] Appointments: PCP ___ ___ at 11:30am; Urology on ___ at
1pm
[] should catheter become blocked in future, trial flushing with
sterile saline to see if obstruction relieved
[] started miralax on an as needed basis for constipation
lasting 3 or more days
CODE STATUS: FULL CODE
CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough/wheeze
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES QID dry
eyes
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Docusate Sodium 100 mg PO DAILY
8. Donepezil 5 mg PO QHS
9. Finasteride 5 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Furosemide 20 mg PO DAILY
12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
13. Metoprolol Tartrate 25 mg PO BID
14. Ascorbic Acid ___ mg PO BID
15. methenamine hippurate 1 gram oral BID
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs QID:prn shortness of breath/wheeze
17. Doxycycline Hyclate 100 mg PO Q12H
18. PredniSONE 10 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES QID dry
eyes
3. Ascorbic Acid ___ mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Docusate Sodium 100 mg PO DAILY
8. Donepezil 5 mg PO QHS
9. Finasteride 5 mg PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Metoprolol Tartrate 25 mg PO BID
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough/wheeze
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Furosemide 20 mg PO DAILY
15. methenamine hippurate 1 gram oral BID
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs QID:prn shortness of breath/wheeze
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation for >3
days
hold if having regular bowel movements. Only give if no bowel
movement in 3 or more days
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*30 Packet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Obstructed foley catheter
-Acute encephalopathy
-Community acquired pneumonia
SECONDARY DIAGNOSES:
- ___ disease
- BPH
- CAD
- Dementia
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for evaluation of your abdominal pain
and confusion. We determined that your symptoms were related to
an obstructed Foley catheter which caused some bloody urine. We
flushed this catheter and the obstruction and bleeding resolved.
We also did a chest x-ray during this admission which showed
that your pneumonia improved. You completed the rest of your
antibiotic course in the hospital and will not need to take
additional antibiotics at home.
Should your catheter become blocked again, try flushing the
catheter with sterile saline to see if this clears the blockage
and urine flows out into the bag. Should no urine come out,
please call Dr. ___ further instruction or go to the nearest
emergency department for further evaluation.
Please continue to take you home medications as prescribed. We
have continued your home ___ services. See below for follow up
appointments.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10631464-DS-2
| 10,631,464 | 27,075,115 |
DS
| 2 |
2166-10-14 00:00:00
|
2166-10-14 13:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol
Attending: ___.
Chief Complaint:
LLQ abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo w/prior ovarian cancer presents with LLQ pain. Pt
presented with same symptoms to ___ last week. She
was admitted for 3 days and received IV antibiotics for presumed
diverticulitis. However there was also concern for malignancy on
CT scan per report. Pt reports symptoms improved after discharge
for a few days but then returned. States she was not instructed
to take antibiotics on discharge. There is a possiblity that the
pt left AMA. She also reports nausea and constipation with last
BM 3 days ago, hard small pellets. Denies fever, emesis, no
blood PR.
In ED pt had repeat CT scan and was given morphine, toradol,
dilaudid and zofran.
On arrival to floor pt still with pain and nausea. No new
complaints.
ROS: + per HPI, 10 points reviewed and otherwise neg
Past Medical History:
Left Ovarian cancer
Social History:
___
Family History:
mother w/DM and HTN
Physical Exam:
VS: 97.9 111/62 55 18 99%ra
PAIN: 7
GEN: nad, lying in bed
CHEST: ctab
CV: rrr
ABD: soft, bowel sounds present tender left abdomen and pelvis
EXT: no e/c/c
NEURO: alert, follows commands, answering questions
appropriately
DISCHARGE EXAM:
Vitals: T 98.0 bp 99/62 HR 57 RR 18 SaO2 95 RA
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, mild LLQ tenderness without rebound or guarding,
bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
___ 02:37PM WBC-7.6 RBC-4.24 HGB-13.3 HCT-38.8 MCV-92
MCH-31.5 MCHC-34.3 RDW-12.7
___ 02:37PM NEUTS-61.2 ___ MONOS-3.3 EOS-1.6
BASOS-0.7
___ 02:37PM PLT COUNT-215
___ 02:37PM GLUCOSE-115* UREA N-14 CREAT-0.5 SODIUM-142
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
___ 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:10PM URINE UCG-NEGATIVE
.
CT abdomen and Pelvis ___ PRELIMINARY REPORT:
No acute pathology within the abdomen or pelvis. No evidence of
diverticulitis. Equivocal bowel wall thickening at the junction
of the
sigmoid and descending colon is present, for which a followup
colonoscopy is recommended.
.
Brief Hospital Course:
The patient's abdominal pain developed more strongly when she
did not have a bowel movement for 3 days. After the oral
contrast with CT and the bowel regimen she was on, she had ___
episodes of loose stools and reported relief of her pain. Her
CT did show fullness of stool. Since she had no radiographic
evidence of diverticulitis, fever, or leukocytosis,
diverticulitis was ruled-out. I discussed her case with the
on-call GI fellow who agreed that constipation was the most
likely diagnosis and that urgent colonoscopy was not indicated.
I had a full discussion with the patient about whether this
would require future stay or close watching as an outpatient.
She agreed that it would be best to try the bowel regimen and to
report to her doctor if she developed bloody stools, vaginal
bleeding, unexplained weight loss, fevers, or shaking chills.
She prefered to arrange a colonoscopy with her outpatient MD
rather than through ___.
.
The final report of her CT scan will need to be followed-up.
She will need a colonoscopy to determine whether the borderline
bowel thickening is of any significance.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Naproxen 500 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*5
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [GentleLax] 17 gram/dose 1 dose by
mouth daily Disp #*30 Pack Refills:*5
5. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 pill by mouth twice a day Disp
#*60 Capsule Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain secondary to constipation
question of bowel wall thickening on CT scan
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 that is likely related to
constipation based on your CT scan and the fact that it imrpved
after you had bowel movements
Followup Instructions:
___
|
10631509-DS-19
| 10,631,509 | 23,417,083 |
DS
| 19 |
2161-05-01 00:00:00
|
2161-05-01 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ (DOB ___ ___ year old female with h/o
RA, chronic pain, history of drug abuse now on methadone, h/o
hypoglycemia who presents as a transfer from ___ with
respiratory then cardiac arrest with unclear inciting factor.
Per the ___ report on transfer , the patient's mother had a
cardiac arrest earlier ___ the day. On the way to the hospital
from home, the patient was reportedly hyperventilating and
panicking en route, then became pulseless and unresponsive just
as she arrived to the ___.
Per report, on arrival to the ___ the patient was
asystolic. CPR was initiated and they obtained ROSC after one
round of compressions and one dose of epinephrine. She was
intubated. Subsequently, propofol was started and she became
mildly hypotensive but reportedly any decrease ___ propofol by
paramedics caused patient to wake up. Levophed was initiated at
that time. ECG at ___ showed SR on EKG. ___ the ___, she had a
large amount of diarrhea.
Of note, the patient was last admitted to ___ ___ ___ for
multidrug use and hypoglycemia which resulted ___ multiorgan
failure with liver failure, rhabdomyolysis with renal failure
requiring intermittent HD for a short period of time, and
NSTEMI, all resolved since discharge. She was admitted to ___
___ from ___ through ___ for a pneumonia and COPD
exacerbation, sent home on inhalers and prednisone 60 mg with
plan for taper to end on ___
On arrival to the ___ ___,
Exam notable for - pupils are constricted minimally reactive
- copious diarrhea.
- Cardiac RRR
initial VS: T 100.4 68 117/89 18 100% RA
Labs significant for: Carboxyhemoglobin 5.5 (normal), positive
urine methadone, tox screen otherwise wnl, negative UA, WBC 11.6
(CBC otherwise wnl), ALT 73, AST 120, AP 163, Tb 0.3, Alb 3.4,
chemistry wnl (creatinine 0.9), Troponin 0.11, lactate 2.6, ABG
7.44, pCO2 37, PO2 176, HCO3 26
Patient was given: Propofol (switched to midazolam), Levophed
(now discontinued), fentanyl drip, cefepime 2 g.
Imaging notable for: CXR: ETT 1.2 cm above the carina,
moderate pulmonary edema, CTA chest pending, CT head pending
ECG with TWI ___ AVL otherwise unremarkable, ___ of 468.
Consults: Post arrest team, who recommended:
1. stopping propofol and assessing if following commands
2. If not following commands, then would do TTM - please obtain
temperature and can text temp to Dr. ___ at ___ to
determine target temp
3. check ABG w lactate - wean oxygen to keep sat > 94% and pCO2
generally between 35-45
4. will obtain EEG ___ the ICU
5. Seek underlying cause
Cardiology was also consulted, recommendations pending.
Decision was made to admit to the MICU for further management.
VS prior to transfer: 71 147/107 22 100% Intubation
On arrival to the unit, the patient was intubated and opening
eyes but not following commands off of sedation. Her blood
glucose was 53.
Past Medical History:
- RA
- chronic pain
- drug use
- ETOH use
Social History:
___
Family History:
Reviewed, and non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: T 99.5 HR 72 BP 150/96 on Levophed RR 22 SpO2 100%
(intubated)
GENERAL: Intubated, still sedated. Opening eyes to painful
stimuli but not following commands
HEENT: Sclera anicteric, MMM, poor dentition
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally anteriorly, 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: NO obvious lesions. Warm, dry, intact
NEURO: Intubated, sedated. Withdrawing to painful stimuli,
DISCHARGE PHYSICAL EXAM:
========================
98.8PO 108/67 HR67 RR20 95% Ra
GENERAL: NAD
HEENT: Sclera anicteric, MMM, poor dentition
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops, pain with palpation of chest
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: NO obvious lesions. Warm, dry, intact
NEURO: AOX3, CN ___ intact, ___ strength ___ ___, gait not
assessed
Access: RIJ, pIV
Pertinent Results:
ADMISSION LABS
=================
___ 06:22AM BLOOD WBC-11.6* RBC-4.22 Hgb-12.4 Hct-41.3
MCV-98 MCH-29.4 MCHC-30.0* RDW-15.9* RDWSD-57.2* Plt ___
___ 06:22AM BLOOD Neuts-79.6* Lymphs-12.4* Monos-6.1
Eos-1.1 Baso-0.2 Im ___ AbsNeut-9.21* AbsLymp-1.44
AbsMono-0.71 AbsEos-0.13 AbsBaso-0.02
___ 06:22AM BLOOD Plt ___
___ 06:22AM BLOOD ___ PTT-25.5 ___
___ 06:22AM BLOOD Glucose-104* UreaN-15 Creat-0.9 Na-147
K-4.1 Cl-108 HCO3-23 AnGap-16
___ 06:22AM BLOOD ALT-73* AST-120* AlkPhos-163* TotBili-0.3
___ 06:22AM BLOOD cTropnT-0.11*
___ 04:20PM BLOOD CK-MB-8 cTropnT-0.04*
___ 06:22AM BLOOD Albumin-3.4* Calcium-7.4* Phos-4.7*
Mg-2.3
___ 06:22AM BLOOD Triglyc-95
___ 06:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:36AM BLOOD ___ pO2-28* pCO2-91* pH-7.16*
calTCO2-34* Base XS-0
___ 08:30AM BLOOD Type-ART pO2-176* pCO2-37 pH-7.44
calTCO2-26 Base XS-1
___ 06:36AM BLOOD Lactate-2.6*
___ 04:32PM BLOOD Lactate-1.2
___ 06:36AM BLOOD O2 Sat-33 ___ MetHgb-0
___ 08:30AM BLOOD O2 Sat-98
DISCHARGE LABS
===============
___ 05:15AM BLOOD WBC-4.9 RBC-3.32* Hgb-9.9* Hct-31.1*
MCV-94 MCH-29.8 MCHC-31.8* RDW-14.7 RDWSD-51.0* Plt ___
___ 05:15AM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-140
K-4.9 Cl-102 HCO3-28 AnGap-10
___ 05:15AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8
IMAGING
==========
___ ECHO
CONCLUSIONS
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis with near akinesis of the inferior
wall. Systolic function of apical segments is relatively
preserved (quantitative biplane LVEF = 33%). The estimated
cardiac index is depressed (<2.0L/min/m2). No masses or thrombi
are seen ___ the left ventricle. Right ventricular chamber size
is normal with mild global free wall hypokinesis and mild
dyskinesis of the apical free wall. 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. Moderate (2+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
and global systolic dysfunction ___ a pattern most c/w a
non-ischemic cardiomopathy. Right ventricular free wall
hypokinesis. Moderate mitral regurgitation.
___ CXR
1. Endotracheal tube terminates 1.2 cm above the carina.
Recommend
retraction.
2. Moderate pulmonary edema.
+ ___ CTA Chest
1. Slightly low lying endotracheal tube terminating 1.7 cm above
the carina.
Endogastric tube positioned appropriately.
2. No aortic dissection or central pulmonary embolism.
3. Bilateral lower lobe consolidation likely the sequelae of
aspiration.
4. Background emphysema.
5. Mild cardiomegaly.
6. No traumatic lung injury.
+ ___ CT Head
1. No acute hemorrhage or large territorial infarct.
2. Mild aerosolized secretions ___ the left sphenoid sinus,
suggestive of
paranasal sinus disease.
+ ___ ECHO
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function (3D LVEF = 61 %). The estimated cardiac index
is normal (>=2.5L/min/m2). 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. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild mitral regurgitation. Mild pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function has improved/ now normal and the
severity of mitral regurgitation is now reduced. The estimated
PA systolic pressure is now slightly higher.
+ pMIBI ___
1. Severe fixed perfusion defect involving the distal anterior
wall
with associated hypokinesis. 2. Mild left ventricular
enlargement with normal systolic function. EF = 61%.
MICRO
============
___ 3:32 am BLOOD CULTURE Source: Line-rcvl.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:21 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 3:01 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 3:38 am BLOOD CULTURE Source: Line-cvl.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:46 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
__________________________________________________________
___ 6:22 am BLOOD CULTURE
Blood Culture, Routine: negative
__________________________________________________________
___ 6:12 am BLOOD CULTURE
Blood Culture, Routine: negative
__________________________________________________________
___ 6:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ female with a history of rheumatoid
arthritis, chronic pain, history of drug abuse now on methadone,
history of hypoglycemia who presents as a transfer from ___
___ with respiratory then cardiac arrest with unclear
inciting factor. She required intubation but was soon after
extubated and transferred to the medicine floor for continued
evaluation of her cardiac arrest and treatment of her pneumonia.
#Hypercarbic respiratory failure c/b ?PEA arrest:
The etiology of the patient's respiratory arrest is unclear but
was thought to be due to breath stacking ___ the setting of
anxiety from her mother's cardiac arrest vs Takotsubo
cardiomyopathy (had LV dysfunction). Patient was ___ the
ambulance with her mother who apparently suffered a cardiac
arrest. While ___ the ambulance, patient was apparently noted to
be tachypneic, appeared to look unwell, and then had an apparent
respiratory arrest ___ the ambulance. She was intubated. There
was a question of lost pulse and so received 1 round chest
compressions (no shocks, given 1x epi, no rhythm strip available
for review to confirm PEA). ROSC obtained prior to arrival.
Notably was not hypoxemic. No toxin was identified ___ tox screen
including send out for cyanide. Mother's cardiac arrest the same
day was due to hemorrhagic shock, so unlikely that they have
co-ingestions/exposures. CTA was negative for pulmonary
embolism. Cardiology was consulted given unclear nature of
cardiac arrest. TTE showed initially reduced EF which raised the
concern for Takutsubo CM; notably, TTE without restriction or
tamponade. pMIBI was performed which showed a fixed perfusion
defect but no reversible change. Patient underwent targeted
temperature and was rewarmed ___ with improvement ___ mental
status. EEG per post arrest protocol showed evidence of moderate
encephalopathy, though likely ___ the setting of sedatives while
she was intubated. She was extubated on ___ and quickly
weaned to room air. Subsequent TTE showed recovery of reduced
EF. She was discharged with plan for close follow up.
#CAD: new diagnosis suggested by positive pMIBI done ___ the
setting of cardiac arrest; pMIBI shows irreversible ischemic
defect ___ anterior wall. Notably patient is on asa 81,
lisinopril, and BB at home but was not on statin, which was
initiated during hospital course. She is recommended to
establish care with cardiology after discharge.
# MSSA pneumonia:
The patient was found to have a fever to 100.4 ___ the ___. She
had a recent admission ___ ___ (discharged ___ for a COPD
exacerbation secondary to pneumonia and recently completed
course of ceftriaxone to cefpodoxime for 7 days along with oral
steroids, and home inhalers. CT showed signs concerning for
bilateral aspiration pneumonia. She was given Vancomycin and
Ceftriaxone (___-) for 7 day course. Sputum culture grew
methicillin sensitive Staphylococcus aureus, so the patient was
narrowed to ceftezolin to complete 7 day course.
#HFrEF: resolved
Patient had an echo on admission with ejection fraction of 33%
and findings consistent with nonischemic cardiomyopathy. Her
last ejection fraction was normal ___ ___. Decreased
ejection fraction likely ___ the setting of stress induced
cardiomyopathy. Troponin was 0.11 on admission but down-trended
to 0.04. EKGs without ischemic changes. She was restarted on her
home Carvedelol, lisinopril, and a reduced dose of home imdur.
She continued her aspirin 81 mg daily. Follow up TTE showed
resolution of reduced ejection fraction.
# Hypoglycemia:
Was briefly hypoglycemic during hospital course likely due to
poor p.o. intake and increased metabolism ___ the setting of
infection. Also some evidence that methadone may cause
hypoglycemia.
# Transaminitis:
She had elevated LFTs on admission that down trended throughout
hospitalization. Etiology likely from decreased perfusion ___ the
setting of cardiac arrest.
# History of opiate abuse:
Due to initial concern for ___ prolonging medications per
toxicology, the patient's home methadone dose was decreased to
90 mg p.o. twice daily. After the patient remained stable, her
methadone dose was slowly increased back to outpatient dosing.
Note for PCP to monitor ___ closely was added.
# Depression:
She was continued on sertraline 25 mg daily
# Substance abuse:
# Loss of family member:
Mother passed away ___ ICU following cardiac arrest on same day
as patient arrested. Social work consulted. Mother's funeral is
on ___.
# Hypertension:
We held home antihypertensives initially given her infection and
arrest but resumed her carvediol, lisinopril, and reduced dose
of imdur.
# Rheumatoid arthritis:
We held her home Enbrel while inpatient.
#Polypharmacy:
Patient taking benzonatate and loperamide which were
discontinued due to concern for long ___.
# Vit D Deficiency:
Holding home vitamin D
TRANSITIONAL ISSUES:
======================
[ ] Please monitor ___ as outpatient
[ ] Methadone dose upon discharge was 105mg daily, please adjust
as necessary
[ ] Not immune to Hepatitis B based on serologies. Recommend
initiation of vaccines series as outpatient
[ ] Recommend outpatient PFTs for evaluation of possible COPD
[ ] Last dose of morphine was 15mg PO given ___ 22:00
NEW medications:
- Tylenol ___ po q8h - sternal pain from chest compressions
- gabapenting 300mg po qhs - chronic pain
- Lidocaine 5% patch qam - for pain
- Atorvastatin 40mg qhs - to reduce risk of heart attack
CHANGED medications:
- Isosorbide Mononitrate ER 30mg daily (decreased from 90mg)
STOPPED/HELD medications:
- Loperamide 2mg po bid:prn - held d/t concern ___
# Communication: Husband ___ ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
2. Methadone (Oral Solution) 2 mg/1 mL 105 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Benzonatate 100 mg PO TID
11. Sertraline 25 mg PO DAILY
12. Ranitidine 150 mg PO BID
13. LOPERamide 2 mg PO BID:PRN loose stool
14. Lisinopril 10 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Gabapentin 300 mg PO QHS for pain
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Keep on 12 hours at a time once a day Disp
#*15 Patch Refills:*0
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Benzonatate 100 mg PO TID
8. Carvedilol 25 mg PO BID
9. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
11. FoLIC Acid 1 mg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. Methadone (Oral Solution) 2 mg/1 mL 105 mg PO DAILY
14. Ranitidine 150 mg PO BID
15. Sertraline 25 mg PO DAILY
16. Thiamine 100 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Vitamin D ___ UNIT PO 1X/WEEK (MO)
19. HELD- LOPERamide 2 mg PO BID:PRN loose stool This
medication was held. Do not restart LOPERamide until directed by
your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Respiratory arrest
Cardiac arrest
Coronary artery disease with positive pMIBI
Secondary Diagnosis:
Pneumonia
Heart failure with reduced ejection fraction with subsequent
recovery
Hypoglycemia
Transaminitis
Polysubstance abuse
Rheumatoid arthritis
Depression
Hypertension
Vitamin D deficiency
Polypharmacy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED?
You were admitted because your heart stopped beating and you
were having trouble breathing.
WHAT WAS DONE WHILE I WAS HERE?
We monitored your heart function and changed your medications to
help your heart beat. We treated you with antibiotics for an
infection ___ your lungs. We monitored your blood sugars to
ensure they were not low.
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10631674-DS-19
| 10,631,674 | 20,190,545 |
DS
| 19 |
2169-12-11 00:00:00
|
2169-12-11 08:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left Hemiarthroplasty
History of Present Illness:
___ s/p mechanical fall p/w L hip pain. Patient was bending over
to tie his shoes when he lost his balance and fell on his L
side. He denies HS/LOC. His daughter called ___. EMS brought him
directly to ___ ED. He denies other complaints other than L
hip pain.
Past Medical History:
prostate ca ___ years ago)
HTN
COPD?
recent GI bleed (BRBPR c/b anemia)
right knee replacement (___)
bph
Social History:
___
Family History:
Sister with ___ and migraines. Mother died at ___ from
CHF. Father died at ___ from unknown causes. Children are
healthy.
Physical Exam:
A&O, NAD, Pain controlled
AFVSS
LLE: incision c/d/i, with erythemia ___. SLIT
s/s/sp/dp/pt WWP
Pertinent Results:
Xray with hip left hip fracture and s/p hemiarthoplasty
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 hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left hemiarthoplasty which the patient tolerated well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable. Post-operatively, his HCT decrease which required
a blood transfusion. His HCT increase appropriately after the
transfusion. He remained asymptomic before and after the
transfusion.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is wbat in the left lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
atenolol 50', HCTZ 25', amlodipine 5', tamsulosin 0.4 qhs, iron
supplement
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc at bedtime Disp #*14
Syringe Refills:*0
5. Hydrochlorothiazide 25 mg PO DAILY
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth qh4 Disp #*80 Tablet
Refills:*0
7. Senna 8.6 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Discharge Instructions:
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Left Lower extremity weight bear as tolerated
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- Left Lower extremity weight bear as tolerated
Treatments Frequency:
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.
Followup Instructions:
___
|
10631674-DS-20
| 10,631,674 | 29,019,488 |
DS
| 20 |
2171-03-06 00:00:00
|
2171-03-08 14:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Foot pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx prostate Ca on Lupron, TIA, HTN, HLD, p/w DOE and
fatigue.
Reported 5 days of worsening exertional dyspnea and fatigue.
Associated with new swelling in the feet, L>R which is painful
in the feet. Denies f/c/n/v, chest pain, recent illness, hx
DVT/PE. Has never had these symptoms before.
In the ED, initial vital signs were: 99.3 75 141/57 16 96% RA
- Exam was notable for:
1. bibasilar crackles, breathing comfortably
2. swelling in the ___ up to ankle
- Labs were notable for: WBC 14.4. BUN/Cr 40/1.7. Trop
negative. DDimer 909. proBNP 7780. INR 1.3.
- Imaging:
CXR: Cardiomegaly and significant tortuosity of the descending
thoracic aorta. No acute cardiopulmonary process.
___: No evidence of deep venous thrombosis in the left lower
extremity veins.
- EKG: NSR with PVC. L axis. Prolonged PR interval. LAE.
- The patient was given: heparin gtt.
Vitals prior to transfer were: 98.1 71 135/69 26 96%.
On the floor, the patient relates he is normally a very active
___. He was having dinner with his son on ___, and when he
attempted to get up, he had excruciating pain of the feet, both
feet, starting at the toes and extending upward to the ankle.
There was no antecedent trauma. He has no history of gout, but
was concerned for this diagnosis, so spoke to his PCP who gave
him a short course of prednisone. This did not help. He spoke
again to his PCP who recommended presentation to the ED.
He has had no CP, SOB, DOE, abdominal pain, bloating,
indigestion. No fevers, chills, n/v, malaise. He does complain
that he feels his feet are swollen in addition to being painful
- he cannot fit into his home loafers. No change in weight,
appetite or mood.
Past Medical History:
Prostate Ca on Lupron
Osteoporosis
TIA
Aortic Insufficiency
HTN
HLD
Social History:
___
Family History:
Mother ___ ___ CONGESTIVE HEART FAILURE
Father Unknown ___ PNEUMONIA
Physical Exam:
ADMISSION EXAM
=====================
VITALS: 97.7 176/74 65 18 98%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: NCAT, pupils symmetric, sclera anicteric, clear OP, MMM
NECK: JVP 8cm
CARDIAC: RRR, no r/g/m
PULMONARY: CTAB
ABDOMEN: Soft NT ND +BS
EXTREMITIES: WWP, no overt edema. The L ankle may be more
swollen than the R but not markedly so. There is pain with
palpation of the plantar surface, particularly closer to the
toes, bilaterally.
SKIN: Without rash.
NEUROLOGIC: AAOx3, face symmetric, moving all four limbs on
command
DISCHARGE EXAM
=====================
VS - Tmax 98.0, HR 60-71, BP 153-176/71-81, RR 18, 96-98% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: NCAT, pupils symmetric, sclera anicteric, clear OP, MMM
NECK: JVP 8cm
CARDIAC: RRR, early diastolic murmur present at LSB
PULMONARY: CTAB, no rales
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: WWP, no pitting edema. The L ankle may be minimally
more swollen than right. There is pain with palpation of the
plantar surface, particularly closer to the toes, bilaterally.
SKIN: Without rash.
NEUROLOGIC: AAOx3, face symmetric, moving all four limbs equally
Pertinent Results:
LABS
=======================
___ 02:30PM BLOOD WBC-14.4*# RBC-3.59* Hgb-10.8* Hct-34.1*
MCV-95 MCH-30.1 MCHC-31.7* RDW-15.5 RDWSD-53.6* Plt ___
___ 02:30PM BLOOD Neuts-83.5* Lymphs-6.1* Monos-9.3
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.99* AbsLymp-0.88*
AbsMono-1.33* AbsEos-0.01* AbsBaso-0.03
___ 02:37PM BLOOD ___ PTT-22.4* ___
___ 02:30PM BLOOD Glucose-121* UreaN-40* Creat-1.7* Na-134
K-4.4 Cl-94* HCO3-29 AnGap-15
___ 02:30PM BLOOD proBNP-7780*
___ 02:30PM BLOOD cTropnT-<0.01
___ 12:52AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:48AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:48AM BLOOD CK(CPK)-60
___ 07:48AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1
___ 02:30PM BLOOD D-Dimer-909*
REPORTS
=======================
CXR ___
Cardiomegaly and significant tortuosity of the descending
thoracic aorta. No acute cardiopulmonary process.
___ ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ ___
No evidence of deep venous thrombosis in the right lower
extremity veins.
V/Q Scan ___
Preliminary report with low probability of PE
TTE ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45%) secondary
to mild global hypokinesis. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Moderate to severe
(3+) aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
___ y/o M with a h/o Aortic Insufficiency, HTN, HLD, Prostate
Cancer, who presents with foot pain, fatigue, DOE. Noted to have
new cardiomegaly on CXR, high BNP, high d-dimer.
ACTIVE ISSUES
=======================
# Fatigue, dyspnea: Although not the patient's chief complaint,
ROS was notable for recent fatigue. Workup notable for
cardiomegaly on CXR, elevated BNP to 7780, high D-dimer to 909.
Troponin negative x2. Has known aortic insufficiency. Could not
get CTA to work up the d-dimer because of his CKD, was started
on heparin drip empirically. ___ and ___ Doppler were negative,
and V/Q scan was negative for PE. TTE was done, showing
depressed EF 40-45% without focal wall motion abnormalities;
global hypokinesis. Given depressed EF, HCTZ was stopped and
changed to Furosemide 20mg daily. Given CKD, atenolol was
stopped and changed to metoprolol succinate 25mg daily. Given
elevated BP's in house, his home Valsartan 80mg was doubled to
Valsartan 160mg daily. Will need outpatient ischemia workup,
likely a cardiac catheterization, as well as cardiology follow
up, for his systolic CHF.
# Foot pain: Bilateral foot pain, severe, new this week, worse
with walking, tender on plantar side. His foot symptoms are most
consistent with plantar fasciitis. Bilateral Dopplers negative
in ED. CK normal. Recommend stretching exercises to treat likely
plantar fasciitis.
# HTN: hypertensive 150-170's. Increased home valsartan 80mg to
160mg daily given high BP's. Changed Atenolol to Metoprolol
given poor renal function. Change HCTZ to 20mg PO Lasix given
new systolic CHF.
# Primary prevention: Has h/o TIA, but not on ASA or Statin.
Started ASA 81mg, Atorvastatin 40mg.
CHRONIC ISSUES
========================
# CKD: Cr 1.6, baseline 1.5
# BPH: Continue Tamsulosin 0.4mg QHS
# Rhinitis: Continue home Flonase
TRANSITIONAL ISSUES
==========================
- TTE showing depressed EF of 40-45%, below prior values, with
global hypokinesis and no focal wall motion abnormalities. Will
need outpatient ischemia workup, likely a cardiac
catheterization, as well as cardiology follow up, for his
systolic CHF.
- Given the depressed EF, his home HCTZ was changed to
Furosemide 20mg daily
- Given poor renal function, his home Atenolol was changed to
Metoprolol Succinate 25mg daily
- Given elevated BP's in house, his home Valsartan 80mg was
doubled to Valsartan 160mg daily
- Given new CHF, as well as history of TIA, he was started on
Aspirin 81mg in addition to Atorvastatin 40mg daily.
- Recommend outpatient stretching exercises and physical therapy
to treat his foot pain which is likely due to plantar fasciitis.
He was also given a short prescription of tramadol for
breakthrough pain.
- TSH pending on discharge
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 30 mg PO DAILY
2. Valsartan 80 mg PO DAILY
3. Leuprolide Acetate 7.5 mg IM ONCE
4. Atenolol 50 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Valsartan 160 mg PO DAILY
RX *valsartan 160 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*1
6. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
8. Leuprolide Acetate 7.5 mg IM ONCE
9. TraMADol 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth up to four times daily
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Systolic Congestive Heart Failure
Plantar Fasciitis
Secondary:
Hypertension
History of transient ischemic attack
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
us because of foot pain. We ran a number of tests, which found
no evidence of blood clots, but there was evidence that your
heart is not functioning quite as well as before. Because of
this, we have changed some of your medications, and you will
need to follow up with a cardiologist.
For your foot pain, this is likely due to plantar fasciitis.
This takes time to get better, but can be helped with stretching
exercises and physical therapy. It is unrelated to your heart.
There have been some medication changes, and several new
medications. Please review these below, and we will give you new
prescriptions.
If you have any questions do not hesitate to ask us, or your
primary care doctor.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10631674-DS-21
| 10,631,674 | 22,861,997 |
DS
| 21 |
2172-08-27 00:00:00
|
2172-08-27 19:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with history of castrate-sensitive prostate cancer
(diagnosed ___ years ago), TIA, stage III CKD, and multiple lower
GI bleeds, gout, anemia and thrombocytopenia (likely mild ITP)
presenting with flank pain found to have a 3 mm stone either in
bladder or R UVJ.
Past Medical History:
Prostate Ca on Lupron
Osteoporosis
TIA
Aortic Insufficiency
HTN
HLD
Social History:
___
Family History:
Mother ___ ___ CONGESTIVE HEART FAILURE
Father Unknown ___ PNEUMONIA
Physical Exam:
ADMISSION EXAM:
VS: 98.0 PO 172 / 83 91 16 94 3L
GENERAL: NAD, alert and oriented ×3
HEENT: AT/NC, EOMI, PERRL, L eye is injected, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, systolic murmur 3 out of 6, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: While his right flank is painful, there is no
tenderness
to palpation, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, trace edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: T 97.8 BP 168/75 HR 66 RR 18 O2 90% RA
GENERAL: Well-appearing gentlemen resting comfortably in bed, in
NAD
HEENT: AT/NC, EOMI, PERRL, L eye with significant conjunctival
hemorrhage
NECK: Supple, no LAD, no JVD
HEART: RRR, systolic and diastolic murmur grade III/VI, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, NT, ND, +BS, no flank tenderness
EXTREMITIES: No cyanosis, clubbing; 1+ non-pitting edema in ___
___
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 05:32PM cTropnT-<0.01
___ 11:20AM GLUCOSE-132* UREA N-40* CREAT-1.4* SODIUM-138
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-29 ANION GAP-10
___ 11:20AM estGFR-Using this
___ 11:20AM ALT(SGPT)-27 AST(SGOT)-43* CK(CPK)-87 ALK
PHOS-104 TOT BILI-0.5
___ 11:20AM LIPASE-44
___ 11:20AM cTropnT-0.02*
___ 11:20AM CK-MB-4
___ 11:20AM ALBUMIN-4.0
___ 11:20AM ___ COMMENTS-TEST REPOR
___ 11:20AM LACTATE-0.9
___ 11:20AM WBC-14.6*# RBC-3.27* HGB-10.1* HCT-31.9*
MCV-98 MCH-30.9 MCHC-31.7* RDW-19.5* RDWSD-69.3*
___ 11:20AM NEUTS-76* BANDS-0 LYMPHS-11* MONOS-7 EOS-0
BASOS-2* ___ METAS-1* MYELOS-2* PROMYELO-1* AbsNeut-11.10*
AbsLymp-1.61 AbsMono-1.02* AbsEos-0.00* AbsBaso-0.29*
___ 11:20AM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+*
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
___ 11:20AM PLT SMR-LOW* PLT COUNT-113*
___ 11:20AM ___ PTT-33.5 ___
___ 11:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:10AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
___ 11:10AM URINE RBC->50 ___ BACTERIA-OCC YEAST-NONE
___
DISCHARGE LABS:
___ 08:39AM BLOOD WBC-18.4* RBC-3.03* Hgb-9.3* Hct-30.4*
MCV-100* MCH-30.7 MCHC-30.6* RDW-19.5* RDWSD-71.3* Plt Ct-99*
___ 08:39AM BLOOD Plt Ct-99*
___ 08:39AM BLOOD Glucose-95 UreaN-43* Creat-1.6* Na-145
K-4.5 Cl-104 HCO3-30 AnGap-11
___ 08:39AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
MICROBIOLOGY:
___ Urine Cx: URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
___ CT HEAD W/O CON:
IMPRESSION:
No evidence of acute intracranial process or hemorrhage.
___ CTU W/O CON:
3 mm calculus in the bladder adjacent to the right UVJ, which
may have just passed but may be causing irritation to the UVJ,
with subsequent mild to moderate right hydroureteronephrosis.
Infrarenal abdominal aortic aneurysm measuring 3.2 cm stable.
Stable common iliac artery aneurysms and prominent left femoral
artery
Small hiatal hernia.
Colonic diverticulosis
Probable mucous plugging lingula
___ BLADDER US:
IMPRESSION:
The bladder is decompressed and not well evaluated.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with history of castrate-sensitive
prostate cancer (diagnosed ___ years ago), TIA, stage III CKD,
and multiple lower GI bleeds, gout, anemia and thrombocytopenia
(likely mild ITP) presenting with abdominal pain found to have a
3 mm stone either in bladder or R UVJ.
ACUTE ISSUES:
=============
# Nephrolithiasis
# Flank pain
Patient presented with 1d sudden onset right flank pain
reminiscent of his prior episode of nephrolithiasis. He was
given IVF and his pain improved. CTU showed a 3 mm calculus in
the bladder adjacent to the right UVJ, which may represent
passed stone, with mild to moderate right hydroureteronephrosis.
Urology was consulted in the ED and recommended admission to
medicine for monitoring. He was given tramadol for pain control
and tamsulosin. Urology recommend outpatient follow up. His
Creatinine was improving slowly with IVF, plan for outpatient
lab check. He still is having some urinary frequency, overall
symptomatic improved, no evidence of urinary tract infection.
# ___, improving
On admission, Cr 1.9 from baseline 1.2. Creatinine improved with
IVF, on discharge 1.6.
# Leukocytosis
WBC initially 24. Thought to be reactive in the setting of
nephrolithiasis. Initial UA unremarkable but repeat UA revealed
6 WBC with few bacteria and trace leuks, so patient was started
on ceftriaxone for presumed UTI. Urine culture came back
negative and ceftriaxone was discontinued. WBC down-trended to
18.4 on day of discharge. No overt abnormalities on
differential.
# L Conjunctival hemorrhage
Unclear precipitating event, no vision change or pain. Should
follow-up with Mass eye and ear.
#Thrombocytopenia: plts 99 on discharge, no evidence of
bleeding, likely chronic ITP
TRANSITIONAL ISSUES:
[ ] Discharge WBC 18.4, 71% neutrophils, Creatinine 1.6
[ ] Holding Furosemide 20 mg daily until resolving renal
function
[ ] Follow up with PCP for repeat CBC and electrolytes on
___ to ensure that leukocytosis and creatinine are
continuing to improve. Rx given.
[ ] O2 92% on RA, breathing comfortably without use of accessory
muscles. Likely secondary to atelectasis, but should be followed
up with repeat O2 sat.
[ ] Follow up with urology
[ ] Follow up with Mass Eye and Ear for L eye conjunctival
hemorrhage
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Leuprolide Acetate 7.5 mg IM Frequency is Unknown
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Furosemide 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Leuprolide Acetate 7.5 mg IM Q4MONTHS
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Valsartan 160 mg PO DAILY
9. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until you have follow up labs and see Dr.
___
10.Outpatient Lab Work
Please check CBC and Basic metabolic panel (Na, K, Cl, CO2, BUN,
Creatinine) by ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Nephrolithiasis
SECONDARY DIAGNOSIS:
- Prostate cancer
- Stage III CKD
- Anemia
- Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because you were having abdominal
pain and you were found to have a kidney stone.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- You had an ultrasound of your bladder
- You were given fluids through your vein to help your kidney
function
- We think you have likely passed your stone as it was very
small
- You were given antibiotics to treat a possible infection in
your urine, but you did not have any infection ultimately so
antibiotics were discontinued.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- WE WANT YOU TO HAVE YOUR LABS CHECKED BY ___ as
your white blood cell count and kidney function were improving
but not quite normalized. Your doctor then can follow these up.
- Please check your temperature at home, especially if you are
warm, to ensure you have no fevers. If any fevers, we want you
to either call your doctor or come to the ED.
- You should continue to drink lots of fluids
- You should weigh yourself every morning and call the doctor if
your weight goes up by more than 3 lbs. We would like you to NOT
take the FUROSEMIDE (LASIX) until you have follow up with your
doctor.
- You should make follow-up appointments, especially the one
with Dr. ___ on ___.
- You should call and make an appointment with urology and tell
them you were recently discharged from the hospital for a kidney
stone. Their number is ___
- You should continue taking all your medications, as prescribed
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10631733-DS-10
| 10,631,733 | 23,867,236 |
DS
| 10 |
2120-08-25 00:00:00
|
2120-08-26 22:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Difficulty ambulating
Major Surgical or Invasive Procedure:
radiation therapy
History of Present Illness:
___ year old male with history of melanoma presents with new
right leg pain, lytic lesions in vertebral bodies with no cord
compression. Yesterday he had difficulty ambulating, felt pain
in his right medial proximal femur as he was getting out of bed.
He has had difficulty ambulating secondary to pain, and has not
attempted to walk today. New lytic lesions were seen on ___
___ (___) X-ray showed no lytic or lastic osseous
lesions on lumbar spine, lytic lesion on right iliac bone above
the acetabulum, 1.4cm lytic lesion in medial distal femoral
diaphysis. An MRI of his L-spine reportedly showed lytic
lesions in the lumbar vertebrae, but no cord compression. CT
chest showed multiple parenchymal lung lesions suspicious for
metastatic disease. He had a biopsy of a lesion on his shoulder
performed at ___ (by Dr. ___ which
reportedly confirmed melanoma. He has had new bilateral lower
extremity edema that started last week, started HCTZ on ___
by PCP, with edema mildly improved.
In the ED, initial vitals were 98.0 86 146/86 14 97% RA. Labs
showed WBC 14.3K, Na 129, Cl 90. UA showed >182 RBCs, 3 WBCs
with no epis, few bacteria. He was given IV morphine 5 mg x 1.
Vitals on transfer were 98.0 89 104/62 16 96% RA.
Upon reaching the floor, the patient complains of no pain.
There is no loss of sensation in his lower extremities. He has
been constipated for several days. He is urinating without
problem.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, abdominal pain.
No recent change in bladder habits. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
Melanoma, excision several years ago, no chemotherapy
___ disease
Hyperlipidemia
Social History:
___
Family History:
No history of melanoma or any other malignancy in family
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.0 BP: 132/79 P: 91 R: 16 O2: 96% on RA
GEN: Alert, oriented to name, place, not to date. Unable to say
days of week backwards. Fatigued appearing but comfortable, no
acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: muscle strength ___ in all major muscle groups in lower
extremities, sensation to light touch intact, downgoing toes
bilaterally, non-focal.
PSYCH: Appropriate and calm.
DISCHARGE EXAM
VS: 97.9, 79, 136/70, 18, 97% on RA
GEN: Alert and oriented X3, no acute distress, low coarse voice
HEENT: NCAT, PERRL, MMM, OP clear
Lymph node: no cervical lymphadenopathy
HEART: RRR, good S1, S2, no m/r/g
LUNG: CTA ___, no w/r/rh
ABD: soft, NT, ND, no HSM
EXT: tender R shoulder to palpation and movement
NEURO: CN2-12 intact, muscle strength grossly intact throughout
Pertinent Results:
ADMISSION LABS
___ 07:50PM BLOOD WBC-14.3* RBC-4.48* Hgb-13.0* Hct-40.7
MCV-91 MCH-29.1 MCHC-32.0 RDW-13.1 Plt ___
___ 07:50PM BLOOD Neuts-76.7* Lymphs-16.3* Monos-6.3
Eos-0.5 Baso-0.3
___ 07:50PM BLOOD Glucose-113* UreaN-17 Creat-0.7 Na-129*
K-4.6 Cl-90* HCO3-32 AnGap-12
___ 07:50PM BLOOD proBNP-731
DIACHARGE LABS
___ 07:00AM BLOOD WBC-14.5* RBC-5.29 Hgb-15.7 Hct-47.7
MCV-90 MCH-29.8 MCHC-33.0 RDW-13.5 Plt ___
___ 07:00AM BLOOD Glucose-89 UreaN-24* Creat-0.7 Na-127*
K-4.6 Cl-88* HCO3-30 AnGap-14
___ 07:00AM BLOOD ALT-10 AST-12 AlkPhos-95 TotBili-0.7
___ 05:50AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
PERTINENT STUDIES
___ MRI brain
IMPRESSION:
1. Multiple intracranial masses compatible with metastatic
melanoma.
2. A right caudate head lesion has signal characteristics that
are not typical for melanoma, but given the intra-axial
location, surrounding edema and lack of dural enhancement, it
also likely represents a metastasis.
3. Left occipital lesion with minimal enhancement may represent
hemorrhage in a metastasis. Tiny left subdural hemorrhage.
___ CT CHEST
Large soft tissue lesion arising from the right scapula as well
as multiple bilateral pulmonary nodules and masses, consistent
with metastatic melanoma.
___ CT ABD/PELVIS
1. Multiple hepatic, soft tissue, and osseous lesions concerning
for
metastatic disease.
2. Lytic lesion of the right acetabulum, in a concerning
location for future pathologic fracture.
Brief Hospital Course:
___ year old male with history of melanoma presents with new
right leg pain, lytic lesions in vertebral bodies with no cord
compression, suspicious for metastatic melanoma.
ACTIVE ISSUES
# Metastatic melanoma: Patient with history of melanoma several
years ago, excised with no further treatment. Recent biopsy of
shoulder showing melanoma, and newly discovered lytic lesions in
his vertebrae and acetabulum. Also has brain mets, lung, liver,
soft tissue nodules. difficulty walking and mild confusion may
be due to brain mets. Pt received decadron and BXRT treatment
during this hospitalization. He is being discharged home for
hospice on ___. His decadron dose will be tapered over the next
several weeks. His biopsy report from ___ was obtained
and shows melanoma, but mutation studies were not performed. The
tissue block was requested by the melanoma service here, in
particular for BRAF testing. However, during this
hospitalization the patient's performance status declined and at
the time of discharge he is not a candidate for systemic
therapy. most likely this is related to his underlying disease
and perhaps fatigue from radiation. If he is able to improve his
nutritional and performance status and wishes to reconsider
treatment, he will call to make an appointment with oncology
here.
# Right Arm pain due to mets: He has completed XRT treatment.
Pain control with oxycodone and lidocaine patch.
# Hyponatremia: This is likely secondary to ___ given pain and
pulmonary nodules, CNS disease. Does not seem to have symptoms.
Not eating or drinking well recently and BUN/Cr also increasing.
CHRONIC ISSUES
# ___ disease: continue home carbidopa/levodopa
# Hyperlipidemia: continue home simvastatin
TRANSITIONAL ISSUES
# Code status: discussed with patient and HCP, as well as rest
of family, on ___. All agree to DNR/DNI status
# Pending studies: none
# MEDICATION CHANGES:
- STARTED oxycodone ___ mg q4 hour prn
- STARTED lidocaine patch
- STARTED senna, polyethylene glycol for constipation
- Will FINISH Decadron taper
- STOPPED aspirin
# FOLLOWUP PLAN: if improvement in functional status, pt knows
to call office to set up appointment for treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa CR (___) 1 TAB PO NOON
2. Carbidopa-Levodopa CR (___) 2 TAB PO QAM
3. Carbidopa-Levodopa CR (___) 1 TAB PO DINNER
4. Simvastatin 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Finasteride 5 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fiber-Caps (psyllium husk) 0.52 gram oral daily
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa CR (___) 1 TAB PO NOON
2. Carbidopa-Levodopa CR (___) 2 TAB PO QAM
3. Carbidopa-Levodopa CR (___) 1 TAB PO DINNER
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID
12. Dexamethasone 4 mg PO Q12H Duration: 5 Days
Start: ___, First Dose: Next Routine Administration Time
RX *dexamethasone 2 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*50 Tablet Refills:*0
13. Dexamethasone 2 mg PO Q12H Duration: 5 Days
Start: After 4 mg tapered dose
14. Dexamethasone 2 mg PO DAILY Duration: 5 Days
Start: After 2 mg tapered dose
15. Dexamethasone 1 mg PO DAILY Duration: 5 Days
Start: After 2 mg tapered dose
16. Lidocaine 5% Patch 1 PTCH TD DAILY shoulder pain
RX *lidocaine 5 % (700 mg/patch) apply to the area of pain for
12 hours daily Disp #*30 Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Melenoma
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 ___ of you during your stay at ___
___. You were admitted for confusion, and
we found that this was related to your melenoma. You received
medical treatment and radiation therapy. We also provided you
medication for pain management. You are now being discharged
from the hospital.
It has been a privilege taking ___ of you here at ___. We
wish you the very best as always.
Followup Instructions:
___
|
10631933-DS-15
| 10,631,933 | 27,184,995 |
DS
| 15 |
2129-09-11 00:00:00
|
2129-09-11 17:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypercalcemia
Major Surgical or Invasive Procedure:
___: Neck Exploration, Parathyroidectomy
Endometrial biopsy (OB/GYN)
History of Present Illness:
HPI(4): Ms. ___ is a ___ year old ___ woman with hx of childhood polio(with residual
bilateral lower extremity weakness), HTN, thought to be benign
adnexal mass, and recently diagnosed hypercalcemia with two
recent admission for hypercalcemia who again presents for
asymptomatic hypercalcemia.
The Patient is ___ speaking and majority of history
is obtained through notes and niece acting as ___.
Per notes she has had two prior admission for hypercalcemia
___ and ___. She was to meet with a surgeon as an
outpatient but prior to this had her calcium checked and was
again high. She was sent to the ED from her endocrinologists
office.
Of note she was also found previously to have an adnexal
mass.She underwent an MRI as an outpatient which showed more
benign features differential was fibroma, ___ vs
___ tumor.She was also noted to have endometrial thickening
which will need follow up and biopsy.
In the ED her vitals were stable. She was given IV fluids and IV
Lasix. Calcium was found to be 14.4. She was subsequently
admitted to medicine for ongoing care.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypercalcemia
Hyperparathyroidism
Hypercalcemia
Uterine mass
Post-polio weakness
Hypertension
Lumbar radiculopathy
Endocervical polyp
Social History:
___
Family History:
Mother Living ___ STROKE stroke age ___
Father ___
Sister Living POLIO
Comments: no fh cancer , heart disease , anemia
Physical Exam:
On Discharge:
A&Ox3, awake and conversing appropriately.
Neck incision c/d/i w/ steris applied. Minimal soft tissue
swelling.
Abd soft, NTND
Moving all 4 extremities.
Pertinent Results:
___ 07:25AM BLOOD WBC-9.8 RBC-4.24 Hgb-11.4 Hct-34.3
MCV-81* MCH-26.9 MCHC-33.2 RDW-14.7 RDWSD-43.1 Plt ___
___ 07:22AM BLOOD Glucose-79 UreaN-8 Creat-0.4 Na-139 K-4.1
Cl-107 HCO3-21* AnGap-11
___ 07:22AM BLOOD Calcium-10.0 Phos-2.8 Mg-1.7
Brief Hospital Course:
SUMMARY/ASSESSMENT:
Ms. ___ is a ___ year old ___
woman with hx of childhood polio(with residual bilateral lower
extremity weakness), HTN, thought to be benign adnexal mass, and
recently diagnosed hyperparathyroidism who presents for
hypercalcemia.
ACUTE/ACTIVE PROBLEMS:
#HYPERCALCEMIA: Elevated Ca, PTH 332, low phos, and area with
increased tracer uptake on sestimibi suggests primary
hyperparathyroidism. she was to follow up for surgical
intervention as an outpatient but prior to appointment she is
again admitted for hypercalcemia
- additional 2L at 250cc/hr
- IV Lasix 20mg IV
- Encourage ambulation (minimizes bone resorption; promotes
calciuresis)
- Moderate calcium diet
- vitamin D 1000u/day
- appreciate other endocrine recs
- Consult ___ service to discuss timing for surgical
intervention
#Hypophosphatemia: Per endocrine consult, risk of respiratory
muscle weakness from inadequate ATP production if Phosphate is
not repleted given ongoing wasting d/t elevated PTH
- IV phos x1
- 500mg phos PO BID x 3 days
#HYPERTENSION
Home lisinopri
#CONSTIPATION
#LEFT PELVIC MASS:
Will need an endometrial biopsy with gyn as outpatient. Per MRI
is c/w with fibroma, ___ tumor.
- Miralax QD
- Senna BID
Patient was brought to OR on ___ for elective
parathyroidectomy for asymptomatic hypercalcemia. Surgery was
uneventful. A right inferior ___ adenoma and possible left
superior ___ adenoma were resected. There was an interval
decrease in PTH level from 288 to 21 confirming removal of
parathyroid adenoma. ___ hospital stay was uneventful and
on POD1 she was stable and medically cleared for discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 20 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 8.6 mg PO BID
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth once a day Disp
#*10 Capsule Refills:*0
2. Calcium Carbonate 1250 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice a day Disp #*30 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Lisinopril 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypercalcemia
Parathyroid adenoma
Endocervical Polyp
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You were admitted because of high calcium in your blood.
WHAT HAPPENED IN THE HOSPITAL?
You received fluids and a "water pill," which lowered your
calcium.
You were taken to the operating room and had a subtotal
parathyroidectomy. This means that some of your parathyroid
glands were removed because they were found to be abnormally
enlarged. You did very well following your surgery. Your lab
results are as expected.
WHAT SHOULD YOU DO AT HOME?
-Please drink ___ liters of fluid per day.
-Please drink fluids that contain phosphorus such as Gatorade,
Milkshakes
-Please walk multiple times per day.
-Please take calcium and vitamin D supplements as prescribed.
-Please follow-up with endocrinology, OBGYN, and your PCP (see
appointments below).
Wound care:
You may shower normally. Allow warm soapy water to run over the
wound, rinse and pat dry gently. There is no need to keep a
dressing over the wound. Do not apply creams or ointments. Do
not submerge the wound in a swimming pool or bath until cleared
at your follow up visit. Your steri strips (paper tapes)
covering the wound will fall off by themselves).
Diet:
You may resume your regular home diet without restriction. You
should use common sense and stick to foods that do not upset
your stomach. You may need to start with small meals first and
may not feel very hungry at first. This will improve over time.
You may supplement your diet with protein shakes as needed if
you do not feel you are taking in enough nutrition.
Activity:
You may resume all of your normal home activities, except for
straining or lifting heavy weight. We recommend you resume
walking, exercise, bathing, per your normal regimen.
OB/GYN Post procedure Care:
You may have a small amount of vaginal bleeding(spotting) and
cramping lower abdominal pain which is normal. You may take
ibuprofen(Motrin) and acetaminophen (Tylenol) as needed for
pain. You may shower and resume normal activities, except:
nothing in the vagina (no sex, tub baths, tampons, douching) for
2 weeks. Please contact a doctor for fevers, chills, increased
vaginal bleeding (greater than 1 pad/hour for two hours),
vaginal discharge, abdominal or pelvic pain, or any new or
concerning symptoms.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10633199-DS-5
| 10,633,199 | 26,255,933 |
DS
| 5 |
2137-10-16 00:00:00
|
2137-10-16 17:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / Phenothiazines / Keflex / Cephalosporins / chloral
hydrate / chlorpromazine
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with a history of dCHF (EF65%), CKD,
IDDM2, recurrent UTI, bipolar, schizoaffective d/o, HTN,
dementia w/ delusions p/w AMS from nursing home.
On the evening of admission the patient was noted to have
generalized weakness, lethargy, sluggish speech, with worsening
mental status, decreased appetite, chills, and sweats. At
baseline she is demented but can answer questions, though exam
by EMS was notable for arousal only to pain. VS at the nursing
home were 100.4 HR 91 RR 23 BP 119.63 97% 12L and was taken to
the ED.
In the ED initial vitals were:102.8 HR 71 RR 16 100/54 96% 3L NC
- Labs were significant for WBC 15.9, Cr 2.2 (baseline 1.2-1.6)
UA positive Leukocyte esterase, positive nitrite, WBC >182, Epi
5. Lactate 2.9-->1.9
- Patient was given 1L NS and Zosyn 4.5 g
Vitals prior to transfer were: 100.1 HR 102 RR 24 BP 107/61 97%
2L NC
On the floor, she is sleeping soundly, arousable only to painful
stimuli.
Review of Systems: Unable to obtain given AMS
Past Medical History:
# Bipolar I
# HTN
# DMII on insulin
# dCHF with EF 65%
# Prior heavy tob use
# Dementia with delusions
# schizophrenia
# CKD
# Recurrent UTIs
Social History:
___
Family History:
Unable to obtain given AMS
Physical Exam:
ON ADMISSION:
Vitals - 98.6 108/62 102 18 100% 2L
GENERAL: Lying in bed sleeping soundly, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, dry MM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Tachycardic, Normal S1/S2, no murmurs, gallops, or rubs
LUNG: Limited due to lack of participation, but clear anteriorly
ABDOMEN: nondistended, +BS, nontender in all quadrants, large
abdominal hernia
EXTREMITIES: warm, erythema on L>R, no edema
PULSES: 2+ DP pulses bilaterally
NEURO: Arousable to painful stimuli
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
Vitals- T 97.6, BP 116/51, P 65, RR 22, O2 93%RA
General- Elderly appearing woman, lying in bed, asleep, no acute
distress
HEENT- MMM, EOMI
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- Large ventral reducible hernia, reducible, bowel sounds
present
GU- no foley
Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Deferred
Pertinent Results:
___ 09:41PM GLUCOSE-226* UREA N-38* CREAT-2.1* SODIUM-137
POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-25 ANION GAP-18
___ 09:41PM CK(CPK)-1413*
___ 09:41PM CK-MB-3 cTropnT-0.02*
___ 09:41PM CALCIUM-8.6 PHOSPHATE-3.4 MAGNESIUM-1.7
___ 09:41PM WBC-9.6 RBC-4.45 HGB-14.2 HCT-44.0 MCV-99*
MCH-31.9 MCHC-32.2 RDW-12.9
___ 09:34PM TYPE-ART PO2-216* PCO2-45 PH-7.36 TOTAL
CO2-26 BASE XS-0 INTUBATED-NOT INTUBA
___ 09:34PM LACTATE-1.9
___ 06:05AM GLUCOSE-304* UREA N-35* CREAT-2.0* SODIUM-143
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-17
___ 06:05AM WBC-13.4* RBC-4.02* HGB-12.4 HCT-39.7 MCV-99*
MCH-31.0 MCHC-31.4 RDW-12.6
___ 11:44PM LACTATE-1.8
___ 08:21PM LACTATE-2.9*
___ 08:20PM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 08:20PM URINE RBC-29* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-5
___ 08:20PM URINE WBCCLUMP-MANY
___ 08:15PM GLUCOSE-254* UREA N-33* CREAT-2.2* SODIUM-144
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-32 ANION GAP-15
___ 08:15PM WBC-15.9*# RBC-4.26 HGB-14.0 HCT-41.6 MCV-98
MCH-32.8* MCHC-33.6 RDW-12.8
___ 08:15PM NEUTS-84.1* LYMPHS-7.9* MONOS-7.4 EOS-0.3
BASOS-0.3
Brief Hospital Course:
Ms. ___ is a ___ y/o female with PMH significant for dCHF
(EF65%), HTN, CKD, IDDM2, recurrent UTI, dementia with delusions
who presents from her nursing home with AMS found to have
urinary tract infection now transferred to ICU for progressive
altered mental status in the setting of hypoxic respiratory
distress and progressive urosepsis.
ICU COURSE:
Respiratory Distress: Ms. ___ initially noted to be
hypoxic requiring O2 supplementation in the ED. She was slowly
weaned to room air through hospital day #1. She was noted to
have worsening respiratory distress with hypoxia in the setting
of a non-rebreather. Noted to have evidence of pulmonary edema
on CXR concerning for acute exacerbation of dCHF. Received PRN
lasix. Her electrolytes were closely trended and her I/Os were
monitored, as she experienced prerenal azotemia. Her lytes
improved and her breathing was at baseline. She was restarted on
her home diuretics and she continued to do well. She was eating
and drinking at baseline prior to dishcarge.
Urosepsis: Patient met 3 of 4 SIRS criteria with known UTI,
concern for urosepsis. AMS and clinical status did not improve
on vanc/ceftriaxone - concern for GNR bacteremia, and
antibiotics were broadened to vanc/zosyn. AMS improved
significantly. She was narrowed back to ceftriaxone and she
continued to do well. She was transioned to cefpedoxime to
complete a 10 day course of antibiotcs. Her last day of
antibiotics is ___.
Her chronic issues of bipolar I, HLD, Diabetes and HTN were
closely monitored and treated with home medications. Her
carvedilol and allopurinol were held during hospitalization.
These can be restarted as an outpatient.
TRANSITIONAL ISSUES:
- Restart he home Coreg as an outpatient.
- Monitor mental status
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Vitamin D 50,000 UNIT PO 1X/MONTH
3. Aspirin 81 mg PO DAILY
4. Furosemide 120 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Carvedilol 3.125 mg PO BID
7. Calcium Carbonate 500 mg PO BID
8. Oxcarbazepine 450 mg PO BID
9. OLANZapine 5 mg PO BID
10. Senna 17.2 mg PO HS
11. Simvastatin 20 mg PO QPM
12. Acetaminophen 325 mg PO Q6H:PRN fever
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
14. ipratropium bromide 0.02 % inhalation Q4H PRN dyspnea
15. Lorazepam 1 mg PO BID PRN anxiety
16. Bisacodyl 10 mg PR HS:PRN constipation
17. Milk of Magnesia 30 mL PO Q12H:PRN constipation
18. LOPERamide 2 mg PO QID:PRN diarrhea
19. Glargine 42 Units Bedtime
Novolog 14 Units Breakfast
Novolog 14 Units Lunch
Novolog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Furosemide 120 mg PO DAILY
7. Glargine 42 Units Bedtime
Novolog 14 Units Breakfast
Novolog 14 Units Lunch
Novolog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. OLANZapine 5 mg PO BID
9. Oxcarbazepine 450 mg PO BID
10. Senna 17.2 mg PO HS
11. Simvastatin 20 mg PO QPM
12. Allopurinol ___ mg PO DAILY
13. Calcium Carbonate 500 mg PO BID
14. Carvedilol 3.125 mg PO BID
15. ipratropium bromide 0.02 % inhalation Q4H PRN dyspnea
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. Lorazepam 1 mg PO BID PRN anxiety
18. Milk of Magnesia 30 mL PO Q12H:PRN constipation
19. Vitamin D 50,000 UNIT PO 1X/MONTH
20. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with a urinary tract infection. You
were treated with antibiotics and intially you didnt do well and
required the ICU but you greatly improved and were transfered
back to the floor. You continued to do well and you were stable
to leave the hosptial. Please follow up with the appointments
listed below.
Followup Instructions:
___
|
10633573-DS-9
| 10,633,573 | 27,664,777 |
DS
| 9 |
2138-12-06 00:00:00
|
2138-12-06 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
___ Laparoscopic cholecystectomy, Intraoperative
cholangiogram
___: ERCP
History of Present Illness:
HPI: Ms. ___ is a ___ woman with PMH s/f IBD, FNH, and
cholelithiasis who has had a two year history of intermittent
RUQ
pain after eating fatty meals. She has changed her diet and has
not had an attack since ___, however today after eating a
burrito she developed RUQ/epigastric pain that felt "like a kick
in the stomach." Pain was ___ and constant, did not radiate,
and was similar to her prior episodes. No emesis. She presented
to the ED and pain resolved after ___ hours, with no pain
medication given.
Past Medical History:
IBD, FNH, cholelithiasis
Social History:
___
Family History:
___
Physical Exam:
Physical Exam:
Vitals: 97.0 78 129/73 18 100% RA
GEN: Thin well appearing woman, A&Ox3, 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, v mild TTP with deep palpation RUQ, no
rebound or guarding, normoactive bowel sounds, no palpable
masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:55PM BLOOD WBC-12.4*# RBC-4.63 Hgb-13.5 Hct-40.1
MCV-87 MCH-29.1 MCHC-33.6 RDW-12.7 Plt ___
___ 11:55PM BLOOD Neuts-70.7* ___ Monos-5.2 Eos-0.3
Baso-0.4
___ 11:55PM BLOOD Plt ___
___ 11:55PM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-143
K-4.2 Cl-106 HCO3-29 AnGap-12
___ 11:55PM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-143
K-4.2 Cl-106 HCO3-29 AnGap-12
___ 06:41AM BLOOD ALT-212* AST-79* AlkPhos-63 Amylase-72
TotBili-0.3
___ 07:39AM BLOOD ALT-310* AST-161* AlkPhos-71 TotBili-0.4
___ 11:35AM BLOOD ALT-494* AST-502* AlkPhos-91 TotBili-0.7
___ 11:55PM BLOOD ALT-115* AST-171* AlkPhos-73 TotBili-0.4
___ 06:41AM BLOOD Lipase-24
___ 11:55PM BLOOD Albumin-4.5
___: chest x-ray:
No radiographic evidence for acute cardiopulmonary process.
___: cholangiogram:
No choledocholithiasis
___: ERCP:
Impression: Normal major papilla
The intrahepatics were normal. The bile duct was normal in size
and contained no gross filling defects. The RUQ surgical clips
and cystic stump were seen. No extravasation of contrast seen.
Given the IOC and abnormal LFTs, a sphincterotomy was performed
in the 12 o'clock position using a sphincterotome over an
existing guidewire.
Sludge was extracted successfully using a balloon catheter.
There was excellent flow of bile and contrast.
Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
___ year old female admitted to the acute care service with right
upper quadrant pain. Her abdominal pain resolved shortly after
admission and she was discharged. She returned to the emergency
room with a recurrence of the abdominal pain. She underwent an
ultrasound and was found to have cholelithiasis. Blood work
done at this time showed an elevated white blood cell count and
elevated liver enzymes. She was taken to the operating room on
HD #1 for a laparoscopic cholecystectomy. The operative course
was stable with a 20cc blood loss. An intra-op cholangiogram
done at this time showed a common bile defect, possibly a stone.
The liver enzymes remained elevated. Based on these findings,
arrangements were made for an ERCP. The patient was extubated
after the operative procedure and monitored in the recovery
room. Her vital signs remained stable and liver enzymes were
monitored.
On POD #1, the patient underwent an ERCP for further evaluation.
A sphincterotomy was performed with the removal of sludge with a
balloon catheter. Post-operative course has been stable. The
abdominal pain has decreased in severity and liver enzymes are
slowly trending down. She has been afebrile and her vital signs
have been stable. The white blood cell count has normalized.
She was discharged home in stable condition on POD # 2 with
post-operative instructions. An appointment for follow-up was
made with the acute care sevice.
Medications on Admission:
metamucil
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN pain
3. Acetaminophen 650 mg PO Q4H pain
4. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis and
underwent a laparascopic cholecystectomy. Post-operatively, your
diet was slowly advanced to a regular diet and your pain was
well controlled with oral pain medications. You will have a
scheduled appointment in the ___ in 2 weeks.
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10633783-DS-18
| 10,633,783 | 29,826,433 |
DS
| 18 |
2154-11-04 00:00:00
|
2154-11-09 13:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Diflucan / pseudoephedrine / adhesive tape
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic drainage of biloma
___: ERCP with common bile duct stent placement
History of Present Illness:
Ms. ___ is a ___ years old woman now ___ s/p lap CCY w/Dr.
___. Patient presents to the ED with sudden onset of
diffuse abdominal pain worse on RUQ and one episode of non
bloody, non bilious emesis. Patient states she was doing well
post operatively until last night when she developed an mild
abdominal ache that hours later was followed by severe onset of
diffuse sharp, stabbing abdominal that was worse in the RUQ. She
vomited once last night and as a resulted decided to present to
OSH. At OSH, labs were within normal range with WBC 7.1, HGb
12.7, Plt 209, BUN/Cr ___, Tbili 0.8, AP 54, AST 93 and ALT
135. She was transferred here given that her operation was done
by Dr. ___. Patient denies any recent diarrhea,
constipation, fever/chills, or urinary symptoms. She has not
passed gas or had a BM since her onset of pain.
ROS otherwise negative
Past Medical History:
PMH:
- Biliary colic
- GERD
PSH:
- Breast reduction
- Lap cholecystectomy w/ Dr. ___ on ___
Social History:
___
Family History:
Both grandmothers: cholecystectomy.
Mom: colon cancer
Physical Exam:
Physical exam on discharge:
Vital Signs:
Temp 98.5
HR: 80
BP: 128/81
RR: 16
O2 sat: 99%
General: alert and oriented x 3, no acute distress
HEENT: mucosas moist, no LAD
PULM: CTAB
CV: RRR
Abd: soft, non-distended, non-tender, normal bowel sounds, no
rebound or peritonitis
Pertinent Results:
___ 06:00PM BLOOD WBC-11.8* RBC-4.18 Hgb-12.3 Hct-37.1
MCV-89 MCH-29.4 MCHC-33.2 RDW-12.8 RDWSD-41.5 Plt ___
___ 03:50AM BLOOD WBC-10.3* RBC-4.02 Hgb-11.8 Hct-35.6
MCV-89 MCH-29.4 MCHC-33.1 RDW-12.9 RDWSD-42.1 Plt ___
___ 04:23AM BLOOD WBC-6.5 RBC-3.53* Hgb-10.3* Hct-31.3*
MCV-89 MCH-29.2 MCHC-32.9 RDW-12.8 RDWSD-42.0 Plt ___
___ 04:30PM BLOOD ___ PTT-27.5 ___
___ 04:30PM BLOOD Glucose-111* UreaN-9 Creat-0.7 Na-140
K-3.9 Cl-100 HCO3-23 AnGap-17
___ 04:23AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-140
K-3.6 Cl-104 HCO3-26 AnGap-10
___ 04:30PM BLOOD ALT-118* AST-70* AlkPhos-65 Amylase-71
TotBili-1.9*
___ 03:50AM BLOOD ALT-115* AST-73* AlkPhos-48 TotBili-1.9*
___ 04:23AM BLOOD ALT-98* AST-52* AlkPhos-68 TotBili-1.4
___ 04:30PM BLOOD Calcium-9.8 Phos-3.1 Mg-1.6
___ 03:50AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.6
___ 04:23AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
CT A/P:
1. Small amount of fluid within the gallbladder fossa with
high-density
components suggestive of blood products, likely postoperative.
Trace
perihepatic ascites is also likely postoperative.
2. Moderate volume high-density fluid in the pelvis suggestive
of blood
products, also presumably postoperative.
3. No other evidence of acute intra-abdominal process. Normal
appendix.
ERCP:
Successful ERCP with sphincterotomy and stent placement
Brief Hospital Course:
Ms. ___ presented to the ED on ___ POD7 from lap
cholecystectomy complaining of severe sudden onset abdominal
pain. She initially underwent CT A/P which was unremarkable. Her
physical exam and abdominal pain worsened fast on her admission
day up to the point of peritonitis so she was taken to the OR on
___ for diagnostic laparoscopy which showed a biloma which was
washed out (for operative details please refer to Operative
note) and a JP drain was left in place for monitoring.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor tolerating clear diet, on IV fluids, and mPCA for
pain control. The patient was hemodynamically stable. The
following day on ___ patient underwent ERCP with GI team for
sphincterotomy and stent placement for Lushka ducts leak (for
details please refer to ERCP report)
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, pain was well
controlled and JP drain continued to have some minimal
serosanguineous output so it was kept in place. The patient was
discharged home with services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 20 mg PO Q24H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Simethicone 40-80 mg PO QID:PRN gas pain
4. Pantoprazole 20 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bile leak from edge of gallbladder bed
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 here at ___
___. You were admitted to our hospital for
abdominal pain after your laparoscopic cholecystectomy and
underwent diagnostic laparoscopy and wash out for bile leak and
bile peritonitis. An intra-abdominal drain was placed in the OR.
You also underwent an ERCP with biliary stent placement. You
tolerated these procedures well and are now ready to be
discharged to home. Please follow the recommendations below to
ensure your continued recovery at home:
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the surgery.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- You are being discharged with a prescription for oxycodone for
pain control. You may take Tylenol as directed, not to exceed
3500mg in 24 hours. Take regularly for a few days after surgery
but you may skip a dose or increase time between doses if you
are not having pain until you no longer need it. You may take
the oxycodone for moderate and severe pain not controlled by the
Tylenol. You may take a stool softener while on narcotics to
help prevent the constipation that they may cause. Slowly wean
off these medications as tolerated.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
- pain that is getting worse over time, or going to your chest
or back
- urinary: burning or blood in your urine or the inability to
urinate
- any change in your symptoms or any symptoms that concern you
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.
WOUND CARE:
-You may shower with your drain in place and with any bandage
strips that may be covering your wound. Do not scrub and do not
soak or swim, and pat the incision dry. If you have steri
strips, they will fall off by themselves in ___ weeks. If any
are still on in two weeks and the edges are curling up, you may
carefully peel them off.
-Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
-Notify your surgeon if you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
JP DRAIN CARE:
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands with soap and warm water before
performing your drain care, which you should do ___ times a day.
Try to empty the drain at the same time each day. Pull the
stopper out of the bottle and empty the drainage fluid into the
measuring cup. Record the amount of fluid on the record sheet,
and reestablish drain suction. A visiting nurse ___ help you
with your drain care.-
- Clean around the drain site(s) where the tubing exits the skin
with soap and water. Be sure to secure your drains so they don't
hang down loosely and pull out.
-Strip the drain tubing, empty the bulb(s), and record the
output ___ times a day as described above.
-Keep a written record of the daily amount from each drain and
bring this to every follow up appointment. Your drains will be
removed once the output tapers off to an acceptable amount.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team
Followup Instructions:
___
|
10634195-DS-20
| 10,634,195 | 20,113,573 |
DS
| 20 |
2158-11-27 00:00:00
|
2158-11-29 14:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics) / Keflex / Xanax /
Demerol (PF) / Ciprofloxacin / Vancomycin / Ambien / Ambien
Attending: ___
Chief Complaint:
abdominal pain, generalized weakness, and inability to perform
care for self
Major Surgical or Invasive Procedure:
Ultrasound guided paracentesis ___
History of Present Illness:
___ yo F w/ OA, chronic pain, Hep C genotype 1 with portal
hypertension/cirrhosis, anxiety/depression who presented with
worsening edema, abdominal pain and deterioration in ability to
perform ADL's. NF admission note reviewed
.
Patient reports progressively worsening functional status over
the last 6 months, but especially over the last 3 weeks, to the
point that she is no longer to transfer herself to/from
wheelchair. Over the last 3 weeks, she also feel that she has
less control of her stool, such that she has stool incontinence
about twice a day, formed. She reports urinary frequency but
states this is chronic for years. She denies any numbness or
tingling in her groin. She noticed significant amount ___
swelling that is worsening. She thinks this is the reason why
she cannot transfer herself anymore. She has some numbness in
her feet. Swelling was also noted in her breasts L > R and
recent biopsy from her left breast showed tissue edema. She
feels that she gained at least 20 lbs overnight, but does not
know what her baseline weight is. She is not on diuretics
because she feels that she is urinates constantly. She is also
developing RUQ/RLQ pain over the last 3 days. There has been
chronic nausea that is not worse. No vomiting.
.
Per NF, the daughter was concerned about her abdominal pain and
stool incontinence. She lives alone with a 24 hr PCA. She is
dependent with her ADLs. She is wheelchair bound at baseline.
.
Initial ED VS 99.2, 70, 124/76, 18, 100%, exam showed diffused
abdominal tenderness, worse on the right. Labs were significant
for proBNP 850 and INR 1.6. Paracentesis was not done because
of anatomy based on bedside U/S. CXR showed mild congestive
heart failure. EKG showed regular 67 without clear P wave, ?
junctional rhythm, normal axis, QTc 450, prominent R wave on
septal leads and low voltage on the limb leads without ST
changes. VS upon transfer were 98.2, 54, 98/60, 20, 100% RA
.
There was no overnight event. Has not gotten her levofloxacin
yet.
.
Review of systems:
(+) Per HPI, + snoring and awakening with choking sensation,
severe OA of the hips and knees, asking for pain medications,
chronic joint pain
- denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
#. Obesity -s/p jejunal-ileal bypass in ___ with reversal in
___
#. Hepatitis C
- HCV , Genotype I In the past she has been resistant to
treatment with interferon and ribavirin.
- no biopsy on record
- cirrhosis on abdominal U/S in ___
#. Osteoarthritis, s/p bilat hip replacements, pending bilat
knee replacement, and possible shoulder replacement
#. Scoliosis
#. Hypertension
#. Anxiety
#. Depression
#. Chronic narcotic dependency, on methadone. Patient states
not being well controlled since oxycodone was discontinued
#. Bilateral hip replacement
#. Bilateral knee orthopedic issues
#. R rotator cuff injury in past
#. High-grade squamous intraepithelial lesion ___, s/p
excision in ___
#. Open cholecystectomy ___
#. Open appendectomy ___
#. Right salpingoophorectomy ___
#. Small bowel obstruction
#. C. diff colitis
#. Urinary incontinence
#. history of receiving transfusion
Social History:
___
Family History:
Mom had a brain aneurysm at age ___ related to untreated HTN.
Grandfather - MI
Father - Lung CA vs. COPD (unsure).
Physical Exam:
Physical Exam on Admission:
VS: 98.7 130/59, 70 18 99%
GENERAL: NAD, no jaundice, lying comfortably in bed with head
raised 30 degrees.
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, ___ systolic murmur heard best along LSB, without
radiation, no murmurs, rubs or gallops. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, minimal
bi-basilar inspiratory crackles otherwise clear.
Breast: bilaterally edematous left > right.
ABDOMEN: Surgical scars, obese, flank tenderness but hard to
assess shifting dullness, tender to palpation RLQ w/o guarding
or rebound, hard to assess whether this tenderness is
dermal/subdermal or intrabdominal as patient tender to
manipulation of both. Unable to asseess for HSM due to habitus.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
leg edema to above knee, right shin diameter > left, no calf
tenderness, chronic erythematous stasis changes on shins with
some blisters, no signs of cellulitis.
Skin: erythematous desquamating patches in groin and under left
breast and abdomen are consistent with fungal infection. Skin
over trunk and lower limbs is diffusely edematous. Decub ulcers
stage ___ on buttocks bil. No spider angiomas.
Neuro: CN grossly intact, motor functions are preserved though
unable to lift legs against gravity due to edema, sensorium
normal, normal tone and cerebellar functions, no asterexis.
Physical Exam on Discharge:
VS: T98.4, BP 97/49, HR 76, RR 18, O2Sat 98% RA, I/O ___
Gen: obese NAD
GENERAL: NAD.
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, ___ systolic murmur heard best along LSB, without
radiation, no murmurs, rubs or gallops. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, minimal
bi-basilar inspiratory crackles otherwise clear.
Breast: bilaterally edematous left > right.
ABDOMEN: Surgical scars, obese, right upper and right lower
quadrant pain to palpation but no guarding or rebound, hard to
assess if it is from the skin edema. Unable to asseess for HSM
due to habitus. Depedent edema.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
leg edema to the hips, right shin diameter > left, no calf
tenderness, chronic erythematous stasis changes on shins with
some blisters, no signs of cellulitis.
Skin: erythematous desquamating patches in groin and under left
breast and abdomen are consistent with fungal infection. Skin
over trunk and lower limbs is diffusely edematous. Decub ulcers
stage ___ on buttocks bil. No spider angiomas.
Neuro: CN grossly intact, motor functions are preserved though
unable to lift legs against gravity due to edema, sensorium
normal, normal tone and cerebellar functions, no asterexis.
Pertinent Results:
___ 12:20AM BLOOD WBC-2.8* RBC-3.05* Hgb-9.0* Hct-27.1*
MCV-89 MCH-29.5 MCHC-33.2 RDW-16.3* Plt Ct-74*
___ 12:20AM BLOOD Neuts-60.6 Bands-0 ___ Monos-5.6
Eos-4.3* Baso-0.7
___ 12:20AM BLOOD ___ PTT-38.3* ___
___ 12:20AM BLOOD Glucose-102* UreaN-9 Creat-0.5 Na-138
K-4.5 Cl-105 HCO3-31 AnGap-7*
___ 12:20AM BLOOD ALT-17 AST-40 AlkPhos-82 TotBili-1.1
___ 12:20AM BLOOD Lipase-13
___ 12:20AM BLOOD proBNP-856*
___ 12:20AM BLOOD Albumin-2.1*
___ 05:05PM BLOOD Calcium-7.4* Phos-2.9 Mg-1.7
___ 07:46PM BLOOD Lactate-1.1
___ 05:25AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:25AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln->12 pH-6.5 Leuks-TR
___ 03:50PM ASCITES WBC-143* RBC-80* Polys-14* Lymphs-66*
Monos-3* Macroph-17*
___ 03:50PM ASCITES TotPro-0.7 Glucose-108 LD(LDH)-28
Amylase-6 TotBili-0.2 Albumin-<1.0
___ 05:05AM BLOOD WBC-1.6* RBC-2.79* Hgb-8.2* Hct-24.9*
MCV-89 MCH-29.3 MCHC-32.9 RDW-16.1* Plt Ct-61*
___ 11:00AM BLOOD Creat-0.8 Na-138 K-3.9 Cl-102
___ 11:00AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0
___ 04:35AM BLOOD WBC-2.0* RBC-2.74* Hgb-7.9* Hct-24.4*
MCV-89 MCH-28.9 MCHC-32.4 RDW-16.3* Plt Ct-63*
___ 04:35AM BLOOD ___ PTT-37.0* ___
___ 04:35AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-134
K-3.7 Cl-100 HCO3-33* AnGap-5*
___ 04:35AM BLOOD Calcium-7.2* Phos-3.2 Mg-2.0
Microbiology:
___ 11:30 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
CXR ___
FINDINGS: AP upright and lateral views of the chest were
obtained. There is no focal consolidation or pneumothorax. There
is some redistribution of fluid into the upper lung zone
vasculature. There is a small, probably left-sided pleural
effusion with a subpulmonic component given that more is seen on
the lateral than the frontal radiograph. Allowing for AP
technique and low lung volumes, the heart is upper limits of
normal for size. The mediastinal silhouette is normal.
Degenerative changes are seen in the shoulder girdles
bilaterally.
IMPRESSION: Findings consistent with mild congestive heart
failure.
EKG ___
Sinus rhythm. Occasional atrial premature beat with aberrancy.
Compared to
tracing #1 there is no significant diagnostic change.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 200 88 ___ 26
KUB ___
Supine and erect views of the abdomen demonstrate air-filled
loops of nondistended small and large bowel. Bowel gas and fecal
matter is seen within the rectum. No definite free air is seen
on the upright view.
Cardiomegaly is present, exaggerated by low lung volumes. Right
hip
arthroplasty is incompletely imaged. Left acetabular cup is
present but its articulation with the femoral head is unclear on
this study. No osseous lesions concerning for malignancy.
IMPRESSION: No evidence of obstruction.
RUQ U/S ___
The liver is nodular in contour, in keeping with patient's known
cirrhosis. No focal liver lesion is identified. There is no
intra- or extra-hepatic duct dilation. The patient is status
post cholecystectomy. The pancreatic body and tail are not well
visualized in this study. The visualized pancreas is normal. The
spleen is enlarged measuring 18.5 cm, previously 16 cm. Moderate
to large volume ascites present.
DOPPLER ULTRASOUND: Color Doppler and spectral analysis
performed. The main, right, and left portal veins are patent
with appropriate waveforms and hepatopetal flow. The right,
middle, and left hepatic veins are patent. The main hepatic
artery is patent with sharp systolic upstroke and forward flow
in diastole. The SMV and IVC are normal in appearance. The
splenic vein was unable to be visualized.
IMPRESSION:
1. Patent hepatic vasculature.
2. Cirrhotic liver with large volume ascites and moderate to
severe
splenomegaly.
Lower extremity U/S
Doppler images performed of the femoral veins, superficial
femoral veins, popliteal veins bilaterally. There is normal
compressibility, flow and augmentation. There is normal
phasicity within the common femoral veins bilaterally. The right
posterior tibial veins are patent and compressible. The
remainder of the calf veins is not well visualized. Note is
made of a 2.8 x 0.7 cm lymph node within the right groin which
was visualized previously and has decreased in size. There is a
___ cyst within the left popliteal fossa measuring 2.1 x 2.4
cm.
IMPRESSION:
1. No evidence of above-knee DVT bilaterally.
2. ___ cyst noted within the left popliteal fossa
___ Guided paracentesis:
The risks, benefits, and alternatives to the procedure were
explained to the patient and written informed consent was
obtained. A preprocedural timeout was performed, confirming the
patient's identity and procedure to be performed. Ultrasound of
the patient's four abdominal quadrants demonstrated a small
quantity of ascites. A suitable site for paracentesis was chosen
over the patient's right lower abdominal quadrant. The
overlying skin was prepped and draped in usual sterile fashion.
The skin
and subcutaneous tissue was then anesthetized with 1% buffered
lidocaine,
following which a 5 ___ catheter was inserted, without
successful
removal of peritoneal fluid. The catheter was therefore removed
and a second suitable site for paracentesis was chosen over the
dome of the liver. The overlying skin was prepped and draped in
usual sterile fashion and the skin/subcutaneous tissue was
anesthetized with 1% buffered lidocaine. A second ___
catheter was then inserted into the peritoneal cavity. Fluid
samples were sent for cell count, chemistry, culture, and
cytology. A total of 2 liters of yellow ascitic fluid was
removed. The catheter was then removed and a sterile dry bandage
was placed over the catheter insertion site. The patient
tolerated the procedure well, without immediate post-procedural
complications. The attending radiologist, Dr. ___, was present
during the entirety of the procedure.
IMPRESSION: Successful therapeutic and diagnostic paracentesis
yielding 2
liters of yellow ascitic fluid. Samples were sent to the
laboratory for cell count, chemistry, culture, and cytology
Transthoracic echocardiogram ___
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. 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. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Biatrial enlargement. Normal left ventricular cavity
size and wall thickness with preserved global biventricular
systolic function. Mild resting left ventricular outflow tract
obstruction. No clinically significant valvular regurgitation or
stenosis. Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ yo F with Hep C genotype 1 cirrhosis/portal hypertension,
chronic pain, OA, anxiety/depression, HTN, presents with
progressive worsening of anasarca, functional capacity, and
abdominal pain.
# Right sided abdominal pain. Patient is s/p cholecystectomy,
appendectomy, right salpingoophorectomy. She was ruled out of
spontaneous bacterial peritonitis with ___ guided paracentesis,
culture is no growth to date. KUB does not show any bowel
obstruction. She does not have symptoms of gastroenteritis at
this time as she denies diarrhea. UA is bland, so unlikely from
UTI or nephrolithiasis. C. diff was ordered but patient has not
had any diarrhea or bowel movement reported while in the
hospital. Her U/S did not show any thrombosis of the portal or
hepatic vein. She received 1 dose of levofloxacin (given
allergy to cephalorsporins) while she was waiting for the ___
paracentesis. However, with negative results, antibiotics was
discontinued. Exam suggests that the abdominal pain is from
severe edema and likely muscular wall weakness. Further workup,
such as CT abd/pelvis with contrast for right sided abdominal
pain is deferred to the outpatient setting, if pain do not
improve with diuresis. She was given her home dose methadone,
prn oxycodone and minimal Tylenol while in the hospital.
Howver, she is discharged on her home methadone and lidocaine
patch only, to keep in line with her narcotic contract that she
has with her primary care physician. Patient was recommended to
have follow up with the pain clinic.
# ___ swelling/chronic venous stasis. Most likely ___
liver failure and chronic diastolic CHF. Weight in ___ was
237.5 lb. It is unclear what her baseline weight really is.
Her admission weight was 275.75 lb. CT scan from recent past
___ did not show significant lymphadenopathy to explain ___
edema. U/S of the ___ did not show evidence of DVT. Diuresis
was attempted with lasix 40 mg and spironolactone 100 mg daily
and she responded well, about net neg 1L a day. Nutrition was
consulted for her and recommended supplements. She was kept at
low salt diet and a fluid restriction of 2L total a day. This
significant anasarca is contribute to her overall weakness and
decreased mobility. She will need continued diuresis but in
lower dosage (lasix 20 mg, spironolactone 50 mg daily) in the
rehab and outpatient setting with close monitoring of her
electrolytes and renal function. She is started on very low
dose potassium repletion only, however, this may need to be
changed based on subsequent labs. Patient can have ACE wrap for
her legs and elevation for her lower extremity edema. She
should be weighed daily.
# Hepatitis C cirrhosis with portal hypertension. Genotype 1.
MELD score was 12 on admission. She does not have signs of
encephalopathy or asterix on exam. She is not on lactulose.
AFP was normal. U/S showed no portal or hepatic vein thrombosis
but significant splenomegaly. Recent CT ab/pelvis in ___ did
not show evidence of liver malignancy. She will need to have
follow up with her primary hepatologist upon discharge from the
___ center.
# Acute renal failure. Crt rose during the hospital course from
0.5 to 0.8 from diuresis but later returned to baseline
spontaneously. Patient was continued on low salt diet given
underlying cirrhosis and diastolic heart failure. This resolved
spontaneously. She was continued on lasix and spironolactone.
This should be monitored in the rehab.
# Chronic diastolic heart failure. Normal EF. Not on diuretics
at home because of patient's preference as she does not want to
urinate constantly. However, based on her gross anasarca and
mild congestion on exam and CXR, diuresis was started. She was
started on lasix 40 mg and spironolacton ___ mg daily with good
response. She will still need diuresis at lower dose 20 mg
lasix and 50 mg spironolactone daily in the rehab setting.
# Stool incontinence. No diarrhea or bowel movement while in
the hospital. Neurological exam does not suggest cord
compression. UA bland, unlikely from UTI. She did not have any
further reported stool incontinence while in the hospital. She
does not feel constipated.
# Stage 2 decubitus ulcer. Wound nursing was consulted.
Special airbed was used. She was turned regularly. Sacral
meiplex was used to cover left buttock ulceration. 4x4 Mepilex
was used to cover the right medial thigh ulcer. These dressing
change can occur every ___ day or as needed when soiled.
# Fungal infection of skin. Her skin fold was separated with
layer of Kerlex to prevent skin contact and moisture build up.
She was continued clotrimazole cream.
# OSA/Obesity hypoventilation. Likely based on history. It is
recommended that she gets outpatient sleep study.
# Osteoarthritis/Chronic Pain. She was continued on home
methadone 10 mg TID. Oxycodone 5 mg q6h was given prn for
breakthrough pain. She is on Narcotic Contract with her primary
care provider who allows her to use methadone 10 mg TID only
without the oxycodone as it is thought that additional narcotics
do not improve her functional status. Therefore, patient was
discharged on methadone only with lidocaine patch.
# Hypertension. Her lisinopril was held while she was on
diuretics. In order for diuresis, lisinopril was discontinued
and her metoprolol home dose 200 mg XL was cut to half and
changed to metoprolol tartrate 50 mg twice a day. She is on
metoprolol tartrate 50 mg BID, lasix 40 mg daily, and
spironolactone 100 mg daily upon discharge.
# Pancytopenia. Likely result of her underlying cirrhosis,
splenic sequestration and likely bone marrow suppression. It
was stable. This should be monitored regularly while in the
rehab.
Transitional Issues:
[] likely will need < 30 days of rehabilitation
[] Check CBC, Chemistry 7, LFTs, and coagulation panel on ___
and ___ and then per rehab protocol
[] monitor weight daily
[] strict I/Os measurements
[] arrange PCP follow up and ensure that patient has a
hepatology follow up upon discharge from the rehab.
[] wound care as mentioned above
Medications on Admission:
- CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day;
- CLOTRIMAZOLE - 1 % Cream - apply to groin twice a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
increase in dose
- METHADONE - 10 mg Tablet - 1 Tablet(s) by mouth three times a
day for pain. due to fill ___
- METOPROLOL SUCCINATE - 200 mg Tablet Extended Release 24 hr -
1 Tablet(s) by mouth once a day
- NYSTATIN - 100,000 unit/gram Powder - apply to effected area
three times a day as needed for rash largest size please
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unit Injection TID (3 times a day).
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day) as needed for rash.
4. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical every eight (8) hours as needed for rash.
6. Outpatient Lab Work
Please check CBC, Chemistry 7, liver function test, and
coagulation panel (PTT, ___, INR) on ___ and ___. Please fax
the results to patient's primary care provider, Dr. ___
___ ___ (fax), and also to the Medical
Director at your ___.
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12 hours and off for 12 hours.
9. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
10. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
- Hepatitis C cirrhosis with portal hypertension
- Right sided abdominal pain
- Anasarca
- Acute renal failure
- Chronic diastolic heart failure
- Pancytopenia
Secondary diagnosis
- Stool incontinence
- Stage 2 decubitus ulcer
- Chronic venous stasis
- Skin candidiasis
- Probable OSA/Obesity hypoventilation
- Osteoarthritis/Chronic pain on methadone
- Hypertension
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 admitted to ___ because
progressively worsening functional status and right sided
abdominal pain. You underwent paracentesis during which fluid
from your abdomen was taken out. It does not show infection in
your abdomen. Your liver ultrasound also did not show mass or
clots in your veins. Your X-ray of the abdomen did not show
obstruction or mass. Your urine was clear. You did not have
diarrhea while in the hospital, and no stool sample was able to
be collected for study. However, you do have cirrhosis and
heart failure based on the available studies. It is possible
that your abdominal discomfort could be from the swelling in
your body. You were tried on diuretics, such as Lasix and
spironolactone, and you responded well. Your lisinopril was
discontinued so that you could be on these 2 new medications
because of blood pressure issue. You should eat a low salt
diet, < 2 grams a day, and try not to drink a lot of fluid, < 2
Liters. You should elevate your legs when you rest and have ACE
wrapping around your legs, to help with the return of the fluid.
With regard to your chronic pain, we could not change your
methadone dose because you are on a narcotic agreement with your
primary care provider. You should follow the recommendations
from your pain medicine provider for pain management.
In addition, you most likely have sleep apnea, but you will need
to have an outpatient sleep study arranged by your primary care
provider for further evaluation.
You will need wound care for your pressure ulcers and your rash.
You do not have infection in your legs. They are red and
swollen because of the chronic fluid retention state that you
are in.
Please note the following changes in your medication.
- Please start heparin 5000 units, subcutaneous injection, 3
times a day to prevent clots. You should have this while in the
rehabilitation center.
- Please STOP lisinopril 40 mg daily
- Please CHANGE metoprolol succinate 200 mg XL to metoprolol
tartrate 50 mg, 1 tab, by mouth, twice a day
- Please START lasix (furosemide) 20 mg, 1 tab, by mouth, once a
day
- Please START spironolactone 50 mg, 1 tab, by mouth, once a day
- Please START potassium chloride 10 mEq, by mouth, once a day.
However, this may need to be changed later based on your lab
results.
- Please START colace 100 mg, 1 tab, twice a day as needed for
constipation
- Please START senna, 1 tab, twice a day as needed for
constipation
You will need to have labs drawn on ___ and ___ to monitor
your underlying liver disease and then afterward per the
healthcare providers at the rehab center.
Followup Instructions:
___
|
10634251-DS-19
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DS
| 19 |
2166-09-22 00:00:00
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2166-09-23 23:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
___:
Left popliteal vein approach recanalization of left femoral,
external iliac, and common iliac vein into IVC. 100cm (10cm
infusion length) ___ placed into left iliac vein.
PICC line placed.
___: Right CFV and left pop access. Stenting of left CIV
and EIV with 16x120mm and 14x90mm VICIs. Plasty to 14 in CIV
and
12 in EIV. Plasty of femoral vein up to 10mm with ___
sweep.
Plasty of proximal popliteal vein with 6mm. Multiple LLE
venograms. Sheaths pulled.
___: 1. Successful recanalization of the left lower extremity
deep venous system extending from the chronically thrombosed
left popliteal vein through the left common iliac vein including
of the thrombosed left common and external iliac vein stents.
2. Successful placement of 5 ___ lysis catheter through the
left lower extremity deep venous system with 20 cm infusion
length extending from the superficial femoral vein through the
popliteal vein.
3. Pulmonary arteriogram demonstrating segmental left upper lobe
pulmonary embolism.
4. Administration of 4 mg of tPA into the left pulmonary artery.
___:
1. Successful recanalization of the left lower extremity deep
venous system extending from the chronically thrombosed left
popliteal vein through the left common iliac vein including of
the thrombosed left common and external iliac vein stents.
2. Successful placement of 5 ___ lysis catheter through the
left lower extremity deep venous system with 20 cm infusion
length extending from the superficial femoral vein through the
popliteal vein.
3. Pulmonary arteriogram demonstrating segmental left upper lobe
pulmonary embolism.
4. Administration of 4 mg of tPA into the left pulmonary artery.
attach
Pertinent Results:
RELEVANT LABS:
=============
___ 02:27PM BLOOD WBC-6.4 RBC-5.27* Hgb-15.2 Hct-46.6*
MCV-88 MCH-28.8 MCHC-32.6 RDW-13.0 RDWSD-42.0 Plt ___
___ 08:55AM BLOOD WBC-5.4 RBC-4.94 Hgb-14.0 Hct-44.2 MCV-90
MCH-28.3 MCHC-31.7* RDW-13.1 RDWSD-42.7 Plt ___
___ 02:27PM BLOOD D-Dimer-<215
___ 02:27PM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-143
K-4.6 Cl-104 HCO3-24 AnGap-15
___ 08:55AM BLOOD Glucose-140* UreaN-19 Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-25 AnGap-12
___ 08:14AM BLOOD ALT-21 AST-21 AlkPhos-73 TotBili-0.2
___ 02:27PM BLOOD cTropnT-<0.01
___ 08:55AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
IMAGING/OTHER STUDIES:
====================
LLE U/S ___:
IMPRESSION:
Nearly complete occlusive deep vein thrombosis of the mid
proximal and distal superficial femoral vein. In addition,
thrombus is seen in the origin of the greater saphenous and the
peroneal veins.
CTA chest ___:
IMPRESSION:
1. Study is limited by respiratory motion. Within this
limitation, there
appears to be a filling defect within a proximal segmental
branch in the left lower lobe concerning for a pulmonary
embolism.
2. Hepatic steatosis.
CT abd/pelvis ___:
FINDINGS:
VASCULAR:
However, the left common and external veins are demonstrate
significantly
narrowed luminal caliber in comparison to the right. The
aforementioned
finding is consistent with chronic obstruction likely secondary
___ syndrome. More over there is a eccentric filling
defect within the mid to distal left external iliac artery,
(series 6, image 133) which is likely chronic, (series 8 images
117 to 144). Additionally there are extensive perineal varices
which makeup a collateral venous system. There is no abdominal
aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries.
LOWER CHEST: Minimal atelectasis is noted in the lung bases.
Additionally
there is pleural thickening of the left lower quadrant, (series
8, image 1). There is no pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates hypoattenuation suggesting
hepatic
steatosis. There is no evidence of focal lesions. There is no
evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits, without stones or
gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions. Anteromedial to the splenic hilum,
abutting the pancreatic tail is a 17 mm soft tissue nodule which
indicates is similarly to the spleen consistent with accessory
splenic tissue (series 4, image 33).
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of stones, solid renal
lesions, or hydronephrosis. There are no urothelial lesions in
the kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits. The appendix is not visualized.
RETROPERITONEUM: Multiple subcentimeter periaortic and
mesenteric lymph nodes do not meet CT criteria for
lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no vidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is surgically absent. The
bilateral adnexa are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Diastases recti is demonstrated. Otherwise, the
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. The left common and external iliac veins are significantly
narrowed in
caliber, likely chronic. The aforementioned finding is likely
secondary to chronic obstruction as ___ be seen with ___
syndrome.
2. Extensive perineal varices are demonstrated within the
pelvis.
3. There is an eccentric filling defect within the mid to distal
left external iliac artery which, associated with decrease in
calibre of the vessels likely represents chronic thrombosis.
4. No evidence of solid organ malignancy. No lymphadenopathy is
demonstrated within the abdomen and pelvis.
5. Diffuse hypoattenuation of the liver is suggestive of hepatic
steatosis.
Repeat lower extremity ultrasound ___
IMPRESSION:
1. Deep venous thrombosis involving the left femoral,
popliteal, posterior tibial, and peroneal veins.
2. Evaluation of thrombosis within the left common femoral
stent is limited.
3. No evidence of deep venous thrombosis in the right lower
extremity.
CTV A/P with lower extremity run-off ___
IMPRESSION:
1. Complete occlusion of the newly placed left common and
external iliac
venous stent. Thrombus extends proximally into the distal IVC
and distally into the popliteal peroneal veins. Extend of calf
vein involvement is better
characterized on the ultrasound from one day prior.
2. Surrounding stranding along the stent and femoral vein are
likely
postprocedural without evidence of fluid collection or
extravasation.
3. Hepatic steatosis as seen previously.
___
FINDINGS:
Thrombosis of the entire length of the left lower extremity deep
venous system from the level of the popliteal vein through the
left common iliac vein. Distal popliteal vein appears patent.
IMPRESSION:
Successful right internal jugular access with placement of 5
___ ___
___ lysis catheter with 50 cm infusion length extending
from the
popliteal vein through the left common iliac vein.
___
IMPRESSION:
1. Successful recanalization of the left lower extremity deep
venous system extending from the chronically thrombosed left
popliteal vein through the left common iliac vein including of
the thrombosed left common and external iliac vein stents.
2. Successful placement of 5 ___ lysis catheter through the
left lower
extremity deep venous system with 20 cm infusion length
extending from the
superficial femoral vein through the popliteal vein.
3. Pulmonary arteriogram demonstrating segmental left upper lobe
pulmonary
embolism.
4. Administration of 4 mg of tPA into the left pulmonary artery.
RECOMMENDATION(S): Patient will return to the angiography suite
tomorrow for repeat venogram.
___
FINDINGS:
1. Initial venogram demonstrates improved antegrade flow through
the femoral vein, common femoral vein, external iliac, and left
common iliac veins with residual chronic thrombus. Patent
stents.
2. Post thrombectomy venogram demonstrates improved antegrade
flow with
residual chronic thrombus predominantly in the femoral vein.
Patent stents.
3. Post angioplasty venogram demonstrates residual chronic
thrombus within the femoral vein and common femoral vein
however there is antegrade flow and diminished opacification of
collateral veins.
4. Completion venogram demonstrates patent stents and residual
chronic
thrombus within the femoral vein however there is antegrade flow
with
diminished opacification of collateral veins.
IMPRESSION:
Successful right internal jugular approach lysis catheter check
with
thrombectomy, stenting, and venoplasty as described above.
Brief Hospital Course:
SUMMARY:
___ yo ___ F PMHx DVT (dx ~7 months prior,
therapeutic on warfarin) who presented with worsening leg pain,
found to have new acute DVT and PE on imaging despite
therapeutic INR, likely in setting of ___ syndrome.
Patient received tPA, plasty and stenting of the left lower
extremity veins with ___. She was monitored on a heparin drip
post procedure. A repeat lower extremity ultrasound and and CT
abdomen/pelvis done a few days post-procedure showed new clot
formation in the stent and stent malfunction. She was taken for
another ___ procedure with tPA, plasty and re-stenting. During
this procedure she developed a second pulmonary embolism which
was treated with direct thrombolysis. She briefly required
oxygen, and then was able to be weaned back to room air. She was
transitioned to Lovenox from heparin drip and tolerated this
well. She was discharged on Lovenox to follow up with
hematology.
___ HOSPITAL COURSE
# Segmental pulmonary embolism # Shortness of breath
# Left lower extremity DVT # Left lower extremity pain
# ___ syndrome
Patient presented with new leg pain and shortness of breath
while on warfarin for DVT diagnosed in ___. She was found
to again have DVT and likely segmental PE. She was
hemodynamically stable, with negative trop and BNP. INR was
therapeutic at 2.1 on admission, though we do not have prior
records to see how often patient has been in therapeutic range
as she receives her care in ___. Hematology was consulted
and suspected that the most likely cause for new thrombosis was
patient being subtherapeutic on warfarin (not verified) but also
recommended CT a/p to exclude occult malignancy and eval for
___ syndrome. CT demonstrated vessel narrowing
consistent with ___ syndrome. She was treated initially
with heparin gtt. Underwent with ___ ___: Left popliteal
vein approach recanalization of left femoral, external iliac,
and common iliac vein into IVC. 100cm (10cm infusion length)
___ placed into left iliac vein. PICC line placed.
Given catheter tpa gtt as well as systemic heparin gtt. On
___, underwent right CFV and left pop access. Stenting of
left CIV and EIV with 16x120mm and 14x90mm VICIs. Plasty to 14
in CIV and 12 in EIV. Plasty of femoral vein up to 10mm with
___ sweep. Plasty of proximal popliteal vein with 6mm.
Multiple LLE venograms. Sheaths pulled. She was doing well
post-procedure, however, a repeat lower extremity ultrasound and
CT A/P showed thrombosis in the newly placed stent. She was
taken for a repeat ___ procedure with tPa, plasty and stenting on
___, after which she was transferred to the ICU for closer
monitoring. On ___, underwent venogram, plasty, penumbra and
mechanical thrombectomy, ___ balloon pull through from left
pop vein through left common iliac vein. Procedure was
complicated by tachycardia and new O2 requirement so a pulmonary
arteriogram was done which showed a new segmental RUL PE for
which tPA was infused. She also required 1 unit of PRBC after
the procedure. On ___, she underwent repeat Venogram and
sheath was pulled as her exam had improved.
# Anemia:
Secondary to bleeding related to anticoagulation as above. The
patient received 1 unit pRBCs on ___. She remained
hemodynamically stable with stable Hb, and no evidence of
further bleeding.
# Hypertension:
On enalapril at home, held in setting of PE as patient likely
preload dependent. BP stable without, can resume at discretion
of PCP as clinically indicated.
# ? chronic venous congestion - home diosmin not on formulary
# Hepatic steatosis - Incidentally seen on CTA chest. LFTs wnl.
TRANSITIONAL ISSUES:
====================
> 30 min spent in discharge planning and counseling
Medications on Admission:
The Preadmission Medication list ___ be inaccurate and requires
further investigation.
1. Enalapril Maleate 20 mg PO DAILY
2. Warfarin 2.5 mg PO DAILY16
3. diosmin (bulk) 500 mg miscellaneous BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Enoxaparin (Treatment) 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL one syringe subcutaneously every
twelve (12) hours Disp #*180 Syringe Refills:*0
3. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. diosmin (bulk) 500 mg miscellaneous BID
5. HELD- Enalapril Maleate 20 mg PO DAILY This medication was
held. Do not restart Enalapril Maleate until directed by your
primary care physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
# acute lower extremity DVT
# acute pulmonary embolism
# ___ syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with a worsening blood clot in
your leg and a new blood clot in your lung, despite being on
warfarin. You were seen by our hematologist who recommended
transitioning to a different blood thinner medication called
apixaban. You had a CT scan to look for other causes of why your
clot got worse. The CT scan showed narrowing of your vessels on
the left called ___ syndrome'. Because of this
condition, you had a procedure to remove the clot in your leg
and open those vessels in order to prevent this from happening
again. During that procedure, you had another pulmonary
embolism; your breathing has improved since then and you have
been able to walk without difficulty, so you are now safe to go
home and follow up with your primary care doctor and with
hematology.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
Please DO NOT take ibuprofen, aspirin, naproxen, or any other
NSAID medications unless directed by your doctor.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10634353-DS-5
| 10,634,353 | 25,039,036 |
DS
| 5 |
2162-03-01 00:00:00
|
2162-03-04 15:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / morphine / Demerol
Attending: ___
Chief Complaint:
L sided facial pain and swelling
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ healthy other than hx meningiomas (see ___) and
hypothyroidism, works as ___ at ___, who presents as transfer
from ___ for dental infection and trismus.
Patient reports that 3dys PTA she first started feeling
___ toothache. She had plans to see her dentist but the
pain progressed until it was a ___ and she began to develop
___ face and neck swelling 1 day PTA. She then called her
dentist who recommended she be seen by an oral surgeon. She saw
the oral surgeon ___ and was found to have trismus. He referred
her to the ___ ED for IV abx with plan to perform root canal in 1
week.
At ___, she was given IV zosyn. She underwent Neck CT, which did
not show evidence of abscess. Due to trismus and L face/neck
edema, there was concern for ludwig's angina and patient was
transferred to ___ ED for ___ evaluation.
Patient reports improvement in pain and swelling since
administration of IV zosyn. Reports continued trismus. Denies
any fevers, chills, dyspnea, trouble swallowing, changes in
voice.
In the ED, initial vitals were: 97.4 60 114/70 15 99% RA
- Labs notable for:
136 ___ AGap=14
------------
3.9 24 0.8
6.8 13.9 146
41.3
- Imaging was notable for:
CT Neck W/Contrast (Eg:Parotids) [439] --
Preliminary Report viewable in WebOMR
1. There is periapical lucency around a left mandibular molar
tooth with adjacent cortical dehiscence is noted. Adjacent sub 2
mm subperiosteal abscess along the lingual surface of the
mandible may be present.
2. Extensive edema is seen within the medial and lateral
pterygoids, the left parapharyngeal fat, and around the left
submandibular gland. 3. Hyperenhancing left tonsil and multiple
prominent subcentimeter left cervical lymph nodes, likely
reactive.
4. Subcutaneous soft tissue nodule overlying the posterior neck.
Correlation with physical exam is recommended.
- ___ was consulted: per ED, "admit to medicine since typically
takes ___ days to improve with IV antibiotics, so not obs
candidate, agrees with unasyn."
- Patient was given:
___ 22:46 IV ___ ___ Started
___ 22:58 IV Dexamethasone 10 mg ___
___ 22:58 PO/NG Levothyroxine Sodium 50 mcg ___
___ 22:58 PO/NG OxyCODONE--Acetaminophen (___) 1
TAB
___ 23:53 IV ___ 3 g ___
Stopped
- Vitals prior to transfer: 97.9 63 104/60 18 98% RA
Upon arrival to the floor, patient recounts the history above.
She feels relatively little pain but can't open her mouth.
Denies fevers or chills. Otherwise denies complete ROS
Past Medical History:
- hx meningioma x2 (___) c/b intracranial bleeding; only
residual neurologic defect is oral numbness/tingling
- hx hip dysplasia (childhood) requiring bilat THR in her ___
- psoriasis, quiescent since adolescence
- hypothyroidism
- insomnia
Social History:
___
Family History:
Mother- IDDM, lung Ca in ___
Father- lung ___ in ___, smoker
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.4PO 115 / 72L Sitting 63 18 96 RA
Genl: well appearing NAD
HEENT: PERRLA, no icterus, MMM. ___ cm mouth opening due to
pain. there is an ovoid area of swelling beneath the L
mandibular ramus that is mildly ttp. Large ulcerated cold sore
on left upper lip with some crust
CV: RRR No m/r/g
Pulm: No stridor or respiratory distress. CTAB.
Abd: Soft NT ND.
GU: No foley
Neuro: AOX3 without gross focal deficit
=========================
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.7 BP 124/77 HR 54 RR 16 O2 sat 99%RA
Genl: well appearing NAD
HEENT: PERRLA, no icterus, MMM. ___ cm mouth opening due to
pain. there is an ovoid area of swelling beneath the L
mandibular ramus that is mildly ttp. Large ulcerated cold sore
on left upper lip with some crust
CV: RRR No m/r/g
Pulm: No stridor or respiratory distress. CTAB.
Abd: Soft NT ND.
GU: No foley
Neuro: AOX3 without gross focal deficit
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD ___
___ Plt ___
___ 09:00PM BLOOD ___
___ Im ___
___
___ 09:00PM BLOOD ___
___
===========================
DISCHARGE LABS:
___ 06:35AM BLOOD ___
___ Plt ___
___ 06:35AM BLOOD ___
___
===========================
IMAGING/STUDIES:
PANOREX ___:
FINDINGS:
Dental amalgam is noted along multiple mandibular and maxillary
teeth.
Periapical lucency along the left mandibular molar tooth is
better evaluated
on neck CT from ___. No acute fracture or dislocation
is detected.
IMPRESSION:
Periapical lucency along the left mandibular molar tooth is
better evaluated on neck CT from ___.
CT NECK W/CONTRAST ___:
FINDINGS:
There is periapical lucency around a left mandibular molar tooth
with adjacent
cortical dehiscence (300b:52) along the lingual surface of the
mandible.
There appears to be a less than 2 mm subperiosteal abscess along
the lingual
surface of the mandible (2a: 35).
There is edema within the enlarged medial pterygoid muscle.
Similar but less
extensive edema also seen of the lateral pterygoid muscle.. The
left
parapharyngeal fat is edematous and there is extensive edema
surrounding the
left submandibular gland. Edema seen within the left
submandibular region.
There is relative preservation of the fat in the sublingual
space.
The bilateral tonsils are prominent with hyper enhancement on
the left, likely
reactive. Multiple hyperenhancing asymmetrically enlarged left
submandibular
lymph nodes are likely reactive.
The neck vessels are patent.
Craniotomy changes with metal hardware noted along the left
temporal bone.
Encephalomalacia in the underlying temporal lobe is noted, not
well assessed
noting that exam is not tailored for evaluation of intracranial
structures.
An osteoma is noted in the right ethmoid. There is mild mucosal
thickening of
bilateral maxillary sinuses, right greater than left, and the
ethmoid air
cells.
A subcentimeter left thyroid nodule is noted.
The imaged portion of the lung apices are clear and there are no
concerning
pulmonary nodules. A 2.4 cm lobulated soft tissue nodule within
the
superficial subcutaneous tissues of the posterior neck at the C6
vertebral
level is noted.
IMPRESSION:
1. Periapical lucency around a left mandibular molar tooth with
adjacent
cortical dehiscence is noted. Adjacent sub 2 mm subperiosteal
abscess along
the lingual surface of the mandible may be present.
2. Extensive edema is seen within the masticator space involving
the
pterygoids, the left parapharyngeal space and in the
submandibular space.
Extensive edema involving the left submandibular gland. No
drainable
collection.
3. Enlarged palatine tonsils with hyperenhancement on the left
and multiple
prominent subcentimeter left cervical lymph nodes, likely
reactive.
4. Subcutaneous soft tissue nodule overlying the posterior neck.
Correlation
with physical exam is recommended.
Brief Hospital Course:
BRIEF SUMMARY:
___ y/o F hx meningiomas and hypothyroidism, who presented as
transfer from ___ for peridontal infection
w/abscess, now s/p treatment at ___ with unasyn
(___), and given clinical stability transitioned to
oral augmentin on ___, will have 14 day course of
Augmentin after discharge and 7 days of peridex mouth rinse.
==============================
ACTIVE ISSUES:
# Subperiosteal Abscess ___ periodontal infection
# Trismus
# Peridontal infection:
CT Neck ___ from ___ showed significant periodontal edema and 2
mm subperiosteal abscess. No signs of sepsis. ___ consulted and
recommended IV antibiotics and monitoring for signs of systemic
infection or airway impingement. For this reason patient
required inpatient admission at ___ as we have ___
and available ___. At this time patient now stable, and will
start Augmentin for ___ontinue Peridex for 7
additional days. She has not required any narcotic pain
medication so this was discontinued at discharge. She can take
Tylenol prn, less than 3g daily.
- ___ with ___ in 1 week
- Augmentin x 14 days
- Peridex x 7 days
# Recurrent herpes labialis:
Stable. Has large ulcerated cold sore on left upper lip with
some crust. As lesions are already crusted, no indication for
treatment at this time. The patient opted to take acyclovir
ointment from home.
# Hypothyroidism:
Stable. Continued home levothyroxine.
==========================
TRANSITIONAL ISSUES:
==========================
- ___ with PCP
- ___ with ___
- Augmentin for 14 day course
- Peridex for 7 day course
- New Meds: Augmentin, Peridex mouthwash
- Stopped Meds: None
- Changed Meds: None
- Follow up: PCP, ___
- ___ findings:
A 2.4 cm lobulated soft tissue nodule within the
superficial subcutaneous tissues of the posterior neck at the C6
vertebral level is noted.
- Tests required after discharge:
N/A
# CONTACT: ___ (___), ___
# CODE: FULL CODE
Discharge took >30 minutes to arrange, counsel, and set up
outpatient ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. biotin 5 mg oral DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. ___ Acid ___ mg PO Q12H Duration: 14 Days
RX ___ clavulanate 875 ___ mg 1 tablet by mouth
every twelve (12) hours Disp #*14 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 7 Days
RX *chlorhexidine gluconate [Peridex] 0.12 % Please use 15mL
twice daily Refills:*0
3. biotin 5 mg oral DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1) Peridontal infection
# Recurrent herpes labialis
# Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You came to ___ because you had a jaw infection. Please see
more details listed below about what happened while you were in
the hospital and your instructions for what to do after leaving
the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- The oral surgeons saw you and recommended IV antibiotics, and
then given you improved considerably they recommended a switch
to oral antibiotics
- You improved considerably and were ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and oral
surgeon
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have new fevers, pain or other
symptoms of concern.
Followup Instructions:
___
|
10634612-DS-4
| 10,634,612 | 23,606,477 |
DS
| 4 |
2136-11-30 00:00:00
|
2136-11-30 18:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Xanax / Tylenol
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a a history of recent
pneumonia, CAD who presents with dyspnea. She lives in an
assisted living facility and she was increasingly short of
breath today. She reports shortness of breath at rest and feels
that she cannot speak in full sentences. She endorses orthopnea,
but usually sleeps on 2 pillows and this has not recently
changed. She endorses a non-productive cough today, but denies
fevers. Of note, she is s/p a course of levofloxacin for
pneumonia. She denies chest pain, nausea, vomiting, abdominal
pain, diaphoresis, leg swelling or calf tenderness. She denies
dysuria, urgency, frequency.
In the ED initial vitals were: HR 132 (rapid afib) BP 150/74 RR
28 99% Non-rebreather
- Labs were significant for WBC 10.3, Cr 1.9 (unknown baseline),
BNP 12337. Lactate 1.1.
UA: Leuk est moderate, blood negative, nitrite negative, WBC 7,
Bacteria few
- Patient was given Diltiazem 20 mg IV for rapid afib and
converted to sinus rhythm
Vitals prior to transfer were: 97.3 HR 74 136/75 19 95% RA
On the floor, she states she is "irritable." Dyspneic with mild
exertion.
Past Medical History:
Bipolar d/o
H/O UTI
H/O AMS
CAD
CKD (baseline Cr unknown)
OA
Esophageal stricture
Hypertrophic cardiomyopathy
Peripheral vascular disease
Hypothyroidism
HLD
HTN
Osteoporosis
Social History:
___
Family History:
No known family history of early cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.6 153/94 87 20 95% 2L
GENERAL: Somewhat irritable, seated at 30 degrees, speaking in
short sentences
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes
NECK: nontender supple neck, no LAD, JVD to mid neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Bibasilar crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.1 BP 162/63 (140s-160s) HR 53 RR 18 O2 97% on 2LNC
I/O: 540/480 since midnight; 1220/___ -830L yesterday
weight: 86.6 (bed wt) <- 85.6 <- 86.8 or 85.6 <- 84.7 <- 88.2kg
<- 90.7
tele: sinus rhythm without alarms, HR ___
GENERAL: alert, dyspneic but speaking in full sentences
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes
NECK: nontender supple neck, no LAD, JVD wnl
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles at bases bilaterally
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD WBC-10.3 RBC-3.58* Hgb-11.4* Hct-35.4*
MCV-99* MCH-32.0 MCHC-32.4 RDW-14.8 Plt ___
___ 09:00PM BLOOD Neuts-74.6* Lymphs-17.3* Monos-5.5
Eos-2.3 Baso-0.2
___ 09:00PM BLOOD ___ PTT-27.8 ___
___ 09:00PM BLOOD Glucose-146* UreaN-31* Creat-1.9* Na-141
K-3.7 Cl-105 HCO3-26 AnGap-14
___ 09:00PM BLOOD cTropnT-<0.01 ___
___ 07:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:00AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9
___ 09:13PM BLOOD Lactate-1.1
PERTINENT LABS:
___ 05:25AM BLOOD %HbA1c-5.7 eAG-117
___ 07:35AM BLOOD Triglyc-103 HDL-35 CHOL/HD-3.2 LDLcalc-56
___ 07:35AM BLOOD TSH-3.4
DISCHARGE LABS:
___ 05:25AM BLOOD WBC-10.4 RBC-3.76* Hgb-12.0 Hct-36.4
MCV-97 MCH-32.0 MCHC-33.0 RDW-14.8 Plt ___
___ 05:25AM BLOOD ___ PTT-39.8* ___
___ 05:25AM BLOOD Glucose-101* UreaN-38* Creat-2.0* Na-140
K-3.7 Cl-103 HCO3-28 AnGap-13
___ 05:25AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
INR TREND:
___ 09:00PM BLOOD ___ PTT-27.8 ___ coumadin
5mg
___ 07:35AM BLOOD ___ PTT-28.5 ___ coumadin
5mg
___ 05:25AM BLOOD ___ PTT-31.5 ___ coumadin
2mg
___ 05:45AM BLOOD ___ PTT-35.2 ___ coumadin
held
___ 05:35AM BLOOD ___ PTT-39.3* ___ coumadin
2mg
___ 05:25AM BLOOD ___ PTT-39.8* ___ coumadin
1mg
MICRO:
___ 09:59PM URINE Color-Straw Appear-Clear Sp ___
___ 09:59PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 09:59PM URINE RBC-0 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD NEGATIVE
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD NEGATIVE
IMAGING:
ECHO ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %) with global hypokinesis and regional inferior akinesis.
There is no ventricular septal defect. Right ventricular chamber
size is normal. with mild global free wall hypokinesis. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
CXR ___: IMPRESSION:
Cardiac failure with pulmonary edema and bilateral pleural
effusions.
EKG: Not obtained in ED, on floor in NSR with frequent PVCs
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of recent
pneumonia, CAD who presents with sudden onset of dyspnea, found
to have radiographic evidence of pulmonary edema and elevated
BNP consistent with new onset heart failure.
# Acute CHF with EF 25%: The most likely etiology of her dyspnea
is a CHF exacerbation vs. acute presentation given elevated JVD,
crackles on exam, and elevated BNP. The precipitant of CHF
exacerbation was unclear and unfortunately no records were
available in our system. She denies any new medications,
troponin was normal in the ED. No known valvular disease, though
again no records available in our system. Arrhythmia is high on
the differential, particularly as she presented in Afib with RVR
to the ED. Her history per nursing home notes is notable for
cardiomyopathy and her current presentation may be progression
of her underlying cardiac dysfunction. Differential also
includes an episode of severe hypertension, renal failure,
hyper/hypothyroidism, PVC induced cardiomyopathy or infectious
process (pneumonia, UTI). No evidence of pneumonia on CXR but
she did have UA concerning for UTI so was started on
ciprofloxacin but discontinued when culture returned negative.
Patient received lasix 20mg IV on ___, 40mg IV on ___, 40mg IV
on ___, 40mg IV lasix x 2 on ___ and switched to 40mg PO on
___. Attempts to contact her PCP were made several times but
there was no response. Records were requested but only the last
progress note from PCP was obtained. Per secretary at ___
office, there were no records of any cardiac work up including
echocardiogram or catheterization. Her problem list includes ?MI
as well as cardiomyopathy. However, patient was not on any
cardiac meds on arrival. She had an echo which showed overall
left ventricular systolic function is severely depressed (LVEF=
25 %) with global hypokinesis and regional inferior akinesis, RV
mild global free wall hypokinesis, Mild to moderate (___)
mitral regurgitation, and moderate pulmonary artery systolic
hypertension. It was suggested that patient undergo ischemic
work up. However, patient declined and insisted on returning to
nursing home. She was started on atorvastatin 80mg and aspirin
81mg. She was intermittently hypertensive during admission to
160s so lisinopril was started at 10mg and uptitrated to 40mg
daily. She was started on metoprolol. She was discharged on 40mg
lasix PO daily. She should have daily weights checked and follow
a low sodium diet. She was admitted on oxygen but weaned off
before discharge.
# Afib with RVR: CHADS2 score= 3. Unclear if this was her first
episode. ___ have been precipitant of CHF as above vs
precipitated by CHF exacerbation. Broke with diltiazem in the
ED. The morning following admission, she went into a fib with
RVR into 130s-140s sustained with spikes into 170s. She was
started on metoprolol for rate control. She remained in normal
sinus rhythm with rates in the 50-60s during admission. She was
started on coumadin at a dose of 5mg and when INR increased to
INR now 2.2, decreased dose to 2mg daily. INR returned at 3.8
___ so held coumadin. Resumed 2mg on ___ and INR increased to
3.7 on ___ so decreased dose to 1mg daily going forward. She
should have frequent INR checks at ___ home to determine
appropriate dose. Continued aspirin 81mg.
# UTI: Patient presented with dirty UA but asymptomatic. She was
started on ciprofloxacin but culture returned negative so DCed
ciprofloxacin.
# Hypothyroidism: Continued home levothyroxine, TSH wnl
# CAD: Continued home aspirin. Started on atorvastatin 80mg. BP
control with lisinopril and metoprolol.
# Insomnia: Trazodone prn for sleep
# Back pain: received tramadol as needed for pain
# Code: DNR/DNI
# Communication: Patient# Emergency Contact: Proxy name: ___
___ ___
Relationship: Son - unable to reach during admission, left
multiple messages
Transitional:
- Patient started on 40mg po lasix daily, please monitor weights
daily
- Patient started on lisinopril and uptitrated to 40mg daily for
BP control
- Patient discharged on 75mg metoprolol succinate XL and
warfarin 1mg daily for Afib
- Please check INR on ___ and adjust warfarin dose as
needed
- Patient had new diagnoses of systolic heart failure with EF
25% of unclear etiology. It was suggested that she undergo
ischemic work up. However, patient declined and insisted on
returning to nursing home. She will follow up with cardiolgy as
an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enulose (lactulose) 10 gram/15 mL oral PRN
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
6. melatonin 3 mg oral PRN insomnia
7. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Levothyroxine Sodium 50 mcg PO DAILY
4. TraZODone 25 mg PO QHS:PRN insomnia
5. Atorvastatin 80 mg PO QPM
6. Lisinopril 40 mg PO DAILY
7. Senna 17.2 mg PO BID:PRN constipation
8. Warfarin 1 mg PO DAILY16
9. Enulose (lactulose) 10 gram/15 mL oral PRN
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
11. melatonin 3 mg oral PRN insomnia
12. Docusate Sodium (Liquid) 100 mg PO BID
13. Furosemide 40 mg PO DAILY
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours prn Disp #*30 Tablet Refills:*0
15. Metoprolol Succinate XL 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute systolic congestive heart failure
Paroxysmal atrial fibrillation
Secondary:
HTN
CKD
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 admitted to ___ for shortness of breath and found to
have acute congestive heart failure. Your breathing improved
with diuretic medication. Please continue to take your lasix and
weigh yourself every day and call you doctor if your weight
increases by more than 3 lbs or if your shortness of breath
worsens. The reason for your heart failure is not clear and you
declined further intervention as you wished to go home. Please
follow up with your new cardiologist as an outpatient.
You were also noted to occasionally have a rapid irregular heart
rhythm so you were started on a medication to slow your heart
rate called metoprolol and a blood thinning medication called
warfarin to prevent strokes. You will need to have frequent
blood draws to check your INR, a marker of how the blood thinner
is working.
Followup Instructions:
___
|
10635114-DS-4
| 10,635,114 | 22,615,452 |
DS
| 4 |
2161-09-17 00:00:00
|
2161-09-18 17:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
citalopram
Attending: ___.
Chief Complaint:
Heavy menses
Major Surgical or Invasive Procedure:
Blood transfusion, FFP, vitamin K
History of Present Illness:
Ms. ___ is a ___ G2P1 with hc of 3 CVA's on coumadin
who is followed by ___ clinic who presents with heavy
menses. She reports that her period started last week ___ and
by ___ this week, she was bleeding heaving and soaking
through pads every 15mins and hence presented for further ED for
further evaluation. Patient reports that this is definitely her
period because her menses occured around the same time last
month and was heavy but no prolonged. She denies any chest pain
or shortness of breath but endorses dizziness and
lightheadedness. Denies syncope. Of note, last INR was 2.9, goal
is 2.0-3.0. Patient was seen by ED resident who reported heavy
vaginal bleeding on exam. Patient denies any pain.
Past Medical History:
GYN Hx:
LMP: ___
Denies STI, abnl Pap smears, last Pap ___ NILM
Diagnosed with fibroids ___
OB Hx: 1 SVD, no complications, 1 TAB
Med hx: Anxiety, Carotid artery dissections, CVA x 3, HTN,
Depression
Surg Hx: Denies
Social History:
___
Family History:
grandmother with dementia
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
Resp: no acute respiratory distress
Abd: soft, nontender, no rebound/guarding
Ext: no c/c/e
Pertinent Results:
___ 09:20PM BLOOD WBC-13.3* RBC-2.78* Hgb-8.5* Hct-26.1*
MCV-94 MCH-30.5 MCHC-32.5 RDW-17.8* Plt ___
___ 10:30AM BLOOD WBC-7.5 RBC-2.41* Hgb-7.5* Hct-21.9*
MCV-91 MCH-31.0 MCHC-34.1 RDW-17.1* Plt ___
___ 09:45PM BLOOD WBC-8.8 RBC-2.34* Hgb-7.8* Hct-21.1*
MCV-90 MCH-33.3* MCHC-36.9* RDW-17.1* Plt ___
___ 06:30AM BLOOD WBC-8.8 RBC-2.30* Hgb-7.4* Hct-20.8*
MCV-90 MCH-32.0 MCHC-35.4* RDW-16.9* Plt ___
___ 12:45PM BLOOD WBC-9.9 RBC-2.55* Hgb-8.2* Hct-22.7*
MCV-89 MCH-32.2* MCHC-36.1* RDW-16.9* Plt ___
___ 12:00AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.5* Hct-26.9*
MCV-87 MCH-30.7 MCHC-35.2* RDW-16.9* Plt ___
___ 06:30AM BLOOD WBC-9.0 RBC-3.28* Hgb-10.4* Hct-29.1*
MCV-89 MCH-31.8 MCHC-35.9* RDW-17.2* Plt ___
___ 09:20PM BLOOD ___ PTT-41.0* ___
___ 09:20PM BLOOD Plt ___
___ 10:30AM BLOOD ___ PTT-31.1 ___
___ 10:30AM BLOOD Plt ___
___ 09:45PM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-28.2 ___
___ 06:30AM BLOOD Plt ___
___ 12:45PM BLOOD Plt ___
___ 12:00AM BLOOD ___ PTT-27.6 ___
___ 12:00AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-26.4 ___
___ 06:30AM BLOOD Plt ___
___ 09:20PM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-21* AnGap-19
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology
service for management of her menorrhagia.
.
On intial presentation, she had a supratherapeutic INR of 3.2.
She was given vitamin K, 1 unit of FFP, and 1 unit of pRBCs. She
was also symptomatic from her anemia.
.
Over the course of her hospitalization, she received a total of
5 units pRBCs with improvement in her symptoms. On ___, she
was started on provera BID, with excellent improvement in her
vaginal bleeding.
.
During her admission, Hematology was consulted regarding
re-initiation of her warfarin. They recommended holding her
warfarin and consultation with the Neurology team. The inpatient
Neurology team was consulted, who recommended a CTA head/neck.
Based on her studies, the inpatient Neurology team as well as
her primary Neurologist recommended that her anticoagulation be
held until stabilization of her bleeding, with planned
re-initiation during outpatient follow up.
.
She was maintained on her home medications for her hypertension
and anxiety.
.
On ___, the patient was discharged home in stable condition
on aspirin and provera with outpatient follow up scheduled.
Medications on Admission:
- Verapamil 180mg daily
- Metoprolol 50mg QAM
- Effexor 75mg daily
- Warfarin 5mg/4mg alternating days
Discharge Medications:
- MedroxyPROGESTERone Acetate 10 mg PO BID
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth twice a day
Disp #*17 Tablet Refills:*0
- Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
- Verapamil 180mg daily
- Metoprolol 50mg QAM
- Effexor 75mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Heavy vaginal bleeding, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service for monitoring of
your bleeding. You received a blood transfusion and were started
on Provera. You have recovered well and the team believes you
are ready to be discharged home. Please call Dr. ___
office at ___ with any questions regarding this
hospitalization. If you have questions regarding follow up, you
may contact Dr. ___. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* Your Neurologist (Dr. ___ has recommended that you
continue taking aspirin 325mg daily until you have a follow up
appointment with him.
* Call the doctor for any of the concerning symptoms listed
below.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
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10635271-DS-18
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2137-08-19 00:00:00
|
2137-08-19 11:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of severe AS, mod AR/MR, dilated Asc aorta who
presented to Dr. ___ today for a routine
office visit. One hour prior to that visit developed acute
chest/back pain, which she notified him about. She was
hemodynamically stable, but given extent of symptoms was
transferred to the ___ ED for CTA to evaluate for aortic
dissection and/or PE. Per report, CTA notable for large R PE and
descending Aortic dissection. Ddimer >1050, tropI 0.15. Started
on labetalol gtt for BP (SBP 140s), and transferred to the ___
ED for further management.
Past Medical History:
Temporal arteritis, aortic stenosis, L CVA ___, syncope,
mitral regurg, Chronic back pain, compression of vertebrae,
Arthritis, Osteoporosis, COPD/Asthma, GERD, Macular degeneration
PSH: Bilateral knee replacements, Right eye cataract surgery
Carpal tunnel release bilaterally, Trigger finger release
Social History:
___
Family History:
Mother died of a stroke. Father had MI in his ___.
No history of clotting disorders, PE, early MI, SCD, or
arrhythmias.
Physical Exam:
Gen: Obese elderly female in nad, alert and oriented
Card: RRR
Lungs: CTA bilat
Abd: soft no m/t/o
Extremities: Warm, no edema
Pulses: fem/dp/pt palpable bilat
Pertinent Results:
discharge labs:
___ 04:12AM BLOOD WBC-8.4 RBC-3.83* Hgb-11.5* Hct-38.2
MCV-100* MCH-30.1 MCHC-30.2* RDW-12.8 Plt ___
___ 04:12AM BLOOD Glucose-108* UreaN-19 Creat-0.9 Na-139
K-4.3 Cl-106 HCO3-29 AnGap-8
___ 04:12AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.5
INR TREND:
___ 03:27AM BLOOD ___ PTT-45.4* ___
___ 01:21AM BLOOD ___ PTT-67.3* ___
___ 08:15AM BLOOD ___ PTT-150* ___
___ 04:00AM BLOOD ___ PTT-80.0* ___
___ 12:15AM BLOOD ___ PTT-92.9* ___
___ 08:00AM BLOOD ___ PTT-72.6* ___
___ 03:49AM BLOOD ___ PTT-87.4* ___
___ 04:12AM BLOOD ___
Cardiac enzymes:
___ 10:23PM BLOOD CK-MB-1 cTropnT-0.08*
___ 03:27AM BLOOD CK-MB-1 cTropnT-0.08* proBNP-846*
___ 12:36PM BLOOD CK-MB-1 cTropnT-0.07*
___ 9:53 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
Pertinent Studies:
Radiology Report CTA ABD & PELVIS Study Date of ___ 5:28 ___
IMPRESSION:
1. Acute aortic dissection with findings similar to the very
recent prior examination aside from the fact that the false
lumen is now clearly opacified with contrast. Although
unchanged, there is a small quantity of acute hemorrhage within
mediastinal fat suggesting recent bleeding outside of the aortic
wall although there is no evidence for change or active
extravasation on this examination.
2. Large pulmonary embolism in the right main pulmonary artery,
of indefinite chronicity, but potentially subacute; correlation
with clinical course is suggested; the main pulmonary artery is
enlarged but right ventricle does not appear enlarged.
3. Large right-sided thyroid nodule for which further
assessment with
ultrasound is recommended when clinically appropriate.
4. Large hiatal hernia.
5. Gallstones.
Radiology Report BILAT LOWER EXT VEINS Study Date of ___
8:53 ___
IMPRESSION: No bilateral lower extremity DVT.
Portable TTE (Complete) Done ___ at 11:09:04 AM
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with normal
global and regional biventricular systolic function. Moderate
aortic stenosis. Moderate aortic regurgitation. Mild mitral
regurgitation. Mild pulmonary hypertension.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
12:20 ___
IMPRESSION:
1. Worsening bilateral pleural effusions, particularly on the
left, now with complete left lower lobe collapse and atelectasis
in the left upper and right lower lobes.
2. Stable type B aortic dissection.
3. Stable right main pulmonary artery embolism.
4. Subcentimeter thyroid nodule. As indicated on the report of
___, this can be further evaluated with ultrasound.
5. Large hiatal hernia.
Brief Hospital Course:
Ms. ___ was admitted to the CVICU on labetolol drip for
agressive blood pressure control, as well as a heparin drip for
her PE. Both drips were titrated carefully for therapeutic
control. She was monitored closely and remained stable. LENIs
were negative for DVTs. Transthoracic Echo showed moderate
aortic stenosis, moderate aortic regurgitation, mild mitral
regurgitation and mild pulmonary hypertension. Repeat CTA/CTV
showed stable dissection and PE, with no signs of pelvic mass.
She was initiated on coumadin, and remained on a heparin drip
until a therpeutic INR was reached. Her IV antihypertensives
were transitioned to oral, and she continued to do well. She was
transfered to the VICU where she continued to make progress. She
worked with ___ and was found to be a rehab candidate. She
tolerated a regular diet, and voided without difficulty. She
was noted to have several episodes of O2 sats dipping into the
high ___ while sleeping. Pulmonology was contacted and felt
that this was not abnormal given her COPD. They felt that O2
sats of 88% or greater were acceptable for this patient, given
that her baseline is likely low. Of note, a thyroid nodule was
seen on both CT scans, and follow up with PCP is ___. She
will follow up with vascular surgery in a month.
Medications on Admission:
plavix 75'. simvastatin 20', metop 12.5'', diovan 40',
levothyroxine 25 mcg', symbicort 2 puffs inh BID albuterol inh
Q4H prn, excedrin prn headache, vit d, vit b12, omega-3,
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP < 100
hold for HR < 60
6. Simvastatin 20 mg PO DAILY
7. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN stuffy nose
8. Warfarin 4 mg PO DAILY16
please check INR daily and adjust as needed for INR goal 2.0 -
3.0
9. Thiamine 100 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. FoLIC Acid 1 mg PO DAILY
12. Bisacodyl ___AILY:PRN constipation
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. pulmonary embolism in the right main pulmonary artery
2. type B aortic dissection
3. thyroid nodule
4. copd
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a Type B Aortic
Dissection and a pulmonary embolism (blood clot in the right
main pulmonary artery). You were treated medically with
agressive blood pressure control for your dissection and
anticoagulation for your PE. You will need to be on coumadin
for at least 6 months. The rehab facility will monitor your
pt/inr and ajust your coumadin dose. When you are discharged
from their care, you will need to follow up with your PCP for
monitoring.
While you were admitted it was noted that your oxygen saturation
dropped at night. You were seen by the Pulmonary team, who felt
that sats greater than or equal to 88 were appropriate for you,
given your long standing COPD.
While reviewing your CT scan, there was a thyroid nodule noted.
This should be followed up by your primary care physician in the
next few months with an ultrasound.
Followup Instructions:
___
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10635271-DS-24
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2143-10-08 00:00:00
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2143-10-09 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / lisinopril
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with a history of aortic
stenosis (s/p TAVR ___, type-B aortic dissection and PE in
___, CHB (s/p dual chamber PPM ___, and recurrent atrial
fibrillation who presents as a direct admit for volume overload
in the setting of recurrent AF.
Recently admitted ___ for elective cardioversion for AF and
was found to be in CHF exacerbation. During that admission, her
reduced EF had recovered to normal. Pt developed recurrent afib
noted during device interrogation prior to discharge. Pt
remained
on Apixaban 5mg bid with no missed doses. Underwent repeat
cardioversion on ___.
Pt started to feel unwell several days after last cardioversion,
diagnosed w/ PNA and treated w/ azithromycin since ___. Seen by
her cardiologist in clinic ___, and noted to again be in AF.
Cardiologist increased amiodarone dose, stopped metoprolol, and
sent patient for admission for IV diuresis and plan for repeat
cardioversion.
In the ED:
Patient was noted to be breathing comfortably and asymptomatic
while lying down. States she feels lightheaded/dizzy and gets
short of breath easily when attempting to ambulate. Denied chest
pain, palpitations, abd pain, diarrhea, dysuria
Vitals: 97.4 70 104/42 18 97% RA
Exam: patient is deaf in left ear and has central field
blindness
in left eye (macular ___. Crackles in lower lung fields, 2+
b/l ___ edema.
Labs: Cr 1.4, BNP 2505
Studies:
#ECG: Rate 70, V-paced
#CXR
1. Mild pulmonary vascular congestion, but no frank pulmonary
edema.
2. Left basilar/retrocardiac atelectasis.
3. No definite focal consolidations.
Given:
___ 15:43 PO/NG Amiodarone 200 mg
REVIEW OF SYSTEMS: as per HPI, otherwise 10 point ROS negative
On the floor, she has no major complaints. Notes her breathing
is
still not great with exertion but is okay at rest.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PACING/ICD: Complete Heart Block s/p ddd ___ pacemaker
___
- aortic stenosis
- type B aortic dissection
3. OTHER PAST MEDICAL HISTORY:
- large PE ___ on coumadin
- Mitral regurgitation
- Left CVA ___
- COPD/Asthma not on home O2
- GERD, hiatal hernia
- Temporal arteritis
- Chronic back pain
- Compression fracture
- osteoarthritis, Rheumatoid arthritis
- Osteoporosis
- Macular degeneration
Social History:
___
Family History:
Mother died of a stroke. Father had MI in his ___.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
================
___ Temp: 97.4 PO BP: 153/70 L Sitting HR: 70 RR: 20
O2
sat: 96% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Well appearing, NAD.
HEENT: PERRL, MMM.
NECK: No significant JVD elevation
CARDIAC: nl s1/s2, rrr, no m/r/g.
LUNGS: Trace rales in the lower lung fields bl
ABDOMEN: NT, ND, normal bs.
EXTREMITIES: Warm, well perfused. Bl trace-1+ pitting edema
SKIN: No significant rashes.
PULSES: Distal pulses palpable and symmetric.
DISHCARGE EXAM:
-----------------
Temp: 97.6 (Tm 97.7), BP: 103/67 (100-127/49-77), HR: 80
(70-80), RR: 18 (___), O2 sat: 92% (91-96), O2 delivery: Ra
GENERAL: Well appearing, NAD
HEENT: PERRL, MMM.
NECK: JVP approx. 10cm
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no crackles, wheezes, rales
ABDOMEN: Soft, non tender, non distended
EXTREMITIES: Warm, well perfused, trace ___ edema
SKIN: No significant rashes
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
Admission Labs:
-----------------
___ 03:06PM GLUCOSE-83 UREA N-16 CREAT-1.4* SODIUM-140
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
___ 03:06PM estGFR-Using this
___ 03:06PM ALT(SGPT)-11 AST(SGOT)-29 LD(LDH)-427* ALK
PHOS-107* TOT BILI-1.1
___ 03:06PM cTropnT-<0.01
___ 03:06PM proBNP-2505*
___ 03:06PM ALBUMIN-3.2*
___ 03:06PM WBC-6.8 RBC-4.37 HGB-14.1 HCT-43.8 MCV-100*
MCH-32.3* MCHC-32.2 RDW-14.1 RDWSD-51.9*
___ 03:06PM NEUTS-71.6* LYMPHS-15.3* MONOS-10.0 EOS-1.0
BASOS-0.9 IM ___ AbsNeut-4.86 AbsLymp-1.04* AbsMono-0.68
AbsEos-0.07 AbsBaso-0.06
___ 03:06PM PLT COUNT-139*
___ 03:06PM ___ PTT-31.8 ___
Imaging:
CXR: ___
IMPRESSION:
1. Mild pulmonary vascular congestion, but no frank pulmonary
edema.
2. Left basilar/retrocardiac atelectasis.
3. No definite focal consolidations.
TTE: ___
The left atrium is SEVERELY dilated. The right atrium is
markedly enlarged. There is moderate
symmetric left ventricular hypertrophy with a normal cavity
size. Overall left ventricular systolic
function is moderately-to-severely depressed (secondary to a
markedly dyssynchronous activation
sequence (pacing-induced). The visually estimated left
ventricular ejection fraction is 30%. There is no
resting left ventricular outflow tract gradient. The right
ventricular free wall is hypertrophied. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic arch
is mildly dilated. An aortic valve
bioprosthesis is present. The prosthesis is well seated with
normal gradient. There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is
severe mitral annular calcification. There is no mitral valve
stenosis. There is mild to moderate [___]
mitral regurgitation. Due to acoustic shadowing, the severity of
mitral regurgitation could be
UNDERestimated. The tricuspid valve leaflets appear structurally
normal. There is moderate [2+]
tricuspid regurgitation. Due to acoustic shadowing, the severity
of tricuspid regurgitation may be
UNDERestimated. There is mild pulmonary artery systolic
hypertension. There is no pericardial
effusion.
Compared with the prior TTE ___, the findings are similar
(LVEF overestimated in prior
study).
Discharge Labs:
___ 06:23AM BLOOD WBC-6.4 RBC-4.28 Hgb-14.1 Hct-42.9
MCV-100* MCH-32.9* MCHC-32.9 RDW-14.2 RDWSD-51.7* Plt ___
___ 06:23AM BLOOD WBC-6.4 RBC-4.28 Hgb-14.1 Hct-42.9
MCV-100* MCH-32.9* MCHC-32.9 RDW-14.2 RDWSD-51.7* Plt ___
___ 06:23AM BLOOD Plt ___
___ 06:23AM BLOOD Glucose-118* UreaN-22* Creat-1.5* Na-143
K-4.3 Cl-101 HCO3-31 AnGap-11
___ 03:06PM BLOOD ALT-11 AST-29 LD(LDH)-427* AlkPhos-107*
TotBili-1.1
___ 06:23AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a history of aortic
stenosis (s/p TAVR ___, type-B aortic dissection and PE in
___, CHB (s/p dual chamber PPM ___, and recurrent atrial
fibrillation who presents as a direct admit for volume overload
in the setting of recurrent AF.
She was recently admitted ___ for elective cardioversion
for AF and was found to be in CHF exacerbation. During that
admission, her reduced EF had recovered to normal. She developed
recurrent afib during her device interrogation prior to
discharge. She remained on Apixaban 5mg bid with no missed
doses. Underwent repeat cardioversion on ___.
She started to feel unwell several days after last
cardioversion, diagnosed w/ PNA and treated w/ azithromycin
since ___. Seen by her cardiologist in clinic ___, and was
noted to again be in AF. Cardiologist increased amiodarone dose,
stopped metoprolol, and sent patient for admission for IV
diuresis and planned for repeat cardioversion.
ACTIVE ISSUES:
===============
# HFrEF w/ recovered EF
Although Ms. ___ present exacerbation was mild with a
BNP(2505) only slightly higher than her baseline and oxygen
requirements that were short lived, she has had frequent CHF
exacerbations since her pacer was placed. This is was suspected
to be caused by ventricular dyssynchrony, which may be amenable
by upgrading her pacer to BiV. We repeated her TTE during
admission as her previous TTE was improperly read with an EF of
50%. The repeat TTE showed a correct EF of 30% which made her
eligible to upgrade her pace to BiV. Her home dose of torsemide
is 60mg QD; during her hospital stay, we gave her IV diuretics
before switching her to PO torsemide 80mg QD. She was sent home
on this dose.
Beta blockers were held during this admission due to her low
heart rate. She would be a candidate for BiV pacing.
# Persistent AF
S/p multiple admissions for cardioversion, most recently
discharged ___, when she reverted back in AF only 6 days after
cardioversion. Patient was V paced during her hospital stay. She
was given Amiodarone 200 TID which managed her AF. She did not
need cardio conversion during this hospital stay. Her metoprolol
was held and apixaban was continued. A TTE was done and showed
an EF of 30%, thus is eligible for BiV conversion outpatient.
CHRONIC ISSUES:
================
# PNA
She was s/p a recent course of azithromycin. Currently
asymptomatic, afebrile, and
without clear evidence of pulmonary process on imaging. This was
not an issue during this hospitalization.
# CAD
She had a cath in ___ showing mild CAD. She was on Atorva 10mg
daily during this hospitalization.
# COPD:
She was continued on her home tiotropium.
# Hypothyroidism:
She was continued on her home levothyroxine
# History of pulmonary emboli
She was continued on her home apixiban
# GERD
She was continued on her home Omeprazole
# Type B Aortic Dissection
Chest CT w/ stable, calcified type B dissection demonstrated at
prior admission. Dilation of 5.2 cm
TRANSITIONAL ISSUES:
===================
[] Please follow up on any electrolyte abnormalities that may be
caused by increased dose of diuretics
[] The patient will need her BMP followed up in 7 days
[] her apixaban may need to be adjusted back to full dose 5mg
BID which was reduced on the day of discharge to 2.5mg due to
her cr. of 1.5
[] She had her torsemide dose reduced and will need this
adjusted due to concern that it may be overdiuresing her
[] She will need to have an evaluation for BiV pacing due to her
HFrEF of 30%
Discharge Weight: 89.8kg
Discharge Hgb: 14.1
Discharge Cr. 1.5
Discharge code status: Full code (attempt resuscitation)
Contact Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 37.5 mcg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Torsemide 60 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Apixaban 5 mg PO BID
6. Amiodarone 200 mg PO TID
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. budesonide 0.5 mg/2 mL inhalation DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Torsemide 80 mg PO DAILY
3. Amiodarone 200 mg PO TID
4. Atorvastatin 10 mg PO QPM
5. budesonide 0.5 mg/2 mL inhalation DAILY
6. Levothyroxine Sodium 37.5 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
- HFrEF (EF 30%)
- Persistent AF
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- When you were seen by your cardiologist in clinic, it was
noted that your heart had an abnormal rhythm (atrial
fibrillation). You were admitted into the hospital to treat your
abnormal rhythm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We increased the dose of your anti-arrhythmic drug and watched
you closely. We also gave you water pills to help reduce the
strain on your heart.
- If your anti-arrhythmic drug didn't work, we would shock your
heart to put it back into the correct rhythm. Luckily, there was
no need to shock your heart.
- We did an ultrasound of your heart which showed us that your
ejection fraction was 30%. This makes you eligible for an
upgraded pacemaker which should help prevent future abnormal
rhythms of your heart.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your appointments
with your doctors.
- ***Weigh yourself every morning, call MD if weight goes up
more than 3 lbs. ****
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10635271-DS-26
| 10,635,271 | 29,717,450 |
DS
| 26 |
2144-01-29 00:00:00
|
2144-01-30 10:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / lisinopril
Attending: ___.
Chief Complaint:
RLE wound
Major Surgical or Invasive Procedure:
right heart catheterization ___
History of Present Illness:
___ woman w/history of CHB
___ pacemaker, AS ___ TAVR, persistent AF, HFrEF (LVEF 30% on
TTE
___ ___ CRT-P upgrade in ___, who presents with right
leg
wound. Her right lower extremity was shut in a car door about 1
month ago and she now has a large non-healing wound which
appears
to be possibly infected. She states that the RLE wound has
become
swollen and has been bleeding (no pus). She notes no swelling in
her LLE. She denies fevers or chills.
Of note, she endorses dysuria over several weeks, no hematuria,
for which she had a urine culture taken at ___ on
___ growing E. coli MDR (no sensitivities on documentation).
She has been on a 7 day course of Macrobid during this time. She
states that over the past four days she has felt increasingly
lethargic and fatigued, thus prompting presentation to ___. She feels that her RLE has gotten worse as
well.
At ___, Tib/fib xray was done showing large
soft tissue wound/ulcer, but no osteomyelitis or bony
abnormality. She received vancomycin and ceftriaxone prior to
transfer. She was subsequently transferred to ___ as it is
felt
that she will eventually need a skin graft to close her wound.
On further assessment, she endorses pain along the distribution
of her right flank with radiation to RUQ of her abdomen. She
states that she has previously experienced Shingles rash along
that distribution and that her symptoms are consistent with her
history. she denies acute changes in her breathing (has new O2
requirement to 4L over past few months), cough, abdominal pain,
vomiting, weakness, numbness, tingling.
In the ED:
- Initial vital signs: 97.5 94 102/62 20 96% 4L NC
- Exam: Dermatologic: large nonhealing wound/ulcer on R lower
leg. some surrounding erythema
- Labs: no leukocytosis, H/H 10.3/33.6, INR 1.3, normal
electrolytes, UA >182 WBC, few bacteria, lg leuks. Blood, urine
cx pending
- Studies: None
- Meds: Zosyn 4.5 grams, APAP 1000 mg
- Consults: Vascular surgery: Obtain NIAEs, plastics consult in
AM.
- Vitals on transfer: 70 110/46 18 94% 5L NC
Upon arrival to the floor, pt endorses the history above.
ROS: Complete ROS obtained and is otherwise negative.
Past Medical History:
- Dyslipidemia
- Hypertension
- PACING/ICD: Complete Heart Block ___ ddd ___ pacemaker
___
- aortic stenosis
- atrial fibrillation
- type B aortic dissection
- large PE ___ on coumadin
- Mitral regurgitation
- Left CVA ___
- COPD/Asthma, on home O2 4L
- GERD, hiatal hernia
- Temporal arteritis
- Chronic back pain
- Compression fracture
- osteoarthritis, Rheumatoid arthritis
- Osteoporosis
- Macular degeneration
Social History:
___
Family History:
Mother died of a stroke. Father had MI in his ___. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
=====================
ADMISSION PHYSICAL EXAM
=====================
VITALS: 97.6PO 110 / 55 71 18 89 4L
GENERAL: Alert and interactive. In no acute distress. AAOx3
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Cataracts bilaterally
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Crackles at bases L >R. No wheezes or rhonchi. No
increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, tenderness to
palpation in suprapubic region. No rebound/guarding
EXTREMITIES: No clubbing or cyanosis. 2+ pitting edema
bilaterally. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No vesicular rash along abdomen or back. Large RLE
ulceration, with minor blood loss, with surrounding erythema,
warmth, tender to palpation. No visible bone.
NEUROLOGIC: ___ strength throughout. Normal sensation. AOx3.
======================
DISCHARGE PHYSICAL EXAM
======================
VS: T 97.4 BP 90 / 44 HR 72 RR 18 O2 Sat 95 3L
GENERAL: Alert and interactive. Lying in bed with NC in
place. In no acute distress.
HEENT: NCAT. Sclera anicteric and without injection. JVP 8-10cm
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Mild crackles at bilateral lung bases with left > right.
Good air movement.
ABDOMEN: Normal bowels sounds, non distended, non-tender
EXTREMITIES: WWP. Large lower extremities trace lower extremity
edema. Right lower extremities mildly tender to palpation. Large
RLE ulceration is wrapped, dressing c/d/I.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 08:07PM ___ PTT-30.7 ___
___ 08:07PM PLT COUNT-156
___ 08:07PM NEUTS-74.2* LYMPHS-9.8* MONOS-13.4* EOS-1.0
BASOS-0.3 IM ___ AbsNeut-4.60 AbsLymp-0.61* AbsMono-0.83*
AbsEos-0.06 AbsBaso-0.02
___ 08:07PM WBC-6.2 RBC-3.66* HGB-11.5 HCT-36.5 MCV-100*
MCH-31.4 MCHC-31.5* RDW-15.1 RDWSD-55.8*
___ 08:07PM estGFR-Using this
___ 08:07PM GLUCOSE-86 UREA N-11 CREAT-1.1 SODIUM-137
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-31 ANION GAP-8*
___ 09:55PM ___ PTT-26.1 ___
___ 09:55PM PLT COUNT-163
___ 09:55PM NEUTS-76.8* LYMPHS-8.4* MONOS-12.5 EOS-1.2
BASOS-0.1 IM ___ AbsNeut-5.21 AbsLymp-0.57* AbsMono-0.85*
AbsEos-0.08 AbsBaso-0.01
___ 09:55PM WBC-6.8 RBC-3.41* HGB-10.3* HCT-33.6* MCV-99*
MCH-30.2 MCHC-30.7* RDW-15.2 RDWSD-54.8*
___ 09:55PM proBNP-1630*
___ 09:55PM GLUCOSE-82 UREA N-10 CREAT-1.1 SODIUM-145
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-31 ANION GAP-11
___ 10:30PM URINE WBCCLUMP-FEW* MUCOUS-RARE*
___ 10:30PM URINE HYALINE-1*
___ 10:30PM URINE RBC-19* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-1
___ 10:30PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-LG*
___ 10:30PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:30PM URINE UHOLD-HOLD
___ 10:30PM URINE HOURS-RANDOM
================
PERTINENT STUDIES
================
NON-INVASIVE PERIPHERAL ARTERIAL STUDY ___:
1. Limited exam. No evidence of flow limiting stenosis in
either lower
extremities.
TTE ___
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg.
There is mild symmetric left ventricular hypertrophy with a
small cavity. There is normal regional and global
left ventricular systolic function. Overall left ventricular
systolic function is hyperdynamic. 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 low normal free wall motion. The
aortic sinus is mildly dilated with moderately
dilated ascending aorta. The aortic arch is mildly dilated. An
aortic valve bioprosthesis is present. The
prosthesis is well seated with normal leaflet motion and
gradient. There is a paravalvular jet of mild [1+]
aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
severe mitral annular calcification. There is mild functional
mitral stenosis from the prominent mitral annular
calcification. There is mild [1+] mitral regurgitation. Due to
acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The tricuspid valve
leaflets appear structurally normal. There is mild
to moderate [___] tricuspid regurgitation. Due to acoustic
shadowing, the severity of tricuspid regurgitation
may be UNDERestimated. There is moderate pulmonary artery
systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Normal right ventricular cavity
size with low-normal systolic function. Well seated
bioprosthetic aortic valve replacement with
normal transvalvular gradients and mild paravalvular aortic
regurgitation. Mild symmetric left
ventricular hypertrophy with normal cavity size, and
hyperdynamic regional/global systolic
function. At least mild to moderate tricuspid regurgitation.
Mild mitral regurgitation.
Compared with the prior TTE ___ , the estimated pulmonary
artery systolic pressure is now higher.
BILAT LOWER EXT VEINS ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. The right peroneal veins were not visualized.
CTA chest ___
1. Finding suggests mild congestive heart failure with vascular
congestion
and bilateral pleural effusions. Mild-to-moderate atelectasis
at each lung
base.
2. Markedly enlarged central pulmonary arteries, as seen
previously, which is
concerning for underlying pulmonary arterial hypertension.
Similar thin web
across the interlobar pulmonary artery which may be somewhat
obstructing, but
unchanged. No evidence for recent pulmonary embolism although
web could be
seen in association with more remote prior thromboembolic
disease.
3. Stable dilatation of the ascending aorta. Status post
endovascular aortic
stent placement. No substantial change in findings associated
with type B
dissection including degree of dilatation of the descending
thoracic aorta.
R heart catheterization ___
Elevated left heart filling pressure.
Moderate pulmonary hypertension.
PA ___ (35)
PCW mean 19, A wave 24, V wave 10
RA mean 6, A wave 7, V wave 10
RV systolic 51, diastolic 1, end diastolic 5, dP/dt 624
TTE ___
The left ventricle has a normal cavity size. There is normal
regional and global left ventricular systolic
function. Left ventricular cardiac index is normal (>2.5
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 is mildly
dilated with moderately dilated ascending aorta. An aortic valve
bioprosthesis is present. The prosthesis is well
seated with normal leaflet motion and gradient. The effective
orifice area index is moderately reduced
(0.65-0.90 cm2/m2). There is trace aortic regurgitation. The
mitral valve leaflets are mildly thickened with no
mitral valve prolapse. There is moderate mitral annular
calcification. There is mild [1+] mitral regurgitation.
Due to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Well seated, normal functioning bioprosthetic aortic
valve with normal gradient and
trace aortic regurgitation. Mildly thickened mitral leaflets
with mild mitral regurgitation. Mild
pulmonary artery hypertension. Dilated ascending aorta.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
============
MICROBIOLOGY
============
__________________________________________________________
___ 5:17 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:05 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. PREDOMINATING
ORGANISM.
INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
__________________________________________________________
___ 5:39 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:40 pm BLOOD CULTURE Random.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:12 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:31 pm BLOOD CULTURE Source: Venipuncture #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:09 am BLOOD CULTURE Source: Line-RUE PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:27 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:02 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ AT
1747 ON
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 5:56 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0010.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 5:10 pm BLOOD CULTURE Source: Line-PICC 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ 14:25.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 5:09 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 10:04 am SWAB Source: RLE wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
=============
DISCHARGE LABS
=============
___ 02:16PM BLOOD Genta-1.5* Vanco-21.3*
___ 07:15AM BLOOD Vanco-27.8*
___ 09:35AM BLOOD Vanco-20.6*
___ 08:07PM ___ PTT-30.7 ___
___ 06:06AM BLOOD WBC-6.4 RBC-2.58* Hgb-8.0* Hct-25.7*
MCV-100* MCH-31.0 MCHC-31.1* RDW-15.9* RDWSD-57.9* Plt ___
___ 06:06AM BLOOD ___ PTT-38.0* ___
___ 06:06AM BLOOD Glucose-95 UreaN-17 Creat-1.4* Na-141
K-3.3* Cl-98 HCO3-32 AnGap-11
___ 06:06AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1
___ 09:35AM BLOOD Vanco-18.5
___ 06:06AM BLOOD Vanco-15.2
Brief Hospital Course:
Ms. ___ is a ___ woman w/history of CHB ___
pacemaker, AS ___ TAVR, persistent AF, HFrEF (LVEF 30% on TTE
___ ___ CRT-P upgrade in ___, who presents with large
RLE non-healing wound. Her course has been complicated by acute
on chronic hypoxic respiratory failure. She was also found to
have S. epidermidis bacteremia as well as pseudomonal UTI.
ACUTE ISSUES:
=============
#RLE non-healing wound, stable
Patient reports that right lower extremity was shut in a car
door about 1 month ago and she has since developed a large
non-healing ulceration with minor bleeding. OSH Tib/fib x-ray
did not appear to have bony abnormality concerning for
osteomyelitis, and her wound on exam appears to be more
superficial and non-infected with BCx negative. Non-invasive
arterial study showed no flow limiting stenosis in either ___.
Plastics plans to see patient in ___ weeks as outpatient with
consideration for possible wound vac placement. For wound care,
would recommend placing dry gauze daily.
#Acute on chronic hypoxic respiratory failure
#Acute on chronic heart failure with recovered EF
#<oderate pulmonary hypertension
Patient presented with new O2 requirement to 4L over the past
several months, likely in the setting of underlying COPD and
heart failure with recovered EF. Prior to presentation, she had
been on ___ NC in ___. On admission, she was satting
mid-90s on 4L. Progression of heart failure likely etiology,
given echo showing increased PA pressure and X-ray showing mild
pulmonary edema & effusions (endorses PND, orthopnea, has bl
crackles). CTA ruled out PE (was on supoptimal dose of apixaban,
had non-pitting ___ edema), confirmed mild vascular congestion,
pleural effusions and pulmonary hypertension. There was no
obvious evidence of pneumonia. There was low suspicion for COPD
exacerbation but she was treated empirically with prednisone and
azithromycin given tenuous respiratory status. RHC showed
elevated L filling pressures but only mildly elevated pulmonary
arterial pressures and normal R filling pressures, likely
indicating diastolic HF is contributing to both her hypoxia and
pulmonary HTN observed on echo/CTA. She was maintained on lasix
drip and transitioned to PO torsemide on discharge- 60mg daily -
with plan to weigh daily and uptitrate or downtritrate as
needed. She was able to maintain her electrolytes within normal
limits for most of the stay although she should have her
electrolytes checked within a week of discharge to ensure
adequate repletion of potassium and magnesium. Her metoprolol
was held on discharge due to hypotension during hospital stay.
Her discharge requirement was about 2L-3L O2 NC but when
titrated to goal O2 > 88%, it could be weaned down to 1L NC.
#S. epidermidis bacteremia
BCx initially drawn on ___ given hypotension. BCx ___,
___ (all from RUE ___) grew S. epidermidis. Previously
had cultures from ___ which had no growth. Her PICC is the
likely source of this. TTE ___ was without vegetations and
patient declines TEE. PICC removed evening of ___. Blood
cultures with NGTD since ___. She was initially treated with
triple therapy (Vancomycin, gentamicin, and rifampin) but was
transitioned to Vancomycin and should complete on ___ but
notably has been supratherapeutic and required vancomycin dosing
1g every ___ days. She last received a dose on ___. On ___,
please draw vancomycin trough. If < 15, redose 1g vancomycin
again for last dose.
#pseudomonas urinary tract infection
#Hypotension
Leukocytosis ___ prompted repeat UA which showed 30 WBCs,
large leuk esterase but negative nitrite. Patient complaining of
dysuria. Concerning for UTI. She was intially treated with
vancomycin and ultimately was discharged with plan to complete
ceftazidime 1g q24h dosing on ___.
#constipation:
continued bowel reg: senna, Miralax, bisacodyl PR. Then had
diarrhea as a result and was given psyllium and discontinued on
bowel regimen. Monitor as able.
#anemia, stable
Hgb 10.3 on arrival, lower than recent baseline of ~13. RLE
wound with minor bleeding as above. Macrocytosis to 100 but
B12/folate within normal limits. She was discharged on every
other day iron for iron deficiency anemia.
#Post-herpetic neuralgia
Reports on-and-off sharp, burning pain along right flank with
radiation to RUQ along the distribution of a former treated
shingles rash. Exam without vesicular rash though pain can
precede acute zoster rash; of note, patient was not treated with
gabapentin or valcyclovir and did not have any further symptoms.
# GOC: transitioned to DNR/DNI on ___. Patient is amenable to
nasal BIPAP. Molst form done.
#atrial fibrillation: Most recent EKG showing sinus rhythm. She
was continued on Amiodarone 200mg BID and metoprolol succinate
12.5 mg PO daily was held as aboe due to hypotension. She was
briefly maintained on warfarin due to rifampin interaction but
should be restarted on apixaban on ___.
CHRONIC ISSUES:
===============
# Hypothyroidism: TSH within normal limits. Continued
Levothyroxine 37.5mg daily
# HLD: Continued aspirin and atorvastatin 10mg QPM
# COPD: Continued standing fluticasone-salmeterol diskus,
tiotropium inhalers with Duonebs, albuterol nebs PRN
# GERD: Continued omeprazole 20mg daily
TRANSITIONAL ISSUES
=============
Discharge weight: Bed weight 94.1kg ( 207.45 lb )
Discharge Cr: 1.4
Discharge O2 requirement: ___ NC, goal > 88%
Medications:
Regarding antibiotics:
[] Please check vanc trough @ 4PM on ___. If level < 15,
then re-dose vancomycin 1g. Otherwise ok not to dose Vancomycin
if her vanc trough is >15 as she has only required one dose of
vanc every ___ days to maintain goal trough. She last received
vanc on ___.
[] Please dose ceftazidime 1g on ___ and ___
[] Please restart apixaban on ___
Regarding diuresis:
[] Discharged on torsemide 60mg daily
-- Please weigh daily and adjust as needed. Follow up at
outpatient clinic.
Other medications:
[] Alteplase as needed for PICC flow problems
[] Artificial tears for dry eyes
[] Sodium chloride nasal spray for dry nose
[] Calcium carbonate for heart burn
[] Iron every other day for iron deficiency anemia
[] Multivitamin with minerals for malnutrition
[] Psyllium as needed for diarrhea
[] Ramelteon as needed for insomnia
Other:
[] Please remove PICC after completion of ceftazidime
[] Please check electrolytes within ___ days of discharge and
replete electrolytes as needed to K > 4 and Mg > 2
#CODE: DNR/DNI
#CONTACT: Daughter, ___, ___
___ is clinically stable for discharge today. On
the day of discharge, greater than 30 minutes were spent on the
planning, coordination, and communication of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Omeprazole 20 mg PO DAILY
4. Levothyroxine Sodium 37.5 mcg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Amiodarone 200 mg PO BID
7. Apixaban 2.5 mg PO BID
8. Torsemide 40 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
12. ProSource (amino ac-protein hydr-whey pro;<br>calcium
caseinate-whey;<br>protein) ___ gram-kcal/30 mL oral DAILY
13. budesonide 0.5 mg/2 mL inhalation BID
14. Docusate Sodium 100 mg PO DAILY
15. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Medications:
1. Alteplase 1mg/2mL ( Clearance ie. PICC, midline, tunneled
access line, PA ) 1 mg IV ONCE PER LUMEN (2 LUMEN)
2. Artificial Tears ___ DROP BOTH EYES PRN dryness
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. CefTAZidime 250 mg IV Q24H Duration: 3 Days
5. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Psyllium Wafer 1 WAF PO DAILY
8. Ramelteon 8 mg PO QHS
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness
10. Torsemide 60 mg PO DAILY
11. Vancomycin 1000 mg IV Q 24H
Give on ___ if trough <15
12. Amiodarone 200 mg PO BID
13. Apixaban 2.5 mg PO BID
Start on ___. Aspirin 81 mg PO DAILY
15. Atorvastatin 10 mg PO QPM
16. Budesonide 0.5 mg/2 mL inhalation BID
17. Docusate Sodium 100 mg PO DAILY
18. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
19. Levothyroxine Sodium 37.5 mcg PO DAILY
20. LOPERamide 2 mg PO QID:PRN diarrhea
21. Omeprazole 20 mg PO DAILY
22. Potassium Chloride 20 mEq PO DAILY
23. ProSource (amino ac-protein hydr-whey pro;<br>calcium
caseinate-whey;<br>protein) ___ gram-kcal/30 mL oral DAILY
24. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
================
PRIMARY DIAGNOSIS
================
RLE wound
acute on chronic hypoxic respiratory failure
===================
SECONDARY DIAGNOSIS
===================
S. epidermidis bacteremia
Pseudomonas UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were here because of a wound in your right lower leg. Our
plastic surgeons followed you for the wound while you were here
did not feel that a wound vac was needed at this time. You will
likely need surgery for this wound in the future. While you are
here you were also having difficulty breathing and required
supplemental oxygen. For this issue you had a number of tests
including an echocardiogram and a right heart catheterization.
Results of these tests and expert opinion from our cardiologists
and pulmonologists suggested that your trouble breathing was due
to excess fluid. We gave you medications, Lasix and torsemide,
which are water pills to help get rid of the excess fluid. You
are now breathing better at your baseline and will be on a
taking a water pill on discharge. Unfortunately while you were
here you developed an infection in your blood. You were started
on Vancomycin which will complete on ___. You also developed a
urinary tract infection and were started on Ceftazidime, which
will finish on ___. After you finish this antibiotic, you can
have your PICC removed.
You do not need to see Infections Disease when you leave the
hospital. However, we would like you to see your cardiologist
and your plastic surgeon (see below for phone numbers for
appointments).
After you leave the hospital, you should take all of your
medications as prescribed and attend your follow-up
appointments.
Weigh yourself every morning, and call MD if weight goes up more
than 3 lbs.
We wish you the best in the future!
Your ___ team.
Followup Instructions:
___
|
10635380-DS-6
| 10,635,380 | 24,390,566 |
DS
| 6 |
2140-06-28 00:00:00
|
2140-06-28 14:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Lisinopril / Cialis
Attending: ___
Chief Complaint:
speech problem
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo man with a history of ICH from an AVM
s/p embolization, afib/aflutter on anticoagulation, HTN, DM type
1, and recent fall who presents to the ED with progressive
speech
difficulty over the past week.
One week ago he was found down in the elevator of his
independent
living facility. His wife ___ find him in the apartment and
ultimately found him sitting in the elevator. His fall was
unwitnessed and it is unknown if he hit his head or had LOC
though he has an abrasion on the back of his neck. He presented
to the ___ ED where he had an elevated lactate and was in afib
with HR of ___ at presentation (converted to sinus
spontaneously). He was observed overnight and was seen by
cardiology for pre-syncope workup, who recommended Holter
monitor
for further evaluation of his arrhythmia.
At baseline he does have some word finding difficulty. But since
discharge home from ED-obs, the patient has had progressively
worsening speech difficulty. It has been getting worse on a
daily
basis. For example, yesterday his wife asked him to exchange $20
for quarters at the bank and waited in the car outside. The bank
teller came out to the car to tell her that he was unable to
appropriately convey to her what he needed at the bank. This
morning, he awoke at 8am and sat at the edge of the bed. He
couldn't speak and was having trouble finding the correct words
to say. He couldn't say his wife's name. Wife was concerned his
BG was low, but his sugar was checked and was 94. She gave him
OJ
and brought him to the ED.
Review of Systems: unable to obtain given his aphasia
Past Medical History:
- Hypertension.
- Type 1 diabetes on insulin.
- Intracerebral hemorrhage secondary to AVM s/p embolization
and CyberKnife therapy in ___. Repeat angiogram without
evidence of other avms and noted complete obliteration of the
previously identified AVM
- Atrial flutter and afib diagnosed on ___ s/p
cardioversion in ___. On anticoagulation
- Dementia
Social History:
___
Family History:
- maternal aunt with ___ disease
Physical Exam:
ADMISSION EXAMINATION
Vitals: 98.5 93 122/58 18 100% RA
FSBG: 413
General: Awake, cooperative, NAD.
HEENT: healing abrasion on posterior neck
Pulmonary: breathing comfortably on RA
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert. Speech is fluent but non-sensical. Unable
to relate history. + paraphasias. Unable to name any objects on
the stroke card. Difficulty with comprehension and makes
mistakes
with multistep and crossed body commands. Able to repeat 3 word
phrase (with repeated prompting) but makes mistakes with longer
phrases. Able to read a sentence. Speech was not dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm bilaterally. VFF to confrontation with
finger wiggling.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift bilaterally. No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 4+ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2+ 2 2 1 0
- Toes were downgoing bilaterally.
-Sensory: No deficits to light touch, pinprick throughout.
?Decreased vibration at feet (exam confounded by aphasia). No
extinction to DSS.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride. Romberg
absent.
=====================================================
DISCHARGE EXAMINATION
Vitals: 97.6 66 136/48 22 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Pulmonary: normal WOB
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended, nontender
Extremities: no edema, warm
Skin: no lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert. Difficulty with word finding. Unable
to relate history. Unable to name high and low frequency
objects. Difficulty with comprehension and makes mistakes with
multistep and crossed body commands. Able to follow simple
commands, and perseverates with the 3 word commands, being able
to register ___, recall ___ at 1 minute, but ___ at 5 minutes
even with clues given.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm bilaterally.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: Symmetric upper and lower facial musculature bilaterally
VIII: Hearing intact to voice
IX, X: Palate elevates symmetrically.
XI: ___ in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
-Sensory: No deficits to light touch bilaterally in upper and
lower extremities.
-Coordination: postural tremor.
-Gait: Good initiation. Narrow-based, normal stride.
Pertinent Results:
======
LABS:
======
___ 10:17AM BLOOD WBC-7.1 RBC-3.98* Hgb-12.7* Hct-37.2*
MCV-94 MCH-31.9 MCHC-34.1 RDW-12.3 RDWSD-42.4 Plt ___
___ 06:10AM BLOOD WBC-5.2 RBC-3.70* Hgb-11.5* Hct-35.2*
MCV-95 MCH-31.1 MCHC-32.7 RDW-12.5 RDWSD-42.8 Plt ___
___ 10:17AM BLOOD Plt ___
___ 10:22AM BLOOD ___ PTT-35.2 ___
___ 06:10AM BLOOD Plt ___
___ 05:50PM BLOOD Glucose-391* UreaN-15 Creat-1.0 Na-133
K-4.5 Cl-94* HCO3-29 AnGap-15
___ 06:10AM BLOOD Glucose-113* UreaN-13 Creat-0.9 Na-142
K-4.5 Cl-105 HCO3-29 AnGap-13
___ 10:25AM BLOOD estGFR-Using this
___ 06:10AM BLOOD estGFR-Using this
___ 05:50PM BLOOD ALT-12 AST-15 LD(LDH)-185 AlkPhos-63
TotBili-0.6
___ 05:50PM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.0 Mg-2.0
Cholest-138
___ 06:10AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
___ 05:50PM BLOOD %HbA1c-9.3* eAG-220*
___ 05:50PM BLOOD Triglyc-44 HDL-69 CHOL/HD-2.0 LDLcalc-60
___ 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:06AM BLOOD ___ pH-7.39 Comment-GREEN TOP
___ 10:23AM BLOOD Glucose-362* Na-134 K-4.4 Cl-95*
calHCO3-24
___ 02:06AM BLOOD Glucose-208* Lactate-0.9 Na-135 K-4.2
Cl-99 calHCO3-26
=========
NEURO IMAGING
=========
.
CT HEAD W/O CONTRAST - ___
No acute intracranial abnormalities. Status post left frontal
lobe AVM
embolization. Evaluation of adjacent parenchyma is limited due
to streak
artifact. Chronic infarcts and progression of age-related
involutional changes.
.
CTA HEAD W&W/O CONTRAST - ___
Dental and left frontal AVM embolization material artifact
limits
examination. Bilateral carotid artery bifurcation
atherosclerotic disease as described without definite stenosis
by NASCET criteria. No evidence of aneurysm greater than 3 mm,
dissection or vascular malformation. Probable pulmonary scarring
as described. Recommend clinical correlation. If clinically
indicated, consider dedicated chest imaging. Paranasal sinus
disease as described. 1.3 x 3.4 x 2.7 right anterior neck
lipoma.
.
MR HEAD W/O CONTRAST - ___
Gyriform diffusion-weighted hyperintense signal with associated
increase
FLAIR hyperintensity and cortical thickness of the left frontal
operculum and orbital frontal gyri surrounding the previously
embolized left frontal AVM. The combination of findings would
suggest potential postictal/ischemic sequela. Infectious
etiology is not entirely excluded, although considered less
likely and clinical correlation is recommended. Otherwise, no
evidence of acute intracranial hemorrhage or infarct.
Unremarkable MRA brain.
.
================
EEG
===============
.
EEG - ___
This is an abnormal continuous video-EEG owing to frequent
highly focal electrographic seizures emerging from the left
frontopolar region: up to 15/hr improving to approximately
6-9/hr with the addition of lacosamide to levetiracetam. Rare
left hemisphere epileptiform discharges, maximal in the
centroparietal region. Continuous theta and delta left
hemispheric slowing. Occasional bursts of
frontally-predominantly left or left greater than right delta
slowing.
.
EEG - ___
This is an abnormal continuous video EEG owing to frequent
highly focal electrographic seizures emerging from the left
frontopolar region: up to 6/hr improving to approximately 5/hr
over the course of the study. Continuous left great than right,
delta and theta slowing of the
background. Compared with the previous epoch, this represents a
significant improvement in seizure frequency.
.
EEG - ___
This is an abnormal continuous video EEG owing to frequent
highly
focal electrographic seizures emerging from the left frontopolar
region: up to 6/hr improving to approximately 5/hr over the
course of the study. Compared with the previous epoch, this
represents a significant improvement in seizure frequency.
.
EEG - ___
This continuous video EEG study captured multiple pushbutton
activations for decreased responsiveness and one for left upper
extremity twitching, but none of these was associated with any
significant change on EEG. No electrographic seizures were seen.
Occasional broad-based left parasagittal epileptiform discharges
were noted. The background findings
suggested a moderate diffuse encephalopathy.
.
EEG - ___
This continuous video EEG study captured multiple pushbutton
activations for decreased responsiveness and lower extremity
movements, but none of these was associated with any significant
change on EEG. No
electrographic seizures were seen. Multifocal isolated
epileptiform
discharges were seen, predominantly from the left central
region, occasionally in semi-periodic runs, but never with any
ictal evolution. The background findings suggested a moderate
diffuse encephalopathy.
.
EEG - ___
This is an abnormal continuous video EEG study due to rare,
blunted epileptiform discharges, predominantly in the left
central region. There were no electrographic seizures. The
background findings suggested a mild diffuse encephalopathy,
non-specific as to etiology. Compared to yesterday's recording,
this study showed significantly fewer epileptiform discharges,
no semi-periodic runs of discharges, and no symptomatic
pushbutton activations.
.
EEG - ___
This is an abnormal continuous video EEG study due to a slow,
disorganized background with bursts of generalized slowing.
These findings indicate a mild diffuse encephalopathy,
non-specific as to etiology. No epileptiform discharges or
electrographic seizures were seen.
.
==================
EKG
==================
ECG - ___
Sinus rhythm. Non-specific septal T wave abnormalities. Delayed
precordial R wave progression. Low limb lead voltage. Compared
to tracing #1 sinus rhythm has replaced atrial flutter. The
appearance of an old inferior wall myocardial infarction is no
longer present.
.
ECG - ___
Sinus rhythm. Left axis deviation. Left atrial enlargement.
Delayed
precordial R wave progression. Left anterior fascicular block.
Non-specific septal and lateral T wave abnormalities. Low limb
lead voltage. Compared to the previous tracing of ___ the
findings are similar.
.
ECG - ___
Baseline artifact. Sinus rhythm. Marked left axis deviation.
Late R wave
progression. Compared to the previous tracing of ___ the
rate is now
somewhat faster. Otherwise, no change. Artifact is more
prominent.
.
ECG - ___
Atrial flutter with rapid ventricular response, new as compared
to the previous tracing of ___. Otherwise, no diagnostic
interim change. Clinical correlation is suggested.
.
==================
NON NEUROLOGIC IMAGING
=================
CXR - ___
No focal consolidation. Slight coarsening of markings at both
lung bases raises the possibility of early post aspiration
changes, but no definite infiltrate is identified. Known upper
zone infiltrates are noted, but not especially well demonstrated
due to technical factors.
.
CXR - ___
In comparison with the earlier study of this date, there is an
placement of a Dobhoff tube with the opaque tip straddling or
just distal to the
esophagogastric junction. For optimal positioning, the tube
should be pushed forward about 5-10 cm. Little change in the
appearance of the heart and lungs.
Brief Hospital Course:
___ is a ___ yo man with a history of ICH from an AVM
s/p embolization, afib/aflutter on anticoagulation, HTN, DM type
1, and recent fall one week ago. He presented to the ED with
progressive speech difficulty over one week. On his previous
admission, he was admitted after an unwitnessed fall with slow
atrial fibrillation and observed overnight by cardiology for
pre-syncope workup. He had progressive difficulty with speech
worsened from baseline since then prompting re-presentation to
the ED.
.
# Seizures leading to aphasia
During this admission, he continued to have a fluent aphasia
with nonsensical speech and impaired comprehension. His MRI
brain was negative for stroke but did show abnormal Flair
enhancement around his known left frontal AVM suspicious for
post-ictal changes. He was connected to cvEEG which showed
multiple ongoing seizures that required multiple AEDs to
control. At maximum, he was on ___, Lacosamide, and
Clonazepam. With this combination, seizure control was obtained
but he became very sedated, causing difficulty with secretions
and dysphagia. After discontinuing clonazepam and Lacosamide,
his sedation improved and he remained seizure free. At the time
of discharge he was alert, with improvement in his speech but
persistent deficits in comprehension with multistep commands,
perseverating with three word commands, short term memory, and
naming of both high and low frequency objects.
.
# Hyperglycemia; Poorly controlled DM
During this admission, he had fluctuating PO intake due to
dysphagia which lead to inadequate control of his finger stick
glucoses with sliding scale. At the highest, the patient had
finger stick glucoses in the 400s. As he was originally admitted
for stroke workup - his HbA1C was sent and returned at 9.3.
___ consult was obtained and they decreased his Lantus to 8
units and adjusted his sliding scale appropriately. They will
continue to follow his as an outpatient. The patient will
continue to check his finger sticks premeal after discharge.
.
# Afib with RVR
The patient went into rapid ventricular response several times
during this admission requiring IV metoprolol with good
response. This was thought to be due to delayed medication
administration in the setting of intermittent dysphagia from
somnolence. He was discharged on his home diltiazem dose.
.
# Dysphagia
Pt had dysphagia in the setting of seizures and sedation from
AEDs. Due to this, he briefly required NG/Dobhoff tube with tube
feeds. He was re-evaluated by speech therapy and he was approved
for soft diet and thin liquids at the time of discharge.
.
# TRANSITIONAL ISSUES
- Follow up with Neurology
- Finger stick glucoses and ___ outpatient follow up - Lantus
- Started ___ 2000mg BID
- Soft diet and thin liquids - Re-evaluation needed by speech
therapy
- Physical therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Hyzaar (losartan-hydrochlorothiazide) 50-12.5 mg oral DAILY
3. Rivaroxaban 20 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Donepezil 10 mg PO QHS
3. Rivaroxaban 20 mg PO DAILY
4. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. LeVETiracetam ___ mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Seizure
Secondary:
1. HTN
2. Atrial fibrillation.
3. DM type I
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of word finding difficulty
concerning for a stroke. We have imaged your brain with CT and
MRI which did not show evidence of stroke. We also checked your
risk factors for stroke which were well controlled. However your
MRI showed changes around your prior AVM site which were
concerning for seizure. You had an EEG study to check your brain
waves for seizure activity which showed multiple seizures in an
hour. We have treated you with 2 antiepileptic drugs to stop the
seizures and have now reduced them to one drug named ___
which you will take 2000mg twice per day. Your clinical status
as well as your brain waves have shown significant improvement.
We have contacted your primary neurologist Dr. ___ to update
him on your status. We have also made you appointment with an
epileptologist to follow this new issue.
Your course has been complicated by issues with glucose control.
For this, the ___ doctors have ___ following daily and given
you some recommendations that we will detail for the rehab
facility.
We have continued your cardiovascular medications as previous.
Instructions:
1. Please continue all your medications as directed by this
document.
2. Please keep your follow up appoitments as below.
3. Please do not hesitate to call with questions.
Instructions:
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Followup Instructions:
___
|
10635441-DS-7
| 10,635,441 | 27,536,393 |
DS
| 7 |
2117-04-08 00:00:00
|
2117-04-07 08:51:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
intubation, mechanical ventilation
History of Present Illness:
Neurology Resident Stroke Admission Note
Time/Date the patient was last known well: ___ at 10PM
Pre-stroke mRS ___ social history for description):
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: on
anticoagulation, outside tPA window
Endovascular intervention: []Yes [x]No
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
HPI:
EU Critical ___, AKA ___, is a ___ year old man with
a
history of HTN, AF on Coumadin, who presents from OSH with
unresponsiveness and left sided weakness.
History is obtained from OSH records as patient is intubated,
sedated, and unable to recount history. Last known well was 10PM
yesterday evening, when patient went to bed. Wife noticed at
around 3AM that he was "grunting in bed," unable to speak. Per
EMS report, he was unresponsive on the scene, fixed right gaze,
moving right side only during transport. He was transported to
___. He was intubated for airway protection in the ED.
CT
at ___ showed image findings concerning for right MCA syndrome.
INR on presentation was 1.9. Given anticoagulation and outside
tPA window, no intervention was made at this time. In addition,
patient was felt to not be a candidate for thrombectomy given
presence of CT findings indicative of already evolving infarct.
He was transported to ___ for further management. En route,
per
EMS staff starting to move the left arm/leg. Bradycardic to ___
on propofol, decreased to 20 from 30, leading to vent
dyssynchrony.
Past Medical History:
HTN
AF on coumadin
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
General: intubated, sedated
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: irregularly irregular, no M/R/G
Pulmonary: bibasilar crackles
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination: (on propofol for CT)
- Mental status: eye open to sternal rub. does not follow
commands.
- Cranial Nerves: PERRL 3->2. BTT not able to be elicited. Right
gaze preference with intact VORs. Corneals intact bilaterally.
+Cough/gag. No obvious facial asymmetry within limits of the
ETT.
- Sensorimotor: Moves right side spontaneously. Withdraws
RUE/RLE
to noxious. LUE extension to noxious, LLE triple flexion.
- Reflexes: upgoing toe on left
- Coordination/Gait: untested
===================================================
DISCHARGE PHYSICAL EXAM:
Patient appears comfortable, eyes open to voice, attempts to
speak. Shakes head no to questions about pain.
Pertinent Results:
===ADMISSION LABS===
___ 08:00AM BLOOD WBC-7.6 RBC-4.72 Hgb-15.6 Hct-47.2
MCV-100* MCH-33.1* MCHC-33.1 RDW-15.5 RDWSD-57.1* Plt ___
___ 08:00AM BLOOD Neuts-69.3 Lymphs-14.1* Monos-14.3*
Eos-1.6 Baso-0.4 Im ___ AbsNeut-5.25 AbsLymp-1.07*
AbsMono-1.08* AbsEos-0.12 AbsBaso-0.03
___ 08:00AM BLOOD Glucose-87 UreaN-32* Creat-1.1 Na-142
K-4.5 Cl-107 HCO3-20* AnGap-20
___ 03:40PM BLOOD ALT-28 AST-31 LD(LDH)-216 CK(CPK)-51
AlkPhos-89 TotBili-1.4
___ 03:40PM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:40PM BLOOD %HbA1c-5.3 eAG-105
___ 03:40PM BLOOD Triglyc-92 HDL-47 CHOL/HD-3.5 LDLcalc-98
___ 03:40PM BLOOD TSH-2.7
___ 01:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
IMAGING:
___ CTA Head and Neck
CT shows loss of grey white differentiation in the right MCA
territory. No significant edema. There is a right distal M1/M2
cutoff.
___ MRI
1. Evolution of subacute infarction in the distribution of the
right middle cerebral artery with hemorrhagic transformation.
2. Subacute infarction in the distribution of the right anterior
cerebral
artery with hemorrhagic transformation.
3. Effacement of the right lateral ventricle without midline
shift.
Brief Hospital Course:
Mr. ___ was admitted to the Neuro ICU as he was intubated at
OSH for airway protection. He was extubated within hours of
arrival in the ICU. He had briefly been on dopamine gtt due to
hypotension after atropine in the ED, which resolved and he did
not need any further hemodynamic support during his ICU stay.
He was treated with permissive hypertension, ASA 81, and
warfarin was held.
He failed bedside swallow evaluation and NG tube was placed. Pt
was started on TFs and received PO meds through NGT. He was
subsequently transferred to the ___ on ___. While in ___,
patient was seen to have intermittent O2 desaturations overnight
with increased pleural effusions on CXR treated with extra doses
of Lasix. He was also seen to have aberrations in his heart rate
requiring adjustment of his home Metoprolol. On ___, he
underwent NCHCT which showed apparent R MCA infarct with
associated hemorrhagic conversion. ASA was subsequently held due
to risk of further bleeding. On echocardiogram, patient was seen
to have severe LV global systolic dysfunction (chronic in
nature) and due to concern for potential LV thrombus underwent
repeat limited Echo with contrast which revealed no thrombi. His
hospital course was complicated by volume overload in the
setting of severe congestive heart failure with reduced ejection
fraction (24%), as well as pneumonia, hypernatremia. He had
waxing and waning mental status in the setting of infection and
metabolic derangements, which persisted despite aggressive
treatment. On ___, a family meeting was held regarding his
overall goals of care; the family was very certain that the
patient would not have wanted to have life sustaining measures
given that he was unlikely to be able to ambulate or have an
independent life. After deliberation, the family decided to
pursue comfort care measures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
2. Hyoscyamine 0.125 mg SL QID:PRN excess secretions
3. LORazepam 0.5-2 mg PO Q2H:PRN anxiety/distress
4. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory
distress
5. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
6. Scopolamine Patch 1 PTCH TD Q72H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA syndrome
Discharge Condition:
CMO
Discharge Instructions:
Dear Mr. ___,
You were admitted with left sided weakness, and were found to
have a large stroke. This was likely due to a large blood clot
resulting from your atrial fibrillation. Due to the size of the
stroke and its location, the prognosis is very poor. After
careful discussion with your family, we decided to focus on
maximizing your comfort to help you pass naturally.
It was a pleasure taking care of you.
Sincerely,
___ Neurology
Followup Instructions:
___
|
10635795-DS-6
| 10,635,795 | 24,730,613 |
DS
| 6 |
2134-01-14 00:00:00
|
2134-01-17 09:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg pain, palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female past medical history significant for LLE DVT
just diagnosed on ___ started on Lovenox (70mg BID)
presenting to the emergency department with worsening of her
left knee pain. She reports this pain had started 6 weeks ago
and initial ___ ultrasound did not show a thrombus. When the pain
continued, she had a repeat ultrasound on ___ at
___ which showed a DVT in the left popliteal and femoral
veins. She was started on therapeutic lovenox. She continued to
have LLE pain in her popliteal fossa which then extended to her
left thigh. She presented to the ED as recommended by her PCP.
Patient denies any chest pain or shortness of breath. Patient
denies any numbness, weakness, tingling. Patient denies any
hemoptysis or recent immobility. In the ED, initial vitals were:
T 99.3, HR 145, BP 164/89, RR 18,
Sat 100% RA
- Labs unremarkable
- Imaging was notable for:
CTA chest: Pulmonary arteries are well opacified to the
subsegmental level, with evidence of filling defect within the
main, right pulmonary artery lobar and subsegmental lobar,
segmental or subsegmental pulmonary arteries. The main and right
pulmonary arteries are normal in caliber, and there is no
evidence of right heart strain.
- EKG showed sinus tachycardia to the 130s without evidence of
strain. Normal axis. No ST segment changes.
- Patient was given: 1L NS.
Upon arrival to the floor, patient confirms the above history.
Continues to have tenderness in the left popliteal fossa which
extends to the left thigh. No numbness or tingling. Strength is
normal. Pain worse with walking. Denies SOB, cough, hemoptysis.
Denies personal history of clots. No history of malignancy or
family history of malignancy. Has a maternal aunt who passed
away from "clots" in her ___ but unclear what the exact cause
was. Maternal great grandmother with breast cancer. She is up to
date with malignancy screening with her last pap smear last year
which she reports was normal. Takes OCPs but no history of
smoking
Past Medical History:
IBS-Constipation
Vitamin B12 Deficiency
Dysmenorrhea
Ovarian cyst s/p rupture
Social History:
___
Family History:
Has a maternal aunt who passed away from "clots" in her ___ but
unclear what the exact cause was. Maternal great grandmother
with breast cancer.
Physical Exam:
ADMISSION:
24 HR Data (last updated ___ @ 1608)
Temp: 98.0 (Tm 98.0), BP: 150/90, HR: 117, RR: 18, O2 sat:
97%, O2 delivery: Ra
GENERAL: Very pleasant ___ female resting in bed
with NAD.
HEENT: NC/AT. no scleral icterus or conjunctival injection.
MMM.
CARDIAC: Tachycardic with regular rhythm. Normal S1, S2. No
MRGs.
LUNGS: No increased WOB. CTAB. No wheezes, rales, rhonchi
ABDOMEN: Hyperactive BS. Soft, NT, ND.
EXTREMITIES: Left lower extremity with TTP in the left calf,
popliteal fossa and thigh. WWP. Pulses in ___ 2+.
NEUROLOGIC: Alert and oriented. Moving all extremities with
purpose.
SKIN: No lesions identified.
DISCHARGE:
___ 0424 Temp: 98.2 PO BP: 112/75 HR: 70 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: Alert and oriented, no acute distress
ENT: NT/AC, PERRLA, EOMI
CV: Tachycardic, regular rhythm, no murmurs, rubs, or gallops
RESP: CTAB
GI: NT/ND, BS+
Extremities: Warm, distal pulses intact. RLE non-edematous, LLE
with trace edema in the calf. Strength and sensation intact
bilaterally.
Pertinent Results:
ADMISSION LABS
___ 09:57AM ___ PTT-89.5* ___
___ 09:57AM PLT COUNT-200
___ 09:57AM NEUTS-61.7 ___ MONOS-4.8* EOS-1.8
BASOS-0.2 IM ___ AbsNeut-3.77 AbsLymp-1.89 AbsMono-0.29
AbsEos-0.11 AbsBaso-0.01
___ 09:57AM WBC-6.1 RBC-5.33* HGB-13.1 HCT-41.3 MCV-78*
MCH-24.6* MCHC-31.7* RDW-12.2 RDWSD-34.4*
___ 09:57AM HCG-<5
___ 09:57AM ALBUMIN-4.2
___ 09:57AM proBNP-52
___ 09:57AM cTropnT-<0.01
___ 09:57AM LIPASE-32
___ 09:57AM ALT(SGPT)-18 AST(SGOT)-22 ALK PHOS-91 TOT
BILI-0.3
___ 09:57AM estGFR-Using this
___ 09:57AM GLUCOSE-92 UREA N-9 CREAT-1.0 SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-21* ANION GAP-18
DISCHARGE LABS:
___ 06:02AM BLOOD WBC-3.2* RBC-4.52 Hgb-11.2 Hct-35.3
MCV-78* MCH-24.8* MCHC-31.7* RDW-12.4 RDWSD-35.1 Plt ___
Brief Hospital Course:
SUMMARY
=======
___ female past medical history significant for LLE DVT
just diagnosed on ___ started on Lovenox (70mg BID) who
presented with in ___ pain and bilateral pulmonary embolism while
on lovenox without evidence of right heart strain. She also was
tachycardic on admission, which resolved with IV fluid
administration and good PO intake.
ACUTE ISSUES
============
#Bilateral Pulmonary Embolism
#DVT
#Sinus Tachycardia
LLE femoral and popliteal DVT diagnosed on ___ and started on
therapeutic lovenox. Has had progression of her DVT and
diagnosed with PE in the main, right pulmonary artery lobar and
subsegmental lobar, segmental or subsegmental pulmonary
arteries. No evidence of right heart strain. VSS aside from
sinus tachycardia, which improved after fluids and
anticoagulation. Not entirely clear whether PE was asymptomatic
and preceded Lovenox or if it developed while on Lovenox. Pt has
one family member (aunt) who died from potential clotting
disorder. No other problems with clotting in the past. On OCP,
but does not smoke. She was initially placed on a heparin drip
and transitioned to Apixaban. Plan for outpatient follow-up with
hematology for hypercoagulability workup due to unprovoked DVT
and possible development of PE while on lovenox treatment.
#Hgb Drop
Likely dilutional in the setting of IVF administration, as plt
and WBC went down as well. No signs/symptoms of bleeding, and
Hgb normalized.
CHRONIC/RESOVLED ISSUES
=======================
#IBS-C
Currently stable. Has used Linzess in the past to positive
effect, no longer on this med now. Occasionally uses mag citrate
when constipated for several days. No issues this admission
#Vitamin B12 deficiency:
- Continued home vitamin B12 100mcg daily
TRANSITIONAL ISSUES
===================
[] Follow up with hematology on ___ for hypercoagulability
workup.
[] Follow up with OB/GYN to change to a new contraceptive
regimen in light of recent unprovoked DVT/PE.
[] WBC 3.5 on discharge. Likely dilutional in the setting of
recent IVF administration, although WBC didn't improve like Hgb
and Plt did after 24 hr without therapy. Repeat in 1 month to
ensure normalization.
[] Continue to watch for signs/symptoms of bleeding with new
anticoagulation regimen.
# CODE: Full (presumed)
# CONTACT: ___ (Mother): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg (74 tabs) asdir tablets(s) by mouth
asdir Disp #*1 Dose Pack Refills:*0
2. Cyanocobalamin 100 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pulmonary Embolism
Secondary:
-Deep Vein Thrombosis
-Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had increased leg pain from your blood clot in your leg
and a high heart rate. You were found to have a pulmonary
embolism.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given IV fluids and we monitored your heart rate,
which came down to normal levels.
- You were treated with IV medication to thin your blood and
then changed to an oral blood thinner called Apixaban (or
Eliquis), which you will continue to take for the next 6 months
or until directed to stop by hematology.
- We stopped your oral contraceptive because they can increase
the risk of future blood clots.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You should follow up with hematology as below.
- You should also follow up with your new PCP, ___, as
below.
- You should follow up with your OB/GYN Dr. ___ to discuss
___ contraceptive options.
- Continue to take all your medicines including your Apixaban as
directed.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10636107-DS-22
| 10,636,107 | 20,812,092 |
DS
| 22 |
2183-08-22 00:00:00
|
2183-08-22 15:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
allopurinol / Cephalosporins
Attending: ___.
Chief Complaint:
gangrenous infection of left second toe
Major Surgical or Invasive Procedure:
1. left second toe amputation (___)
History of Present Illness:
Mr. ___ is a ___ with known PAD, DM who was scheduled for a
left second toe amputation for nonhealing toe ulcer w/ chronic
osteomyelitis to take place ___ but who cancelled surgery due
to fears about losing his toe. Today he was evaluated by his
podiatrist as an outpatient who determined that the wound
warranted evaluation in the emergency department and thus
directed him to the ___ ED.
Today Mr. ___ reports that he feels well other than occasional
pain in the left second toe at the site of the ulcer. He
describes
the pain as "twinge like" and intermittent. He also endorses a
small wound on the right third toe which he states has been
present for several weeks but is not painful. He denies
fevers/chills, abdominal pain, diarrhea, nausea/vomiting.
Past Medical History:
DIALYSIS
GOUT
ATRIAL FIBRILLATION on coumadin
HYPERPARATHYROIDISM
Cataract
Dry senile macular degeneration
ONC History:
History of melanoma: L flank 0.7mm/IV/ no ulc/no mitoses exc 1
cm margins ___ Stage1A
History of squamous cell carcinoma of skin: in-situ: R and L
forearm, R helical rim ___
History of basal cell carcinoma: upper back exc ___
Social History:
___
Family History:
Brother No Significant Medical History
Father ___
Mother died after childbirth
Physical Exam:
DISCHARGE EXAM:
Gen - NAD, resting comfortably in bed, AAOx3
HEENT - MMM
Cardio - RRR
Pulm - nonlabored breathing on RA
Abd - soft, NT, ND
LLE - ___ toe amp site incision site c/d/I, no purulence or
active drainage, no erythema
Pulses - L: p/p/p/p R: p/p/p/p
Pertinent Results:
___ 11:20AM BLOOD Glucose-90 UreaN-17 Creat-5.0* Na-136
K-3.9 Cl-94* HCO3-28 AnGap-18
___ 07:00AM BLOOD Glucose-88 UreaN-29* Creat-6.5*# Na-137
K-4.0 Cl-96 HCO3-25 AnGap-20
___ 04:26PM BLOOD ___ PTT-77.4* ___
___ 10:03AM BLOOD ___
___ 10:24AM BLOOD ___ PTT-47.8* ___
___ 11:20AM BLOOD Neuts-74.3* Lymphs-11.9* Monos-11.3
Eos-1.7 Baso-0.4 Im ___ AbsNeut-7.65* AbsLymp-1.23
AbsMono-1.16* AbsEos-0.18 AbsBaso-0.04
___ 11:20AM BLOOD WBC-10.3* RBC-3.43* Hgb-11.5* Hct-33.5*
MCV-98# MCH-33.5* MCHC-34.3 RDW-13.0 RDWSD-46.5* Plt ___
___ 07:00AM BLOOD WBC-9.2 RBC-3.31* Hgb-11.0* Hct-31.6*
MCV-96 MCH-33.2* MCHC-34.8 RDW-13.0 RDWSD-44.9 Plt ___
___ 08:45AM BLOOD WBC-10.9* RBC-3.10* Hgb-10.4* Hct-30.0*
MCV-97 MCH-33.5* MCHC-34.7 RDW-13.2 RDWSD-46.5* Plt ___
___ 08:45AM BLOOD Glucose-97 UreaN-28* Creat-6.0*# Na-134
K-4.6 Cl-93* HCO3-26 AnGap-20
___ 08:45AM BLOOD Calcium-10.0 Phos-3.9 Mg-2.2
___ 5:42 pm TISSUE LEFT SECOND TOE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
STAPH AUREUS COAG +. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Brief Hospital Course:
The patient was admitted to the vascular surgery service after
presenting with gangrenous infection of his left second toe. He
was started on IV antibiotics (cipro, flagyl, and vanc dosed at
hemodialysis). His INR was noted to be supratherapeutic at 8.8
upon admission so he was given 5mg IV vitamin K in preparation
for upcoming surgery. He was then taken to the operating room
the following day for left second toe amputation, which he
tolerated well. His INR the morning of surgery was 2.4 and he
received an additional 1mg vitamin K prior to the procedure. He
remained hemodynamically stable and afebrile. He tolerated a
regular diet, voided appropriately, and worked with physical
therapy. On POD 2(day of discharge), he was transitioned to oral
antibiotics Minocycline, Cipro, and Flagyl to complete a 14-day
course. His INR on day of discharge was 1.5 so his coumadin was
3mg.
He will follow up in vascular surgery clinic in 2 weeks.
Medications on Admission:
TORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth
daily - (Prescribed by Other Provider)
CINACALCET [SENSIPAR] - Sensipar 60 mg tablet. tablet(s) by
mouth
- (Prescribed by Other Provider)
EPOETIN ALFA [EPOGEN] - Dosage uncertain - (Prescribed by Other
Provider; given at HD )
FLUOROURACIL - fluorouracil 5 % topical cream. apply to scar at
left dorsal forearm twice a day use for 6 weeks, use small
amount
only
METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth one daily -
(Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1
capsule(s) by mouth twice a day - (Prescribed by Other
Provider)
SEVELAMER CARBONATE [RENVELA] - Renvela 800 mg tablet. 2
tablet(s) by mouth three times a day with meals - (Prescribed
by
Other Provider)
TIMOLOL MALEATE - timolol maleate 0.5 % eye drops. 1 drop in
each
eye daily - (Prescribed by Other Provider)
WARFARIN [COUMADIN] - Coumadin 2.5 mg tablet. ___ tablet(s) by
mouth daily/HS 2.5mg on ___, sat all other days is 5mg.
Last
dose of Coumadin ___ pre cath - (Prescribed by Other
Provider)
Medications - OTC
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHRO-VITE] - Nephro-Vite 0.8
mg
tablet. 1 tablet(s) by mouth daily - (Prescribed by Other
Provider)
SENNOSIDES [SENNA] - senna 8.6 mg tablet. 1 tablet(s) by mouth
twice day - (OTC)
VIT C-VIT E-COPPER-ZINC-LUTEIN [PRESERVISION LUTEIN] -
PreserVision Lutein 226 mg-200 unit-5 mg-0.8 mg capsule. 1
capsule(s) by mouth twice a day - (OTC)
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q24H Duration: 14 Days
Please take as directed for 14 days total.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for loose stools.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H Duration: 14 Days
Please take as directed for 14 days total.
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
5. Minocycline 100 mg PO BID Duration: 14 Days
Please take as directed for 14 days total.
RX *minocycline 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
6. Senna 17.2 mg PO HS
Hold for loose stools
RX *sennosides [senna] 8.6 mg 1 tablet by mouth at bedtime Disp
#*40 Tablet Refills:*0
7. walker miscellaneous ONCE
Rolling Walker
Dx: L ___ toe osteomyelitis s/p amputation
Px: good
Duration: 13 months
RX *walker Rolling Walker once Disp #*1 Each Refills:*0
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Metoprolol Tartrate 25 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
14. Warfarin 3 mg PO DAILY16
Please dose Coumadin according to close INR monitoring.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left second toe infection
supratherapeutic INR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the vascular surgery service with an
infection of your left second toe and underwent amputation. You
were treated with IV antibiotics and are being discharged home
to complete a 14-day course of Minocycline, Ciprofloxacin, and
Flagyl. Please follow the discharge directions below:
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
-You should continue taking coumadin with INR checks per your
usual routine. Your INR was very high when you came to the
hospital so your dosing should be done with care.
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage, you
may leave the incision open to air.
Your sutures will remain in for at least 4 weeks. At your
followup appointment, we will see if the incision has healed
enough to remove the sutures.
ACTIVITY: You can use the left heal for transferring weight
while walking but the left foot should otherwise be
non-weight-bearing.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD
DETERMINE IF YOUR SUTURES ARE READY TO BE REMOVED FROM YOUR
AMPUTATION SITE!
IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
SUTURES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT
THE WOUND HAS SUFFICIENTLY HEALED.
Followup Instructions:
___
|
10636690-DS-4
| 10,636,690 | 23,060,726 |
DS
| 4 |
2179-11-10 00:00:00
|
2179-11-11 12:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
CT guided biopsy with ___ of left lung lingual mass
EUS with lymph node biopsy
History of Present Illness:
The pt is a ___ man with medical history of hypertension
who presents to the ED as an outside hospital transfer for
evaluation and management of intracranial bleed.
History of obtained from the patient. He reports was in her
units usual state of health which includes independence in all
activities of daily living until 1 week prior to admission when
he woke up and noticed that his left leg was dragging. He found
it difficult to walk but did not make much out of it. He
thought
that this was from his walk, or not sleeping appropriately as he
sometimes sleeps in the recliner. He denies any pain at that
time. He reports has been ambulating with some difficulty and
felt wobbly but has not had any falls. He denies headache,
double or blurry vision, denies pain, dizziness, numbness. He
reports he has not had incidents like this in the past however
had a similar sensation in his legs when he had the cervical
fusion surgery ___.
Past Medical History:
Hypertension
Cervical fusion ___
Status post cholecystectomy
Prostate cancer status post prostatectomy
Social History:
___
Family History:
Patient reports he has no family and does not know of any
history
of medical disease.
Physical Exam:
VS: T 97.8 BP 146/87 HR 64 RR 18 O2 95%RA
General: NAD
HEENT: EOMI, MMM, neck supple.
CV: RRR S1 and s2 normal
Lungs- CTAB.
Abdomen- Soft NT ND
Extremities- No edema.
Neuro- Alert and oriented, LUE and LLE ___ strength. RUE and
RLE- ___.
Pertinent Results:
___ 04:45PM BLOOD WBC-5.9 RBC-5.04 Hgb-12.8* Hct-42.3
MCV-84 MCH-25.4* MCHC-30.3* RDW-12.8 RDWSD-39.6 Plt ___
___ 07:40AM BLOOD WBC-9.9 RBC-5.12 Hgb-13.6* Hct-42.6
MCV-83 MCH-26.6 MCHC-31.9* RDW-13.3 RDWSD-40.3 Plt ___
___ 04:57PM BLOOD ___ PTT-31.6 ___
___ 04:45PM BLOOD Glucose-104* UreaN-11 Creat-1.1 Na-137
K-4.2 Cl-100 HCO3-24 AnGap-17
___ 07:40AM BLOOD Glucose-87 UreaN-19 Creat-1.1 Na-137
K-5.0 Cl-95*
___ 07:05AM BLOOD ALT-11 AST-22 LD(LDH)-223 CK(CPK)-252
AlkPhos-96 TotBili-0.5
___ 07:05AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:05AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.6 Mg-2.1
Cholest-138
___ 07:05AM BLOOD %HbA1c-5.9 eAG-123
___ 07:05AM BLOOD Triglyc-90 HDL-45 CHOL/HD-3.1 LDLcalc-75
___ 07:05AM BLOOD TSH-0.47
___ 07:20AM BLOOD CEA-5.4* ___
MRI ___:
1. Avidly enhancing lesion in the right basal ganglia measuring
approximately
16 x 20 mm in transverse dimension associated with vasogenic
edema and mild
mass effect, producing narrowing of the right lateral ventricle,
with no
evidence of shifting of the normally midline structures or
hydrocephalus.
This lesion appears slightly heterogeneous with avid areas of
enhancement and
target pattern on the diffusion-weighted images.
2. There is an additional focus of enhancement is noted in the
left temporal
lobe, measuring approximately 6 x 6 mm in transverse dimension.
An equivocal
area of enhancement is visible on the right temporal lobe on the
T1 weighted
images with contrast which is not visible in other sequences,
attention in
this area is advised (image 9, series 14). Given the presence
of at least two
enhancing lesions, the possibility of metastatic disease is a
consideration.
CT Torso ___. Bilateral lung masses as described above in the
setting of severe
emphysema and hilar lymphadenopathy are concerning for
multifocal primary lung
cancer with the differential consideration of metastatic
disease. Few
additional smaller indeterminate lung nodules.
2. Periportal lymphadenopathy could represent metastatic
disease. Dilated
proximal common bile duct, intrahepatic bile ducts, normal
caliber distal
common bile duct. Common bile duct caliber transition may be
from periportal
lymphadenopathy and local mass effect. Underlying infiltrative
lesion cannot
be excluded.
3. Multiple subcentimeter ill-defined hypodense lesions in the
spleen are
nonspecific, but in the setting of malignancy could represent
metastases.
Small indeterminate lesion in the liver.
4. A 5 mm hypodense lesion in the tail of the pancreas is
nonspecific and may
represent a side branch IPMN, however in the setting of
metastatic disease,
metastatic disease should also be considered.
5. Subtle indeterminate T11 vertebral body lesion, may
represent hemangioma.
Pathology ___:
1. Lung, left lingula, biopsy:
2. Lung, left, biopsy: Invasive adenocarcinoma, see note.
Note: Tumor cells are positive for keratin cocktail and CK19,
focally positive for glypican 3, CK7 and
negative for TTF-1, Napsin A, CK20, CDX-2, S100, Hepar1, PSA,
NKX3.1 and P40. The site of
origin of this tumor is unclear. A lung or pancreatico-biliary
origin should be considered.
MRI C-Spine ___:
Small focus of spinal cord hyperintensity on the T2 weighted
images at C4-5.
Susceptibility artifact related to C3-C6 anterior cervical
fusion and
discectomy, with mild spinal canal narrowing at C2-C3 and C6-C7
as detailed
above.
Uncovertebral and facet joint osteophytes result in severe
neural foraminal
narrowing at multiple levels as detailed above.
Brief Hospital Course:
___ left-handed male with history of hypertension
presented with right basal ganglia hyperdensity found to have
left-sided weakness. The appearance on the CT was concerning for
IPH so the patient was initially admitted to the stroke service.
Neurologic exam on admission significant for weakness in the
left deltoid, IP, hamstring, mild left-sided dysmetria. MRI did
not show any evidence of hemorrhage, instead it showed 2
contrast-enhancing lesions in the basal ganglia and temporal
lobe, most likely metastases. With the basal ganglia lesion
responsible for the hyperdensity on CT. A CT torso revealed
bilateral lung masses and hilar lymphadenopathy. Clinically, his
brain lesions are most suspicious for lung metastases. In order
to pursue a tissue diagnosis interventional radiology was
consulted for CT-guided biopsy, which was performed on ___.
Neuro-oncology was consulted as well. Patient was started on
dexamethasone 4 mg daily because of his gait symptoms.
Omeprazole 40 mg daily was started as patient was started on
steroids. Bactrim ppx 1 tab DS MWF was intiated. Per
neuro-oncology, MRI c-spine was performed, and sinemet
25mg/100mg half tab BID was started. Benefit of sinemet is that
it may help with posture and gait. ___ saw patient and
recommended rehab. There was development of an ___, Cr peaked at
1.3 ___, baseline this admission was ~1.0. FeNa was 0.9%,
likely pre-renal. Patient was given 500 cc bolus, Cr downtrended
to 1.2 the next day. Pathology results came back and were
consistent with invasive adenocarcinoma, the tissue of origin
was not clear based on path, per report lung or
pancreato-biliary source should be considered. The patient was
transferred to the oncology hospitalist service from the stroke
service for further management. Oncology was consulted. Checked
PSA, CA ___, and CEA. Recommended additional biopsy. EUS with
biopsy done ___, pathology pending at the time of discharge.
Plan for one treatment of cyberknife next week. He will follow
up with neuro oncology as an outpatient. He will also follow up
with oncology as an outpatient once the final pathology is
complete.
Medications on Admission:
NIFEdipine CR 90 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Carbidopa-Levodopa (___) 0.5 TAB PO BID
4. Dexamethasone 4 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Omeprazole 40 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN Constipation
8. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
steroids
9. NIFEdipine CR 90 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic Cancer of Unknown Primary
Metastatic Brain Lesions
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 in the hospital because you felt weak on the left side
side. CT Imaging of your brain showed something that was
originally concerning for a bleed. However, we did a MRI which
showed that this was in fact a mass in your brain, concerning
for metastatic disease. We did a CT scan of the rest of your
body which showed masses in your lungs as well, which were
concerning for lung cancer. This was biopsied as well as a lymph
node in your abdomen. The biopsy results are still pending. You
were started on steroids to help your symptoms. You were seen by
the neuro oncologists and radiation oncologists.
Followup Instructions:
___
|
10636786-DS-25
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DS
| 25 |
2133-04-05 00:00:00
|
2133-04-14 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
bilateral leg numbness and pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with complex PMH including
pseudotumor cerebri s/p lumbar drain/VPS with multiple
revisions,
low back pain due to lumbar drain with history of peroneal nerve
palsy/foot drop on the left, juvenile rheumatoid arthritis,
bilateral hip bursitis, and hepatitis C who returns to ED for
bilateral leg numbness. Of note, she came to ED with similar
complaints on ___, but left AMA before evaluation could be
completed.
She has multiple complaints today:
1. bilateral leg numbness, difficulty ambulating
2. nausea, not being able to hold anything down (believes due to
pain)
3. difficulty urinating
4. back/leg pain
She reports that ___ was the last time that she felt
that
her legs were baseline. She woke up on ___, had shooting
pain down the left leg to ankle (similar to the pain that she
had
when her lumbar drain was placed, but her previous radicular
pain
had stopped at the knee). Then she developed left leg numbness,
spoke with her pain physician, and went to a retreat in ___.
She tripped and fell quite a few times during the retreat. She
returned home and woke up on ___ with bilateral leg numbness,
as if both legs were "asleep." She banged them against the side
of the bed for 30 minutes until sensations somewhat returned.
She
didn't feel that she could ambulate so "crawled" to her walking
stick. She called on call pain clinic physician and did come to
ED on ___, but left as the ED attending would not give her IV
dilaudid (reports that PO pain medications do not work for her).
Urine issues also started ___ but she called her pain clinic
physician again and mentioned it today. He asked her to come to
ED right away and told her that it could become permanent, so
returned today. She reports that she does have sensation of
needing to urinate, but has difficulty releasing, and urinates
in
spurts. No incontinence. Chronic diarrhea due to IBS, but she
had
no BM for few days. Did have a BM last night.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo.
Denies
difficulties producing or comprehending speech.
+Left ankle weak, tripping. Numbness in the legs as well.
On general review of systems, the pt denies recent fever or
chills. No night sweats. Lost some weight in the last few weeks.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies diarrhea, constipation or
abdominal pain. No dysuria. Denies rash.
Past Medical History:
- JRA at age ___
- HEPATITIS C s/p tx with interferon
- Pseudotumor Cerebri s/p shunt placement and 4 shunt revisions
and back surgeries as well
- History of L peroneal nerve palsy in setting of lumbar drain,
now resolved
- Low back pain/sciatica pain since lumbar drain placement
___
- Headaches from pseudotumor cerebri
- Scoliosis s/p rods; "80% of spine is fused"
- Lumbar stenosis
- Fibromyalgia - new diagnosis
- Tendonitis in both hands/wrists, plantar fasciitis
- DM T2 - borderline
- HLD
- Osteoarthritis
- NSAIDs cause "chemical meningitis"
- ?Seizures - 2 episodes of LOC and tongue biting ___ and
___
Social History:
___
Family History:
Brother/father - ___, Mother passed away from lung cancer,
Grandmother passed away from lung cancer, Aunt had lung lesion
removed. -> all thought to be not related to smoking. Sister had
T2 DM. Depression/Anxiety.
Physical Exam:
ADMISSION EXAM:
Vitals: 98 88 ___ 99% RA
General: Sleeping in bed, arouses to voice without difficulty
HEENT: NC/AT. Mild R hemihypertrophy.
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: obese, soft, nontender.
Extremities: no edema, warm to touch. Diffusely tender to deep
palpation in both arms/legs. Diffuse tenderness to palpation
along the back.
Skin: no rashes or lesions noted.
Neurologic:
- Mental Status: Alert, oriented to person, place and date.
Able
to relate history with good details, but tends to go into other
details about her many medical issues. Attentive to questions
and
examination. Language is fluent with intact comprehension.
Normal
prosody. 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 intact to light touch.
VII: No facial droop, facial musculature slightly asymmetric (R
hypertrophy, baseline per patient).
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. Mild R pronation
(documented in previous neuro notes). No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ ___ 5 4 4
R 5 ___ ___ ___ 5 4 4
*pain limited
-Sensory: Normal pinprick, cold and LT in face/arms. In the
lower
extremities, decreased pinprick, LT and cold in L4-L5
distribution bilaterally (though somewhat preserved pinprick in
big toe space on L). Proprioception intact at the big toes
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Ambulates with a walker, slow, decreased floor clearance.
DISCHARGE EXAM:
- afebrile and stable vital signs throughout admission
- General exam: obese F, cooperative, no acute distress
Neurological Exam
- MS: A&Ox3, language fluent, comprehension intact, good fund of
knowledge
- CN: PERRL, EOMI, facial motor and sensation symmetric
- Motor: normal bulk and tone, ___ motor: full power throughout
- DTR: 2 in UEs B/L, R quad 2, L quad 1, 0 at ankles
- Sensory: light touch is intact over posterior lower leg and
great toe B/L, impaired light touch over anterior shins B/L +
plantar surface + digits ___
- Coord: intact FNF B/L
- Gait: ambulating with and without a walker with no apparent
difficulty
Pertinent Results:
___ 06:29AM BLOOD WBC-8.0# RBC-4.07* Hgb-12.6 Hct-38.1
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.4 Plt ___
___ 02:25PM BLOOD Neuts-73.1* ___ Monos-5.7 Eos-1.0
Baso-0.4
___ 06:29AM BLOOD Glucose-78 UreaN-8 Creat-0.7 Na-143 K-4.0
Cl-107 HCO3-27 AnGap-13
___ 06:29AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.1
___ MR ___ SPINE W and W/O CONTRAST
1. At L4/L5 level, there is disc desiccation and disc
protrusion, causing bilateral neural foraminal narrowing as
described above, more severe towards the left with a possible
disc fragment located posterior to the L4 vertebral body and,
causing narrowing of the left neural foramen.
2. All other multilevel degenerative changes throughout the
lumbar spine remains relatively stable since the prior study,
there is no evidence of abnormal enhancement to indicate are
arachnoiditis.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with complicated PMH including
pseudotumor cerebri s/p multiple lumbar drain/VPS with revisions
who now present with bilateral leg numbness, difficulty
ambulating and urinary complaints.
The bilateral leg numbness does not correspond to a clear nerve
distribution (see exam) and there does not appear to be
associated strength deficits, though the exam is somewhat
limited by pain. The gait difficulty is likely secondary to a
combination of pain and numbness. While she does complain of
urinary difficulty, she has intact sensation, able to urinate
without significant PVR.
Her symptoms improved spontaenously during her admission. She
did have some residual numbness of the feet bilaterally. MR ___
spine: L4/L5 level, there is disc desiccation and disc
protrusion, causing bilateral neural foraminal narrowing as
described above, more severe towards the left with a possible
disc fragment located posterior to the L4 vertebral body and,
causing narrowing of the left neural foramen.
Pt was evaluated by neurosurgery, who conclude: We would agree
with outpatient
management with the ___ injections as well as
weight loss strategies. If conservative management fails to
adequately relieve her pain, would be happy to see her in clinic
as an outpatient to assess her for possible surgical
intervention in the future.
Pt to follow up in pain clinic.
*FINAL DIAGNOSIS: modest L4/5 disk protrusion causing radicular
numbness*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. ClonazePAM 3 mg PO QHS
3. Duloxetine 60 mg PO QAM
4. Duloxetine 30 mg PO QPM
5. Enbrel SureClick (etanercept) 50 mg/mL (0.98 mL) subcutaneous
once every other week
6. Gabapentin 900 mg PO QID
7. Hydroxychloroquine Sulfate 200 mg PO Q48H
8. Omeprazole 20 mg PO BID
9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
10. Tizanidine 12 mg PO QPM
11. Vitamin B Complex 1 CAP PO DAILY
12. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral
twice a day
13. Acetaminophen 650 mg PO HS
14. Ferrous Sulfate 325 mg PO BID
15. LOPERamide 4 mg PO TID:PRN diarrhea
16. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO HS
2. Atorvastatin 40 mg PO DAILY
3. ClonazePAM 3 mg PO QHS
4. Duloxetine 60 mg PO QAM
5. Duloxetine 30 mg PO QPM
6. Ferrous Sulfate 325 mg PO BID
7. Gabapentin 900 mg PO QID
8. Hydroxychloroquine Sulfate 200 mg PO Q48H
9. LOPERamide 4 mg PO TID:PRN diarrhea
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
12. Tizanidine 12 mg PO QPM
13. Vitamin B Complex 1 CAP PO DAILY
14. Calcium Carbonate 1500 mg PO BID
15. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral
twice a day
16. Enbrel SureClick (etanercept) 50 mg/mL (0.98 mL)
subcutaneous once every other week
17. Fish Oil (Omega 3) 1000 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: back pain, lower extremity pain likely due to lower
spine disc fragment
Secondary: pseudotumor cerebri
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized for symptoms of lower extremity numbness,
pain, and difficulty urinating. These symptoms have resolved
spontaneously and it is possible that they resulted from a lower
spine disc fragment seen on MRI. Your right calf pain was most
likely due to a muscle cramp.
Your right leg ultrasound did not show any evidence of clot in
the right calf.
You may resume all prior medications without change.
It was a pleasure caring for you during this hospitalization.
Followup Instructions:
___
|
10636786-DS-26
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| 26 |
2133-04-27 00:00:00
|
2133-04-27 20:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Radiculopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with L4-5 disc herniation presents
with worsening
radiculopathy. Patient was seen as outpatient for evaluation of
disc herniation in which surgery was discussed. She presents
today to the ED with complaints of bilateral radiculopathy and
frequent falls related to bilateral foot drop. She denies any
bowel or bladder, worsening weakness or paraesthesia.
Past Medical History:
- JRA at age ___
- HEPATITIS C s/p tx with interferon
- Pseudotumor Cerebri s/p shunt placement and 4 shunt revisions
and back surgeries as well
- History of L peroneal nerve palsy in setting of lumbar drain,
now resolved
- Low back pain/sciatica pain since lumbar drain placement
___
- Headaches from pseudotumor cerebri
- Scoliosis s/p rods; "80% of spine is fused"
- Lumbar stenosis
- Fibromyalgia - new diagnosis
- Tendonitis in both hands/wrists, plantar fasciitis
- DM T2 - borderline
- HLD
- Osteoarthritis
- NSAIDs cause "chemical meningitis"
- ?Seizures - 2 episodes of LOC and tongue biting ___ and
___
Social History:
___
Family History:
Brother/father - ___, Mother passed away from lung cancer,
Grandmother passed away from lung cancer, Aunt had lung lesion
removed. -> all thought to be not related to smoking. Sister had
T2 DM. Depression/Anxiety.
Physical Exam:
On the day of discharge:
Strength is intact in all extremities ___
Bilat numbness in feet/toes extends at times to knees
Pertinent Results:
MRI ___:
1. Subtle enhancement of the left L4 nerve root, which may be
secondary to inflammatory changes from compression.
2. Multilevel degenerative changes of the lumbar spine, most
prominent at L4-5 where there is a disc extrusion in the left
lateral recess, which contacts the left exiting and a traversing
nerve root. Degenerative findings are unchanged from prior exam.
Brief Hospital Course:
The patient was admitted on ___ for worsening radiculopathy
secondary to known L4-5 disc herniation. On ___ the patient
underwent MRI that showed stable disc protrusion. Throughout
her stay she remained neurologically intact. The patient had
full strength ___ in bilateral upper and lower extremities.
Pt made several demands for IV Dilaudid. She did receive IV
Dilaudid for breakthrough however she made demands for higher
dosing. She reported persistent nausea and vomiting and cited
this as the need for IV pain medications over oral agents.
However the patient was not witnessed to vomit nor was there
evidence of pills or medications in her emesis bin to suggest
that the oral medications were not absorbed.
Patient was seen by the chronic pain service on ___ who
recommended stopping all IV narcotics and obtaining a
psych/addiction specialist consult for the possibility of
inpatient addiction rehab. Psychiatry evaluated the patient.
Patient refused addiction services at this time and psychiatry
saw no contraindication for discharge home.
At the time of discharge is ambulating with a walker, afebrile
with stable vital signs. She will follow up with Dr. ___ in
Pain ___ and follow up as scheduled for her outpatient
surgery with Dr. ___ on ___.
Medications on Admission:
tylenol, loperamide, b-complex, caltratet, cymbalta, enbrel,
atorvastatin, clonazepam, ferrous sulfate, gabapentin,
hydroxychloroquine, omeprazole, zofran, oxycodone
Discharge Medications:
1. Acetaminophen 1000 mg PO QHS
2. Atorvastatin 40 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. ClonazePAM 1.5 mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 60 mg PO BID
8. Ferrous Sulfate 325 mg PO BID
9. Gabapentin 900 mg PO QID
10. Hydroxychloroquine Sulfate 200 mg PO QOD
11. LOPERamide 4 mg PO TID
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*24 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID
15. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L4-5 Herniated nucleus pulposus
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:
L4-5 herniated nucleus pulposus
Dr. ___
¨ Do not smoke.
¨ No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
¨ Take your pain medication as instructed. Pain medication
should be used as needed when you have pain. You do not need to
take it if you do not have pain.
¨ Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
¨ Pain that is continually increasing or not relieved by pain
medicine.
¨ Any weakness, numbness, tingling in your extremities.
¨ Loss of control of bowel or bladder functioning
Followup Instructions:
___
|
10636829-DS-5
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DS
| 5 |
2150-10-05 00:00:00
|
2150-10-05 08:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ankle fracture
Major Surgical or Invasive Procedure:
RIGHT ankle ORIF
History of Present Illness:
___ female with past medical history notable for fibromyalgia and
PVCs (on atenolol) who presents as a transfer from OSH with the
above fracture s/p mechanical fall 2:30 ___ while cleaning her
bulkhead. She denies head strike or LOC. She denies pain in
other extremities or joints. She denies numbness or tingling in
the right lower extremity.
Past Medical History:
See ___
Social History:
___
Family History:
NC
Physical Exam:
General: Well-appearing, breathing comfortably
MSK:
Dressing s/d/I
Compartments soft, compressible
Fires ___, ___, TA
Gross sensation intact
Foot WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a trimalleolar ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF, whichthe 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 home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the operative extremity, and will be discharged on ASA___
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:
See OMR
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin EC 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr prn Disp #*30
Tablet Refills:*0
4. Atenolol 25 mg PO DAILY
5. Savella (milnacipran) 50 mg oral bid
Discharge Disposition:
Home
Discharge Diagnosis:
Ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter andmay be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Aspirin 325 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
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10637168-DS-10
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|
2196-01-24 13:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
incarcerated ventral hernia
Major Surgical or Invasive Procedure:
___ - exploratory laparotomy, lysis of adhesions, reduction
___ - ventral hernia Trach ___ bovina
___ - component separation, skin closure
History of Present Illness:
___ w COPD, DM, hx of prior abdominal surgeries p/w severe
___ abdominal pain which started early this morning
~2am. Pain was sharp, constant, and non-radiating. Patient has a
known ventral hernia but per her son (patient very poor
historian), the hernia is much larger today than when he last
saw
her ___ days ago. She also complains of nausea and multiple
episodes of non-bloody/non-bilious emesis. Has not passed any
flatus for the past two days, and did have a small bowel
movement
this morning however it was diarrhea. Denies fever, chills,
fatigue/malaise, jaundice, melena, hematochezia, or dysuria
Past Medical History:
- Type II Diabetes
- Hypertension
- Diverticulosis w/SBO due to intrapelvic abscess s/p small
bowel resection then subsequent sigmoid colon resection ___
- History of C-section
- Two large parauterine cysts s/p TAH/BSO ___
- History of C.diff colitis (remote ___
- Chronic hypoxia and CO2 retention attributed to obesity
hypoventilation syndrome, diastolic heart failure and possibly
pulmonary hypertension. She requirse 3L home O2.
Social History:
___
Family History:
No known history of heart or lung disease.
Physical Exam:
PE:
99.1 92 94/44 30 96 CPACP PSV 30% ___
Gen: NAD, patient mouths words, obese
CV: RRR
R: distant lung sounds ___ habitus, CTAB anterior lung fields
Abd: soft, obese, + skin closed with whip stitch, + abdominal
binder
Ext: WWP
Pertinent Results:
140 ___ AGap=12
4.2 30 0.6
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 7.8 Mg: 2.0 P: 2.2
Source: Line-PICC
89
16.3 7.8 379
27.0
___
10:00p
Source: Line-PICC
27.5
Brief Hospital Course:
Ms. ___ was taken to surgery the evening she arrived and
underwent an exploratory laparotomy, extensive lysis of
adhesions and reduction ventral hernia. The patient was left
intubated and transferred to the ICU, she was still requiring
pressors at this point. Her skin was closed after this
operation, but her fascia was unable to be approximated.
POD1, there was some concern for seizure activity, neurology was
called, the patient underwent a 20minute EEG with no concerning
findings.
POD2, tube feeds were started via a dobhoff, but residuals were
high so these were held.
POD2-5 - Diuresis was attempted in order to improve the
patient's respiratory status, but she was unable to tolerate it
her urine output responded well, but her pressures would drop.
POD5, the patient was finally able to be weaned off pressors,
but was not able to be weaned from the vent. Given the
patient's pulmonary history and inability to wean, the decision
was made to place a Trach ___ bovina).
POD6-7, diuresis was attempted again, and the patient was still
unable to tolerate, requiring pressors again.
POD7, the patient was taken back the OR for a component
separation and attempted fascial closure, again, the fascia was
unable to be approximated and so the skin and subcutaneous
tissue was closed, but the fascia was not able to be closed.
POD ___, the patient's vent was weaned to pressure support from
CMV with good ___. Her residuals from her tube feeds
decreased and she was advanced to goal. She is able to follow
commands and mouth words. POD9, the patient was given blood for
a drifting hct from which she was asymptomatic. She was started
on vanc/cefepime ___.
Upon discharge her white count was trending down and she was
tolerating tube feeds. She still requires PSV.
Medications on Admission:
- Spiriva 18mcg inh'
- Flovent 220''
- Albuterol neb q6h prn
- Albuterol inh q8h
- Humalog sliding scale
- Humalin 15U qAM, 20U qPM
- Glyburide 10''
- Lisinopril 40'
- Simvastatin 20'
- ASA81'
Discharge Medications:
1. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheezing
2. Bisacodyl ___AILY constipation
3. CefePIME 2 g IV Q12H
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Heparin 5000 UNIT SC TID
9. NPH 15 Units Breakfast
NPH 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Ipratropium Bromide MDI 2 PUFF IH QID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Senna 1 TAB PO BID
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Vancomycin 1000 mg IV Q 8H
15. OxycoDONE-Acetaminophen Elixir ___ mL PO Q6H:PRN pain
16. Lisinopril 40 mg PO DAILY
17. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
small bowel obstruction
incarcerated ventral hernia
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:
You underwent a ventral hernia repair because your hernia was
causing a small bowel obstruction.
Please call your surgeon if you experience, temp > 101.4,
drainage or redness around incision, inability to tolerate feeds
or anything else that concerns you.
Please continue wearing your abdominal binder at all times.
Followup Instructions:
___
|
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2196-02-15 00:00:00
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2196-02-15 13:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of DM, HTN, OSAS, OHS, SBO recently admitted to ___ for
ex-lap and repair of incarcerated ventral hernia c/b respiratory
failure secondary to pna now trached, re-presenting from rehab
with ___.
Please see ACS admission note, but in brief the patient was
recently discharged from ___ on ___ after presenting with
incarcerated ventral hernia, for which she underwent
ex-lap/LOA/reduction of hernia (___), trach (___), VHR with
component separation and closure of skin (unable to close fascia
due to significant loss of domain and bowel edema) (___).
Her hospital course was complicated by a stay in the ICU,
initially on pressors and intubated, and respiratory failure
which necessitated placement of a tracheostomy. Approximately 1
week post-op, pressors were ultimately weaned off and she stable
on the vent (CMV to CPAP at times, per rehab notes). She was
discharged to ___ on ___.
Returns to ED ___ due to Hct drop 25.6 -> 22.6 since
admission. Also has ___ w/ Cr 1.4 from 0.5 w/ decreased UOP. She
has been on vanc/cef since discharge for enterobacter
respiratory infection. Pt reports distended abdomen and pain in
LLQ. Has had several soft bowel movements. Denies nausea,
vomiting. In the ED,the patient had guaiac neg brown stool. FAST
negative. CT abdomen/pelvis demonstrated extensive post op
changes. large ventral hernia without frank obstruction. No well
defined fluid collection. The non-contrast appearance of the
kidneys demonstrates no hydronephrosis and the bladder appeared
unremarkable. Labs noteable for Cr 2.0 from baseline of 0.5.
Patient also had WBC of 15.4, and H/H of 7.3/ ___.9 (at
baseline). In ___, however, her H/H was 12.9/42.2.
Since in the TSICU, the patient's Cr has continued to trend
upward, now 4.3 and become oliguric. Renal is consulted and
thinks possible ATN from recent sepsis. She was trialed on IV
lasix 160mg last night and another dose this AM which she
responded to at 40cc/hr UOP. She also developed hyerkalemia
today which resolved with kayexelate and lasix. Received 1u prbc
for crit 21 on HOD #2.
Currently, patient denies any complaints. She says her breathing
is at baseline.
Past Medical History:
- Type II Diabetes
- Hypertension
- Diverticulosis w/SBO due to intrapelvic abscess s/p small
bowel resection then subsequent sigmoid colon resection ___
- History of C-section
- Two large parauterine cysts s/p TAH/BSO ___
- History of C.diff colitis (remote ___
- Chronic hypoxia and CO2 retention attributed to obesity
hypoventilation syndrome, diastolic heart failure and possibly
pulmonary hypertension. She requirse 3L home O2.
Social History:
___
Family History:
No known history of heart or lung disease.
Physical Exam:
Admission Physical Exam:
========================
Vitals: 98.8, 128/59, 75, 27, 100% on vent CPAP
General: Alert, oriented, no acute distress, mouths words
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Coarse breath sounds bilaterally, no rales, decreased
breath sounds at bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly tender, abdominal binder in place
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 129/61 90 20 100% CPAP at ___
General: Alert, oriented, no acute distress, mouths words
HEENT: Sclera anicteric, MMM, oropharynx clear, dobhoff in place
Neck: supple, no LAD
Lungs: Coarse breath sounds bilaterally, no rales, decreased
breath sounds at bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly tender, abdominal binder in place. No
surrounding erythema.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 07:10PM BLOOD WBC-15.4* RBC-2.88* Hgb-7.3* Hct-25.9*
MCV-90 MCH-25.6* MCHC-28.4* RDW-15.4 Plt ___
___ 07:10PM BLOOD Neuts-81.7* Lymphs-11.2* Monos-5.0
Eos-1.7 Baso-0.5
___ 07:10PM BLOOD ___ PTT-27.3 ___
___ 07:10PM BLOOD Glucose-161* UreaN-27* Creat-2.0* Na-131*
K-5.0 Cl-92* HCO3-27 AnGap-17
___ 03:43AM BLOOD Calcium-8.0* Phos-4.5# Mg-1.8
___ 02:29AM BLOOD calTIBC-126* Ferritn-794* TRF-97*
___ 09:22PM BLOOD Cortsol-21.6*
ADMISSION IMAGING:
==================
___ CT Abd/Pelvis IMPRESSION:
1. Status post multiple surgeries with an extensive
wide-mouthed ventral
hernia through which the majority of the bowel of this patient
resides. Oral contrast is seen up until a portion of the distal
ileum. While there are loops of bowel that measure up to 4.5
cm, there is no frank transition point, suggesting the
dilatation is probably reactive.
2. Extensive surgical changes include subcutaneous edema and
locules of gas as well as generalized anasarca. A collection of
fluid and air directly below the patient's open incision
measures 13.0 x 5.4 x 7.9 cm; the amount of air is substantial
owing to the open defect, however superinfection is not ruled
out, particularly on this non-contrast study.
3. Cholelithiasis without cholecystitis.
___ Renal US
Limited evaluation of the kidneys due to the limited sonographic
window. No hydronephrosis is identified.
___ KUB
Course of the feeding tube is unchanged since ___, ending
in the midline, probably distally in the stomach. There is no
gaseous
distention of the intestinal tract in the upper abdomen.
___ CXR
As compared to the previous radiograph, there is no relevant
change. The tracheostomy tube, the nasogastric tube and the
right PICC line are in unchanged position. The heart remains
slightly enlarged, with signs of bilateral hilar enlargement and
moderate centralized pulmonary edema. No larger pleural
effusions. Small areas of atelectasis at the lung bases. No
pneumonia.
MICROBIOLOGY:
===============
- Urine cultures on ___, and ___ grew yeast. Foley
catheter was changed and surveillance culture on ___ was
negative
- ___ C. dif negative
- ___ and ___ blood cultures negative
- ___ Sputum:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROBACTER AEROGENES. RARE 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.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ACINETOBACTER BAUMANNII
COMPLEX
| | ENTEROBACTER
AEROGENES
| | |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 8 S 8 S <=1 S
CEFTAZIDIME----------- 2 S 16 I 4 S
CEFTRIAXONE----------- 4 R
CIPROFLOXACIN--------- =>4 R =>4 R <=0.25 S
GENTAMICIN------------ 4 S =>16 R <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 4 I =>16 R <=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S =>16 R <=1 S
TRIMETHOPRIM/SULFA---- 8 R <=1 S
DISCHARGE LABS:
===============
___ 03:21AM BLOOD WBC-9.5 RBC-2.78* Hgb-7.1* Hct-25.7*
MCV-92 MCH-25.5* MCHC-27.6* RDW-15.6* Plt ___
___ 03:21AM BLOOD Glucose-103* UreaN-49* Creat-1.3* Na-141
K-3.5 Cl-91* HCO3-42* AnGap-12
___ 03:21AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.5*
___ 03:53AM BLOOD ___ pO2-39* pCO2-91* pH-7.36
calTCO2-54* Base XS-20
Brief Hospital Course:
Ms. ___ is ___ with history of DM, HTN, OSAS, OHS, SBO
recently discharged after attempted repair of incarcerated
hernia ___ and ___ with open fascia complicated by
respiratory failure requiring tracheostomy. She presented from
rehab with with ___ (Cr 2.0 from 0.6 at discharge).
ACTIVE ISSUES:
==============
# ___: Admission creatinine was 2.5, up from 0.6 at her last
discharge. Her Cr peaked at 5.6 on ___ before trending back
down. Given the microscopic appearance of her urine, her ___ was
felt to be consistent with ATN. ATN was likely from
post-operative hypotension and previous sepsis, possibly
exacerbated by lisinopril and vancomycin. Given recent
antibiotics for urosepsis, AIN was considered, but urine
eosinophils were rare, making ATN more likely. Patient was
initially diuresed on a furosemide drip then began to
autodiurese. Hemodialysis was deferred this admission as the
patient's volume and electrolyte status improved with resolution
of her ATN.
# Metabolic Alkalosis: With improvement in her renal function
and auto-diuresis in the setting of resolving ATN, the patient
was noted to be hypochloremic with an elevated bicarbonate
level, thought most likely due to contraction alkalosis. Her
serum bicarb began climbing ___, peaking at 45 on ___. The
patient was treated with acetazolamide intermitently but this
was D/C'd due to lack of effect, and concern for chronic CO2
retention. The patient had a normal pH with a bicarb of 42 at
discharge, which reflects compensation.
# Hyperkalemia: Peaked at 5.6 on ___ before trending down to
normal limits; thought most likely due to her ___. The patient
received intermittent lasix (to improve her urine output, but
eliminating potassium for her system). On day of discharge,
patient's potassium was 3.4 and she was repleted with 40 mEq
prior to transfer.
# Asymptomatic Bacteruria: Patient noted to have bacteria on UA.
Three urine cultures grew yeast only. WBC count remained stable
and the patient afebrile. She had received empiric treatment
with CTX for 7d finishing ___. Her foley was changed and a
surveillance urine culture was negative for yeast and other
organisms.
# Positive Sputum Culture: Patient's sputum showed
sparse-to-rare growth of pseudomonas, acinetobacter baumannii,
and enterobacter aerogenes. Because the growth was not
impressive and the patient was hemodynamically stable without
respiratory complaints or objective distress, these organisms
were felt to represent colonization and patient was not treated.
# Respiratory failure s/p trach: Patient remained stable on PSV.
She was started on trials of trach mask during the day,
tolerating up to 12 hours of trach mask on day prior to
discharge. She was continued on night-time PSV at ___. She was
seen by speech and swallow but could not be fitted with Passey
Muir valve due to increase in tracheal pressures to -20 cm H2O.
Please continue to increase time off of vent and retry ___ valve
at rehab.
# High Tube Feed Residuals: Patient had intermittent high
residuals that did not resolve with change in tube. Abdominal
imaging showed a high stool burden and she was continued on
bowel regimen. Tube feeds were at goal at time of discharge.
# Abdominal Hernia s/p Repair: Wound is closed at skin but
fascia remains open due to bowel edema. Surgery believes the
wound is stable, and that the patient should continue with her
abdominal binder. They would like to see her in outpatient
clinic two weeks post-discharge.
# Anemia: Patient was monitored with HCT transfusion goal of <
21. She received a total of 2 units of pRBC during her
hospitalization.
CHRONIC ISSUES:
===============
# DM2: Continued NPH and HISS.
TRANSITIONAL ISSUES:
====================
- Abdominal Hernia s/p Repair: To see Surgery in outpatient
clinic 2wks post-discharge. Patient must wear abdominal binder
at all times.
- Continue to wean vent
- Reevaluate for ___ valve
- Monitor alkalosis (likely contraction)
- Monitor tube feed residuals
- Monitor electrolytes at least daily for now
- Continue bowel regimen (had large stool burden on imaging)
- PICC line was placed on ___
- NGT is placed in stomach
Medications on Admission:
1. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheezing
2. Bisacodyl ___AILY constipation
3. CefePIME 2 g IV Q12H
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Heparin 5000 UNIT SC TID
9. NPH 15 Units Breakfast
NPH 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Ipratropium Bromide MDI 2 PUFF IH QID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Senna 1 TAB PO BID
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Vancomycin 1000 mg IV Q 8H
15. OxycoDONE-Acetaminophen Elixir ___ mL PO Q6H:PRN pain
16. Lisinopril 40 mg PO DAILY
17. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Heparin 5000 UNIT SC TID
6. NPH 15 Units Breakfast
NPH 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Senna 1 TAB PO BID:PRN constipation
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, SOB
10. Miconazole Powder 2% 1 Appl TP BID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Simethicone 80 mg PO TID
13. Psyllium 1 PKT PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acute Renal Failure
Secondary: Respiratory Failure s/p Tracheostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You were cared for in our Intensive Care Unit
for renal insufficiency, which was most likely from low blood
pressures during your hernia repair. During your time with us,
your kidney function has progressively improved. Your
electrolyte abnormalties present on admission have also
resolved.
During your time here, we also began to wean you off of the
ventilator. You tolerated increasinly long periods on trach
mask, when you breathed on your own. At rehab, your respiratory
therapist will continue to wean you off of the ventilator. We
hope you will be able to use a speaking valve soon.
Please follow up with your outpatient providers as recommended
below. Again, we wish you all the best!
Followup Instructions:
___
|
10637168-DS-13
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2198-09-11 07:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of CHF, COPD, DM, and HTN who presented with
dyspnea.
She reports several days of worsening shortness of breath,
wheezing and cough productive of yellow sputum. She denies
fevers, chills, runny nose, sore throat. This is similar to a
mild COPD exacerbation she's had in the past. It is not similar
to that point in time where she required intubation. She denies
chest pain, leg swelling, leg pain.
In the ED, initial vitals were: 98.2 96 135/79 40 94% Nasal
Cannula.
Labs were notable for unremarkable CBC, BNP 1518. UA with 34
WBCs, few bacteria, 1000 glucose and 10 ketones.
CXR revealed bibasilar opacities, likely atelectasis but unable
to exclude aspiration or subtle pneumonia.
She also received 1g IV ceftriaxone, 500mg IV azithromycin,
125mg IV methylprednisolone, and duonebs X 2.
She was initially placed on bipap for one hour and respiratory
status improved, so she was admitted to the floor. Upon arrival
to the floor, she was triggered for altered mental status. VBG
showed respiratory acidosis and she was transferred to MICU for
BiPAP.
On arrival to MICU, pt has BiPAP mask on and reports her
breathing is improved. She feels her mouth is very dry. She has
no other complaints.
Past Medical History:
- Type II Diabetes
- Hypertension
- Diverticulosis w/SBO due to intrapelvic abscess s/p small
bowel resection then subsequent sigmoid colon resection ___
- History of C-section
- Two large parauterine cysts s/p TAH/BSO ___
- History of C.diff colitis (remote ___
- Chronic hypoxia and CO2 retention attributed to obesity
hypoventilation syndrome, diastolic heart failure and possibly
pulmonary hypertension. She requirse 3L home O2.
Social History:
___
Family History:
No known history of heart or lung disease.
Physical Exam:
========================
Admission Physical Exam:
========================
General: Somnolent, arousable to voice. Oriented x3.
HEENT: BiPAP mask in place, anicteric sclerae
CV: Regular rate and rhythm, normal S1 + S2, distant heart
sounds
Lungs: Diffuse expiratory wheezes, distant lung sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, chronic venous
stasis changes
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
========================
Discharge Physical Exam:
========================
VS: ___ 81-102 20 100% 2L
Gen: Appears comfortable, NAD
HEENT: Sclerae anicteric, conjunctivae noninjected, MMM, OP
clear
CV: RRR, no m/r/g
Pulm: Mildly decreased breath sounds bilaterally; no w/r/r
Abd: soft, nontender, nondistended
Ext: WWP, no edema
Neuro: Alert, interactive
Pertinent Results:
===============
Admission Labs:
===============
___ 12:58PM BLOOD WBC-6.3 RBC-4.45 Hgb-11.6 Hct-41.2
MCV-93# MCH-26.1 MCHC-28.2* RDW-14.6 RDWSD-48.8* Plt ___
___ 12:58PM BLOOD Neuts-68 Bands-2 Lymphs-17* Monos-11
Eos-0 Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-4.41 AbsLymp-1.20
AbsMono-0.69 AbsEos-0.00* AbsBaso-0.00*
___ 12:58PM BLOOD Glucose-266* UreaN-13 Creat-0.9 Na-138
K-6.5* Cl-93* HCO3-38* AnGap-14
___ 12:58PM BLOOD proBNP-1518*
___ 12:58PM BLOOD Calcium-8.5 Phos-2.1* Mg-1.7
___ 01:23PM BLOOD Lactate-1.4 K-4.9
===============
Discharge Labs:
===============
___ 06:18AM BLOOD WBC-8.2 RBC-4.28 Hgb-11.3 Hct-39.5 MCV-92
MCH-26.4 MCHC-28.6* RDW-14.6 RDWSD-48.8* Plt ___
___ 06:18AM BLOOD Glucose-153* UreaN-16 Creat-0.8 Na-139
K-4.5 Cl-91* HCO3-42* AnGap-11
___ 06:18AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
========
Imaging:
========
CXR ___
Impression: Bibasal opacities likely atelectasis, difficult to
exclude subtle pneumonia/aspiration.
CXR ___
Compared to ___, pulmonary vascular congestion has
improved, and
bibasilar opacities have decreased in extent. Small bilateral
pleural
effusions are persistent finding.
=============
Microbiology:
=============
___ Urine Culture - <10,000 organisms/ml
___ Blood Culture x 2 - Pending
___ Influenza PCR - Negative
___ Respiratory Viral Screen - negative
Brief Hospital Course:
___ is a ___ with COPD, ___, HTN, and OSA poorly
compliant with home CPAP, who presented with dyspnea, cough, and
increased sputum production due to a COPD exacerbation likely
caused by a URI. She required BiPAP in the MICU due to
hypercarbic respiratory failure but was never intubated and
subsequently improved with steroids and azithromycin.
Investigations/interventions:
# Hypercarbic respiratory failure/COPD exacerbation: Ms. ___
presented with severe dyspnea and cough productive of yellow
sputum. She was found to be acidemic and hypercarbic with pH
7.27/pCO2 93 on VBG. A chest X ray showed some vascular
congestion but no evidence of pneumonia. Flu swab was negative.
She was thought to have COPD exacerbation likely driven by a
viral URI given her precipitating cough. She was afebrile and
had no leukocytosis. She was transferred to the ICU immediately
after admission to the floor due to AMS secondary to
hypercarbia. She was started on BiPAP and received 125 mg IV
methylpred and started on azithromycin for a 5 day course. She
subsequently was also started on a 5 day course of 40 mg
prednisone. Her dyspnea was thought to be exacerbated by her
___ given evidence of mild pulmonary congestion and a BNP of
1518. She received gentle IV diuresis (20 mg IV x2). She was
transferred out of the ICU after 3 days with improvement of her
breathing back to her baseline O2 requirement. She was
transitioned off of standing nebs back to her home inhalers and
was started on 10 mg PO Lasix with goal to maintain euvolemia.
Transitional issues:
- Patient treated with prednisone 40mg x5 days ___ - ___
- Patient treated with azithromycin x 5 days ___ - ___
- Patient started on 10 mg PO Lasix, please check creatinine and
electrolytes
- Patient was put on ISS and had some hyperglycemia requiring
increase in her home Lantus dose from 10 to 14, however this was
while she was on prednisone. She was discharged on her home
regimen as she was discharged off steroids. Please ensure BGs
well controlled at home now that prednisone discontinued.
- Full code
- Contact: ___ (daughter/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Simvastatin 20 mg PO QPM
4. Glargine 10 Units Bedtime
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Omeprazole 40 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. albuterol sulfate 90 mcg/actuation inhalation Q8H
9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH QAM
10. GlipiZIDE XL 2.5 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. GlipiZIDE XL 2.5 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. albuterol sulfate 90 mcg/actuation inhalation Q8H
7. Simvastatin 20 mg PO QPM
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH QAM
9. Omeprazole 40 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. Glargine 10 Units Bedtime
12. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
COPD
Upper respiratory tract infection
Obstructive sleep apnea
Diastolic heart failure
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 in the hospital at ___
because you were having trouble breathing. This was due to your
COPD, which was made worse most likely by a viral infection. You
were treated with antibiotics, steroids (prednisone), and
breathing treatments.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10637168-DS-19
| 10,637,168 | 28,279,669 |
DS
| 19 |
2201-11-13 00:00:00
|
2201-11-13 16:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of COPD (on 3L
of O2), OHS, and HFrEF who presents with a 3 day history of
lethargy. During this time she has also experienced increasing
shortness of breath, and is having difficulty walking long
distances. Per the patient and her family, she has not had
fever,
chills, cough, or chest pain, or shortness of breath. ___ sick
contacts, denies aspiration event.
On arrival to the ED she was somnolent and vitals were noted to
be T 97.8, HR 99, BP 113/66, RR 20, and SpO2 95% on 4L NC. He
examination was notable for decreased breath sounds bilaterally,
likely due to poor inspiratory effort. Due to habitus assessment
of volume status was impaired. Her labs were significant for a
VBG with 7.15/146. Her BNP was also elevated to 1372. Her O2
requirement continued to increased to the point where she
required BIPAP. He SpO2 improved to 92% and she became less
somnolent. A repeat VBG improved to 7.24/112.
A CXR was significant for bibasilar opacities and marked
atelectasis of the right middle lobe and possible basilar
segments of the posterior lobe as well, with associated
mediasteinal shift.
Treatment for pneumonia and COPD exacerbation was commenced in
the ED (Cefepime, Vancomycin, methylprednisolone, and duoneb
x1).
She was then transferred to the FICU for further management.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
-COPD on 3L home O2
-OHS
-HFpEF
-DM II with peripheral neuropathy
-HLD
-morbid obesity
-GERD
Social History:
___
Family History:
-Mother: alive and in good health
-She has two potential biological fathers. She thinks one of
them died of cancer.
Physical Exam:
VS: reviewed in metavision
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: unable to assess JVD due to PIV and habitus
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: diffusely diminished breath sounds and expiratory wheezes
bilaterally
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. Xerosis over distal lower
extremities
NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.
Normal sensation. Gait is normal. AOx3.
Pertinent Results:
___ 10:45AM BLOOD WBC-7.2 RBC-4.23 Hgb-10.9* Hct-43.0
MCV-102* MCH-25.8* MCHC-25.3* RDW-14.6 RDWSD-54.3* Plt ___
___ 10:45AM BLOOD Neuts-81.5* Lymphs-12.0* Monos-4.7*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.85 AbsLymp-0.86*
AbsMono-0.34 AbsEos-0.01* AbsBaso-0.02
___ 10:45AM BLOOD ___ PTT-29.8 ___
___ 10:45AM BLOOD Glucose-172* UreaN-16 Creat-0.8 Na-146
K-5.2 Cl-92* HCO3-49* AnGap-5*
___ 10:45AM BLOOD proBNP-1372*
___ 10:45AM BLOOD cTropnT-<0.01
___ 10:45AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.7
___ 10:50AM BLOOD ___ pO2-37* pCO2-146* pH-7.15*
calTCO2-54* Base XS-14 ___ TOP
___ 01:12PM BLOOD ___ pO2-70* pCO2-112* pH-7.24*
calTCO2-50* Base XS-15 ___ TOP
___ 05:34PM BLOOD ___ pO2-42* pCO2-103* pH-7.29*
calTCO2-52* Base XS-17
___ 02:30AM BLOOD ___ Temp-36.7 pO2-49* pCO2-83*
pH-7.40 calTCO2-53* Base XS-21
___ 12:04PM BLOOD ___ Temp-36.2 pO2-54* pCO2-84*
pH-7.35 calTCO2-48* Base XS-16
___ 10:50AM BLOOD Lactate-0.7
IMAGING
=======
CXR 1 ___:
Limited exam due to rotation and low lung volumes. Patchy
opacities in the lung bases may reflect atelectasis with
infection or aspiration not excluded. Possible small right
pleural effusion.
CXR 2 ___:
Probable pleural effusions and persistent basilar opacities,
somewhat
improved. Mild suspected vascular congestion.
CXR 3 ___:
There is a small to moderate right and small left pleural
effusions with
subjacent atelectasis and/or consolidation. No pneumothorax or
evidence of pulmonary edema. The size of the cardiac silhouette
is unchanged.
Brief Hospital Course:
ADMISSION SUMMARY STATEMENT
===========================
___ year old woman with a history of COPD on 3L home O2 with
multiple past exacerbations, and HFpEF who presented to the ED
with a 3 day history of lethargy, found to be in hypercapneic
hypoxemic respiratory failure requiring ___ transferred to the
FICU for further management.
ACUTE ISSUES ADDRESSED
======================
#Acute hypercarbic hypoxemic respiratory failure
FICU Course:
Initially presented with dyspnea, lethargy, and VBG significant
for respiratory acidosis and markedly elevated pCO2 of 146
compared to baseline ___ to ___. CXR was concerning for
atelectasis versus pneumonia, with small bilateral pleural
effusions. COPD exacerbation was considered the most likely
diagnosis given marked hypercarbia. Azithromycin and
corticosteroids were given. She arrived and remained on BIPAP
for 12 hours, with subsequent resolution of her respiratory
acidosis and reduction of her pCO2 on serial VBGs. Because of
her elevated BNP and pleural effusions, she was also treated for
CHF exacerbation with IV furosemide. On arrival pneumonia could
be not ruled out, so she was treated for CAP with risk for MRSA
and Pseudomonas with vancomycin and cefepime. Sputum gram stain
and culture was obtained, along with urine strep and legionella.
Blood cultures were drawn. In the AM it was determined that
pneumonia was unlikely, and cefepime was discontinued.
Vancomycin was kept on board as ___ blood culture vials had
GPCs. Her respiratory interventions were titrated down to 3L NC,
and she was called out to the floor.
Floor course:
On the floor her blood cultures resulted as growing coag
negative staph in ___ bottles so vancomycin was discontinued.
She was continued on AECOPD therapy with duonebs and
azithromycin but on day of discharge was not noted to have any
wheezing or respiratory distress and was satting at her baseline
(3L). IV Furosemide was discontinued as well because she was at
her dry weight of 258 lbs and didn't appear to be clinically
volume overloaded. She had a mild pleural effusion on 2v CXR but
was noted to be peeing briskly.
TRANSITIONAL ISSUES
[ ] encourage fluid restriction to <2L daily and <2g salt daily
[ ] encourage patient to weigh self daily
[ ] pt to take one more day of prednisone and azithromycin for
AECOPD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fludrocortisone Acetate 0.1 mg PO DAILY
7. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL ___ SPRY NU DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
11. Albuterol Inhaler 1 PUFF IH Q8H
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
13. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
14. Glargine 50 Units Breakfast
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Dose
RX *azithromycin 250 mg 1 tablet(s) by mouth every morning Disp
#*1 Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 1 Day
RX *prednisone [Deltasone] 20 mg 2 tablet(s) by mouth every
morning Disp #*2 Tablet Refills:*0
3. Glargine 50 Units Breakfast
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
5. Albuterol Inhaler 1 PUFF IH Q8H
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fludrocortisone Acetate 0.1 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Fluticasone Propionate NASAL ___ SPRY NU DAILY
11. Gabapentin 400 mg PO TID
12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
13. Omeprazole 40 mg PO DAILY
14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
15. Simvastatin 20 mg PO QPM
16. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Respiratory failure due to HFpEF exacerbation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. We
treated you for a heart failure and COPD exacerbation and you
improved.
Followup Instructions:
___
|
10637168-DS-21
| 10,637,168 | 29,385,031 |
DS
| 21 |
2202-03-28 00:00:00
|
2202-03-28 16:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Intubation (___)
Extubation
attach
Pertinent Results:
ADMISSION LABS
================
___ 05:05PM BLOOD WBC-11.7* RBC-4.11 Hgb-9.9* Hct-36.9
MCV-90 MCH-24.1* MCHC-26.8* RDW-15.5 RDWSD-51.1* Plt ___
___ 05:05PM BLOOD Neuts-75.4* Lymphs-16.3* Monos-6.6
Eos-0.2* Baso-0.3 NRBC-0.6* Im ___ AbsNeut-8.84*
AbsLymp-1.91 AbsMono-0.77 AbsEos-0.02* AbsBaso-0.03
___ 06:16PM BLOOD ___ PTT-29.4 ___
___ 05:05PM BLOOD Glucose-201* UreaN-17 Creat-0.7 Na-135
K-6.6* Cl-88* HCO3-39* AnGap-8*
___ 05:05PM BLOOD Calcium-9.3 Phos-3.2 Mg-1.8
MICRO/OTHER PERTINENT LABS
==========================
___ 02:10AM BLOOD proBNP-7809*
___ 05:14AM BLOOD ALT-17 AST-30 AlkPhos-133* TotBili-0.4
___ 2:53 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 3:35 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING
=======
TTE ___
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal
cavity size. There is suboptimal image quality to assess
regional left ventricular function. Overall left
ventricular systolic function is normal. The visually estimated
left ventricular ejection fraction is
55-60%. There is no resting left ventricular outflow tract
gradient. There is Grade I diastolic
dysfunction. Moderately dilated right ventricular cavity with
mild global free wall hypokinesis. The
aortic sinus diameter is normal for gender with a normal
ascending aorta diameter for gender. The aortic
arch diameter is normal with a normal descending aorta diameter.
The aortic valve leaflets (?#) are
mildly thickened. There is no aortic valve stenosis. There is
trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is mild [1+] mitral regurgitation. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is mild
[1+] tricuspid regurgitation. There is moderate pulmonary artery
systolic hypertension. There is no
pericardial effusion.
CXR ___
1. Interval increase in moderate retrocardiac atelectasis.
2. Area of consolidation right lower lobe that may be
concerning for
pneumonia in the appropriate clinical setting.
3. Mild pulmonary edema.
4. Bilateral pleural effusions.
CXR ___
Comparison to ___. The patient is extubated. Lung
volumes are normal. Minimal right and left basilar atelectasis
but no evidence of
pneumonia, pulmonary edema or pleural effusion. No
pneumothorax. Borderline size of the cardiac silhouette.
DISCHARGE LABS
===============
___ 06:57AM BLOOD WBC-9.0 RBC-4.28 Hgb-10.6* Hct-38.7
MCV-90 MCH-24.8* MCHC-27.4* RDW-16.7* RDWSD-54.2* Plt ___
___ 06:57AM BLOOD Plt ___
___ 06:57AM BLOOD Glucose-241* UreaN-21* Creat-0.8 Na-139
K-4.2 Cl-87* HCO3-39* AnGap-13
___ 06:57AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with COPD on 3L home O2, HFpEF,
T2DM, OSA, GERD, who presented with increased SOB and cough
requiring intubation in the MICU, treated for COPD vs. CHF
exacerbation and community acquired pneumonia. She was
transferred to the floor and placed back on her home oxygen
requirement. However, she continued to have significant
shortness of breath with ambulation. She declined rehab and
endorsed overall poor compliance with recommendations and
medications but insisted on going home.
TRANSITIONAL ISSUES:
====================
[] Discharge weight: 241.84 lb
[] Patient discharged on Lasix 60mg daily, should have close
monitoring of volume status and may require dose adjustment.
[] She was significantly deconditioned and not very ambulatory,
should work with ___ to encourage ambulation
[] BUN remained slightly elevated, plan for repeat BMP at follow
up in ___ weeks
[] Glucose control continues to be an ongoing challenge
[] would plan for repeat CBC for anemia monitoring in ___ weeks
[] Patient would benefit from ongoing health education and
medication compliance counseling
ACTIVE ISSUES:
==============
# Hypoxic respiratory Failure
# Acute on chronic COPD
# Community acquired Pneumonia
# Acute on chronic HFpEF
Patient presented with worsening cough, SOB, fatigue,
hypercarbia
(7.27/103 --> 7.22/115, intubated and improved to 7.32/82) and
CXR notable for patchy lateral right base opacity. She was
afebrile with
mild leukocytosis and was suctioned for ___
thick sputum per ___ RN notes. She received 125mg solumedrol in
the ___.
proBNP was significantly elevated to 7800 on admission. Flu swab
was negative. Initial CXR showed mild pulmonary edema. She had
signs and symptoms consistent with possible CAP, COPD
exacerbation and HFpEF exacerbation. Blood/urine cultures
negative, RVP negative, strep and legionella Ag negative. She
received a 5 day course of steroids ___ and was
transitioned back to her home oxygen requirement (3L home O2).
She also received diuresis and was transitioned back to her home
diuretic dose of Lasix 60mg daily prior to discharge.
# Acute on chronic HFpEF
Presented similarly during her last hospitalization with proBNP
of 3855. proBNP 7800 on admission. Last TTE ___ demonstrated
LVEF 70% with moderate pulmonary hypertension. Received 1L of
IVF
in the ___. Per outpatient notes, patient was to discontinue home
furosemide as she had symptoms of overdiuresis. TTE on ___
showed mildly kinetic RV, PAH. She first received higher doses
of diuresis and was transitioned back to home Lasix (60mg daily)
on ___.
CHRONIC ISSUES:
===============
# Type 2 Diabetes
Per history, patient's diabetes is poorly controlled with last
A1c 12.6% in ___. We held her home trulicty. She remained on
her home lantus 24 units daily and was placed on insulin sliding
scale while inpatient.
# Normocytic Anemia
Baseline hemoglobin appears to be ___. Iron studies ___
notable for normal iron, low ferritin. TIBC and TRF within
normal
limits. Likely secondary to mixed picture of anemia of
inflammation and iron deficiency anemia.
# GERD
Continued home omeprazole 40mg daily
# HLD
# ASCVD prevention
Continued home Aspirin 81mg daily and home Simvastatin 20mg
daily qHS
#CODE STATUS: Full
#CONTACT: Daughter ___, ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NS DAILY
4. Omeprazole 40 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
7. Albuterol Inhaler 1 PUFF IH Q8H
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
10. Gabapentin 400 mg PO TID
11. Glargine 24 Units Breakfast
12. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. Furosemide 60 mg PO DAILY
Discharge Medications:
1. Glargine 24 Units Breakfast
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Albuterol Inhaler 1 PUFF IH Q8H
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Fluticasone Propionate NASAL 2 SPRY NS DAILY
8. Furosemide 60 mg PO DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
12. Simvastatin 20 mg PO QPM
13. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
14. umeclidinium 62.5 mcg/actuation inhalation DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
COPD exacerbation
HFpEF exacerbation
SECONDARY DIAGNOSIS
====================
Type 2 Diabetes
Normocytic Anemia
GERD
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were short of breath
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a tube placed to help with your breathing
- We gave you extra fluid pills to help with your breathing
- We also gave you breathing treatments and steroids
- Your breathing improved
- You worked with physical therapy who recommended it is
important for you to move around a lot
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please return to the hospital if you experience any new or
worsening symptoms
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10637168-DS-9
| 10,637,168 | 25,370,666 |
DS
| 9 |
2195-04-20 00:00:00
|
2195-04-20 20:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
___ yo F with COPD and obesity hypoventilation, presented to the
ED with dyspnea and cough. She had noted worsening shortness of
breath over the last few days, and had also developed a
non-productive cough. She has no sick contacts.
In the ED, initial vitals 97.6 ___ 24 87% 3L. She was
felt to have a COPD exacerbation so was given azithro,
solumedrol and duonebs. Within hours of arrival to the ED, she
became lethargic. An ABG showed a CO2 of 144. She was
immediately intubated and placed on fent/versed. Ceftriaxone was
added for treatment of pneumonia.
On arrival to the MICU, she is intubated and sedated. Arrousable
to voice.
Past Medical History:
- Type II Diabetes
- Hypertension
- Diverticulosis w/SBO due to intrapelvic abscess s/p small
bowel resection then subsequent sigmoid colon resection ___
- History of C-section
- Two large parauterine cysts s/p TAH/BSO ___
- History of C.diff colitis (remote ___
- Chronic hypoxia and CO2 retention attributed to obesity
hypoventilation syndrome, diastolic heart failure and possibly
pulmonary hypertension. She requirse 3L home O2.
Social History:
___
Family History:
No known history of heart or lung disease.
Physical Exam:
Admission:
Vitals: 97.4 131/79 92 16 97%
GEN: intubated, sedated, arrousable to voice
CV: RRR no murmurs
LUNGS: diffuse wheezing throughout
ABD: soft non tender, non distended
EXT: no edema, dopplerable pulses
Discharge:
Pertinent Results:
___ 03:40PM BLOOD WBC-7.8 RBC-3.76* Hgb-9.8* Hct-35.0*
MCV-93# MCH-26.2* MCHC-28.1* RDW-14.8 Plt ___
___ 03:40PM BLOOD Neuts-87* Bands-0 Lymphs-12* Monos-1*
Eos-0 Baso-0 ___ Myelos-0
___ 03:40PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
___ 04:36AM BLOOD ___ PTT-29.7 ___
___ 12:20PM BLOOD Glucose-211* UreaN-12 Creat-0.7 Na-139
K-5.4* Cl-94* HCO3-36* AnGap-14
___ 12:20PM BLOOD Calcium-8.9 Phos-3.7 Mg-1.6
___ 03:00AM BLOOD Vanco-21.2*
___ 12:31PM BLOOD ___ pO2-107* pCO2-70* pH-7.38
calTCO2-43* Base XS-13
___ 01:50PM BLOOD Type-ART pO2-46* pCO2-144* pH-7.14*
calTCO2-52* Base XS-13
___ 03:23PM BLOOD Type-ART pO2-209* pCO2-90* pH-7.27*
calTCO2-43* Base XS-10
___ 11:23PM BLOOD Type-ART Rates-16/ Tidal V-450 PEEP-450
FiO2-50 pO2-43* pCO2-74* pH-7.38 calTCO2-45* Base XS-14
-ASSIST/CON Intubat-INTUBATED
___ 12:31PM BLOOD Lactate-0.9
___ 02:56PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:56PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-250 Ketone-TR Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
___ 02:56PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1
Respiratory Virus Identification (Final ___:
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Viral antigen identified by immunofluorescence.
Reported to and read back by ___ @ 2155,
___.
___ 12:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
VANCOMYCIN AND CEFTRIAXONE Susceptibility testing
requested by
___ ___ ___.
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
Reported to and read back by ___ ___
___ ___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0715.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0715.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
CXR: AP upright portable view of the chest was obtained. The
exam is somewhat suboptimal due to underpenetration due to
patient body habitus. The lung bases are relatively
underpenetrated due to overlying soft tissue. Bibasilar
opacities are seen, which could relate to the overlying soft
tissue, although infection or aspiration is not excluded in the
appropriate clinical setting. No large pleural effusion is
seen. The cardiac and mediastinal silhouettes are unremarkable.
There is mild prominence of the hila which may be due to
pulmonary vascular engorgement.
Brief Hospital Course:
___ yo F with COPD and obesity hypoventilation, admitted to the
MICU for hypercarbic respiratory failure.
# Hypercarbic respiratory failure: Patient intubated for pCO2 of
144, likely multifactorial from COPD and obesity
hypoventilation, improved with mechanical ventilation. She had
multiple SBTs starting on vent day #2 that she failed for
tachypnea. She was eventually extubated on ___. She was
empirically started on tamiflu and swab result came back
positive for influenza A so tamiflu continued for 5 day course.
She was also started on Ceftriaxone/Azithro for CAP and Vanc was
added for MRSA coverage in setting of flu. IV steroids also
started and tapered. Bronchodilators ordered standing and PRN.
On transfer to regular nursing floor, pt was back to baseline O2
requirement, now 97-100% on 2L NC. Blood cx positive for Strep
viridans. She likely developed a post-influenza bacterial PNA
with S. viridans leading to bacteremia. Although only positive
on ___ bottles, unlikely to be a contaminant. ID was consulted
and she was discharged home with 14 day course of Ceftriaxone IV
for bacteremia.
# Bacteremia: pt presented with c/o SOB, no fevers, chills or
lethargy. She was found to have ___ blood cx bottle positive
for S. viridans and Corynebacterium (Diptheroids). Given her
acute presentation with respiratory failure, she potentially had
a secondary bacterial component to her PNA resulting in seeding
of her blood stream with S. viridans. Per ID S. viridans is NOT
a contaminant and should be treated as true bacteremia with a
full course of IV abx. Given S. viridans predilection for heart
valves a TTE was ordered and was negative for vegetations.
# ___: Cr increased from baseline 0.9 to 1.5, likely pre-renal
given pt was diuresed in MICU prior to transfer and is 5L
negative since admission. ___ have also been worsened by
Lisinopril which was restarted prior to tx ___ hypertension.
Her lisinopril was held and she was bolused 500cc NS. Her Cr
subsequently decreased to baseline prior to discharge. Her
lisinopril was not restarted ___ low BPS (see below), but can be
restarted PRN as an outpatient.
CHRONIC ISSUES:
# DM: FSG not well controlled in MICU, given additional 1x doses
of NPH and ISS increased. Her glucose improved and ISS was
continued. She was discharged on home NPH and instructed to
resume home sulfonylureas upon discharge.
# HTN: initially antihypertensives held in case of sepsis, then
restarted and was actually hypertensive in MICU. However, on tx
to regular nursing floor pt Bps on the lower side ranging
___ systolic. Combined with ___ as outlined above
lisinopril was held, but can be restarted PRN as an outpatient.
TRANSITIONAL ISSUES:
- Lisinopril not restarted prior to discharge ___ lower bps.
Can be restarted prn as outpatient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Simvastatin 20 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Aspirin 81 mg PO DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
7. Albuterol Inhaler 1 PUFF IH Q8H
8. GlyBURIDE 10 mg PO BID
9. NPH 15 Units Breakfast
NPH 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb IH every 6
hours Disp #*2 Container Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 PUFFS IH twice
a day Disp #*1 Inhaler Refills:*0
4. NPH 15 Units Breakfast
NPH 20 Units Dinner
RX *NPH insulin human recomb [Humulin N] 100 unit/mL 15 Units
before BKFT; 20 Units before DINR; Disp #*1 Vial Refills:*0
5. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. CeftriaXONE 1 gm IV Q24H
RX *ceftriaxone 1 gram infuse 1 gram every 24 hours Disp #*8
Gram Refills:*0
7. PredniSONE 20 mg PO DAILY
RX *prednisone 5 mg 4 tablet(s) by mouth daily Disp #*13 Tablet
Refills:*0
8. Albuterol Inhaler 1 PUFF IH Q8H
RX *albuterol sulfate 90 mcg 1 PUFF IH every 8 hours Disp #*1
Inhaler Refills:*0
9. GlyBURIDE 10 mg PO BID
RX *glyburide 5 mg 2 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
10. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
Capsule IH daily Disp #*1 Capsule Refills:*0
11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
RX *sodium chloride 0.9 % [BD PosiFlush Normal Saline] 0.9 %
Inject 10mL before and after each use Disp #*20 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Influenza
Secondary Diagnosis: Hypercarbic respiratory failure, Pneumonia,
Bacteremia, COPD exacerbation
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 ___
___ with complaints of shortness of breath. You were
found to have the flu, and infection in your blood and a COPD
exacerbation.
Followup Instructions:
___
|
10637206-DS-11
| 10,637,206 | 21,813,184 |
DS
| 11 |
2133-05-06 00:00:00
|
2133-05-06 13:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
tachycardia/anxiety
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with a PMHx of HTN on atenolol who
presented for tachycardia to OSH, found to have thyrotoxicosis
now transferred for further care.
She visited a new PCP ___ ___ to establish care and was found to
be hypertensive to SBP 160s and tachycardic. She was started on
atenolol and labs were drawn.
On ___, labs resulted with undetectable TSH (<assay) and high
T3/T4 (>assay), so family was called to bring patient to ___
ED. Of note, patient has been asymptomatic over the last few
weeks except for increased episodes of anxiety. She denies heat
intolerance, chest pain, tremors, sweating, rigidity, abdominal
pain, or headaches.
At ___, the patient was given PTU 200mg Q4, propranolol 1mg
IV Q3, and solumedrol 100 q8. She was transferred to ___.
In the ED, initial vitals:
140 151/83 20 99% RA
- Labs were notable for: Hgb 13.9, INR 1.1, Cr 0.3, Lactate 1.2.
No imaging was operformed
- Patient was given:
___ 16:21 IV Propranolol 1 mg
___ 16:21 IV LORazepam 1 mg
___ 17:07 PO/NG Propylthiouracil 200 mg
___ 17:29 IV Propranolol 1 mg
___ 17:29 IV Lorazepam 1 mg
___ 17:46 IV Propranolol 1.5 mg
- Endocrine was consulted and had the following recs: Switch to
methimazole 15 mg x1, and then 15 mg BID. Discontinue
hydrocortisone as she does not have thyroid storm. Switch
propranolol atenolol ___ mg based on heart rate.
On arrival to the MICU, T 98.5, HR 102, BP 150/73, RR 30, O2 97%
RA. She had one episode of small-volume clear emesis but denied
nausea. She was given Zofran x1.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
HTN
Nuchal cord delivery (APGAR 2 at birth)
Social History:
___
Family History:
Grandmother with hypothyroid and CHF
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.4, ___, 31, 95% RA
GENERAL: Sitting in bed, appears anxious, poor eye contact
HEENT: AT/NC, EOMI, PERRL
NECK: slightly enlarged thyroid gland, no JVD
CARDIAC: Regular rhythm, tachycardic rate, no m/r/g
LUNG: CTAB, no wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: Blanching rash over neck
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION LABS:
___ 10:06PM URINE HOURS-RANDOM
___ 10:06PM URINE UCG-NEGATIVE
___ 08:45PM GLUCOSE-98 UREA N-12 CREAT-0.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-20* ANION GAP-19
___ 08:45PM ALT(SGPT)-42* AST(SGOT)-31 LD(LDH)-164 ALK
PHOS-189* TOT BILI-2.4*
___ 08:45PM CALCIUM-9.1 PHOSPHATE-4.4 MAGNESIUM-1.8
___ 08:45PM TSH-<0.01*
___ 08:45PM T4-25.2* T3-365*
___ 08:45PM WBC-5.7 RBC-4.77 HGB-12.5 HCT-37.0 MCV-78*
MCH-26.2 MCHC-33.8 RDW-13.8 RDWSD-39.0
___ 08:45PM NEUTS-73.0* ___ MONOS-6.2 EOS-0.2*
BASOS-0.0 IM ___ AbsNeut-4.15 AbsLymp-1.15* AbsMono-0.35
AbsEos-0.01* AbsBaso-0.00*
___ 08:45PM PLT COUNT-253
___ 04:42PM LACTATE-1.2
___ 04:15PM GLUCOSE-101* UREA N-11 CREAT-0.3* SODIUM-134
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-20* ANION GAP-20
___ 04:15PM estGFR-Using this
___ 04:15PM WBC-5.6 RBC-5.41* HGB-13.9 HCT-41.9 MCV-77*
MCH-25.7* MCHC-33.2 RDW-13.7 RDWSD-38.8
___ 04:15PM NEUTS-80.6* LYMPHS-16.7* MONOS-2.3* EOS-0.2*
BASOS-0.0 IM ___ AbsNeut-4.55 AbsLymp-0.94* AbsMono-0.13*
AbsEos-0.01* AbsBaso-0.00*
___ 04:15PM PLT COUNT-320
___ 04:15PM ___ PTT-23.6* ___
Brief Hospital Course:
FICU Course:
___ is a ___ with a PMHx of HTN on atenolol who
presented for tachycardia to OSH, found to have ___
transferred to ___ and admitted to ___ for further care.
#Thyrotoxicosis
#Sinus tachycardia: Patient did not formally meet criteria for
thyroid storm (by ___ ___ criteria), but she
did have a low TSH (less than assay) and high free T4 with
anxiety and tachycardia. Endocrine consulted who strongly felt
that this presentation was due to Graves disease and not thyroid
storm. She will need close outpatient follow-up where antibody
tests will be performed. Received solumedrol, PTU, and
propranolol at OSH which was initially continued on admission
here. Discontinued solumedrol as per endocrine recs. Switched to
methimazole and atenolol on transfer to the ward, and these were
titrate and tolerated well.
#anxiety-likely worsened by the above. SW consulted to assist
with coping and management strategies. This should improve with
ongoing management of her thyrotoxicosis.
#Transaminitis
#Hyperbilirubinemia: Mildly elevated transaminases and bilirubin
of unclear etiology, and no known baseline. Could be simply in
the setting of thyrotoxicosis, medication effect of
methimazole/PTU, or mild rhabdo. CK wnl. Improving by discharge,
discussed with endocrine on day of discharge, given improvement,
no opposition to discharge from their perspective, will be
rechecked day following discharge. RUQ u/s from ___ discussed
with radiology on day of discharge - reportedly NORMAL ruq u/s.
LFTs to be rechecked on ___ and reviewed by ___
___ of endocrinology, they will plan stop of methimazole if
not continuing to improve and continue surveiallance of LFTs as
appropriate in my d/w them on day of discharge.
#HTN: New diagnosis as of ___.
-Continued atenolol as above.
TRANSITIONAL ISSUES:
will follow up with endocrine here (arranged)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Methimazole 10 mg PO BID
RX *methimazole 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3.Outpatient Lab Work
CBC with differential and LFTs (alt/ast/alk phos/total
bilirubin) on ___ fax to: ___ attn: Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
thyroxtoxicosis
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted and treated for thyrotoxicosis due to
hyperthyroidism.
Please have your labs checked tomorrow as we discussed (see
prescription for same), and please follow instructions below
Followup Instructions:
___
|
10637228-DS-8
| 10,637,228 | 27,564,617 |
DS
| 8 |
2181-05-07 00:00:00
|
2181-05-07 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
EGD ___ w/ biopsy
EGD ___ w/ clipping of duodenal bleeding site
History of Present Illness:
This is a ___ woman with HTN, DM, reflux who presented
several hours after EGD with hematemesis.
Patient underwent scheduled EGD on ___ with no notable
findings; 5 random biopsies were taken from esophagus, stomach,
and duodenum. Several hours after the procedure, patient
vomiting "a lot" of brigh red blood into the toilet x 5. An hour
later she had multiple brown/maroon stools with clots.
She also had cramping lower abdominal and back pain. In the
bathroom, she had a syncopal episode during which she lowered
herself to the floor, no head stroke, lasting approximately 2
minutes. Dizzy with standing afterwards.
The patient called EMS, who noted SBP in 80's and gave 250ml NS
to which she was responsive. On arrival to the ED, vitals
stable. However, patient had a large bloody BM in the ED and
acutely became hypotensive with systolics in the ___. She
required fluid bolus and received 2 units of blood, then
transferred to the ICU.
In the ED, initial vitals: 97.3 63 117/70 15 100% RA
Labs notable for: Hb 8.7, BUN 40, Cr 0.7
Patient received:
___ 02:15 IV Esomeprazole sodium 40 mg ___
1L IVF bolus
2 units PRBCs
Consults: GI
Vitals on transfer: 72 110/54 18 98% RA
Upon arrival to ___, patient no longer having active hemoptysis
or GI bleeding. She is still dizzy when she sits up. Still with
mild cramping back and abdominal pain. No chest pain or dyspnea.
Past Medical History:
HTN
Diabetes
Depression
Hyperlipidemia
Asthma
Social History:
___
Family History:
Mother with HTN and DM.
Physical Exam:
ADMISSION EXAM
==============
VITALS: Reviewed in MetaVision
GENERAL: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, non-distended, bowel sounds present; slightly tender
to palpation in lower quadrants without rebound
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rash
NEURO: AOx3
ACCESS: PIV x 3
DISCHARGE EXAM
==============
___ 0822 Temp: 98.7 PO BP: 144/79 HR: 72 RR: 18 O2 sat: 97%
O2 delivery: RA FSBG: 138
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
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
SKIN: Very mild hyperpigmented macular rash in the skin folds
under the b/l breasts without excoriations, blisters, or ulcers.
Appearance consistent with mild intertrigo vs. candidiasis
PSYCH: pleasant, appropriate affect
NEUROLOGIC: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
ADMISSION LABS
==============
___ 12:14AM BLOOD WBC-11.6* RBC-2.99* Hgb-8.7* Hct-25.6*
MCV-86 MCH-29.1 MCHC-34.0 RDW-12.8 RDWSD-39.8 Plt ___
___ 12:14AM BLOOD Neuts-80.3* Lymphs-13.7* Monos-4.1*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.29* AbsLymp-1.59
AbsMono-0.48 AbsEos-0.08 AbsBaso-0.03
___ 12:14AM BLOOD ___ PTT-21.2* ___
___ 12:14AM BLOOD Plt ___
___ 12:14AM BLOOD Glucose-262* UreaN-40* Creat-0.7 Na-141
K-3.8 Cl-101 HCO3-27 AnGap-13
NOTABLE LABS
============
___ 12:14AM BLOOD WBC-11.6* RBC-2.99* Hgb-8.7* Hct-25.6*
MCV-86 MCH-29.1 MCHC-34.0 RDW-12.8 RDWSD-39.8 Plt ___
___ 04:00AM BLOOD WBC-11.8* RBC-2.59* Hgb-7.6* Hct-22.5*
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.0 RDWSD-40.4 Plt ___
___ 08:21AM BLOOD WBC-9.7 RBC-3.30*# Hgb-9.6*# Hct-27.7*
MCV-84 MCH-29.1 MCHC-34.7 RDW-13.4 RDWSD-41.3 Plt ___
IMAGING
=======
___ CTA
IMPRESSION
1. A curvilinear focus of enhancement (3:145, 601:60) in the
junction of the second and third part of the duodenum may
represent focus of active hemorrhage. Recommend ___ consult.
2. Multiple pulmonary nodules measuring up to 6 mm. For
incidentally detected multiple solid pulmonary nodules measuring
6 to
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.
___ EGD
IMPRESSION
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other procedures: Cold forceps biopsies were performed for
histology at the middle third of the esophagus.
Cold forceps biopsies were performed for histology at the
gastro-esophageal junction.
Cold forceps biopsies were performed for histology at the
stomach body.
Cold forceps biopsies were performed for histology at the
stomach antrum.
Cold forceps biopsies were performed for histology at the second
part of the duodenum.
Impression: (biopsy, biopsy, biopsy, biopsy, biopsy)
Otherwise normal EGD to second part of the duodenum
DISCHARGE LABS
==============
___ 03:50AM BLOOD WBC-4.8 RBC-2.89* Hgb-8.3* Hct-25.1*
MCV-87 MCH-28.7 MCHC-33.1 RDW-13.6 RDWSD-43.1 Plt ___
___ 03:50AM BLOOD Glucose-152* UreaN-16 Creat-0.6 Na-143
K-3.5 Cl-108 HCO3-24 AnGap-11
___ 03:50AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
Brief Hospital Course:
MICU COURSE ___ - ___
This is a ___ woman with HTN, DM, reflux who presented
several hours after EGD with hematemesis and maroon stools. She
had biopsies during EGD the day prior to admission which were
the presumed source of bleeding. She was transiently hypotensive
in the ED with systolics in the ___, but improved with fluid
bolus and 2 units of blood.
CTA abdomen showed a curvilinear focus of enhancement in the
junction of the second and third part of the duodenum, possible
focus of active hemorrhage. Transferred to the FICU, where GI
performed a repeat EGD. The biopsy site in the duodenum showed
stigmata of recent bleeding, so a clip was placed. Patient
hemodynamically stable with no clinical signs of recurrent
bleeding. CBC stable. Called out to floor.
FLOOR COURSE (___)
# UGIB ___ bleeding from recent EGD biopsy site(s)
# Acute blood loss anemia
- treated with omeprazole 20 mg PO BID per GI recs
- continued to have dark red blood per rectum on ___, with
downtrending Hgb
- ultimately given another 1 unit pRBCs for Hgb of 6.9 on ___
good response to transfusion with Hg up to 8.3 on ___
- blood loss per rectum stopped in the early AM on ___
- tolerating diet, no abdominal pain, nausea, vomiting,
diarrhea, lightheadedness with standing, or dyspnea with
exertion on day of discharge
#HTN
-Home antihypertensives held in setting of active UGIB and
relatively normal BP
-Resumed home nifedipine on ___ given apparent resolution of
bleeding and increasing BP: ___ 0822 BP: 144/79.
-Patient to resume remainder of home antihypertensive meds
(nevibolol, valsartan-HCTZ) tomorrow at home
# Chronic hypokalemia
-Can resume home potassium supplement (40 mEq daily) tomorrow
when she resumes diuretic-containing meds
# NIDDM2
-Held her home metformin in setting of CTA (IV contrast)
performed on ___ held for >= 48 hours after IV contrast.
-Renal function on day of discharge demonstrates no evidence of
CIN
-Will resume metformin on ___ (at home)
# Asthma: stable with no evidence of acute exacerbation
-Continued home budesonide, monetlukast
-Patient instructed that she needs to clarify with PCP ___:
whether she should be taking either/both Pulmicort & Symbicort
(as both contain budesonide). She is currently taking both of
them as 1 puff BID.
# Incidental finding: Multiple small bilateral pulm nodules seen
on CTA. Patient is a non-smoker. No hx of TB or exposure to TB
that she is aware of.
- She will need follow-up for this per Radiology
recommendations: "For incidentally detected multiple solid
pulmonary nodules measuring 6 to 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."
- Letter sent to PCP to notify of the incidental finding and
recommended f/u.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Bystolic (nebivolol) 20 mg oral DAILY
4. Vitamin D ___ UNIT PO 1X/WEEK (___)
5. NIFEdipine (Extended Release) 60 mg PO DAILY
6. Potassium Chloride 40 mEq PO DAILY
7. valsartan-hydrochlorothiazide 320-12.5 mg oral DAILY
8. Simvastatin 40 mg PO QPM
9. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
10. Citalopram 20 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
13. Amitriptyline 10 mg PO QHS
14. Fexofenadine 60 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Headache
2. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 40 %
topical BID:PRN skin fold rash Duration: 3 Days
RX *zinc oxide-cod liver oil [Desitin] 40 % Apply to affected
skin area BID:PRN Refills:*0
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. Amitriptyline 10 mg PO QHS
5. Bystolic (nebivolol) 20 mg oral DAILY
6. Citalopram 20 mg PO DAILY
7. Fexofenadine 60 mg PO BID
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Montelukast 10 mg PO DAILY
10. NIFEdipine (Extended Release) 60 mg PO DAILY
11. Potassium Chloride 40 mEq PO DAILY
12. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
13. Simvastatin 40 mg PO QPM
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
15. valsartan-hydrochlorothiazide 320-12.5 mg oral DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis - UGIB
Acute blood loss anemia
Post-procedural complication (from EGD w/ biopsy on ___
Mild skin irritation vs. intertrigo vs. candidiasis of b/l
breast folds
Chronic HTN
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 bleeding from the site of
a recent biopsy in your intestine. You were treated initially
with blood transfusion and underwent an EGD with clipping of the
area that was bleeding. You continued to have some bloody stool
output after the procedure, and required one additional blood
transfusion for anemia. Eventually, the bleeding slowed and
stopped. The GI doctors ___ that ___ were safe for discharge
home and recommended continuing to take the omeprazole twice
daily, at least until you follow-up in clinic.
Regarding your asthma medications, please clarify with your
primary care physician if you should be taking either Symbicort
(inhaler), Pulmicort (inhaler), or BOTH, and how often you
should be taking (once or twice daily).
For the mild skin irritation and rash underneath your breasts,
be sure to keep that skin dry and well-ventilated. Moisture
will allow the rash to get worse. If the rash continues to
worsen despite keeping it well-ventilated and dry, you can try
applying Desitin (zinc sulfate paste).
Please plan to follow-up with your primary care physician
regarding this hospitalization and to have your blood counts
checked in the next ___ weeks.
It was a pleasure caring for you while you were here at ___,
and we wish you a full and speedy recovery.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
10637368-DS-14
| 10,637,368 | 27,738,841 |
DS
| 14 |
2142-08-16 00:00:00
|
2142-08-17 08:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ laparoscopic removal of gastric band
History of Present Illness:
___ year olf female with history of lap band ___ now with
nausea, abdominal pain and fever for 24 hours prior to
presentation. Patient was in usual state of health until four
days prior to presentation when noted vague epigastric
discomfort. This progressed in severity with pain characterized
as dull with sharp intervals, moderate to severe in severity.
No alleviating/aggravating factors. Accompanied by nausea and
poor appetite. Day prior to presentation pt noted development
of subjective fever and chills. Sought attention of PMD ___ and
was found in office to have temperature to 102. Referral made
to ___ ED and patient presents now for eval. CT scan obtained
to evaluate for nephrolithiasis given hx recurrent
nephrolithiasis and was found to have inflammation surrounding
intra-abdominal portion of band appliance. Surgery consult
obtained for question of lap band complication.
On surgery eval patient describes abdominal pain, fever and
chills as above. Tolerating diet though with decreased po
intake ___ poor appetite. Passing flatus. Chronically
constipated with intermittent usage of miralax. Had not had BM
for four days prior to ___ but produced stool with miralax at
that time. Of note states that her urine appears darker than
normal. Denies headache, chest pain, SOB, vomiting, dysuria.
Past Medical History:
Past medical history: OBESITY, HYPERCHOLESTEROLEMIA, HTN,
DEVIATED SEPTUM, ANEMIA, ASTHMA, POLYCYSTIC OVARIES
Past Surgical History: C-section (___), Lap band (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
On Discharge:
VS: T 98.2 HR 83 BP 150/90 RR 16 02Sat 99RA
GEN: NAD, AOx3
CV: RRR, nl S1 and S2
PULM: CTA b/l, no respiratory distress
ABD: Soft, Non-tender, Non-distended; incisions c/d/i. JP site
clean, covered with dsd and tegaderm.
EXT: No c/c/e.
Pertinent Results:
___ 03:20PM BLOOD WBC-11.3* RBC-3.55* Hgb-10.9* Hct-31.4*
MCV-88 MCH-30.6 MCHC-34.6 RDW-12.4 Plt ___
___ 08:05AM BLOOD WBC-8.2 RBC-3.24* Hgb-10.0* Hct-28.8*
MCV-89 MCH-30.9 MCHC-34.7 RDW-12.2 Plt ___
___ 05:55AM BLOOD WBC-10.8 RBC-3.40* Hgb-10.3* Hct-30.4*
MCV-90 MCH-30.3 MCHC-33.8 RDW-12.8 Plt ___
___ 06:55AM BLOOD WBC-15.6* RBC-3.46* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.7 Plt ___
___ 06:35AM BLOOD WBC-8.9 RBC-3.29* Hgb-10.0* Hct-29.7*
MCV-90 MCH-30.4 MCHC-33.7 RDW-12.5 Plt ___
___ 06:35AM BLOOD WBC-8.0 RBC-3.37* Hgb-10.1* Hct-30.1*
MCV-89 MCH-30.1 MCHC-33.7 RDW-12.7 Plt ___
___ 03:20PM BLOOD Neuts-80.9* Lymphs-11.2* Monos-6.6
Eos-1.0 Baso-0.3
___ 06:20AM BLOOD Neuts-89.9* Lymphs-4.8* Monos-3.7 Eos-1.3
Baso-0.2
___ 03:20PM BLOOD Glucose-98 UreaN-7 Creat-0.7 Na-132*
K-3.3 Cl-96 HCO3-25 AnGap-14
___ 05:55AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-14
___ 06:35AM BLOOD Glucose-117* UreaN-7 Creat-0.6 Na-133
K-3.7 Cl-98 HCO3-30 AnGap-9
___ 06:35AM BLOOD Amylase-27
___ 03:20PM BLOOD ALT-11 AST-12 TotBili-1.3
___ 06:35AM BLOOD Lipase-28
___ 03:20PM BLOOD Lipase-23
___ 08:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
___ 06:20AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8
___ 06:35AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7
___ 08:24PM BLOOD Vanco-7.0*
___ 10:22PM BLOOD Lactate-0.7
CT scan from ___:
Extensive inflammatory changes about gastric banding catheter
tubing
spanning approximately 10 to 11 cm with small amount of free
fluid in the
right hemipelvis. No focal fluid collection identified.
Punctate nonobstructing left renal stone.
UGI ___: IMPRESSION: No evidence of holdup or leak at the
site of the prior lap band.
KUB ___: IMPRESSION: Nonspecific bowel gas pattern without
ileus or free air.
CT Abdomen ___: IMPRESSION:
1. Status post removal of infected gastric band. A surgical
drain is
identified with tip location at the level of the gastrohepatic
ligament. No
drainable fluid collections are identified in the abdomen.
2. A moderate amount of ascites is identified in the pelvis. A
subcentimeter tube-like structure is identified in the
peritoneal space in the most dependent portion most likely
representing a small foreign object.
3. There is mild dilation of the proximal small bowel without
identifiable
transition point most likely representing postoperative ileus.
4. Marked subcutaneous anasarca.
5. New bilateral pleural effusions with associated compressive
atelectasis.
CXR ___: IMPRESSION:
1. PICC in low SVC.
2. Bibasilar atelectasis.
3. Gastric distention.
Brief Hospital Course:
The patient presented to the Emergency Department on ___ at the suggestion of her PCP due to abdominal pain with
associated fevers and hematuria. Upon arrival, intravenous
fluids/ pain medication were administered and radiographic
imaging was obtained. An abdominal CT scan suggested
'extensive inflammatory changes about gastric banding catheter
tubing spanning approximately 10 to 11 cm with small amount of
free fluid in the right hemipelvis' without fluid collection.
Given the findings, intravenous metronidazole and ciprofloxacin
were administered and the patient was taken to the operating
room where she underwent laparoscopic exploration with lysis of
adhesions, infected band removal, washout, and upper endoscopy.
There were no adverse events in the operating room; please see
operative note for details. The patient was extubated and taken
to the PACU for recovery. Once deemed stable, she was admitted
to the general surgical ward for further observation.
Neuro: The patient was alert and oriented throughout her
hospitalization; pain was initially managed with intravenous
hydromorphone and tylenol and then transitioned to oral
oxycodone and tylenol once tolerating clears.
CV: The patient was persistently tachycardic to 110-120s on
POD1, which responded to fluid boluses and aggressive IV fluid
resuscitation. She remained stable from a cardiovascular
stanpoint throughout the remainder of her hospitalization; vital
signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: She was initially kept NPO until an upper GI study
was performed on post-operative day 1, which was negative for a
leak. Therefore, her diet was advanced to a clears, however on
POD2, the patient developed nausea with associated dry heaves
and mild abdominal distention. Her nausea resolved by POD3 and
she began passing flatus with + BM on POD4; she was subsequently
able to tolerate diet advancement. She continued to report
bloating and fullness which was relieved with Reglan. Of note,
the patient had one left-sided JP drain placed intraoperatively.
On POD4, drain output changed in character from
serous/serosanguionous to dark brown, returning to serous over
the next day. A JP amylase was 3263 and total bilirubin was
1.3. Patient was clinically improving but this prompted a CT
abdomen on POD 5 which failed to demonstrate a a leak or abcess.
However, it did continue to show pelvic fluid with a small
foreign body in the dependent fluid with a tubular structure,
thought to be a small piece of the trocar sheath, and the
decision was made not to intervene. JP drain was discontinued
POD 7 before discharge. Also, immediately post-operatively,
urine output remained marginal requiring mulitple fluid boluses.
A foley catheter, placed on POD2 for urine output monitoring,
was discontinued on POD 4 due to adequate urine output after
aggressive fluid resuscitation. Subsequently, the patient was
able to void adequate amounts of urine throughout the remainder
of her hospitalization.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. She was treated empirically
with intravenous ciprofloxacin and metronidazole. This was
changed to vancomycin once gram stain from intra-operative
cultures showed gram + cocci in pairs/clusters. Cultures were
consistent with strep anginosus; ID recommended starting
ceftriaxone and resuming metronidazle for a total of 2 weeks.
Patient received a PICC line on POD 5 in order to continue home
abx therapy. WBC peaked at 15.6 on POD4, consistently
normalizing throughout her hospitalization. Her abdominal drain
was discontinued on POD 7 before discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible. She also receieved a PPI
thoughout her stay for GI prophylaxis.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
to assist her with her PICC line and IV antibiotics for a 2 week
duration. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Lactulose 10g/15mL Oral 15mL'' prn, Lorazepam 0.5 QAM prn, 1 QHS
prn
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) g Intravenous Q24H (every 24 hours) for 14 days.
Disp:*28 g* Refills:*0*
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
5. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours).
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*50 Tablet(s)* Refills:*2*
8. nystatin 100,000 unit Tablet Sig: One (1) Tablet Vaginal HS
(at bedtime).
9. Saline Flush 0.9 % Syringe Sig: One (1) syrine Injection
every eight (8) hours for 14 days: flush ___ q8h.
Disp:*42 syringes* Refills:*0*
10. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
once a day for 14 days: please flush PICC qday and prn.
Disp:*21 flushes* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lap Band erosion with retained foreign body
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 or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10637868-DS-3
| 10,637,868 | 21,472,738 |
DS
| 3 |
2139-12-19 00:00:00
|
2139-12-19 13:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
oxycodone / hydrocodone
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with medical history of IVDA and hepatitis C presenting w/
three days of fever, cough and acute abdominal pain as well as
hematemesis at 7 ___ today. He states that this has never
happened before. he had been in detox at ___ and was doing
well (sober since ___. Two days ago he awoke with fever
and chills and reports receiving several doses of Tylenol q4h.
He is concerned that the Tylenol in combination with his hep C
resulted in this acute episode. Patient reports pain in the
epigastric region radiating up to the throat. No recent IVDU
(last use 1 month ago), no recent travel, no blood in stool
(last BM 2 days ago), no hematuria. No family history of
autoimmune disorders. He reports that he had fever to 103 at
home (lives in a half-way house and attends ___ clinic at
___.
In the ED, initial vitals: 97.6 75 144/84 18 100% RA.
- Exam notable for: epigastric ttp, scant hematemesis.
- Labs notable for: CBC: wbc 6.8, Hct 39.9, downtrended to 35
in ED, platelets 139, chem-7 WNL, trop negative, ALT 1389, AST
997, INR 1.3, negative serum tox, including acetaminophen.
- Imaging notable for: CTA chest, CT abdomen/pelvis ordered.
- Patient given: 1L NS and metoclopramide.
- He was admitted to medicine for management unknown baseline
transaminases, severe abdominal pain, poor access to follow up,
reported hematemesis admission for serial hematocrits and
transaminases.
- Vitals prior to transfer: 98.3 68 118/76 16 100% RA.
On arrival to the floor, pt reports severe abdominal pain. He
was just involved in a verbal altercation with his roommate and
is agitated. He relays the history above. He is very anxious
about his prognosis and angry about his experience at ___. He
is particularly upset that he was given acetaminophen while
there.
REVIEW OF SYSTEMS: a complete ROS was negative except as noted
in HPI.
Past Medical History:
- IVDU
- Viral hepatitis C not treated
Social History:
___
Family History:
No known history of liver disease (patient states he does not
really know about family history)
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
VS: 98.7 115/52 65 20 97%RA
GENERAL: sitting in bed with cheese quesadilla waiting to be
eaten
Eyes: Anicteric without conjunctival injection
ENT: MMM. No oral lesions
NECK: supple
___: RRR, no m/r/g
LUNGS: CTAB, no w/r/c
ABDOMEN: soft, diffusely tender along liver capsule on all
edges, nondistended, normoactive bowel sounds
SKIN: Warm. Dry.
EXT: well perfused, no edema
NEURO: [x] Oriented x3 [x] Fluent speech [ ] asterixis
Psych: [x] Alert [x] Calm
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Vitals: 97.9 103/64 59 18 96% RA
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, no deposition noted in ___, 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: Soft, tender to palpation in RUQ and epigastrium,
non-distended, bowel sounds present, mild rebound tenderness, no
heptosplenomegaly
Ext: Warm, well perfused, no cyanosis or edema. Extensive
tattoos along bilateral arms.
Skin: Without rashes or lesions
Neuro: A&Ox3. Can do MOYB. Grossly intact. No asterixis.
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 09:15PM BLOOD WBC-6.8 RBC-4.37* Hgb-13.5* Hct-39.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-12.0 RDWSD-40.6 Plt ___
___ 09:15PM BLOOD ___ PTT-35.7 ___
___ 09:15PM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-137
K-4.2 Cl-98 HCO3-24 AnGap-19
___ 09:15PM BLOOD ALT-1389* AST-997* AlkPhos-127
TotBili-1.1
___ 09:15PM BLOOD Lipase-11
___ 09:15PM BLOOD cTropnT-<0.01
___ 09:15PM BLOOD Albumin-4.3
___ 10:43AM URINE Color-Straw Appear-Clear Sp ___
___ 10:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
PERTINENT INTERVAL LABS:
========================
___ 03:00PM BLOOD calTIBC-311 Ferritn-172 TRF-239
___ 09:15PM BLOOD HBsAg-Negative HBcAb-Negative HAV
Ab-Negative IgM HAV-Negative
___ 03:00PM BLOOD AMA-NEGATIVE
___ 05:15PM BLOOD Smooth-NEGATIVE
___ 05:15PM BLOOD ___
___ 03:00PM BLOOD IgG-895 IgA-262 IgM-192
___ 04:03AM BLOOD HIV Ab-Negative
___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:00PM BLOOD tTG-IgA-4
___ 09:15PM BLOOD HCV Ab-Positive*
___ 03:00PM BLOOD HCV VL-4.4*
LAB RESULTS ON DISCHARGE:
=========================
___ 06:20AM BLOOD WBC-5.2 RBC-4.08* Hgb-12.6* Hct-37.2*
MCV-91 MCH-30.9 MCHC-33.9 RDW-12.3 RDWSD-40.8 Plt ___
___ 06:20AM BLOOD ___ PTT-33.0 ___
___ 06:20AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-138
K-3.8 Cl-101 HCO3-24 AnGap-17
___ 06:20AM BLOOD ALT-261* AST-73* LD(LDH)-191 AlkPhos-104
TotBili-0.4
___ 06:20AM BLOOD Albumin-3.8 Calcium-8.6 Phos-4.6* Mg-1.9
IMAGING:
========
CTA CHEST ; CT ABD & PELVIS WITH CONTRAST ___
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. The heart, pericardium, and great vessels
are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of
parenchymal
opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN:
HEPATOBILIARY: There is a subcentimeter hypodensity in segment
VI (3B/166),
too small to characterize. The liver otherwise demonstrates
homogenous
attenuation throughout. There is no evidence of focal lesions.
There is no evidence of intrahepatic biliary dilatation. The
common bile duct is at the upper limits of normal, measuring 0.7
cm (3B/154). The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: Small anterior splenule. The spleen shows normal size
and attenuation throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. There is a 1.2 cm round calcific
density in the ascending colon (3B/ 169) of indeterminate
etiology. The colon and rectum are otherwise within normal
limits. The appendix is normal. There is no free
intraperitoneal fluid or free air.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome
osseous lesions or acute fracture. Incidentally noted 0.6 cm
sclerotic focus in the right
femoral neck (___), likely representing a bone island. The
abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of pulmonary embolism or aortic injury.
No findings in the chest, abdomen or pelvis to explain patient's
symptoms.
LIVER OR GALLBLADDER US ___
INDICATION: ___ male with newly diagnosed hepatitis,
please perform with Doppler to evaluate for thrombosis.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation
of the abdomen was performed.
COMPARISON: CT of the abdomen and pelvis dated ___.
View
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No
focal liver
lesions are identified. There is no ascites.
Bile ducts: There is up to intrahepatic biliary ductal
dilation. The common hepatic duct measures 4 mm.
Gallbladder: There is moderate gallbladder wall edema without
gallbladder
distention. There is debris within the gallbladder lumen,
likely gallbladder sludge.
Pancreas: The imaged portion of the pancreas appears within
normal limits, with portions of the pancreatic tail obscured by
overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and
measures 10.5 cm.
Kidneys: The kidneys were not evaluated, better seen on the
recent CT of the abdomen and pelvis.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate
direction.
Main portal vein velocity is 38.5 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with
appropriate waveforms. Splenic vein and superior mesenteric vein
are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. Moderate gallbladder wall edema without gallbladder
distention is likely attributable to underlying liver
dysfunction.
Brief Hospital Course:
___ year old gentleman with history of intravenous drug use and
acute hepatitis C presenting with epigastric and RUQ abdominal
and marked transaminitis c/w acute hepatitis, thought
potentially related to hepatitis C re-infection.
# Acute hepatitis, likely hepatitis C re-infection:
Hepatocellular pattern of injury with transaminitis in 1000s
(AST 997, ALT 1389) upon presentation, also with episode of
reported fever to 103. Empiric 20-hour NAC protocol completed,
as patient reported ingesting unknown doses of acetaminophen q4H
for several consecutive days while at ___ rehab. However,
upon reaching out to ___, they stated that he only received
650 mg BID x two days, which makes acetaminophen toxicity very
unlikely. Hence, NAC was discontinued.
Given his very elevated transaminases, differential is limited
to viral versus toxin-induced versus an autoimmune cause. He had
no history to suggest ischemic cause, including no recent
cocaine use, and declines any new drugs/toxins other than those
that were being administered to him at ___ (we have no such
records). This leaves viral etiologies at top of differential.
Hepatology suggested most likely etiology is acute HCV. Patient
reports being diagnosed with acute hepatitis C whilst at
___ in ___ with LFT in 3000's; he may have
cleared initial infection and gotten another one, as he had
episode of drug use after that hospitalization. This is a
difficult theory to prove- if it so happens that genotype of
current HCV is different from that from his ___
hospitalization, could be c/w this theory. Unfortunately,
despite repeated calls and faxing over release of information,
to date we still have not received any medical records from
outside facility. In addition, we note that genotype 1 is most
prevalent in the ___, accounting for ~70%.
Summary of work up is as follows:
1) Viral:
PENDING: HCV genotype pending
POSITIVE: HCV Ab+, viral load 10^4.4 ___, VZV IgG+
NEGATIVE: Hepatitis A/B negative, CMV negative, HIV negative,
monospot negative
EQUIVOCAL: VZV IgM
2) Autoimmune:
PENDING: Anti-liver/kidney microsomal antibody type 1
NEGATIVE: AMA, ___ and anti-Sm negative, IgG/IgA/IgM WNL
3) Other: Iron panel wnl (r/o hemochromatosis), ceruloplasmin
WNL, RUQ U/S without clot
Patient's transaminitis rapidly downtrending, and on day of
discharge was AST 73 ALT 261 Tbili 0.1 from AST 997 ALT 1389
Tbili 1.1 on admission. He will establish care with a primary
care doctor, ___, if after 6 months he still does not clear
hepatitis and remains in recovery from heroin/cocaine use, can
refer to ___ further treatment options. He will
require HAV, HBV and PPSV23 vaccine.
# Abdominal pain: It is most likely that that liver inflammation
has resulted in stretching of the capsule that is painful. He
had a CT A/P on admission which was unrevealing for structural
causes of abdominal pain; RUQ U/S also unremarkable. As patient
complained of dark brown urine despite fluid intake and normal T
bili, we contemplated acute intermittent porphyria as part of
the differential and sent out urine PBG. This was pending at
time of discharge.
Regarding management of his abdominal pain, patient initially
was receiving IV morphine. However, as he was on suboxone, this
did not have much effect on pain control. Hence oped to stop
suboxone ___ and treat his pain with hydromorphone 0.5-2 mg
mixed in 50 mL water, to run slowly over 15 minutes. However, on
___ he stated that he would really prefer to be back on
suboxone and that his pain was tolerable, hence switched him
back. He was able to tolerate ginger ale, ice cream, and chips
at time of discharge.
# Hematemesis: One episode reported in ED, Hgb 13.5 -> 11.7
Likely consistent with ___ tear given reports of
repeated dry heaving. No evidence of varices on his CT abdomen.
Hemodynamically stable throughout stay. No coffee-grounds or
melena or BRBPR. Platelets WNL and INR not markedly elevated and
not suggestive of coagulopathy. He was treated with IV PPI BID,
sucralfate, zofran for nausea, and did not require any blood
transfusions throughout stay. He was discharged on 2 week supply
of zofran and sucralafate. Discharge Hgb 12.6.
# Fever: Reports chills and fever to 103 at detox; none
documented during admission and patient was not on antipyretics
nor on antibiotics. One episode of leukocytosis in setting of
dry heaving which resolved the next day. Infectious work up,
including blood cultures, urinalysis, flu swab, and viral
serologies (CMV, HIV, hepatitis, VZV, monospot) were only
positive for Hep C as above. Imaging with CTA chest and CT
abdomen unrevealing. Could be inflammatory response to viral
infection.
# Anxiety: Patient received lorazepam PRN: anxiety, as well as
trazodone for sleep. Please consider outpatient psychiatry/dual
diagnosis. He may benefit from starting SSRI.
TRANSITIONAL ISSUES:
====================
ACUTE HEPATITIS
- Per hepatology, likely acute hepatitis C (re-infection)
- On day of discharge LFTs AST 73 ALT 261 Tbili 0.1
- Please re-draw LFTs within ___ weeks to ensure that
transaminitis has resolved
- Please follow up on pending studies: Hepatitis C genotype,
anti-liver/kidney microsomal antibody type 1
Genotype 1A
- Please obtain ___ records; we were unsuccessful.
If they had performed HCV genotyping and it is different from
current genotype, would be consistent with theory of
re-infection
- He was given script for 2 weeks of ondansetron, sucralfate,
and bowel regimen
- Patient should establish care with PCP; he was referred to
___ (per his preference) but they did not have
appointment until ___ so we set up post follow up
appointment at ___. We note that he would likely benefit the
most from a healthcare system that offers PCP ___ + dual
diagnosis psychiatry.
- PCP to coordinate further management of hepatitis treatment.
If within 6 months patient has not cleared infection and is
stable from IVDU standpoint, please refer to ___
follow up
- He will require HAV/HBV/PPSV23 vaccinations as outpatient
ANXIETY/SUBSTANCE ABUSE
- Patient would likely benefit from SSRI given frequent
complaints of anxiety
- Given high complexity situation with recent detox and
continued recovery, he would likely benefit the most from
psychiatric provider that provides dual diagnosis services
MISCELLANEOUS:
- Please follow up on urine PBG results
# CODE: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL QAM
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL QPM
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*28 Capsule Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 14 Days
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*28
Tablet Refills:*0
4. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times
a day Disp #*56 Tablet Refills:*0
5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL QAM
6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute hepatitis
Hepatitis C
Person who injected drugs (PWID), now in recovery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___!
You presented to us after experiencing excruciating right upper
quadrant abdominal pain, fever to 103, and an episode of
vomiting blood. We discovered that your liver function tests
were very high, in the 1000's. You told us that you had an
episode of hepatitis C in ___ of this year, with liver
function tests in the 3000's.
There are not that many things that cause such elevations in
liver function tests- and they include medications, viruses,
autoimmune causes), and having not enough blood supply to the
liver (which can happen in setting of low blood pressures- which
you did not have).
In your case, we think that the most likely cause is that you
had acquired acute hepatitis C in ___, cleared it, then
acquired another hepatitis C infection. You have 10^4.4 (which
is about 25,118) copies of the hepatitis C virus in your blood.
All other viral studies were negative, and most of the
autoimmune studies came back normal as well. There was initial
concern about whether you could have gotten too much Tylenol,
but we called the detox center and they had only given you 650
mg twice which is very unlikely to be the cause of such
elevations of liver function tests.
We proceeded with supportive care, and your liver function tests
quickly got better.
It is very important that you find a primary care doctor to
discuss your hepatitis C and to make sure your liver function
tests are going in the right direction. Your primary care doctor
___ check your viral load (how many copies of virus you have)
in 6 months. If you clear it, then it is solved; if not, he or
she can refer you to the ___ treatment. You will
also need vaccinations against Hepatitis A, Hepatitis B, and
pneumonia. Because there was not a soon enough appointment at
___, we scheduled you for an appointment at ___
___ to make sure a doctor was available to see you within
the next 2 weeks.
Given your frequent anxiety while you were with us, we think you
might also benefit from starting anti-anxiety medication like
SSRIs- please discuss this with your psychiatric provider.
Regarding your lost personal items, please call the Patient and
Family relations hotline to register a complaint about your
items: ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10638098-DS-17
| 10,638,098 | 23,657,050 |
DS
| 17 |
2186-09-17 00:00:00
|
2186-09-17 19:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ yo M from ___, who presents to the ED with left side pain
and found to have PEs. He reports the pain has been worsening
over the last couple of weeks. He initially reported to his PCP
prior to take off and was given antibiotics. Within a day or two
of this flight, he began to notice this left side pleuritic
chest pain and difficulties taking big breaths. He then
presented to the ED.
In the ED, initial vs 98.3 89 116/80 16 96% RA. Labs were
remarkable for a D-dimer of 2500. A CTA was performed which
showed numerous multiple scattered bilateral non-occlusive
pulmonary emboli. He was started on a heparin drip and admitted
to the floor.
On the floor, he is comfortable and has only a small amount of
left sided pain. Denies fevers, chills, cough, hemoptysis, abd
pain, n/v.
Past Medical History:
Hemochromatosis
Social History:
___
Family History:
Both mother and father died of MIs (age ___. No known hx of
clotting or blood disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.3 ___ 98%RA
General: well appearing, NAD
CV: RRR no murmurs
Lungs: clear bilaterally
Abd: soft nontender
Ext: warm and dry, no edema
Neuro: A+Ox3
DISCHARGE PHYSICAL EXAM
VS:
Tmax(24hr):98.1F
BP(24hr):127-139/86-105
HR(24hr):90
RR: 18
SaO2: 100% on RA
GEN: Lying in bed, easily awoke, cooperative, in no acute
distress.
CARDIO: RRR, S1 and S2 heard, no murmur appreciated.
LUNGS: CTA b/l, no wheezing or crackles heard. Breathing
comfortably.
ABD: BS present. Soft, nondistended, nontender. No HSM.
EXT: No calf tenderness. No ___ swelling or edema.
Pertinent Results:
ADMISSION LABS
___ 06:21PM LACTATE-1.4 K+-4.2
___ 06:16PM D-DIMER-2543*
___ 06:05PM GLUCOSE-89 UREA N-16 CREAT-1.0 SODIUM-139
POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
___ 06:05PM WBC-8.7 RBC-5.20 HGB-16.1 HCT-45.7 MCV-88
MCH-30.9 MCHC-35.1* RDW-12.9
___ 06:05PM NEUTS-63.3 ___ MONOS-7.5 EOS-1.9
BASOS-0.7
___ 06:05PM PLT COUNT-178
___ 06:05PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
DISCHARGE LABS
___ 07:16AM BLOOD ___ PTT-36.4 ___
PERTINENT IMAGING
Chest Xray (___):
IMPRESSION: No acute cardiopulmonary process.
Chest CTA (___):
IMPRESSION:
Bilateral pulmonary emboli, as above. No CT sign of right heart
strain.
Pulmonary infarct not excluded underlying area of atelectasis at
the inferior left lung base. Trace left pleural effusion.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
___ yo ___ speaking male from ___, here vising family
presented to the Emergency Department with L-sided chest pain,
found to have bilateral PEs on CT scan.
ACTIVE ISSUES:
#Pulmonary embolism:
CTA performed in Emergency Department consistent with bilateral
nonocclusive PEs. Patient described chest pain for several
weeks prior to flying ___ from ___. Had been
treated for presumed pneumonia in ___ without resolution of
chest pain. He had no personal or family history of blood clots
or blood disorders. In the ED as well as throughout his
admission he was hemodynamically stable. He was initially
started on a heparin drip, which was discontinued once he
arrived to the floor. He was then put on Lovenox and warfarin.
His symptoms diminished and on hospital day 3 he was discharged.
He was seen that day in Health Care Associated primary care
clinic and will followup in the ___ clinic here to
establish a therapeutic INR. We stressed the need for his close
followup with a PCP once he returns to ___.
CHRONIC ISSUES:
#Hemochromatosis:
Patient reported having a disorder in which he has too much
iron, which was presumed to be hemochromatosis. He normally is
phlebotomized every 2 months. We did not address this issue
during his hospitalization.
TRANSITIONAL ISSUES:
-Has followup scheduled with ___.
-Advised to followup closely with PCP in ___, patient
acknowledged understanding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 5 tablet(s) by mouth daily Disp
#*150 Tablet Refills:*0
2. Outpatient Lab Work
Please check an INR the morning of ___ (before noon).
Results should be sent to the ___:
___. ICD 9 Code: ___
3. Warfarin 5 mg PO DAILY16
4. Enoxaparin Sodium 100 mg SC Q12H
RX *enoxaparin 100 mg/mL ___very 12 hours Disp #*20
Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you while you were at ___. You
were admitted on ___ after presenting to the Emergency
Department with chest pain. Imaging of your chest (a CT scan)
showed you had blood clots in your lungs, called a Pulmonary
Embolism.
You were treated with blood thinning medications to prevent you
from forming additional clots. You will continue with these
medications after your discharge, until you are further
evaluated as an outpatient. One of the medications you will be
taking after discharge (Coumadin/Warfarin) requires frequent
monitoring during the first few weeks after discharge. It is
very important you go to these appointments.
If you have any chest pain, shortness of breath, difficulty
breathing, leg swelling, new leg pains, please visit an
Emergency Department immediately.
Again, it was a pleasure to meet and care for you.
Followup Instructions:
___
|
10638281-DS-13
| 10,638,281 | 25,900,125 |
DS
| 13 |
2153-10-03 00:00:00
|
2153-10-04 11:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin base / niacin / lisinopril / ACE Inhibitors /
Macrolide Antibiotics / Aminoglycosides
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION LABS
==============
___ 02:48PM BLOOD WBC-2.9* RBC-2.90* Hgb-9.8* Hct-30.6*
MCV-106* MCH-33.8* MCHC-32.0 RDW-15.3 RDWSD-59.5* Plt ___
___ 02:48PM BLOOD Neuts-40.1 ___ Monos-25.0*
Eos-7.9* Baso-1.0 Im ___ AbsNeut-1.17* AbsLymp-0.74*
AbsMono-0.73 AbsEos-0.23 AbsBaso-0.03
___ 02:48PM BLOOD Glucose-136* UreaN-37* Creat-1.2* Na-139
K-5.1 Cl-98 HCO3-24 AnGap-17
OTHER PERTINENT LABS
=====================
___ 02:48PM BLOOD cTropnT-0.02* proBNP-8966*
___ 06:53AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS
==============
___ 06:22AM BLOOD WBC-2.7* RBC-2.95* Hgb-9.9* Hct-31.1*
MCV-105* MCH-33.6* MCHC-31.8* RDW-15.5 RDWSD-59.6* Plt ___
___ 06:22AM BLOOD Glucose-129* UreaN-39* Creat-1.3* Na-140
K-4.6 Cl-100 HCO3-21* AnGap-19*
___ 06:22AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.4
MICRO
=====
___ 02:48PM URINE Color-Straw Appear-Clear Sp ___
___ 02:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 02:48PM URINE RBC-2 WBC-16* Bacteri-FEW* Yeast-NONE
Epi-2 TransE-<1
___ 2:48 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======
___ CXR
Cardiac silhouette size remains moderately enlarged. The aorta
is tortuous.
Mediastinal and hilar contours are similar. Pulmonary
vasculature is not
engorged. Patchy ill-defined opacity is seen in the left lower
lobe. No
pleural effusion or pneumothorax. Chronic deformity of the left
glenohumeral
joint, possibly degenerative in etiology, and high-riding right
humeral head
indicative of underlying rotator cuff disease redemonstrated.
___ TTE
EF 58%. Severe trileaflet calcific aortic stenosis. Moderate
symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function. Increased PCWP. Mild
right ventricular cavity dilation with normal systolic function.
Moderate to severe tricuspid
regurgitation. Moderate mitral regurgitation. At least moderate
pulmonary artery systolic hypertension.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Please repeat labs at patient's next office visit on ___
with CBC to follow up anemia and leukopenia as well as Chem-7 to
check on kidney function.
[ ] Patient with TTE showing severe aortic stenosis, moderate to
severe tricuspid regurgitation, and moderate mitral
regurgitation. The AS the severe enough to warrant outpatient
TAVR workup. Patient will be seen as an outpatient by the TAVR
team with CTA and clinic visit. She was seen by Cardiac Surgery
and deemed not to be a surgical candidate.
[ ] Patient with dyspnea on exertion with initial slight
troponin leak and EKG with conduction abnormality. Patient would
benefit from outpatient nuclear stress test. However, as she is
undergoing outpatient TAVR workup, and can be discussed further
with the Structural Cardiology team.
BRIEF HOSPITAL COURSE
======================
___ woman with history of CKD III, T2DM, leukopenia, and
anemia who presents with dyspnea on exertion found to have
severe aortic stenosis on TTE warranting TAVR workup. Patient
remained hemodynamically stable with normal oxygen saturation on
room air throughout entire hospitalization. She will be set up
with close follow-up with the Structural Cardiology team for
outpatient TAVR workup.
ACTIVE ISSUES
==============
#Dyspnea on exertion
#Severe Aortic Stenosis
Patient presented to ED after episode of dyspnea during ___
session for mechanical fall in ___. CXR with ?LLL opacity but
confirmed with radiology that it is more likely vascular
congestion and not pneumonia, also present on past CXR. Patient
with age indeterminate RBB on EKG with mild trop leak likely due
to increased demand and age-related conduction disease (trop
downtrended to <0.01). Patient with loud systolic murmur on
exam, elevated BNP on admission (8966), mild pulmonary edema on
CXR, and bibasilar crackles suggestive of symptomatic AS. TTE on
___ showed severe aortic stenosis, moderate to severe tricuspid
regurgitation, and moderate mitral regurgitation. Patient is
asymptomatic at rest. Structural cardiology team was consulted
and believed that because the patient has an elevated wedge
pressure, her her AS could be hemodynamically significant
warranting TAVR workup. Patient was evaluated by Cardiac Surgery
and deemed not to be a surgical candidate. Structural cardiology
recommended outpatient TAVR workup and clinic visit as patient
hemodynamically stable and satting well on room air throughout
admission. Patient would benefit from outpatient nuclear stress
test, possibly included in TAVR workup.
CHRONIC/STABLE ISSUES
======================
#Anemia
#Leukopenia
Patient is followed by hematology at ___. Felt to be
multifactorial including MDS, anemia of CKD, and possible
medication effect. Recommended conservative monitoring given age
and comorbidities. Labs stable during admission.
#CKD
Creatinine at baseline of 1.1-1.2 during admission. Discharge Cr
1.3.
#Hypertension
Patient continued on home losartan and HCTZ.
#T2DM
Diet-controlled, not on home medications. She was placed on ISS
during admission, with blood sugars in 100-160s.
#Dyslipidemia
Patient placed on atorvastatin because home lovastatin not on
formulary. Restarted lovastatin on discharge.
#Depression
Patient continued on home mirtazapine, bupropion, and
venlafaxine. Held home lorazepam during admission, patient did
not require this medication. Consider discontinuing standing
lorazepam as patient has had falls in the past and did not
require this medication in the hospital.
#Glaucoma
Patient continued on home timolol drops. Held home AREDS-2 as
non-formulary.
#Hypothyroidism
Patient continued on home levothyroxine
#GERD
Patient continued on home ranitidine
#Bladder spasms
Patient continued on home tolterodine
#CODE: Full (confirmed)
#CONTACT: ___ Phone number: ___
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Levothyroxine Sodium 75 mcg PO DAILY
3. LORazepam 0.5 mg PO BID
4. Losartan Potassium 25 mg PO DAILY
5. Lovastatin 20 mg oral DAILY
6. Mirtazapine 30 mg PO QHS
7. Ranitidine 150 mg PO BID
8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
9. Tolterodine 1 mg PO BID
10. Venlafaxine XR 37.5 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. Docusate Sodium 100 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Docusate Sodium 100 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. LORazepam 0.5 mg PO BID
7. Losartan Potassium 25 mg PO DAILY
8. Lovastatin 20 mg oral DAILY
9. Mirtazapine 30 mg PO QHS
10. Multivitamins 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
12. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
13. Ranitidine 150 mg PO BID
14. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
15. Tolterodine 1 mg PO BID
16. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Severe Aortic Stenosis
SECONDARY DIAGNOSIS:
=====================
Diabetes Mellitus Type II
Leukopenia ___ MDS
___ Kidney Disease stage 3
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were noticed to have a change in your breathing while
walking.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had an ultrasound of your heart which showed a very tight
valve that is likely causing your trouble breathing
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
- You will hear from the Cardiology office about scheduling all
of the follow-up appointments to evaluate the valve.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10638506-DS-22
| 10,638,506 | 25,125,722 |
DS
| 22 |
2191-12-07 00:00:00
|
2191-12-10 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
tramadol
Attending: ___.
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year-old female known to our service given history
of grade 1 neuroendocrine tumor s/p robot-assisted laparoscopic
central pancreatectomy nearly ___ years ago, as well as renal
cell carcinoma s/p partial right nephrectomy, presents today
with
a 12-hour history of abdominal pain. Patient had been in her
usual state of health until this afternoon, when she experienced
sudden-onset cramping right-sided abdominal pain while
exercising
at the gym. Pain subsided after resting from her activities,
however once back home, she noticed new-onset mid-abdominal
pain.
She describes this pain as colicky, with intermittent waves of
severe intensity, non-radiated, with concomitant nausea and two
episodes of bilious, non-bloody emesis. Denies fevers but
endorses occasional chills. Last bowel movement earlier
yesterday
morning, does not recall last flatus. She decided to come to our
institution for further evaluation and management.
Of note, patient reports a similar episode last year while
visiting her home town in ___, which resolved
spontaneously after a short stay at a local hospital.
Past Medical History:
Past medical history:
Grade I pancreatic neuroendocrine tumor, renal cell carcinoma,
anxiety, depression, chronic pelvic pain likely due to
adenomyosis, recurrent urinary tract infection, oral herpes,
aphthous stomatitis
Past surgical history:
Right partial nephrectomy ___ - Dr ___, robot-assisted
minimally invasive central pancreatectomy, completion open
enucleation of pancreatic head with pancreatogastrostomy (___)
Social History:
___
Family History:
Mother with hyperlipidemia and hypertension, as well as kidney
cyst and a skin cancer. Maternal uncle died of colon cancer.
Maternal sister has had two children who have had stomach
cancers, both in their ___. Father died from emphysema
Physical Exam:
Admission exam:
Vital signs - 98.0 77 133/80 18 98% RA
HEENT - PERRLA, EOMI. Nasogastric tube in place
Constitutional - Well appearing, in no acute distress
Cardiopulmonary - RRR, normal S1 and S2. No murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally
Abdominal - Well-healed incisional scars from prior surgical
procedures. Soft, mildly distended, diffusely tender, worst over
left upper quadrant. No rebound tenderness or guarding
Extremities - Atraumatic. Warm and well-perfused. No clubbing,
cyanosis or edema
Neurologic - Alert and oriented x3. Grossly intact
Discharge exam:
VS: within normal limits, not tachycardic or hypertensive,
oxygenating well on RA
Gen: NAD in bed
Pulm: breathing comfortably, bilateral chest rise
Cardiac: pink and perfused
Abd: soft, nontender, nondistended
Ext: WWP, no edema
TLD: none
Pertinent Results:
Admission labs:
___ 07:00PM WBC-11.0# RBC-4.70 HGB-14.4 HCT-43.2 MCV-92
MCH-30.7 MCHC-33.4 RDW-13.4
___ 07:00PM NEUTS-77.6* LYMPHS-16.0* MONOS-4.1 EOS-1.9
BASOS-0.5
___ 07:00PM GLUCOSE-92 UREA N-15 CREAT-0.7 SODIUM-141
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
___ 07:00PM ALT(SGPT)-26 AST(SGOT)-27 ALK PHOS-159* TOT
BILI-0.3
___ 07:00PM LIPASE-51
___ 06:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
CT Abdomen/Pelvis (___):
Multiple dilated, fluid-filled loops of small bowel, with a
transition point seen in the left hemiabdomen, concerning for
small bowel obstruction. The involved loops of small bowel do
not
appear thickened, and demonstrate normal enhancement. No
stranding is seen within the adjacent mesentery. The distal
small
bowel appears collapsed. The proximal small bowel also appears
somewhat collapsed, which may be secondary to vomiting and
nasogastric tube suctioning
Brief Hospital Course:
Ms. ___ was admitted to the ___ Surgery Service for
non-operative management of small bowel obstruction. On
admission, she was made NPO, a nasogastric tube was placed, and
she was started on intravenous fluids. Serial abdominal exams
were performed; she was given morphine for pain and ondansetron
for nausea. The output from her nasogastric tube was noted to be
blood-tinged, and she was started on pantoprazole. On hospital
day 2 a KUB showed no evidence of obstruction, with air seen in
nondilated loops of large and small bowel. The NGT was clamped,
with subsequent low residual output. NGT removed on hospital day
2 and she was started on clear liquids. At the time of discharge
on HD3, Ms. ___ had successfully progressed to a full liquid
diet with no nausea or vomiting, transitioned to PO pain
medication, and moved her bowels. She continued to pass flatus
and her abdominal exam improved by discharge.
Medications on Admission:
Wellbutrin SR 100mg qAM, citalopram 30mg qAM; zolpidem 5mg qHS;
sulfamethoxazole 800mg-trimethoprim 160 mg BID; ibuprofen 600mg
QID prn; vitamin D3 1,000h qD; MVI; valacyclovir 2 g daily prn
cold sore
Discharge Medications:
1. Citalopram 30 mg PO QAM
2. BuPROPion (Sustained Release) 100 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10638644-DS-21
| 10,638,644 | 27,236,808 |
DS
| 21 |
2185-07-07 00:00:00
|
2185-07-08 06:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ with history of polyarthritis, primary
biliary cirrhosis, and recurrent diverticulitis who presents
with abdominal pain. The patient reports several days of
abdominal distention and bloating with one day of abdominal
pain. She reports increased gas and bloating starting on ___,
but thought that she could make it through ___ before
going to urgent care. She describes the pain that started
yesterday as concentrated in the lower abdomen in a band, worst
in the left lower quadrant. She denies vomiting. She admits to
anorexia, malaise, chills. She has had watery diarrhea for ___
hours with >10 smaller bowel movements daily. She denies urinary
frequency, dysuria. She reports having multiple episodes of
diverticulitis before but has declined surgical referral with
her PCP in the past.
She also admits to a history of exertional dyspnea over several
months that limits her to walking around 2 blocks over flat
terrain. She has not had pedal edema, wheezing, weight gain,
orthopnea, PND, or angina. She is a never-smoker.
In the ED, initial vital signs were 98.4 111 138/78 14 96%. Labs
demonstrated no leukocytosis, but a left shift (N80),
unremarkable chemistries and LFTs, lactate 1.4, and UA with
small leukesterase and few bacteria. A CTAP was performed and
demonstrated sigmoid diverticulitis without abscess or evidence
of perforation. The patient was given ciprofloxacin and
metronidazole as well as IVF.
Review of Systems:
(+) per HPI
(-) fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
#Polyarthritis, NOS
#Primary biliary cirrhosis
#Psoriasis
#Recurrent diverticulitis: 3 episodes in ___ episode ___
has had >>5 episodes
#GERD c/b ___ esophagus
#Obesity
#Hx of colonic polyps - last colonoscopy ___ (normal)
#Lactose intolerance
#Osteopenia
#Hx of oral thrush
#s/p Prevnar ___
Social History:
___
Family History:
Father had ___ at ___, but died of other causes. Younger brother
had partial colectomy for diverticulitis. No hx of IBD,
autoimmune disease.
Physical Exam:
ADMISSION EXAM:
==============
Vitals - T: BP: HR: RR: 02 sat:
GENERAL: well appearing elderly woman in bed in NAD
HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, tender in LLQ without rebound/guarding,
no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
MSK: no findings of joint effusion, erythema, or deformity in
DIPs, PIPs, MCPs, wrists, elbows, knees, ankles, MTPs.
GU: no foley, no CVAT
PULSES: 2+ DP pulses bilaterally
NEURO: Alert and oriented. CN II-XII intact. Strength is ___
throughout. DTRs 2+ throughout and 1+ at Achilles. Babinski is
down-going. Negative pronator drift. Normal FNF.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
==============
VS: T 97.7 BP 133-141/50s-60s HR ___ R 18 98%RA
I/O: not recorded (yesterday 3 recorded BMs)
GENERAL: elderly woman sitting upright in bed appearing
comfortable, about to eat breakfast
HEENT: MMM
CV: normal rate, regular, no m/r/g
PULM: CTAB
ABD: soft, no tenderness to palpation. No guarding. No RT.
EXT: warm, no edema, 2+ pulses
Pertinent Results:
ADMISSION LABS:
==============
___ 12:29AM ___ COMMENTS-GREEN TOP
___ 12:29AM LACTATE-1.4
___ 12:17AM GLUCOSE-112* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 12:17AM estGFR-Using this
___ 12:17AM ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-96 TOT
BILI-0.5
___ 12:17AM ALBUMIN-4.6
___ 12:17AM WBC-10.3 RBC-4.79 HGB-13.3 HCT-40.0 MCV-84
MCH-27.8 MCHC-33.2 RDW-17.0*
___ 12:17AM NEUTS-80.5* LYMPHS-11.6* MONOS-6.7 EOS-1.0
BASOS-0.2
___ 12:17AM PLT COUNT-214
___ 12:10AM URINE HOURS-RANDOM
___ 12:10AM URINE HOURS-RANDOM
___ 12:10AM URINE UHOLD-HOLD
___ 12:10AM URINE GR HOLD-HOLD
___ 12:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
___ 12:10AM URINE RBC-2 WBC-18* BACTERIA-FEW YEAST-NONE
EPI-1
___ 12:10AM URINE MUCOUS-FEW
IMAGING/STUDIES:
===============
+ ___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
No Growth To Date x 2
+ ___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
+ ___BD & PELVIS WITH CO
IMPRESSION:
1. Mild sigmoid diverticulitis without abscess or evidence of
perforation.
2. 1.4 cm left lower lobe pulmonary mass is indeterminate and
might contain fat, and given no prior studies short interval
followup dedicated chest CT in ___ months is recommended to
evaluate for interval change.
3. Suggestion of hepatic steatosis.
DISCHARGE LABS:
==============
___ 06:00AM BLOOD WBC-4.9 RBC-4.01* Hgb-11.3* Hct-33.0*
MCV-83 MCH-28.2 MCHC-34.1 RDW-16.4* Plt ___
___ 06:00AM BLOOD Glucose-93 UreaN-3* Creat-0.7 Na-145
K-3.2* Cl-101 HCO3-32 AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ with history of significant autoimmune
disease on methotrexate, adalimumab, and long-term
corticosteroids who presents with recurrent acute uncomplicated
diverticulitis.
#Acute Uncomplicated Diverticulitis: The patient has a history
of recurrent diverticulitis. On admission her CT scan showed
mild sigmoid diverticulitis. She was seen by surgery and was
kept on sips and IVF initially until her pain improved. She was
started on ciprofloxacin and metronidazole on ___ to complete
a 14 day course. She did have ___ bowel movements a day which
improved by day of discharge. C. diff was negative. She was
initially given morphine PRN for pain control and nystatin oral
rinse. By day of discharge her bowel movements had decreased in
frequency and she was able to tolerate a BRAT diet without
nausea or abdominal pain. She was discharged on ciprofloxacin,
metronidazole, and nystatin. She will need outpatient follow up
with GI for colonoscopy with Dr. ___ also with surgery for
a discussion regarding sigmoidectomy.
#Primary biliary cirrhosis: The patient has a long history of
PBC which had been well controlled on 2 mg methylprednisolone
daily, adalimumab q2weeks, and methotrexate 20 mg weekly. She
was continued on her methylprednisolone during hospital stay,
but her methotrexate, leucovorin, and adalimumab were held in
the setting of acute diverticulitis. She was maintained on
ursodiol. She has a follow up appointment with her PCP ___ ___
at which time the decision for resuming MTX and adalimumab can
be made. Upon discharge she will need to follow up with
transplant surgery (given her PBC) in 8 weeks regarding her
sigmoidectomy.
#Polyarthritis: The patient had no active synovitis on exam. Her
ESR was 28 ___. During hospital stay she did have some
morning stiffness and body aches. As above, she was continued on
methylprednisolone and methotrexate and adalimumab was held.
___: The patient was maintained on home pantoprazole
40mg daily.
#Osteopenia: The patient was continued on Vitamin D and Ca for
long-term steroid use.
TRANSITIONAL ISSUES
[]will need colonoscopy in ~6 weeks per surgical consultants
[]will need surgery evaluation for sigmoidectomy
[]will need coordination of immunosuppression between Dr.
___ surgeons around the time of her operation so as to
promote healing and prevent infection. On discharge preadmission
methotrexate/leucovorin and Humira were held.
[]Patient has a small density in the lung with density of
adipose tissue, consistent with hamartoma. Radiology recommended
repeat non-contrast chest CT in ___ months to show stability.
[]Discharged to complete a 14-day course of cipro (500mg BID)
and metronidazole (500mg q8hrs); last day ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Methotrexate 20 mg PO QFRI
3. Ursodiol 300 mg PO BID
4. Sucralfate 2 tsp PO QHS
5. Leucovorin Calcium 15 mg PO 1X/WEEK (FR)
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
7. adalimumab 40 mg/0.8 mL subcutaneous q2 weeks
8. Vitamin D 3000 UNIT PO DAILY
9. Citracal + D Maximum (calcium citrate-vitamin D3) 315-250
mg-unit oral QID
10. Methylprednisolone 2 mg PO DAILY
Discharge Medications:
1. Methylprednisolone 2 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Ursodiol 300 mg PO BID
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days
To complete a 14 day course
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*19 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 9 Days
To complete a 14 day course
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*29 Tablet Refills:*0
6. Vitamin D 3000 UNIT PO DAILY
7. Sucralfate 2 tsp PO QHS
8. Citracal + D Maximum (calcium citrate-vitamin D3) 315-250
mg-unit ORAL QID
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
10. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth QID:PRN Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
#Acute uncomplicated diverticulitis
#Inflammatory polyarthritis, NOS
#Primary biliary cirrhosis
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 a recurrent episode of acute
uncomplicated diverticulitis. The CT scan of your abdomen did
not show an abscess (collection of pus) or obstruction. Given
that you take immunosuppressants for your primary biliary
cirrhosis and arthritis, you have a risk of developing severe
diverticulitis in the future. Typically, in patients without
immunosuppression, we recommend surgical removal of the section
of colon with diverticuli after a few episodes. In patients WITH
immunosuppression, some doctors recommend surgery sooner. As we
discussed, there are risks to taking antibiotics, such as
clostridium difficile colitis, a dangerous bacterial infection
that can occasionally require surgery. Therefore, we strongly
recommend that you have an appointment with a general or
colorectal surgeon to discuss partial colectomy to prevent
recurrent diverticulitis. We will make you an appointment with
your gastroenterologist to perform colonoscopy in ~6 weeks and
then with a colorectal surgeon to evaluate you for elective
surgery after that. We will also schedule you to follow up with
our transplant surgeons.
Additionally, while you were here we held your methotrexate
given your infection. Please discuss this with your Primary Care
Physician before restarting. You will need to take oral
antibiotics for ~14 days. Dr. ___ should
coordinate your immunosuppression with the surgeons around the
time of your operation.
Finally, you had a small area in your lung with the density of
fat tissue that may be a hamartoma, or benign tissue in the
wrong place. The radiologist recommended a repeat CT scan of the
lungs in ___ months to confirm that it is stable.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10638652-DS-16
| 10,638,652 | 27,547,770 |
DS
| 16 |
2113-03-12 00:00:00
|
2113-03-12 12:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cholecystitis
Major Surgical or Invasive Procedure:
lap ccy
History of Present Illness:
Ms ___ is a ___ year old female with a PMH significant for
of
pacemaker placement ___ bradycardia following syncope who
presents with 6 months of vague RUQ pain that acutely worsened
over the last 5 days. She reports that she has had RUQ
discomfort
for years, but about 6 months ago the symptoms became more
constant and gnawing. Occasionally she would feel back pain.
Does
not describe frank pain in the RUQ at baseline, just discomfort.
It sometimes will abate completely, but she usually notices it.
Months ago, however, her husband reports that she had jaundice
for about a month with loose stools, at which time she was
started on Creon by her PCP. She does not recall additional
workup at that time, and the jaundice self-resolved. About 3
weeks ago she developed fevers and a cough, and she was treated
in the outpatient setting with azithromycin. Her cough improved,
but her abdominal pain worsened. She again had fevers at home up
to 101.5 about ___ days ago. No recent episodes of jaundice or
yellowing of the eyes. Stools have been normal recently.
Past Medical History:
Pacer for heart block/syncope
Reflux
Parotidectomy for parotid tumor
Social History:
___
Family History:
CAD
Physical Exam:
GEN: A&Ox3, 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, appropriately tender. surgical incision
c/d/i
Ext: No ___ edema, ___ warm and well perfused
Neuro: Grossly intact
Psyc: appropriate mood/affect
Pertinent Results:
___ 02:04PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
___ 01:15PM GLUCOSE-95 UREA N-10 CREAT-0.5 SODIUM-139
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13
___ 01:15PM estGFR-Using this
___ 01:15PM ALT(SGPT)-9 AST(SGOT)-14 ALK PHOS-68 TOT
BILI-0.4
___ 01:15PM LIPASE-26
___ 01:15PM ALBUMIN-3.8
___ 01:15PM WBC-20.5* RBC-4.48 HGB-12.3 HCT-39.3 MCV-88
MCH-27.5 MCHC-31.3* RDW-18.4* RDWSD-57.7*
___ 01:15PM NEUTS-51.8 LYMPHS-11.3* MONOS-31.3* EOS-4.0
BASOS-0.9 IM ___ AbsNeut-10.59* AbsLymp-2.31 AbsMono-6.40*
AbsEos-0.82* AbsBaso-0.19*
___ 01:15PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 01:15PM PLT SMR-HIGH* PLT COUNT-544*
Brief Hospital Course:
___ with acute on chronic cholecystitis who underwent a lap ccy
on ___ with no intra-op complications. Post op she developed a
fever. UA was negative but a WBC was elevated to 22.6. CXR was
nonspecific, c/f pneumonia. By POD1, she was not improving. A CT
scan was negative. WBC rose to 29.5 EP cardiology was consulted
to interrogate the pacemaker which showed no arrhythmia. Over
POD3 and 4, her WBC was down trending. She was tolerating a
regular diet. Her pain was improving. Ms. ___ was
discharged from the hospital in stable condition. She was
voiding and her pain was well controlled. She had a BM prior to
D/C. Ms. ___ was asked to follow up in ___ clinic and also
to see hematology/onc for workup of her very high WBC count.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*15
Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*15 Tablet
Refills:*0
3. Aspirin 325 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10638652-DS-18
| 10,638,652 | 22,905,262 |
DS
| 18 |
2113-07-10 00:00:00
|
2113-07-10 09:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Fluarix Quad ___ (PF)
Attending: ___.
Chief Complaint:
sore throat
Major Surgical or Invasive Procedure:
throat drainage x2 in the ED
History of Present Illness:
Ms. ___ is a ___ woman with HTN,
bradyarrhythmia s/p PPM, and recent diagnosis of CMML (started
hydroxyurea on ___ presenting with sore throat.
She developed symptoms of nasal congestion and mild sore throat
about a week ago. Then, the night before presentation the sore
throat became very severe. She could no longer open her mouth or
swallow water due to pain and swelling. She felt SOB when she
lay
down flat, but attributes this more to nasal congestion than
throat swelling. The right side of her jaw and neck became
swollen and her voice sounds hoarse and like she is "speaking
inside of a barrel". She measured her temperature at home and
did
not have a fever
ED Course:
Vitals: Afebebrile, satting high ___ on RA
Data: WBC 12.7 (similar to prior), CT neck w/ peritonsillar
abscess with compression of airway at the level of abscess but
otherwise patent
Interventions: NS 1.5L, unasyn, toradol, tylenol
Course: Abscess drained x2 at the bedside. Patient feeling
significantly improved but continues to have pain with PO and so
after discussion with oncology planning to admit to medicine for
continued IV antibiotics.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
CMML
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization
Physical Exam:
VITALS: T: 97.6 PO BP: 114/55 HR: 62 RR: 18 O2 sat: 95% O2 RA
GENERAL: Well appearing, in no distress
EYES: Anicteric, pupils equally round
ENT: +Swelling over left mandible and neck, no palpable fluid
collection, no trismus, MMM, no oral lesions, uvula not deviated
CV: Heart regular, no murmur, no S3/S4. JVP 6cm
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 06:10AM BLOOD WBC-7.4 RBC-3.87* Hgb-9.8* Hct-31.9*
MCV-82 MCH-25.3* MCHC-30.7* RDW-22.5* RDWSD-66.6* Plt ___
___ 02:10PM BLOOD WBC-12.7* RBC-4.20 Hgb-10.8* Hct-35.3
MCV-84 MCH-25.7* MCHC-30.6* RDW-23.3* RDWSD-69.9* Plt ___
___ 02:10PM BLOOD Neuts-46.4 Lymphs-14.5* Monos-32.0*
Eos-5.3 Baso-1.4* Im ___ AbsNeut-5.90 AbsLymp-1.85
AbsMono-4.07* AbsEos-0.68* AbsBaso-0.18*
___ 02:10PM BLOOD Hypochr-NORMAL Anisocy-1+*
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-1+*
Polychr-OCCASIONAL Ovalocy-OCCASIONAL Burr-OCCASIONAL
Stipple-OCCASIONAL Tear ___
___ 06:10AM BLOOD Glucose-80 UreaN-13 Creat-0.5 Na-142
K-4.2 Cl-105 HCO3-26 AnGap-11
___ 02:10PM BLOOD Glucose-86 UreaN-14 Creat-0.6 Na-142
K-5.1 Cl-103 HCO3-23 AnGap-16
___ 06:10AM BLOOD Calcium-8.2* Mg-2.2
___ 02:10PM BLOOD Lactate-1.2
CT neck:
IMPRESSION:
1. 2.3 x 1.5 cm right peritonsillar abscess with mild
mass-effect upon the
airway at the level. Otherwise, the airway is widely patent.
2. Neck vessels are patent.
3. Reactive prominent lymph nodes in the neck without evidence
of
lymphadenopathy.
4. Unchanged 1.4 cm thyroid nodule in the right thyroid lobe
Brief Hospital Course:
___ w/ HTN, bradyarrythmia s/p PPM, recent dx
of CMML (on hydrea) presenting with 1 week of URI sx followed by
1 day of severe odynophagia/trismus/neck swelling found to have
peritonsillar abscess now s/p drainage x2 in the ED and
improving
on IV antibiotics.
#Peritonsillar abscess
#Odynophagia
#Nasal congestion
Presenting with 1 week URI sx followed by one day of severe sore
throat, difficulty swallowing, voice changes, face/neck
swelling.
Found to have peritonsillar abscess on CT neck. No respiratory
symptoms and has been satting well on RA since arrival. S/p
drainage x2 in the ED with note suggesting 3cc were drained. Pt
continued to improve on IV unasyn, no SOB, odynophagia and jaw
pain improved. Discussed case with ENT who recommended to
monitor her symptoms, consider CT scan tomorrow/sat if no
improvement but otherwise that the ED documented drainage of 3mm
of pus should be
adequate at this time. ENT f/u after DC. Pt was transitioned to
PO augmentin on DC for a total of 14 day course of therapy.
Symptom control provided with Tylenol and ibuprofen.
#CMML
Outpt oncologist aware of admission.
Held Hydrea during admission, can resume at ___.
#HTN
Continued home metoprolol tartrate ___.5mg QHS ( dosing
confirmed with patient)
>30 minutes spent on discharge planning including face to face
time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO QHS
4. Omeprazole 20 mg PO DAILY:PRN GERD
5. Hydroxyurea 500 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
peritonsillar abscess
CMML
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated for evaluation of throat pain after having a
respiratory virus. You were found to have a peritonsillar
abscess after having a CT scan. The ER doctors ___ this
___ x2 in the emergency room. Your symptoms improved after
this drainage and having antibiotic therapy. You should continue
to take your antibiotics (augmentin) to total a 14 day course.
You will also need to follow up with an ENT/otolaryngologist
after discharge next week to ensure that your infection is
healing well. You swallowing improved by discharge, you were
able to tolerate regular food, and you did not have any
shortness of breath by the time of discharge.
Followup Instructions:
___
|
10638873-DS-14
| 10,638,873 | 21,974,488 |
DS
| 14 |
2163-04-25 00:00:00
|
2163-04-25 20:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Odynophagia
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
___ previously healthy M presenting for evaluation of pain
with swallowing. He had been in ___ rehearsing a musical for
the last ___ weeks when four days ago he started feeling weak
and lightheaded and developed subjective fevers and night
sweats. He subsequently developed pain while swallowing. The
next day he he went to urgent care clinic where rapid strep and
flu testing were performed, negative per his report. He visited
the ED twice (___) and was found to have a temperature of
104. They found: leukocytosis of 18, U/A negative for for
___ with trace protein, negative monospot, EKG
unremarkable, CT chest+abd/pelv negative. He had a downtrending
white count to 14 on ___ visit and was recommended to get an
endoscopy. He flew back to ___ where his family lives and now
presents for further evaluation. He states he has had difficulty
tolerating PO for the last four days secondary to pain. The pain
is localized to the mid-sternum, burning, intermittent, ___ to
___, radiates slightly downward, worse with movement and
drinking. He denies pharyngeal pain or dysphagia, notes that he
has had some mild reflux. In terms of exposures, he went
horsebacking riding in ___. His sexual history is notable for
intercourse with women only, and ~10 weeks ago had unprotected
encounter including oral sex (that partner had STD testing a
month later which was reportedly negative). He noticed tender
swollen inguinal nodes a few weeks ago but has had this prior to
being sexually active as well. Per report he has had negative
STD and HIV testing in the past, most recently within the last 6
months.
Past Medical History:
None
Social History:
___
Family History:
Paternal grandfather with dysphagia of unknown etiology. Sister
with T1D. ___ uncle with ___ disease.
Physical Exam:
ADMISSION
=========
PHYSICAL EXAM:
VS: 97.9 71 122/68 16 99% ra
GENERAL: Alert, oriented, no acute distress
HEENT: oropharynx erythematous with white patch in R pharynx
NECK: supple, mildly tender cervical lymph nodes without LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no rashes, sores. Inguinal LAD R>L, nontender.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: motor function grossly normal
SKIN: No excoriations or rash.
DISCHARGE
========
VS: 98.7 98.1 ___ 100s-120s/70s-80s ___ 98%+RA
GENERAL: Alert, oriented, no acute distress
HEENT: no oral lesions
NECK: supple, mildly tender cervical lymph nodes without LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no rashes, sores. Inguinal LAD R>L, nontender.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: motor function grossly normal
SKIN: erythematous discrete lesions, starting to coalesce,
?vesicular in L armpit, not painful. Red papular/pustular rash
on back and R chest.
Pertinent Results:
Admission Labs
===============
___ 11:55AM GLUCOSE-90 UREA N-12 CREAT-0.7 SODIUM-134
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
___ 11:55AM WBC-6.6 RBC-4.64 HGB-13.9 HCT-41.4 MCV-89
MCH-30.0 MCHC-33.6 RDW-12.6 RDWSD-41.0
___ 11:55AM NEUTS-69.4 LYMPHS-16.7* MONOS-12.6 EOS-0.8*
BASOS-0.0 IM ___ AbsNeut-4.56 AbsLymp-1.10* AbsMono-0.83*
AbsEos-0.05 AbsBaso-0.00*
___ 11:55AM ___ PTT-31.0 ___
___ 07:10PM HIV Ab-NEGATIVE
Discharge Labs
===============
___ 07:25AM BLOOD WBC-6.2 RBC-5.16 Hgb-15.3 Hct-45.6 MCV-88
MCH-29.7 MCHC-33.6 RDW-12.2 RDWSD-39.8 Plt ___
___ 07:25AM BLOOD Glucose-103* UreaN-7 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-24 AnGap-15
Microbiology
==============
___ 6:20 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
___ 6:20 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 6:15 pm THROAT CULTURE
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
HERPES SIMPLEX LIKE CYTOPATHIC EFFECT.
CULTURE CONFIRMATION PENDING.
___ 7:10 pm SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
___ 6:08 pm URINE Source: ___.
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___: Negative for Chlamydia trachomatis by
___ System,
APTIMA COMBO 2 Assay.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria gonorrhoeae by
___
System, APTIMA COMBO 2 Assay.
Chest Xray ___
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
This is a ___ year old male recently engaged in oral sex with a
new partner presenting with substernal chest pain with eating
found to have esophagitis on EGD concerning for HSV infection,
started on acyclovir and treated symptomatically with
improvement in pain and ability to tolerate regular diet,
discharged home on course of acyclovir and PPI, final
immunohistochemical stains pending at discharge, returning to
confirm HSV following discharge, patient notified via telephone.
# Herpes Esophagitis / Odynophagia - patient presented with
substernal chest pain and PO intolerance; his pain was
controlled on IV toradol, Magic Mouthwash and Lidocaine Viscous
solution. He was not able to tolerate food or drink so was given
maintenance IV fluids. He reported recent oral sex and so STD
etiology was suspected. He was worked up for STDS, including
HIV antibody/viral load, urine GC/chlamydia, RPR. Endoscopy
showed moderate to severe esophagitis concerning for HSV
esophagitis. He was empirircally started on acyclovir. His
symptoms improved and he was able to tolerate PO intake. He was
discharged with tylenol, PPI, lidocaine, sucralfate for symptom
control, with instructions to complete a seven day course of
acyclovir. On day of discharge results returned confirming HSV
esophagitis--patient informed. He was recommended to have close
follow up with his primary doctor.
Transitional
=============
- Can consider discontinuation of PPI once symptoms resolve
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is
Unknown
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight hours Disp
#*18 Tablet Refills:*0
2. Lidocaine Viscous 2% 15 mL PO QID:PRN pain
RX *lidocaine HCl 2 % 15mL four times a day Refills:*0
3. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1gm suspension(s) by mouth four
times a day Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
5. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*20
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Preliminary Herples simplex esophagitis
Discharge Condition:
Mental status: alert and oriented
Ambulatory status: independent
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with pain when swallowing and fevers
and chills a few days previously. We sent tests to look for
infectious causes and you also had an upper endoscopy performed
which showed esophagitis. The biopsy had not returned finalized
but you were improved so you were discharged.
Followup Instructions:
___
|
10639069-DS-20
| 10,639,069 | 28,711,371 |
DS
| 20 |
2143-12-17 00:00:00
|
2143-12-19 18:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking male with a history of mixed
connective tissue disease with features of Sjogren's, systemic
sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy)
and SLE with class V membranous nephritis, who presented with
abdominal pain.
He reports onset of symptoms last ___, with epigastric
pain,
frequent N/V, inability to keep down PO, also diarrhea.
Abdominal
pain is intermittent. Emesis has not been bloody or coffee
ground. He had 3 watery BMs in last day. He reports that at the
beginning he had a few drops of BRBPR but none recently. Stools
are recently dark brown-black in color.
He denies f/c, SOB. Notes dry cough that is not new, also
reports
pleuritic chest pain. Reports mild burning with urination. No
___.
In the ED:
- Initial vital signs were notable for: 98.5, 77, 84/51, 18,
100%
RA
He triggered for hypotension and received IVF and stress dose
steroids with improvement.
- Exam notable for: Abd is Soft, mild epigastric tenderness,
nondistended, no guarding, rebound or masses, brown guaiac
positive stool
- Labs were notable for:
4.9 10.8 249
>------<
36.0
128 98 35 99 AGap=13
------------<
5.7 17 1.6
AST 26, ALT 10, AP 57, Tbili <0.2, Alb 2.1, Lipase 87
INR: 1.2
Lactate:1.3
Trop-T: <0.01
UA 300 protein
- Studies performed include:
CT A/P with contrast
The study is limited by absence of oral contrast and minimal
intra-abdominal fat. Within these limitations, no acute
intra-abdominal process is identified. The esophagus is patulous
and air-filled. Apparent small bowel thickening is favored to be
artifactual secondary to decompression and absence of
intervening
intra-abdominal fat.
CXR: No acute intrathoracic process.
- Patient was given:
IV Zosyn 4.5 g
IV Hydrocortisone Na Succ. 100 mg
2L NS, 1L LR
IV pantoprazole 40 mg, PO Aluminum-Magnesium Hydrox.-Simethicone
30 ml, PO Donnatal 10 mL, PO Lidocaine Viscous 2% 10 mL
Vitals on transfer: 97.8, 57, 100/62, 17, 100% RA
Upon arrival to the floor, patient history reported as above.
Currently he is feeling well and does not have any nausea or
abdominal pain.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative except as HPI above.
Past Medical History:
- Hypothyroidism
- Iron deficiency anemia
- ? SLE, diagnosed abroad, previously on plaquenil
Social History:
___
Family History:
Aunt and cousin have lupus. Mother has diabetes. Reports no
family history of cancer or heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.4PO, 98 / 63L Lying, 43, 20, 100 RA
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric and without injection.
ENT: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: no ___
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. moving all extremities. appropriately
interactive
DISCHARGE PHYSCIAL EXAM:
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric and without injection.
ENT: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: no ___
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. moving all extremities. appropriately
interactive
Pertinent Results:
ADMISSION:
___ 08:45PM BLOOD WBC-4.9 RBC-4.61 Hgb-10.8* Hct-36.0*
MCV-78* MCH-23.4* MCHC-30.0* RDW-16.4* RDWSD-46.4* Plt ___
___ 08:45PM BLOOD Plt ___
___ 08:45PM BLOOD Glucose-99 UreaN-35* Creat-1.6* Na-128*
K-5.7* Cl-98 HCO3-17* AnGap-13
___ 08:45PM BLOOD ALT-10 AST-26 AlkPhos-57 TotBili-<0.2
___ 08:45PM BLOOD Albumin-2.1*
___ 08:55PM BLOOD Lactate-1.3
DISCHARGE:
___ 06:00AM BLOOD WBC-3.9* RBC-4.27* Hgb-9.9* Hct-33.8*
MCV-79* MCH-23.2* MCHC-29.3* RDW-16.9* RDWSD-48.3* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-84 UreaN-22* Creat-0.8 Na-136
K-4.4 Cl-105 HCO3-21* AnGap-10
___ 06:00AM BLOOD Calcium-7.3* Phos-3.6 Mg-2.0
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
___ ___ speaking male with a history of mixed
connective tissue disease with features of Sjogren's, systemic
sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy)
and SLE with class V membranous nephritis, who presented with
abdominal pain and N/V, found to have likely gastroenteritis as
per CT.
====================
TRANSITIONAL ISSUES:
====================
[ ] Ciprofloxacin and Flagyl - 7 day course to be completed
___
[ ] Please follow up stool cultures
[ ] Please follow up blood cultures - no growth to date
[ ] Restarted home lisinopril at discharge given resolution of
___
[ ] Discharge Cr 0.8
[ ] Noted to have sinus bradycardia to 40-50s while in hospital,
asx. Can consider further workup as needed as this does not
appear to be his baseline
#CODE: presumed full
#CONTACT: ___, Phone: ___
============
ACUTE ISSUES:
=============
# Gastroenteritis: 6 day history of N/V, abdominal pain,
associated with diarrhea. CT A/P negative for acute process but
showing moderate amount of fluid within the small bowel which
could suggest nonspecific enteritis, without CT signs to suggest
IBD. He was given IV fluids and started on IV to PO antibiotics.
He improved with stable vital signs and resolution of vomiting /
diarrhea and tolerated regular diet. PLAN: Continue
Ciprofloxacin and Flagyl for 7 day course (end of treatment
___, please follow up stool cultures and blood cultures.
# Hypotension: BP 84/51 initially in ED, now s/p >4L IVF and one
time dose of stress dose steroids. Most likely hypovolemia in
setting of N/V/diarrhea and poor PO. BP on discharge 100/63.
PLAN: As per above.
# ___, pre-renal
Admission Cr 1.6 from baseline 0.7. Improved to 0.8 at discharge
with aggressive IV fluid repletion. PLAN: Restarted lisinopril
at discharge.
# Hypovolemic hyponatremia
Admission Na 128. Improved with IV fluids as above. Discharge Na
136.
# BRBPR: Pt initially reported diarrhea with small BRBPR to ED;
on further history seems more c/w hemorrhoidal bleeding and
since resolved. Of note he had been planned for outpatient
endoscopy and colonoscopy given +occult blood noted in setting
of chronic iron deficiency anemia, to look for GAVE iso
sclerodermatous features. H/H at baseline. Low suspicion for
active GIB at this time. PLAN: outpt EGD/colonoscopy for further
workup of +occult blood and iron deficiency anemia, continue
home pantoprazole, continue home ferrous sulfate.
===============
CHRONIC ISSUES:
===============
# MCTD
MCTD with features of SLE, sjogrens and systemic sclerosis.
Disease manifestations have included serositis, polyarthralgias,
skin pigment changes, photosensitivity, Raynaud's, sicca,
achalasia/esophageal dysmotility (improved s/p myotomy),
pleuritis, nephritis, and GERD. In addition PFTs showed a
restrictive ventilator pattern concerning for shrinking lung
syndrome which has now improved. PLAN: cont home MMF 1500 BID,
cont home hydroxychloroquine 200 daily, cont home lisinopril
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO DAILY
3. Mycophenolate Mofetil 1500 mg PO BID
4. Levothyroxine Sodium 200 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Ferrous Sulfate 325 mg PO DAILY
7. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID gastroenteritis
2. MetroNIDAZOLE 500 mg PO TID
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Mycophenolate Mofetil 1500 mg PO BID
9. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
Gastroenteritis
Acute kidney injury
Hypovolemic hyponatremia
Hypotension
Bright red blood per rectum
SECONDARY DIAGNSES
Mixed connective tissue disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having diarrhea, vomiting,
and your blood pressure was low
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were diagnosed with gastroenteritis, a problem caused by a
bacteria or virus
- You were started on antibiotics for possible bacteria and
given IV fluids
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10639500-DS-22
| 10,639,500 | 24,104,993 |
DS
| 22 |
2117-01-10 00:00:00
|
2117-01-18 14:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
___ Right heart cath/swan ___ cath placement
___: ICD placement
History of Present Illness:
___ hx HFrEF (LVEF 15%, on LifeVest), recent STEMI s/p PCI with
DES to LAD, NIDDM, morbid obesity, HTN, p/w DOE.
To the ED, he reports several days of worsening DOE and
orthopnea. No CP. +N/V, has taken Zofran from OSH ED. Had CPAP
last admission, no sleep study, so no home mask. No fevers,
chills, cough, additional complaints.
In the ED, initial vital signs were: 97.1 98 108/58 20 100% RA
- Labs were notable for: proBNP 8838. INR 4.4. BUN/Cr ___.
Trop negative.
- Imaging: CXR w/o pulmonary edema.
- EKG: NSR with PAC. LAE, LAD. Similar to prior with more
artifact.
- The patient was given: Nothing.
Vitals prior to transfer were: 97.3 76 111/68 16 98% RA
On the floor, patient endorses SOB and DOE for the past several
days. There has been vomiting more recently. He has had a cough
when he attempts to lay supine (which he was able to do when he
left the hospital). His weight has increased by a kilogram in
the past week. He has been unable to get a full night's sleep,
which he attributes to the lack of a CPAP machine. Denies f/c,
cp/pressure, abdominal pain, diarrhea or urinary sx. Complaint
with his meds as below.
REVIEW OF SYSTEMS: Per HPI.
Past Medical History:
Morbid Obesity
Type 2 Diabetes Mellitus
Hypertension
Mixed Cardiomyopathy; Systolic Heart Failure with Reduced
Ejection Fraction
Myocardial Infarction s/p DES to the LAD (___)
Social History:
___
Family History:
Family history of ESRD in both his father and grandmother. No
known family history of cardiovascular disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.5 ___ 18 100%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: NCAT, pupils symmetric, sclera anicteric, clear OP
NECK: Unable to appreciate JVP d/t body habitus
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: CTAB
ABDOMEN: Soft NT ND +BS
EXTREMITIES: WWP, no edema
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, moving limbs
normally.
DISCHARGE EXAM
VS: 99.0 90-95/36-70 ___ 18/min 100% ra
I/O: 2680/___ +unrecorded
Weight ___ kg
GENERAL: Obese AA male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVD to mandible
CARDIAC: Distant heart sounds, RRR normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: trace ankle edema, right foot with minimal edema,
markedly improved pain at ankle joint. no warmth, erythema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
===============
ADMISSION LABS
===============
___ 09:30PM BLOOD WBC-5.8 RBC-4.21* Hgb-11.7* Hct-35.7*
MCV-85 MCH-27.8 MCHC-32.8 RDW-15.3 RDWSD-46.4* Plt ___
___ 09:30PM BLOOD Neuts-40.2 ___ Monos-7.5 Eos-0.2*
Baso-1.0 Im ___ AbsNeut-2.34 AbsLymp-2.97 AbsMono-0.44
AbsEos-0.01* AbsBaso-0.06
___ 10:08PM BLOOD ___ PTT-43.3* ___
___ 09:30PM BLOOD Glucose-100 UreaN-29* Creat-1.6* Na-133
K-4.0 Cl-97 HCO3-20* AnGap-20
___ 09:30PM BLOOD ALT-34 AST-32 AlkPhos-79 TotBili-1.4
___ 09:30PM BLOOD Lipase-52
___ 09:30PM BLOOD proBNP-8838*
___ 09:30PM BLOOD cTropnT-<0.01
___ 04:56AM BLOOD Calcium-9.8 Phos-5.0* Mg-1.5*
___ 09:30PM BLOOD Albumin-3.8
============
PERTIENT LABS
============
White count related to leukopneia:
___ 04:04AM WBC-5.1
___ 02:17AM WBC-5.2
___ 06:38AM WBC-3.8*
___ 03:00AM WBC-3.5*
___ 05:23AM WBC-4.
___ 03:13AM WBC-4.4
Trops:
___ 09:30PM cTropnT-<0.01
___ 04:56AM CK-MB-2 cTropnT-<0.01
Lactate
___ 05:43PM 2.8*
___ 09:47PM 2.9*
___ 03:40AM 1.8
___ 03:32PM 2.7*
___ 04:08AM 1.7
___ 08:04PM 1.2
___ 05:23AM 1.4
___ 09:30PM BLOOD proBNP-8838*
___ 09:30PM BLOOD Lipase-52
___ 04:56AM BLOOD Lipase-117*
___ 10:38PM UricAcd-12.0*
___ 05:40PM VitB12-907* Folate-7.0
___ 04:32AM BLOOD Sickle-NEG
___ 03:52PM BLOOD Osmolal-284
___ 05:40PM BLOOD HBsAb-Positive HBcAb-Negative
___ 05:40PM BLOOD ___
=======
MICRO
======
BCx ___ 2X No growth final
Staph aureus Screen (Final ___: NO STAPHYLOCOCCUS AUREUS
ISOLATED.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
========
CARDIAC
=======
Right Heart Cardiac Cath ___
Site Systolic Diastolic EDP A Wave V Wave Mean HR
RV systolic 49 EDP 15 HR 82
PA systolic 47 diastolic 19 mean 34 HR 88
PCW A wave 27 V wave 27 mean 22 HR 91
RA A wave 18 V wave 16 mean 12 HR 90
Cardiac Output L/min 6.18
Cardiac Index L/min/m² 2.29
Oximetry
Site Oxygen Content Saturation Hemoglobin PO2
PA O2 content 10.59 ___ 66 hgb 11.8
SVC O2 content 10.59 ___ 66 hgb 11.8
ART O2 content 16.05 ___ 100 hbg 11.8
TTE ___
The left atrial volume index is mildly increased. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= ___ %). . No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Doppler parameters
are most consistent with Grade III/IV (severe) left ventricular
diastolic dysfunction. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. 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. The mitral valve
leaflets do not fully coapt. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
left venticular cavity is more dilated. The right ventricle is
poorly visualized but appears at least moderately depressed in
function. Estimated pulmonary artery pressure is lower. The
severity of mitral and tricuspid regurgitation is reduced.
=======
IMAGING
=======
CXR ___
In comparison with study of ___, there is an placement of a
left subclavian ICD with the lead extending to the region of the
apex of the right ventricle. No evidence of post procedure
pneumothorax.
Huge enlargement of the cardiac silhouette without vascular
congestion,
suggesting cardiomyopathy or pericardial effusion.
MR ___ ___
Examination covers the mid and forefoot. The hindfoot is not
included in the field-of-view. Fine detail is limited by motion
artifact. No suspicious bone marrow signal is identified to
suggest osteomyelitis bone contusion or fracture. No focal bone
erosions identified. . There is a small amount of fluid at the
first MTP joint. A small talonavicular joint effusion is seen
at the edge of the film.
Subcutaneous soft tissue edema is noted overlying the dorsum of
the forefoot, slightly more prominent towards the lateral
aspect.
There is mild diffuse muscle edema. There is mild fatty atrophy
of the digiti minimi muscle.
Flexor and extensor tendons are intact. Mild flexor ___
synovitis. Mild
tenosynovitis about the flexor hallucis and flexor digitorum
tendons at ___ knot. Possible mild peroneus longus
tenosynovitis.
IMPRESSION:
1. No abnormal bone marrow signal to suggest osteomyelitis.
2. Subcutaneous and interstitial soft tissue edema and also
muscle edema,
which is nonspecific, but can be seen with cellulitis and
myositis in the
appropriate clinical setting.
3. No bone erosions or focal soft tissue mass is detected. In
this respect, no findings specific for gout identified.
4. Mild synovitis and tenosynovitis, detailed above. No
significant free
fluid identified in relation to the joints are tendons. No
fluid collections suggestive of abscess identified.
5. The hindfoot is not included on these views.
R Ankle/Foot ___
Moderate soft tissue swelling. Pes planum. No evidence of
fracture. The
mortise is unremarkable, the joint space at the level of the
ankle is normal. No evidence of fracture, no signs of chronic
erosive bone or joint disease.
CXR PICC placement ___
Since the prior chest radiograph performed earlier on the same
date, there has been interval placement of a right-sided PICC
which terminates at the mid SVC. ___ catheter has been
removed in the interim. Lungs are clear consolidation, pleural
effusion or pneumothorax. Marked cardiomegaly is again noted.
IMPRESSION: New right-sided PICC terminates in the mid SVC.
___ catheter has been removed. Otherwise no significant
change.
CXR ___
No evidence of pulmonary edema.
RUQUS ___
7 mm CBD (top-normal in size), without evidence of biliary
obstruction. This finding is of indeterminate significance.
Gallbladder and intrahepatic biliary tree appear unremarkable.
Otherwise, unremarkable ultrasound of the abdomen.
CT Abd/pelvis ___
IMPRESSION
1. Allowing for limitations of a noncontrast examination, the
biliary tree and pancreas are grossly unremarkable.
2. Small periumbilical hernia containing large and small bowel
loops, without evidence of bowel obstruction.
DISCHARGE LABS
___ 05:20AM BLOOD WBC-8.7 RBC-4.25* Hgb-11.7* Hct-36.1*
MCV-85 MCH-27.5 MCHC-32.4 RDW-15.8* RDWSD-48.5* Plt ___
___ 05:20AM BLOOD ___
___ 05:20AM BLOOD Glucose-126* UreaN-26* Creat-0.9 Na-138
K-4.7 Cl-100 HCO3-26 AnGap-17
___ 05:20AM BLOOD Albumin-3.6 Calcium-9.9 Phos-4.1 Mg-2.0
PREALBUMIN 27 ___ mg/dL
Brief Hospital Course:
___ year old man with NIDDM, Morbid Obesity, Hypertension and
HFrEF (LVEF 15% in ___ with recent MI/LV thrombosis s/p PCI
with DES to the LAD who is admitted with orthopnea, shortness of
breath, nausea, and persistent vomiting on oral intake.
# CORONARIES: DES to LAD and DES to ___ Diagonal
# PUMP: EF ___
# RHYTHM: NSR with PVCs
# Acute on Chronic Systolic Heart Failure: Pt presented with
worsening orthopnea, shortness of breath, nausea and feeling of
fullness. BNP elevated to 8800. Pt had been off afterload
reduction and only recently restarted diuresis. Upon admission,
metoprolol was held. Patient's symptoms improved significantly
on milrinone and diuresis. Underwent RHC on ___ that revealed
elevated CVP, low cardiac index. Milrione was uptitrated to
0.375 mcg and he was actively diuresed with a Lasix gtt @ 20
mg/hr for neg ___ per daily. With milrinone and diuresis, CVP
downtrended and cardiac index improved. Other markers of
perfusion, including LFTs and Creatinine improved as well. Given
risk of VT with reduced EF and milrinone dependence, an ICD was
placed ___ for primary prevention. Ultimate treatment of his
heart failure is likely heart transplant, however his BMI
currently precludes him from this. Next step would be LVAD
followed by attempts at weight loss and potential bariatric
surgery. His discharge regimen was as follows:
- PRELOAD: torsemide 20mg daily
- PUMP: metop XL 25mg, milrinone 0.375 mcg/kg/min
- AFTERLOAD: Valsartan 40mg BID, milrinone 0.375 mcg/kg/min
# #History of LV thrombus and likely cardioembolic STEMI -
Patient was maintained on heparin for most proceduralization but
warfarin 5 mg was restarted for goal INR ___. Extensive genetic
hyper coagulability workup thus far negative. B2 microglobin,
cardiolipin, sickdex screen were negative. Factor V Leiden was
negative Cardiac MRI without significant fibrosis. Atorvastatin
was stopped given no evidence of CAD. Patient was continued on
aspirin and plavix for DES.
# Leukopenia: on ___, patient was noted to be leukopenic with
WBCs 3.5-3.8 and a decrease in neutrophils to 1000-1500. Heme
onc was consulted. Work up for leukopenia including vitamin B12,
HBV, HCV, HIV were negative. Additionally, patient's ranitidine
and omeprazole was discontinued. Infectious work up including
UA, BCx 2X, chest Xray were negative for infectious causes.
Leukopenia resolved within two days and neutrophil count
increased to 3K.
#Gout: Patient suffered from suspected episode of gout in R
ankle in setting of diuresis. Pain was significant and
debilitating. X-ray and MRI not revealing of significant
pathology. Pain minimally responded to colchicine and pain was
not even well controlled on narcotic pain medications. However,
prednisone burst of 60mg x3 days was effective in relieving
symptoms. He was discharged with short taper to complete.
# Abdominal Pain: Patient's predominant symptoms on admission
related to nausea and abdominal pain. These resolved with
optimization of heart failure suggesting these symptoms are
reflective of his heart failure. RUQUS negative, CT Abd/Pelvis
demonstrated a small periumbilical hernia with loop of
small/large bowel without obstruction unchanged from prior CT in
___ and unlikely the etiology of his abdominal pain.
Pain/nausea had completely resolved by discharge
#OSA: Patient with suspected sleep apnea. He received CPAP while
in house and at home sleep study was scheduled for him at time
of discharge.
# CAD s/p STEMI and PCI: continued ASA and metoprolol.
Atorvastatin discontinued
# Vitamin D deficiency, patient on weekly dosing. Continue
previous regimen
=============
Transitional Issues:
=============
-Discharge weight: 154.5kg
-Discharge Creatinine: 0.9
-Heart failure medications: milirinone 0.375 mcg/kg/min,
Metoprolol Succinate XL 25 mg, torsemide 20 mg, Valsartan 40 mg
BID. Patient may benefit from introduction of spironolactone as
an outpatient. Note milrinone is dosed for weight of 159kg.
-Stopped medications: atorvastatin was discontinued as
atherosclerosis was not cause of CAD
-discharged on two days of Keflex for ICD infection prophylaxis
-Patient to receive home sleep study.
-Bariatric surgery was consulted during admission given BMI
preclusion to heart transplant. Current recommendations indicate
surgery only be done if Plavix and coumadin were to be held with
normalization of INR. Information sessions can be scheduled at
___
-Hypercoag workup largely negative. Will follow up with Heme/Onc
-Future presentations of GI symptomology may be related to CHF
exacerbation
-Patient will continue with weekly BMP + INR checks
-Gout: Patient will finish quick steroid taper. 60mgx3 days,
40mg x2 days, 20mg x 2days. He will take 40mg ___, 20mg ___,
and 20mg ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2 mg PO DAILY16
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Vitamin D ___ UNIT PO 1X/WEEK (WE)
7. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Milrinone 0.375 mcg/kg/min IV DRIP INFUSION
RX *milrinone in 5 % dextrose 20 mg/100 mL (200 mcg/mL) 0.375
mcg/kg/min infusion continuous Disp #*1 Intravenous Bag
Refills:*12
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Vitamin D ___ UNIT PO 1X/WEEK (WE)
7. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
8. Valsartan 40 mg PO BID
RX *valsartan 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY Duration: 1 Dose
This is dose # 1 of 2 tapered doses
RX *prednisone 20 mg ASDIR tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
10. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 2 tapered doses
11. Cephalexin 500 mg PO Q6H Duration: 2 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*8 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
Systolic congestive heart failure
Thromboembolic STEMI s/p DES x2 to LAD
Gout
Leukopenia
Acute kidney injury
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for worsening shortness of breath and
nausea/vomiting abdominal pain. Your symptoms were from heart
failure.
WHAT WAS DONE
==============
-Milrinone, a drug to help your pump better, was started and
will be continued as an outpatient
-You underwent a procedure called a right heart catheterization
and a catheter was placed in you right neck in order for us to
measure the pressure in your heart. Medications for blood
pressure were restarted based on these pressures.
-Fluid was removed through medications called diuretics.
Initially, you were on Lasix through the IV which was
transitioned to oral torsemide 20 mg daily.
-A flare of gout was treated with steroids, which you should
continue. You should take 40mg the night of ___. 20mg for the
nights of ___, and ___ and that will complete your taper.
-An defibrillator (ICD) was placed to protect you from dangerous
heart rhythms
WHAT TO DO NEXT
===============
-Take all medications as prescribed
--- you will need two more days of antibiotics to prevent
infection at site of ICD placement.
-Follow up with appointments as scheduled
-Weigh yourself every morning, call the heart failure clinic if
weight goes up more than 3 lbs.
-If interested in planning for Bariatric Surgery, call
___ to schedule a group info session.
-Call your doctor if you experience chest pain, shortness of
breath, abdominal pain, nausea, palpitations, or fainting.
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
10639651-DS-23
| 10,639,651 | 28,854,504 |
DS
| 23 |
2138-05-19 00:00:00
|
2138-05-25 07:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH of CAD s/p CABG in ___, CHF, renal insufficiency,
diabetes, obesity, and chronic pain syndrome, presented via EMS
after being found unresponsive. Patient has had limited food
availability. Last night, around midnight, he checked his blood
sugar (183) and gave himself 100 units of insulin R (he had run
out of lantus). He went to bed with his wife and she found him
around 8 am seeming sleepy and looking as if he had passed out.
EMS found patient to be hypoglycemic to 20 and administered
glucagon and oral glucose the patient's subsequent fingerstick
was 18. EMS unable to establish IV access and patient refused IO
access.
Pt also reports 6 week history of little bugs all over his
apartment and bed. It started after their bathroom plumbing
failed and their tub filled with stagnant water. The bugs get in
his ears, nose and mouth and up his anus. There are mites all
over his apartment and inside his CPAP. He was last in the ED on
___ complaining of itching and bites.
In the ED, initial VS were 67 133/73 16 98% RA. Received 1L NS,
Dextran 40 In Dextrose 5% IV, Aspirin 325mg, OxycoDONE (___)
5mg,Gabapentin 300mg
Transfer VS were 97.0 80 174/80 20 100% RA.
On arrival to the floor, patient reports that he needs to see
dermatologist and podiatrist. He brings with him his blanket
from the ED and points out dark spots and flakes that he feels
are bugs or parts of spiders.
Past Medical History:
Diabetes type II, Insulin Dependent
Coronary Artery Disease: 3v CABG ___, with no ETT since.
Hypertension
Hypercholesterolemia
Sleep apnea with CPAP
Gastroesophageal Refulx Disease
Arthritis: diffuse and severe, including involvement of chest
and arms
Social History:
___
Family History:
Father had heart disease, died at ___. Mother died of a blood
clot in her neck.
1 sister = asthma
Physical ___:
ADMISSION EXAM:
VS: 98.4 183/85 74 18 100/RA
General: Well appearing, mildly anxious morbidly obese gentleman
lying comfortably in bed. Pleasant and conversant but repeatedly
clearing his throat
HEENT: NCAT, EOMI, PERRL. Dark red crusting along lower lip.
Oropharynx clear
Neck: Supple, JVD not able to be assessed, no LAD
CV: RRR, distant heart sounds
Lungs: Clear to ausculatation
Abdomen: Obese, TTP on right side. Non distended. No rebound or
guarding. Cannot assess organomegaly
Ext: RLE with scars from vein grafts. Warts on bottom of right
foot and between toes. Dystorphic nails. No tracking from web
spaces, no bites or scabs from bites
Neuro: A&O x3. CNII-XII grossly intact. Gait WNL
Skin: No scabs, bites
.
.
DISCHARGE EXAM:
VS: 98.3 166/88 75 18 99/RA
General: Well appearing, mildly anxious morbidly obese gentleman
lying comfortably in bed. Pleasant and conversant but repeatedly
clearing his throat
HEENT: NCAT, EOMI, PERRL. Oropharynx clear
Neck: Supple, JVD not able to be assessed, no LAD
CV: RRR, distant heart sounds
Lungs: Clear to ausculatation
Abdomen: Obese, non tender. Non distended. No rebound or
guarding. Cannot assess organomegaly
Ext: RLE with scars from vein grafts. Warts on bottom of right
foot and between toes. Dystorphic nails. No tracking from web
spaces, no bites or scabs from bites
Neuro: A&O x3. CNII-XII grossly intact. Gait WNL
Skin: No scabs, bites
Pertinent Results:
ADMISSION LABS:
___ 09:30AM BLOOD Neuts-77.8* Lymphs-15.3* Monos-5.7
Eos-0.6 Baso-0.7
___ 09:30AM BLOOD Glucose-141* UreaN-14 Creat-1.2 Na-138
K-3.4 Cl-101 HCO3-28 AnGap-12
___ 09:30AM BLOOD ALT-17 AST-28 AlkPhos-41 TotBili-0.7
___ 09:30AM BLOOD Lipase-25
___ 05:20PM BLOOD cTropnT-<0.01
___ 09:30AM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.3 Mg-2.0
___ 02:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:15PM URINE CastHy-1*
___ 02:15PM URINE Mucous-RARE
___ 02:15PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-8.2 RBC-4.89 Hgb-13.7* Hct-38.2*
MCV-78* MCH-28.1 MCHC-36.0* RDW-13.3 Plt ___
___ 08:10AM BLOOD Glucose-82 UreaN-15 Creat-1.1 Na-139
K-4.1 Cl-100 HCO3-30 AnGap-13
___ 08:10AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9
.
.
IMAGING:
- CXR (___)
FINDINGS: The patient is status post median sternotomy. There
are low lung volumes. The patient's body habitus also leads to
underpenetration. The low lung volumes accentuate the
bronchovascular markings. However, there may be mild pulmonary
vascular congestion. No definite focal consolidation is seen.
There is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is likely in part accentuated by
the low lung volumes and AP technique.
IMPRESSION: Low lung volumes, which accentuate the
bronchovascular markings. However, there may be mild pulmonary
vascular congestion.
Brief Hospital Course:
PRIMARY REASON FOR ___ w/ PMH of CAD s/p CABG in ___,
CHF, renal insufficiency, diabetes, obesity, and chronic pain
syndrome, presented with hypoglycemia after taking 100 units of
Humalog around midnight because he ran out of Lantus
.
.
ACTIVE ISSUES:
#)Uncontrolled Type 2 Diabetes Mellitus/Hypoglycemia: Patient
presented after being unresponsive and having hypoglycemia in
the setting of taking 100units of Humalog rather than Lantus the
night prior. He understood the difference between his long and
short-acting medications but felt that he should take some
insulin since his blood sugar was 183. His sugars normalized
with orange juice and sugar tabs prior to admission and he had
no further episodes of hypoglycemia. He received education by
the primary team about the importance of taking the different
varieties of insulin as prescribed and was felt to understand
this. He also was taking metformin only when he felt his blood
sugar was too high and, although he was educated about how
metformin works, it is unclear if he will take this medication
routinely in the future. Despite this, his most recent HbA1c was
6.9 (___), suggesting that he does actually have good
glucose control.
.
Prior to discharge, a new insulin regimen was prescribed (100
units Lantus hs, 25 units Humalog prior to meals). His Lantus
was refilled (prescription picked up and given to the patient on
discharge) and he was given new glucometer and strips as he felt
his old testing kit was not working properly. Despite his HbA1c,
he will require close monitoring as an outpatient.
.
#) Diabetic Neuropathy/Concern for bugs/being bitten: The
patient was very concerned about the bugs in his home that he
felt were biting him and going up his nose and into his mouth
and rectum. He also reports a spider coming out of his toenail.
He had previously been to the ED for these symptoms and had
shared his concerns previously with his PCP (Please see PCP
progress note for more details.) On arrival to the floor, he
presented his ED blanket and pointed out tiny specks of material
(not actual bugs). He was repeatedly reassured that there were
no marks on his skin suggestive of bites. When pushed, he
recognized that maybe he did not see these bugs but felt as if
he were being bitten. He sees outpatient psychiatry at ___
but we were unable to reach his Psychiatrist. Per PCP, the
patient does not have underlying psychiatric disorder beyond
anxiety and depression. The description of the bites (primarily
on his feet, shooting pains and tingling) was suggestive of
diabetic neuropathy (patient currently taking 2700mg of
gabapentin daily). While redirectible, upon discharge he
expressed significant concern about returning home because of
the bugs so it is unclear how much continued reassurance while
he was inpatient will have helped. Of note, his home is
reportedly in disarray (wife is a ___, EMS reported only
candy in the home) and may very well contain some bugs. He had
"roach bombed" his home previously and had bathroom plumbing
issues resulting in standing water in his tub, all of which may
have contributed to his concerns (see below Social Issues). He
will likely require significant support around this issue in the
future.
.
#) Social issues: The patient has significant social issues that
will require resources and support. Of note, during admission
his wife was detained (although not admitted) in the psych ED
while trying to receive her psych medications. Mr. ___
appeared to be her primary caretaker.
1. Housing: Per EMS, patient's home was dirty and in disrepair.
The patient reports being forced by Fire Dept to clean home in
the past because of this. His wife is a ___ and per the
patient "she does not know how to clean so the house is
disgusting". As noted above, they did seem to have a bug
infestation problem and plumbing issues leading to standing
water in the bathtub for several days.
2. Food: Per EMS and patient, the only food available in the
home was candy. Patient reports being unable to afford food at
times.
3. Medication availability: Patient expresses concerns that
should his wife start to work he would lose his health coverage.
He reports having difficulties always obtaining his medications
from pharmacy and that he took the Humalog insulin only because
he had run out of Lantus and was unable (unclear why) to have it
refilled.
.
#) Medication adherence: In addition to medication access, the
patient does not take his medications as prescribed. It was
difficult to ascertain exactly what and when he is taking his
meds. He reports some medications "he does not tolerate" and may
be increasing doses of some of his medication on his own. It is
unclear how he ran out of the Lantus early. The patient feels he
needs higher doses of his metoprolol and gabapentin but did
agree to stay at current regimen until seeing PCP.
.
.
CHRONIC ISSUES:
#) HTN, uncontrolled: Long-standing issue. On admission,
systolic pressures in the 180s. Patient reports taking
metoprolol for his HTN but does not take his prescribed
nifedipine.
.
#) Depression: Followed by outpatient Psychiatry. Continued home
meds.
.
#) Diabetic neuropathy: Currently taking gabapentin 900mg TID.
His sensation of being bitten on his feet may be related to this
neuropathy. He was maintained on home medications.
.
#) BPH: On doxazosin. Discontinued nortriptyline (prescribed by
outside Psychiatry for insomnia) given complaints of urinary
retention.
.
#) Fibromyalgia/chronic pain: continued on home narcotics.
TRANSITIONAL ISSUES:
- Insulin regimen: 100 units Lantus + 25 units Humalog with each
meal. He was given Lantus and glucometer/test strips and
instructed to call PCP with sugar readings
- Held nortriptyline because patient complained of urinary
retention. ___ require another agent to help with insomnia
- Patient reports not taking multiple prescribed medications
(because he "does not tolerate them"); reports not taking all of
his anti-hypertensives
- Would likely benefit from significant housing/finance/food
support.
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. Doxazosin 2 mg PO HS
3. Enalapril Maleate 10 mg PO BID
4. Escitalopram Oxalate 40 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. fluticasone 50 mcg/actuation NU BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Gabapentin 900 mg PO TID
9. HYDROcodone-acetaminophen 7.5-750 mg Oral TID
10. Glargine 150 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Takes 150 Units at home
11. Meclizine 25 mg PO Q12H:PRN motion sick
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Tartrate 100 mg PO BID
14. Mupirocin Ointment 2% 1 Appl TP BID
15. NIFEdipine CR 30 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL DAILY
17. Nortriptyline 100 mg PO HS
18. Omeprazole 20 mg PO BID
19. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
20. Simvastatin 40 mg PO DAILY
21. Aspirin 81 mg PO DAILY
22. Cetirizine 10 mg Oral daily
23. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Glargine 100 Units Bedtime
Humalog 25 Units Breakfast
Humalog 25 Units Lunch
Humalog 25 Units DinnerMax Dose Override Reason: Takes 150 Units
at home
RX *insulin glargine [Lantus] 100 unit/mL 100 Units before BED;
Disp #*4 Bottle Refills:*0
2. ClonazePAM 1 mg PO TID
3. Blood Glucose Monitoring (blood-glucose meter)
Miscellaneous 4 times a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite
Strips. use to monitor blood sugar four times a day dx: iddm
RX *blood-glucose meter 4 times a day Disp #*1 Box Refills:*0
4. Blood Glucose Test (blood sugar diagnostic) Miscellaneous
4times a day
BLOOD-GLUCOSE METER [FREESTYLE FREEDOM LITE] - FreeStyle Freedom
Lite Kit. use to monitor blood sugar four times a day
RX *blood sugar diagnostic 4 times a day Disp #*2 Box
Refills:*0
5. Enalapril Maleate 10 mg PO BID
6. Escitalopram Oxalate 40 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Gabapentin 900 mg PO TID
10. Meclizine 25 mg PO Q12H:PRN motion sick
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Tartrate 100 mg PO BID
13. Mupirocin Ointment 2% 1 Appl TP BID
14. NIFEdipine CR 30 mg PO DAILY
15. Omeprazole 20 mg PO BID
16. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
17. Simvastatin 40 mg PO DAILY
18. Cetirizine 10 mg Oral daily
19. Doxazosin 2 mg PO HS
20. Ferrous Sulfate 325 mg PO BID
21. fluticasone 50 mcg/actuation NU BID
22. HYDROcodone-acetaminophen 7.5-750 mg Oral TID
23. Nitroglycerin SL 0.4 mg SL DAILY
24. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Hypoglycemia secondary to taking too much insulin
Secondary diagnosis:
- Hypertension
- Diabetic neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure participating in your care while you were at
___. You were admitted on ___ after taking too much short
acting insulin the night before. You were unresponsive because
your blood sugar was very low. It is VERY IMPORTANT that you
follow the new insulin regimen:
- Lantus (long acting) insulin: take 100Units at night
- Short acting insulin: take 25Units before every meal. It is
VERY important you eat after taking this
It is also very important that you do not take one type of
insulin in place of the other kind.
Please call Dr. ___ (___) to let them know
what your blood sugar is. If you feel dizzy or think you are
going to faint agian or if your blood sugar is low (<100),
please eat some sugar and call your doctor.
You should try to keep your apartment as clean as possible. The
very good news is that you do not have signs of bug or spider
bites on your skin. The sensations you feel might be related to
your nerve pains from diabetes. Please continue to take your
medications as prescribed until you see your PCP.
MEDICATION CHANGES:
STOP: nortriptyline (can make urination difficult)
CHANGE:
- Insulin (long acting) Lantus: Take 100 Units at night
- Insulin short acting: Take 25 Units before each meal
Again, it was our pleasure participating in your care. We wish
you the best of luck!
Followup Instructions:
___
|
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